Our next speaker is Dr. Brett Sanderlin. We're on his home turf, literally. He is currently the chair of primary care in clinical medicine and an associate professor here. Joined the faculty last April. He received his degree from University of North Health Science Center, Texas College of Osteopathic Medicine. He did his internship and residency in family medicine with the US Navy and has served as a Naval flight surgeon. He's also been faculty of the University of the Incarnate Word School of Osteopathic Medicine, where he was also associate dean for clinical affairs. And he served as faculty at his alma mater medical school. In the interim, he has done clinical work as a family physician now in Kyle, Texas. He's been active in multiple professional organizations and he's previously served as president of the Texas Osteopathic Medical Association. He's board certified in family medicine by both the American Osteopathic Board of Family Physicians and the American Board of Family Medicine. He is board certified in clinical informatics by the American Board of Preventive Medicine and has received a certificate of additional qualification in occupational medicine, as well as certificate in tribal health. And he has served for several years as an FAA senior medical examiner. And today he's gonna talk about psychiatric issues in military drone operators. Welcome Dr. Sangerloh. Thank you. Thank you, this is literally my home turf. Even though I haven't lived here for 40 years, I grew up about 15 miles from here. So came back home, had an opportunity to come here. So in reference to the last lecture, there are some really interesting things there and exposures that we just don't know how to deal with. And we're having to deal with psychiatric exposures, I mean, psychiatric things as well. And I'm gonna talk a little bit, we've got a couple of our faculty members here too. One of our psychiatrists is here, our psychologist is here too. She's gonna correct me when I make mistakes, but I have some, I have personal experience dealing with drone operators. When I was the senior medical officer at NASJRB in Fort Worth, first of all, no financial disclosures or conflict of interest, but that experience at NASJRB is a weird animal. It's strangely enough, has one of the highest military populations in the Navy. What used to be Carswell Air Force Base, a SAC base, the Navy moved the NAS Dallas over to NASJRB and I was the SMO there for a few years. And we had about half the personnel were Air Force, then the other half were a mix of Navy and Marine Corps. We had a few Coast Guard people, and then we also had to deal with DEA and CIA and other people. So we were giving people shots who came in with social security numbers, all nines, going, I'm sure some of you have done that. And they're going, I'm going somewhere in Africa, where, well, just give me the shots for everything. So, okay, you want all the shots and all the meds for Africa, then that's fine. As part of the, with the Air Force teams, I did work with some drone operators. They don't prefer to be called drone operators. They prefer RPAs or remote pilot aircraft. But they, and so I saw some of the psychiatric issues, but that was early 2000. So that's been 15, 20 years ago. And it's becoming a much bigger deal now. So the objectives here, y'all can, if I'm an active mission, so I have to do objectives. So we'll talk, you can look at that at your leisure. Drones are very popular right now. They're used by a lot of different countries. About 70 different countries use drones. More than 30 of them have weaponized drones. So they put missiles on them, bombs on them, everything from little bitty drones that just carry a grenade, all the way up to huge drones that can fire, Hellfire missiles and other kinds of missiles. All right. You think that I'm used to being in this room, I would be. I don't actually lecture much in this room. I usually lecture at the big rooms downstairs. So where we had our luncheon yesterday. They have some tactical advantages in combat. They're small. They, I don't know if any of you have seen the tiny little drones. They can go in places that nothing else can go into. They can provide a lot of information to the military personnel. And they're much lower risk to the pilots, at least from a physical risk. Now, psychiatric risk, we'll go into that a little bit more. They do, because the drone pilots are there and they take long shifts and they're watching the cameras for long periods of time, they can be more precise as to when the strike happens because they can see the target actually move into the building. They can see the car driving down the road. And so they usually are watching these effects for long periods of time. The RPA team isn't just the drone pilots. It's the ground crew. They have maintenance personnel, sensor operators, mission intelligence coordinators and then intelligence analysts, whether, especially if you're talking about some of these larger drones that may be operated by the CIA or the Air Force. There's a lot of joint CIA, Air Force stuff with drones, with the bigger drones. There are a lot of different types of drones. Everybody is familiar. The ones that I worked with were mostly MQ-1 Predators. They are phasing those out. In fact, I think they're almost all completely gone now. A descendant of the Predator was the Reaper, which was basically the Predator that they designed to be able to carry missiles. They didn't just strap missiles on it. There's the Dark Star, the Global Hawk, which is, anybody who've ever seen a Global Hawk, I'll show you a picture in a minute. Those things are monstrous. They are huge. There's the Sentinel, which is also used by the CIA. The Wasp, which is a little handheld. It has a little green box that comes with it. The black console has a TV screen on it and they hand launch it. And then it's like joystick controls. So it's more used by people in the field. The Navy has the Triton and strangely enough, the Fire Scout, which is a helicopter. It's a rather peculiar looking little helicopter. And then they're working on the X-47B, which looks like the B-2 Stealth bomber or the newer bomber. And then the Army has the RQ-7 Shadow. That's again, a small one that has a box that they carry around with them. And then the Marines use the Raven, which is another hand launched one. There are the newer ones that are coming out, the little small mini ones. The problem with the small mini ones is that they're really expensive. You'd think this little thing is $20,000, $30,000. It's like $200,000. So it's really expensive with all the support stuff. I think it's made in Sweden. So this is what the Shadow looks like, the RQ-7 Shadow. And that's its control truck behind it. So most of these pictures are Air Force stock pictures. There are a few that I use from other sites. And I will say about this lecture, because I haven't done this in a few years, there were several studies, some of which Jeffrey actually found for me and other people found for me, but I'm looking at studies, very recent studies, and some of them from like 2002, but some of them very recent about, for most of the information. So this is not necessarily from me, but it's from other people who are actually doing studies on these pilots. So that's a Global Hawk. So as you can see, it's a beast. It's big. The dome on the front that you see that's covered this one up, that dome up there actually has a satellite link. It has a dish that tracks the satellite and in turn keeps locked on a geosynchronous satellite. So it's a pretty good size bird. So this is a Reaper. You can see it has mounts for pods or missiles, or they can do surveillance pods. It has the IR and visual cameras up front, as well as it has a dome in the front, similarly to for the satellite link. It has in the pods, some of the pods can, they can actually, these things can fly for days at a time. They have very high loitering time. They fly something 50, 60, sometimes even 70,000 feet. So they can either, some of them are designed to fly in very low, so they can, the smaller ones are, but the big ones can fly very, very high. And so with their high altitude, they're also relatively quiet, much quieter than a standard jet. And so they're very low profile. It's hard for people to know if they don't, they have a fairly long radar signature as well. So it's hard for people to know that they're being surveilled and this is a predator firing, a Reaper, sorry, firing a missile. So that's a Hellfire missile, which is one of the ones they typically use. There is a new version of the Hellfire missile, which I'm not in DOD anymore. So I don't have to necessarily go with the classification structures anymore. And so this one, the DOD does not acknowledge it exists. However, there's a lot of evidence, including pieces pulled out of cars and stuff, showing that this version, the normal in the center right here is normally where the warhead is, the seeker, the sensor system is up here. And then there's the rocket motor back here and right about here is where the motors that control the flight surfaces. This thing has a tendency, or well, instead of having a warhead section, it has blades that open out. I've seen two different guesses as to how they work. One is that they fold out. The other one is that they unroll, that they're a metal that just unfolds. And they are designed, they jokingly refer, well, jokingly refer to it as the Gensu missile. So those of you that remember the old Gensu knife commercials, this is what it does to a car. So you can see this hit, this actually, someone was killed in this car, obviously. These missiles, when they go in, there was one of the, Al-Qaeda leadership was actually taken out with one of these missiles and the, I'm trying to remember exactly who pulled it out. I think it was Hezbollah pulled out some of the pieces and they showed how he was basically, this missile came in and did almost no damage to the building, except just like where it was hit. But the people that were, the individual and someone who was standing next to him were basically sliced into pieces, like being, you have a samurai sword go right through you. So it chopped them up pretty badly. And obviously this one came in from the top of the car. So it, you can see the slash marks diagonally, the cut marks. And strangely and funny enough, this is, this is actually somewhat, this car has some armoring in it. So it has some Kevlar on the top, on the roof panels, trying to protect it from attack and it still went right through it, so. That's gonna get a lot of people worried, you're all clean. Yeah. So, our Air Force, Rams may understand this, but most people don't realize that the largest number of pilots actually in the Air Force are drone pilots. So they have their, and they used to allow enlisted when there were predators. Some of the ones I took care of were enlisted, but they don't anymore. Now they're only officers. So the pilots are officers, enlisted personnel could be all the other things, flight engineers, sensor operators, maintenance techs, whatever, but they're the only officers. They have to start their training before age 29. They have to have a bachelor's degree, same thing for any other officer. They can be graduate from the Academy, ROTC, or the Air Force Officer Training School. They have to meet the standards for RPA pilots, which is a little bit different than, I mean, they don't have to have the vision requirements that the regular pilots do. They do have to have color vision, pretty specific color vision standards, but they have a series of schools they go to. The first three months is in Pueblo, Colorado. Then they go do four months in, at Randolph Air Force Base in San Antonio. And then they finish their formal unit training at Beale. So anybody been at Beale before or stationed at Beale? Okay, so. The drone operator work environment. This is what's difficult. This is a difficult work environment. They're in a conics box. And I'll show you a picture of one, but it's basically, it's a shipping container. They stay there for usually 12 hours at a time. They may have, you think about some of our Gen Z people who are like gamers playing hours and hours and hours on video games. That's kind of what these guys are doing. They're sitting there in front of a video screen for 12 hours straight. And then they go off shift and then they also do rotating shifts, which is like those of you who've taken care of firefighters and police and EMS that do the rotating shifts. You know what that does to your system. So they have sleep deprivation. And, but they're usually at a military base outside of the combat area. Now the base may be, for example, some of the guys I worked at, they were in UAE while their drones they were operating were over Iraq and Afghanistan or whatever. So, but it's outside of the conflict area and that causes its own problems. And they have problems in that they witness stuff. And it's not just like a fighter pilot that fires a missile and flies off. These guys have to stay and keep filming. They keep recording. So they are, they're watching all the aftermath. They're watching all of the little kids that are pulled, bodies are pulled out when they got collateral damage. They're watching the families come in screaming. They're watching all the crazy stuff that you would think and it's uncensored. So they don't have any way of censoring it. They are required to watch it because they have to control the drone. So they often witness the events as they unfold over several hours. They don't commute to the battlefield. So they go home every night or whenever they, they go see their kids, they go see their spouses. And so they may have just killed somebody and then they turn around and go right back. It's not even comparable to like a police officer because it's, they really aren't, they're not in the environment. They are, they're just like anybody else working at an NMTF, military treatment facility or whatever that they just are working in a maintenance hangar. Yes, Naomi, you. Well, I felt here, just control, what do you mean by control the drone? The drone's done at that point, isn't it? No, the drone, the drones stay there for surveillance purposes. Usually when the drone has, is flying, these drones will be flying at thousands of feet. They'll be watching for the target for several hours. They fire the missile and then they stay there for several more hours to witness all the aftermath. Sometimes it's to see the bodies pulled out so they can identify that they got the right target. So they wanna see the face of the individual that's pulled out of the car or pulled out of the building. So they're often watching this scenario and they finish their shift. Say they're an hour into the shift, they fire a missile, they do another 11 hours flying this drone. And they all often have people that will fly the drone all the way. In fact, some of them like the Reaper and others can, you send it, you do a pre-programmed track where it flies by itself all the way over to the mission area. So it may take off at Beale or wherever and then fly off to Afghanistan and then it's hovering over there and then they're actually watching the video when it's on site. They're usually not watching the video. I mean, they are, but they're not as engaged in it when it's just flying to its operational area. So another thing is most combat units, those of you who've worked with combat units, when I was enlisted, I worked with SEALs. There's a camaraderie there. I mean, I was not a SEAL. I can't do any of the garbage that those guys did. They're crazy. Wonderful people, love to work with them again. But they, I was an electronics guy. I fixed their toys and they took care of me like I was one of them. There is a camaraderie there, just really. It's like being in a squadron too. The squadrons take care of their docs. It's, they don't have that as the drone operators. They come into work, it's like doing a shift work in an office. They come in, they do their job, they go home. They are not part of the unit and because they're not part of the unit, they don't feel the same way. They do feel, however, what, they often see U.S. personnel being killed or allied personnel being killed. And so that's a problem for them as well. Because then they feel it like these are people, these are our people, but it's not like in a combat unit where it's my brother, my band of brothers kind of sentimentality. They often also don't get the awards or the recognition because when they take somebody out, it's like sometimes it's a secret who did it and who was firing it. And so they don't, they may get an achievement medal or something like that, but they don't get the same kind of stuff that the combat people do. They don't get the combat ribbons. They don't get the ribbons and stuff for being there. So it's difficult for them in that situation. This is what a typical workstation looks like. So they're watching the camera on the screen, but they've got other sensors that they're watching. They have a joystick to control it. So it is like a glorified video game. It's more like people who are the backseaters in the B-1 bombers or something, how they have the remote sensor operators, they're looking at the FLIR images and stuff. They're not actually like the pilots looking out the cockpit windows. So, and this is, that's another typical station. This is inside a Connex box. So there's two operators there. One of them could be the pilot and the other one's a sensor operator. And that's what they look like. So this ground control station, go in the box, sit down in front of a console, you stay there 12 hours, you leave. You may have to get up to go to the bathroom or something, but that's it. So who are drone operators? Who becomes a drone operator? They're typically people who are very bright. They're intellectuals. They tend to be obsessive. So they have OCD traits, even if they're not OCD. They're also typically very introverted people. Typically they're the Matthew Broderick war games kind of people. So they're the people that you see they're seen as nerdy. They don't fit in well, which causes its own problems because they don't fit in well with the other units, the other Air Force personnel or Navy personnel. They typically have, like if you've ever been around, like I have a couple of my sons and my son-in-law. My son-in-law is currently active duty, but they're all three gamers and they get really focused on specific things. They'll talk about little tiny details about stuff. It's like talking to a gastroenterologist about GI stuff. It's like, okay, fine, you just lost me. But they're often get very focused on certain things, the technical details of what they're doing. They are usually video gamers. In fact, the Navy and Air Force both have recruit people who are gamers to do these jobs. So they get what the military refers to as the PlayStation mentality. So they're playing with joysticks and they're having fun. And to them, just like in the video game, you pull the trigger, somebody dies. For many of them, it's not a big deal until they start seeing kids, until they start realizing. So it wears on them over time. So initially it's not considered to be a big deal. So what do they do? Identify, track, target, and killing enemy combatants. That's in their MOS job description. Destroying enemy assets. So they could be taking out other things, such as like military, they could take out tanks. They could take out any type of facility that's needed. They do surveillance. They do an awful lot of surveillance. They just watch. And they can direct special forces or special operations personnel, talk to them from literally over a satellite link, talk to them, direct them, tell them there've been drone operators who've told them, you have an enemy coming in on your position over here. They're coming from this direction. We can see them. They're about this far out so that they know what they're doing. So that's why they direct and protect U.S. and allied ground forces. They also, they provide overwatch for convoys. So anytime we're having convoys, and then this was what nailed me to your question, surveying post-strike battle damage. So they have to make an assessment of how successful the strikes were, whether it's strikes that they did or strikes that our personnel did when we fired Tomahawks, and they will often do the damage assessment. So they're going in, looking at what kind of damage the Tomahawks did. And Tomahawks cause a lot more damage than a Hellfire missile. So even though they're not deployed in the combat zone, they're fully involved in the realities of combat. They see people die. They see our own people die. They see enemies and often civilians and collateral damage. They have witnessed like some of the people that have been tortured and killed, people burned alive, things like that by some of the terrorist organizations. The drone operators witnessed it. They were watching it as it happened and they couldn't do anything about it. So they're watching that captured pilot from one of the, I don't remember what country he was from, but he was burned alive. Some drone operators actually witnessed that. So they often have to watch the stride and then hours later, their missions continue 24 hours a day, seven days a week. So once that, when those drones are flying and they may have one drone that takes off, flies out, does its mission and another one goes up to take its place, and it's just around the clock, it never ends. So they may have multiple drones that they're taking care of, at least the pilots and their shifts, even though they says 12 hours, like those of you who have taken care of law enforcement, law enforcement, often their shift ends, but they still got to book the individual that they just arrested and do all the paperwork. And so they may actually have 14 or 15 hour shift when it's supposed to be 12 hours. Yes, ma'am. I don't know how long it's been in the past, but how do we know yet how long can we believe last in years to get a new drone? Some of them last a long time. Some of them don't, but it's only, they've only had the drones really since, well, see, I was working with them in around 2000, 2002, but they had them before that, the Predators before that. So, okay. Dr. Clark, do you know how long they've been around? 2005? Yeah. I was in a pilot training base. Her name was Sharpen, she designated a drone pilot in 2001. And that's all I can tell you, but it's not, and that's before the program years off. So, it was nothing from each other. Yeah. The other pilots were to kill them because they said they're not real pilots. Yes. And yeah, that was one of the problems. I took care of it from like 2002 to 2005, that timeframe. And they were considered the video gamers by the other pilots. They're like, you're not real pilots. You're not doing real stuff, which added to their problems. I was saying with Spade, how quickly that technology came in and took over. I was at the Infantry Officer of the Basic Force in 90. We were still training on the Dragon missile where you had those wire-guided, you had them down and open and track the tank for 13 seconds for it to actually act. Murray, you probably remember doing it with the Dragon. Yeah, I was earlier. I'm not the Infantry Officer. But it took me 10 years to get right from that to this, you know? They still use Dragons, by the way. So, it's still... Well, they went to that AT-4, which at least is a fire-prohibited missile. Yeah. Yeah, but you were there next to me. Christ. And probably... We were the Dragon. Yeah, a good friend of mine was in the first Gulf War when I was enlisted, and he was an officer. He was a Bradley Company commander, and so he was firing tow missiles and the wire-guided, and he was like, when we fire them, we're sitting ducks until it hits because we got to let that wire play out until it actually hits the target. So, these are some of the newer drones. What about local operators? Now, local operators have it differently because not only are they drone operators, but they're in the combat environment. So, they're dealing with all the stuff that combat people do, plus they're seeing the same kind of stuff on the video screens. They're not trained anywhere near to the level that the bigger drone operators are, and because they're seeing these things, they're feeling it a lot more intensely because these are their buddies. These are the people that they train with and work with every day, and they're seeing them get shot and they're seeing the enemy, and there's all kinds of moral issues that go with them too because one of the things we're going to talk about in a second is, this is all the stuff that they witness, most of which I've talked about already, real-time torture of civilians and U.S. personnel, uncensored grief reactions of family members when the family member comes running up, sees that their spouse was killed, they start screaming, and in some cultures, it's a huge thing with all the weeping and wailing and gnashing of teeth. So, you see the first responders pulling body parts out. You actually watch sometimes mortuary and burial services for those people. So, 88% of the drone operators see live uncensored video of the death of targets. It's a very high percentage. So, what do they say they have? They have emotional disengagement. They have to disconnect. They just feel like they can't respond anymore or it just gets to be too much for them. They get physical and emotional exhaustion, physical from the rotating shifts, long-hour shifts, and emotional because of what they're dealing with, which, as you can probably surmise, causes family issues, problems with spouses and children. They get burnout, very real burnout, even as bad or worse than ER physicians do. It's just crazy levels of burnout and cynicism. So, all difficult things to deal with. So, what do we see? Survivor guilt, because when they see U.S. personnel killed and they're still here, if I'd been there with them, maybe. So, it's this typical survivor guilt. Sleep deprivation. Sleep deprivation. One thing that, Naomi, you were referring to, and Dr. Clark as well, there's no end in sight. They don't know if they're ever going to. They may cross-train to another specialty at some point, but if they're going to be a drone pilot their whole career, it's like just over and over and over again until they get a staff job. Murray, yeah. Yeah, the other thing is that, you know, typically, especially starting in Vietnam here, you are on a tour of X amount of months duration, and in a combat theater you're in that theater for, whereas if you're flying a Reaper or some other thing out of Nellis, let's say, that's a four-year tour. Until you get your next staff tour or whatever. Right. Yeah. Okay. So, many of them feel trapped or stuck. They want out, but they don't feel like they can get out. So, what do we do or what do we see? Very high percentage of PTSD. These studies show wide variations, partially because, okay, like when you work with hard charging, like you work with spec ops, you work with pilots, you work with divers, they don't report things, because they don't want to be seen as less than their peers. They don't talk about things, and so when you look for like surveys for looking for PTSD, they don't answer the questions honestly. And so, some surveys have shown 7% PTSD rates. Other studies where they tried to do them anonymously, it was more like 35%. So, very high levels of PTSD. That's double the rate that most of the military people have. So, the one study I looked at said at least 4.5%, but likely much higher. The military actually only diagnoses 1% of the RPA operators with PTSD. Most of them get diagnosed by the VA or by a civilian afterwards. So, and many of them, even though they did not meet the full DSM criteria, almost half of them had symptoms or things that came close to the diagnosis of PTSD. So, they had a lot of PTSD traits or symptoms, but they were severe enough to affect their job performance. So, most common symptoms, these are when they come to you and say, what kind of symptoms are you having? They can't fall asleep. They work these long shifts. They're tired. They go home. They can't sleep. They find themselves trying to avoid memories, avoid thoughts, trying to change the subject. Many of them, believe it or not, go home and play video games to try to get their mind off of it. So, even though they've been on the screen all kinds of hours, they do something to get their mind off of something else, or they do mindless behavior. They're irritable. Their family members claim that they have angry outbursts. It's almost like they're on steroids. They get those kind of emotional flashes. They're aggressive. They find more increasingly difficulty in concentrating, and they feel cut off from other people because, again, they're in a box all day long. And then when they go home, they try to get sleep and try to stay with their families, but then they're back in the box again. And when you remind them of stuff, one of the things that we'll talk about at the end is treatment, and one of the preferred treatments is actually desensitization therapy. And so when they go through and start reliving some of those experiences, when they first start it, they don't want to do it because these are painful experiences for them. So what else do you get? Adjustment disorders, depression, relationship problems, and many of them require counseling. And a lot of times they'll go off base to get the counseling because they don't want it in their record. So just like any other pilot, they don't want to get grounded. There's a new concept in psychiatry, psychology, that's been developed in the last 15 or 20 years called moral injury. When you do things that go against your personal moral standards, your mores, when you go against those on a repetitive basis, it injures your psyche. So it has a permanent or near-permanent effect on you. So the actual definition is that this results from experiences that involve perpetuating, failing to prevent, bearing witness to, or learning about acts that transgress deeply-held moral beliefs and expectations. So those that went to the WALLS unit yesterday when we were in the death row chamber in the execution chamber, we were talking to the warden. I was thinking about this with the warden, she's witnessed how many, what'd she say, 12 in the last, since she's been the warden, she's actually stood by the side of someone who's been executed 12 times now. So that's, you worry about the effects of that on a person long-term. This moral injury, the definition that they talk about is guilt, betrayal. They feel that their personality or their life has been changed by exposure to death. So they think that just by seeing people dying, they're different. They have disturbances in their relationships, which we talked about. They have spiritual difficulties. Many of them suddenly think, become agnostic or atheist, or they question the, is there a God, whatever, even though they may have been deeply religious growing up. So, and they feel alienated. So the risk factors for PTSD, what can we identify that makes them more likely to get PTSD? The number of times that they had the shared responsibility for the act of killing. So if they were one of the ones who was pulling the trigger or they were sitting next to the person pulling the trigger, the more times that happens, the higher the risk of PTSD. The number of times they witnessed, whether they're a sensor operator or they're an intel person in there, the number of times they witnessed events involving death. When they view innocent deaths as justified killing. So what happens when someone is dealing with this on a daily basis is they start looking at the enemy as, I mean, my grandfather served in World War II on an aircraft carrier, and he started calling about the Japanese, they were the Japs, and they were, there was nothing good about them. They had to dehumanize them in order to be able to fight them and kill them. And so that's what happens to these operators. They start looking at, they're becoming a faceless person or nameless person who just, they're Hezbollah or they're Hamas or whatever. It's okay to kill them. If they do more than 50 hours a week, that's a high risk factor. If they work longer than 12 hour shifts, obviously that's going to take a toll, rotating shifts. So all the things that they're doing are risk factors. Age younger than 25, that's strangely enough is, and a lot of these, when they were doing enlisted, some of these enlisted guys were like 18, 19. So they're coming straight out of high school, going through the training, and then they're pulling the trigger. And if they do more than 24 months, which many of them have four-year tours as an RPA operator. So that puts them at risk. But just doing long-term surveillance alone. So if they're just sitting in the screen, watching things happen, but they don't see any killing, they don't have any increased risk. Good question. Yeah, Karl. You mentioned, I don't have the microphone. So you mentioned that some of this, the direction of these activities is by the military, and other times it's through your people. What percentage of the time do these operators even know why they're going after some target? Is it just some spooky person that comes in and says, yeah, that one. And that's all the story they've got. I mean, I'm really curious if that, if this is the guy that planted the bomb and blew up your buddies, is it a different story than just some guy walking in and going, yeah, this one, that would be good to know. I'm just really curious about that. I think that would change if you're participating in an armed activity, versus just assassinating. I think early on it was more, yeah, that one, pull the trigger. And now I think they're more aware of who it is they're shooting at because they're tracking them over days and days trying to find them, and so they do have some knowledge of that. But I don't know. I don't know what the percentage is. Well, they probably issued some form of what we used to call, which is basically your situation, your mission, how to execute it. But they're not going to give you the strategic direction. And, you know, whether this comes from the president or the director of the theater or any of that, they're just going to give you their mission and what you need to know as an operator to execute it. But just like anybody else working intelligence, they often talk amongst themselves, even though they're not supposed to. Yeah. We invent things and we invent reasons amongst the troops, and it's usually a bunch of BS. That's the nature of being a human. But they may say that they're supposed to take out al-Zahiri or whatever, so they know that they're going after this individual, but they may not know what he's done or what he's doing. Other things that increase risk. So strangely enough, well, I don't know if it's strange enough or not, female gender, female assigned at birth gender, tend to have higher risk of this. There have been some studies that think it may be because of a cultural thing. It's that in our culture or in cultures where the female accepts predominantly the mothering as they're growing up. That may be why, but that's just a bunch of psychiatrists guessing as to why. But they do say that females have a slightly increased risk. People who have a very conscientious personality, people who are tenderhearted or as they're growing up who have trouble when they see a dog get hit on the highway, things like that, they have a lot more trouble doing this. And then for those that are in Gen Z, low resilience. People with it don't have a lot of resilience, which a lot of – yeah, John? Well, I have to be honest. It's the Cambodian border at night, $300 a night, now and sometime, it was like 10 mile by spot of the border for 15 miles a month. We caught you there, we killed you. It is, there is, you know, we didn't call it. You know, we just filled out a reformed damage employment. And I can just tell you that the only people that really survived a halfway attack were, you just had to say, hey, they're a bad person, and we killed them. You know, until you got to that point. And later on, I was talking to a nurse and she was telling me about her son who came back from Afghanistan. And he said, he has a lot of problems. I said, why does he have a lot of problems? Well, he says, he shot one guy. Well, you know, if you shoot one guy and you got a face in your mind, that's funny. I said, by the time he killed 20 guys, it's a joke. You know, and that's the way it is. You get harder to it. And, you know, I remember, you know, talking to a bunch of pilots at the bar, which I'm turning. And I just said, you know, we'll warn the guys we lost when we get home. Right now, we're going to get admissions out tomorrow. And that's just the way you deal with it. And, yeah, I had PTSD. I mean, anger, health curse, sleeping problems, nightmares. You know, it's just, it's more. Well, you know, it's just bullshit. Yeah. It gets worse as we go. Yeah. I further removed from it, too. At least for some of them. And so I'm just saying my son was a gas stance and intermittent as best friend blown up on screen. Part of his best friend on the space. And so it's a real deal. There's a flight surgeon or, you know, a tank, sir. And change or the infantry units. I mean, you have to get somebody that relates to these people that are. I mean, I'm just saying until they get to the point where they can work their way through it. And we're going to purchase. I used to take care of all the prisoners. We're best. And I'm taking care of veterans who are in Somalians. But they just completely, you know, screwed up. You know, the point where they were drug addicts. You have to work your way through it and talk about the survival of guilt. But what their friends, if they were alive to talk to them, what they would tell them. You know, let's not be too careful. You lost your friend. Let's not lose you. Me, too. Thanks, John. So, how do we identify problems? First, you have to it's hard to identify if they're not going to talk about it. So, you got to get them to talk about it. One of the things you can do is things you typically do when you're suspecting things is screen for substance use disorders. Oftentimes, the substance they're trying to self medicate, they're trying to cover the problem up. So, if you find a substance abuse disorder, which is often hard to find, but if you find it, start looking for something else. If you suspect it, try to get them a full psychological evaluation. Now, they're going to fight against you. They're not going to want that unless they're really hurting badly. And then get them into counseling. Now, psychotherapy seems to be more effective than medications, although both of them are usually required. Cognitive behavioral therapy and a specific type of which I'm not familiar with, but our psychologists might be, called cognitive processing therapy or CPT. It's a special form of CBD or CBT. It seems to work better than just normal CBT. Exposure therapy, that's the one they don't like. That's where you have to take them back and take them through it and desensitize them again. And then there's a new one that is a new thing called eye movement desensitization and reprocessing. That actually has some very promising results, but it's not widely used yet. Medications, there are only two medications currently FDA approved for PTSD, and that's sertraline and paroxetine. Any of the SSRIs can help. And if they're really having problems, they need to change careers or at least get reassigned to something less hazardous to their mental state.

military drone operators

psychological challenges

emotional exhaustion

moral injury

PTSD

work-life balance

mental health care

cognitive behavioral therapy