According to Wolters Kluwer Clinical Drug Information, Inc., free testosterone should be measured in patients with conditions associated with increased or decreased SHBG, or in patients with total testosterone concentrations in the borderline zone around the lower limit of the normal range (e.g. 200 to 400 ng/dL). For the treatment of hypogonadism, a total testosterone goal in the mid-normal therapeutic range (e.g. 450 to 600 ng/dL for most laboratories) is reasonable for most patients to prevent over- or under- treatment. For injectable formulations (IM, SubQ), a range of 350 to 600 ng/dL may be reasonable. Dose titration is not necessary if complete symptom resolution occurs with testosterone levels below the suggested target range (Hirsch, 2019). Quiet Professional #8 states, “I’ve had them check it once. They said it was on the low side but not enough for them to give me supplemental T. I think It was over 300 but not by much.” It is concerning that physicians generally wait for one’s testosterone levels to drop well below “the lower limit of the normal range (e.g. 200 to 400 ng/dL)” before beginning testosterone replacement therapy (TRT) while “a total testosterone goal in the mid-normal therapeutic range (e.g. 450 to 600 ng/dL for most laboratories) is reasonable.”
High stress is also associated with low testosterone. Both acute and chronic stress have physiologic effects on the body. Deployed soldiers (particularly those outside the wire such as Special Operations) have acute and chronic stress. These men function at very high physical and mentally demanding levels for hours on end. In a discussion with one Special Forces Operator, he remarked: “Being and growing on an A team is a huge responsibility and requires enormous personal sacrifice both to the mission and home life, i.e. family. Particularly in a time of war with an unrelenting operational tempo, better known as op tempo. With this thesis in mind, I suppose Low-T, stress of declining performance and depression would absolutely affect an Operator’s mental wellness” (Quiet Professional #1).
“Warriors, bravery, and change, and the one. I have been fortunate to know many warriors, have observed much bravery, and witnessed many positive changes. I have also met a very few of “the one” (Donner, 2017). The Greek philosopher Heraclitus had written, “Out of every one hundred men, ten shouldn’t even be there, eighty are just targets, nine are the real fighters, and we are lucky to have them, for they make the battle. Ah, but the one, one is a warrior, and he will bring the others back” (Donner, 2017).
Parallels can be drawn from the ancient quote with this verse from the Ballad of the Green Berets written by Special Forces Medic SSG Barry Sadler during the Vietnam War. “Silver Wings upon their chest -These are men America’s best – 100 men will test today – But only 3 win the Green Beret” (Moore & Sadler, 1966). The verse references the Army’s rigorous selection process for Special Forces Green Berets. My grandfather was a WWII veteran and we would always watch war movies together when I visited.
One of the most memorable we had watched was, The Green Berets starring John Wayne (Kellogg & Wayne, 1968) and it opened with Barry Sadler’s Ballad of the Green Berets. The first scene takes place at the United States Army, John F. Kennedy Center for Special Warfare, Fort Bragg, North Carolina. There a Special Forces A-Team conducts an orientation of its capabilities as Green Berets to a group of civilians and reporters. These men appear larger than life, displaying professionalism as each informs the crowd of their individual skill sets and abilities. In a true Quiet Professional manner, lead character Master Sergeant Muldoon informed the crowd that he and Sergeant First Class McGee had been “ordered to volunteer to answer questions” they may have. The two answered all questions with wit, character and expertise. I was inspired by the scene and it influenced me to select the Infantry when enlisting.
Depression and suicide in the military as well as with our veterans are complex issues for mental health and medical professionals to combat. Alfred Adler (1870-1937), world-renowned philosopher and psychiatrist, stressed the need to understand individuals within their social context. Adler developed the first holistic theory of personality, psychopathology, and psychotherapy that was intimately connected to a humanistic philosophy of living. According to Adler, when we feel encouraged, we feel capable and appreciated and will generally act in a connected and cooperative way. When we are discouraged, we may act in unhealthy ways by competing, withdrawing, or giving up (Alfred Adler: Theory and Application, 2019). Suicide is considered to be the ultimate “giving up.” Adler began his career as a physician and received an invitation from Freud in 1902 to join a discussion group that would later start the psychoanalytic movement. Adler put off his psychology lectures and studies to serve as a military physician during World War I and he later disengaged from Freud’s circle.
The two reportedly disliked each other because Adler held fast to his own ideas, which differed significantly from those of Freud. Alder believed people are motivated by striving for success, that it’s largely responsible for whom they are, that a view of the future shapes present behavior, and that psychologically healthy people are consciously aware of what they are doing (Feist, Feist, & Roberts, 2013). I feel that Adler’s combat experiences serving as a physician for the Austrian Army on the Russian Front during WWI helped contribute to his later theories. These theories can easily be applied to the unique lifestyles of Quiet Professionals. Adlerian individual psychotherapy encourages clients to overcome their feelings of insecurity, develop deeper feelings of connectedness, and to redirect their striving for significance into more socially beneficial directions.
Through a respectful Socratic dialogue, they are challenged to correct mistaken assumptions, attitudes, behaviors, and feelings about themselves and the world. Constant encouragement stimulates clients to attempt what was believed impossible. The growth of confidence, pride, and gratification leads to a greater desire and ability to cooperate. The objective of therapy is to replace exaggerated self-protection, self-enhancement, and self-indulgence with courageous social contribution (Alfred Adler: Theory and Application, 2019). I believe Adlerian individual psychotherapy combined with testosterone replacement therapy (TRT) for depression in conjunction with Low-T would be an effective treatment plan for our Quiet Professionals.
The Quiet Professionals have left their homes to live in a very different world known only to those of like mind and ability. They find the world as they knew it to be very different when redeploying stateside and ultimately returning to civilian life after discharge. Our society has evolved when it comes to personal wellness. There are wellness programs available now in the workplace to encourage better lifestyles such as weight loss and smoking cessation programs. With all the resources available to civilians to improve their mental health we have neglected the needs of these Special Force’s Operators; largely in part because society does not understand what these needs are. A wellness program, which includes low-testosterone screening and treatment, should be made readily available to them when they leave military service. They should be made to feel just as comfortable seeking assistance for depression and low testosterone as a civilian would feel seeking help for a weight loss program.
Part of the ARSOF vision is that:
We must recruit, train, and retain the very best talent available. ARSOF succeeds because of the excellence and determination of our Soldiers. We exemplify disciplined, independent, intelligent, adaptable, and combat fit Men and Women. We value, more than anything, being trusted and empowered teammates. ARSOF must produce Special Operations Forces with the skills, cultural expertise, and education to excel in all operational environments. We value the strength of our specialized and professional civilian work force and remain committed to the world-class care of Soldiers and families. ” (Army SOF Vision, 2018)
The exploration at hand is important because twenty-two Quiet Professionals took their own lives in 2018 (Birkenbuel, 2019) and the relationship between Low-T and grave depression suggests that the connection between these two variables among Quiet Professionals’ is worthy of exploration more thoroughly in military settings. “People tell us, we are in charge of our careers, and the same should be said about our health care. (But) there is so much that we, as Green Beret’s don’t know. ” (Quiet Professional #8)
This first appeared in The Havok Journal on August 10, 2020.
Alfred Adler: Theory and Application. (2019). Retrieved from Adler Graduate School: https://alfredadler.edu/about/alfred-adler-theory-application
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