Bringing the War Home

Post traumatic stress disorder: How to treat the mental wounds of Iraq's war veterans.

War is hell, but Iraq is a perfect festering pot for psychological damage

BY CECILIA CAPUZZI SIMON, Psychotherapy Networker, January 01, 2007 >>

Sometimes it's a loud bang, like a car's backfire. Sometimes it's the sound of children screaming or crying. Sometimes it's the benign drone of a classroom lecture, or a stranger's ill-informed comments about the war in Iraq, or the drive over a bridge in the dark of night. All are triggers that send Jesus Bocanegra's mind straight back to the hot, dusty streets of Tikrit, where he and his unit of cavalry scouts tore down Iraqi flags and monuments and raided homes searching for weapon caches, civilian soldiers, and Saddam Hussein himself.

It was a tour of duty that Bocanegra, now 24, unemployed and suffering a 100-percent disability from post-traumatic stress disorder, signed on for willingly, but wishes he hadn't. When he joined the Army in 2000, it was a way out of his small Mexican border town of McAllen, Texas, he says, and a future of flipping burgers. After a year in Ft. Hood and another in Korea, he liked military life well enough to reenlist. But his plan "backfired," he notes. Within a month, he was shipped out to Iraq.

As a scout, Bocanegra says, you're trained to be the eyes and ears of the mission commander--"You look for the enemy, spot them, and report back." But in Iraq, his job was different. "My initial thought was that we'd be fighting people in uniform." What he found instead was a lack of mission, little planning, and an elusive, often invisible, enemy. All of which left him questioning the war's meaning, sowed the seeds of self-doubt, and wore him down emotionally.

"It was patrol, patrol, patrol," he observes. "Break down murals. Look for WMDs. Pull people over and search their cars. When we went on raids, we'd knock doors down, pull the family out of their homes, scare the living shit out of them, and then find out we had the wrong house."

What Bocanegra witnessed in Iraq, he says, was "the worst that a human can see." Murdered women and children, dismembered and incinerated bodies. Utter fear. Debilitating guilt.

"I don't want to go into detail," Bocanegra says of an incident that to this day makes him avoid children. But when he discovered crates of enemy ammunition being moved into a house along the Tigris River, he called for an Apache helicopter strike. He discovered there were children inside only after the gunfire stopped and he heard their screams. "That," he says, "is my nightmare. My flashback. It was nothing we did intentionally."

One night, driving patrol in the city, an improvised explosive device (IED) detonated on the side of the road, rocking, but not damaging, his truck. For Bocanegra, it was "the last straw," he says. "You feel the concussion. Your heart skips. You don't know what to do. I grabbed my arms, legs, checked my body. I kept on driving." But emotionally, he shut down.

"There was no time for emotion," he says. "I told myself, 'I'll deal with it when I get home. I just want to make it out alive.'"

A Very Special Horror

All wars are hell. Iraq, however, is a unique brand of horror--a confluence of environmental, political, and cultural factors that make it "the perfect festering pot for psychological damage," says former Iraq sniper and Veterans for America outreach coordinator Garett Reppenhagen, who finished a yearlong tour in Iraq in May 2005.

Some 17 percent of Iraq soldiers suffer from major depression, generalized anxiety, or post-traumatic stress disorder (PTSD), according to a 2004 Department of Defense (DOD) study published in the New England Journal of Medicine and conducted three to four months after the troops' return from combat. But it's PTSD that's emerging as this war's signature disability. In this study, its prevalence ranged from 10 percent to 20 percent, depending on the number of firefights a soldier was involved in. And while its toll isn't as visible as that of a missing leg or arm, or multiple amputations--the injuries we've come to most associate with the guerilla warfare of Iraq--it's the most pervasive and, perhaps, pernicious. It's "the number one issue facing soldiers of Iraq and Afghanistan," says Paul Rieckhoff, the founder of advocacy group Iraq and Afghanistan Veterans of America.

There are signs that the incidence of mental health problems among the troops may be even larger than the 2004 study suggests. Conducted early in the war and soon after those surveyed concluded six- to eight-month deployments, that study doesn't take into account that PTSD, characterized by flashbacks, nightmares, intrusive thoughts, anxiety, and social withdrawal, often manifests months or years after the trauma. Furthermore, much has changed in the two years since the research. Now many of the troops are on second and third tours of duty, and the war itself has dragged on much longer than expected, while its objectives are becoming increasingly muddy and support for the war is rapidly waning.

A newer DOD study offers more detailed information on the scope of the mental health difficulties encountered by veterans, and is now being cited more frequently than the earlier one. Published in March 2006 in the Journal of the American Medical Association, Â it reports that 35 percent of Iraq war veterans sought treatment for mental health issues within a year of coming home--a startling percentage, given the military's well-known resistance to therapy, and these were only the soldiers who admitted needing help. Some 12 percent of those who sought help received a psychiatric diagnosis. Veterans who served in Iraq, where there's more combat, were twice as likely to seek help as those returning from Afghanistan, and 19 percent of the Iraq veterans met criteria for a "mental health concern." The DOD now estimates that between 15 percent and 29 percent of veterans from the wars in Iraq and Afghanistan will suffer from PTSD.

Those numbers echo what the Veterans Administration is reporting in its caseload, which is six times higher than anticipated and has caught it off guard. With 1.3 million troops deployed so far, more than 400,000 could need mental health treatment by 2008, if the trend continues. There has been no large-scale study on the war's emotional toll on Iraqis, but pieces of data are beginning to paint a grim picture. For example, children are suffering depression and behavioral problems at a rate three times greater than that before the war, according to a BBC report.

A "tsunami" of mental health problems resulting from the war in Iraq is "headed our way," concludes Charles Figley, director of the Traumatology Institute at Florida State University, and a Vietnam veteran. Neither the government, nor the mental health community, nor society, he adds, is prepared to handle it. He testified as much before Congress. "No one disagreed," he says of his testimony before the country's lawmakers. "But they shrugged their shoulders." The subject of Iraq and troop mental health is so politically polarizing, he says, that no one wants to speak out for fear of "giving the impression that the war is bad."

Unfortunately, avoiding the subject won't change the rightness or wrongness of the war, nor will it make PTSD go away. As Steve Robinson, director of government relations for Veterans for America says, post-traumatic stress disorder is "the elephant in the room. It's leaning on everybody. You can pretend it isn't there, but it's coming home."

Dirt, Fear, and Misery: Daily Life Outside the "Green Zone"

Many questions dog our engagement in Iraq--the biggest and deepest surrounding the purpose of the conflict and what America stands to gain, or lose, from it. But there are also the microcosmic questions, those that relate to individual human sacrifice and suffering--the inevitable cost of any war--and are the more painful to consider. More than 2,800 American troops have died in the wars in Iraq and Afghanistan as of the end of 2006. In addition, a huge number of Iraqis have lost their lives. A controversial study published in Lancet by researchers at Johns Hopkins University, who compared mortality rates in 47 different areas of the country, puts that figure at 655,000. Another group, The Iraq Body Count, which compiles civilian deaths based on credible media reports, says up to 53,000 have died as a result of the war.

But body counts don't quantify the war's emotional toll. The media have reported in detail the guerrilla tactics that characterize combat in Iraq: roadside IEDs, suicide bombers, sniper fire, an undistinguishable insurgency. There's no front line, no safe zone. Nearly 90 percent of troops are involved in some kind of firefight. Many have seen buddies blown to pieces, and more than half of the soldiers there have handled human remains. All of this increases the risk for PTSD. As one veteran put it: "Dealing with exploded vehicles and body parts and roadways blanketed with shrapnel all day, every day, is incomprehensible." Less well known is the harsh relentlessness of daily life in this kind of war zone, which slowly chips away at one's sense of safety, emotional resiliency, and character. Soldiers live in combat 24/7. Some call it a "360-degree war."

"You're in a war where you are isolated at base. There's no rear," says Reppenhagen, who was stationed in Baquba, about 35 miles northeast of Baghdad, and was part of a sniper team whose main mission was to kill Abu Masab Al-Zarqawi, known to be hiding out in the nearby town of Hibhib. (He was killed there about a year after Reppenhagen's tour ended). "You can't put your rifle down to go off base and get a drink at the local bar like you could in Saigon. You're trapped, isolated. You can't leave your hooch without your helmet on, because there are falling mortars and RPGs [rocket propelled grenades] coming over the wire all the time. There's no rest or relaxation for these soldiers--they're sleeping, eating, living in war. When they roll out of the wire, the common form of weapons the insurgents use is indirect--roadside bombs, car bombs, suicide bombs, RPGs, mortar attack. They have an ability to damage you without an enemy to retaliate against, and they come out of nowhere. No matter how skilled you are, no matter how alert you are as a soldier, it's indiscriminate. It doesn't matter how good you are at low-crawling or moving, shooting or communicating: if your number's up, your number's up."

Add to such combat strain a series of lesser but continuous assaults to one's personal dignity--what Colonel Kathy Platoni calls "the hardship of living in a place like Iraq." A clinical psychologist in civilian life in Beavercreek, Ohio, Platoni has been in the Army for 27 years, 23 as a Reservist. She spent the last year in Iraq as part of a combat stress team--military mental health professionals who work in the battlefields. During her time in Iraq, she made eight stops in various combat theaters--"godawful places," she calls them in an interview. The last was at a base in Ramadi, an insurgent stronghold she described in an article in the Columbus Federal Voice as "what the devil envisioned when he created hell." With an average temperature of 126 degrees ("130 in the steaming latrines") the summer she helicoptered in, even her glasses were affected by the "blistering heat and blowing grit," she wrote. Lack of privacy, bad food, difficulty sleeping because of the heat and noise, limited ability to shower ("You just make up your mind that no one smells better than you do, and live with it"), and often limited access to latrines ("You use a bag and carry it to the poo-burning pile") are all typical of a soldier's daily life in Iraq, says Platoni--all of it lived with "the constant threat of your own demise, as well as those that you slept with or ate with the day before."

In addition, says Figley, soldiers suffer persistent physical discomfort. They're often dehydrated, but drenched in sweat. Because of the nature of the fighting, they're usually carrying their own weight in protective clothing and gear. And then there's the sand: fine as talcum powder, it floats in the air, soldiers breathe it all day long, and it settles onto everything--clothing, skin, hair, food, equipment. "You feel like a wreck," says Figley.

The day-to-day monotony of base life can also be wearing. With no clear rules of engagement, soldiers spend time waiting on orders and thinking about home. If Vietnam was the first "television war," Iraq is the first "internet war." In many areas of Iraq, the availability of computers makes e-mailing and blogging commonplace; cell-phone service gives many soldiers a regular connection to friends and family--and dramas they can do little about from the Middle East. It seems counterintuitive, but trouble on the home front is one of the leading stressors at base camp, says Platoni. Financial worries, marital problems, kid troubles: "If you're worried about family issues all of the time," she says, "it's hard to concentrate. Too much of that information can be bone crushing." For soldiers on second and third tours of duty--half of whom are Reservists or National Guard who leave jobs or businesses for wartime service--repeated and unpredictable separations from home are often devastating to family and career.

The availability of news sites and a 24-hour news cycle can add to a sense of agitation and helplessness, keeping soldiers who are in the thick of war briefed on its developments. Living with a foot in both the wartime and civilian worlds, says Figley, "is a surreal experience for these men and women."

Coming Home

Just as surreal for many is coming home. Specialist Abbie Pickett was 20 years old when she was deployed to Baquba. In the field, she'd been prescribed Ambien and antidepressants after a mortar attack hit her chow hall one night and she attended to the bleeding and injured in the chaos and the dark, an experience that left her panicked, depressed, and "spazzing out." "It's stuff you can't talk about in the civilian world," says Pickett, who wasn't diagnosed with PTSD until three months after her return stateside. "I came back and my friends wanted to talk about American Idol. I had no idea what that was."

She remembers seeing Fahrenheit 911 and crying throughout the movie. "It was way too much, too soon," she says. But the reaction she got from the friend who accompanied her was the coarsely flippant question: "Why would you ever go over there with that attitude?"

As Rieckhoff puts it, "You're in Baghdad one day, Brooklyn the next." Though not suffering from PTSD, he says even he had problems reentering a society he called detached from the war and "almost entirely deaf to the issues" because only one percent of the population is directly touched by service, and life for most Americans has gone on normally. "It's like a reality TV show that people think they can turn off," he says. "I was out with my girlfriend last night, everyone was hanging out and enjoying themselves, and I thought, 'Okay, but don't you realize people are being blown up in Ramadi right now?' You feel like you don't fit in."

That outsider status may be showing up in the employment numbers for the youngest veterans--15 percent can't find work, about three times the national average, according to the Bureau of Labor Statistics. Some veterans expressed concern that employers are biased against them; 11 percent wouldn't identify themselves as such.

In a veteran's blog, former army specialist scout Matt Frank starkly sums up what it feels like to come home from Iraq having been psychologically changed by warfare: "For the soldier, war is his drug," he writes. "Life [back home] becomes dull and frustrating. Normal situations make one feel a sense of anxiety, of desperation, as if constantly hoping for a sudden, horrible rage to sweep across and take normal right down to hell, where things are violent and gruesome and stimulating and the adrenaline flows. Where veins bulge and the mind sweats and purpose is abundantly clear. . . . I am alienated from these people who buy me drinks and praise me for service to their country. Who thank me for all those dirty Arab bastards I ghosted in the name of freedom, democracy, basic cable, and free trips to the salad bar."

Legacy of Vietnam: What's Wrong with the PTSD Diagnosis?

More than 25 years ago, Vietnam veterans forced the military and mental health communities to pay attention to the psychological costs of war and give a name to the mental injuries afflicting as many as 31 percent of those returning soldiers. Post-traumatic stress disorder was added to the DSM-III in 1980 after heavy lobbying by veterans' advocates and prominent mental health professionals who made no secret of their antiwar stance. The PTSD diagnosis medicalized the Vietnam veterans' symptoms, providing an opportunity for treatment and a kind of redemption by forcing a cultural and scientific recognition of the mental, physical, and social impact of traumatic stress, especially in warfare.

But today, some of the loudest voices who led the PTSD charge are rethinking the parameters and implications of the diagnosis drafted a quarter-century ago. "We took a lot of angry, dysfunctional vets and got them labeled PTSD," says Bobby Muller, who heads Veterans for America, founded Vietnam Veterans of America, and is the winner of the 1997 Nobel Peace Prize for another of his organizations, the International Campaign to Ban Landmines. "Now, 26 years later, this stuff has become institutionalized, and a medical industry has grown around PTSD. But there was something wrong about what we did back then, and something wrong with what we're doing today."

What's wrong, says Muller, is that nowhere in the diagnosis, which describes the results of traumatic stress stemming from a variety of incidents--rape, car accident, witnessing street-gang violence--are the specific ramifications of wartime trauma acknowledged. Muller, now silver-haired and 60, should know. Paralyzed from the waist down after being shot in battle at the age of 23, he animatedly talks about his near-death Vietnam experiences--in the battlefield and at home--from a wheelchair in his bright office in downtown Washington, alternating between hearty laughter and ongoing anger.

For Muller and others, the most important missing piece in our understanding and treatment of combat PTSD has to do with the meaning attached to the sacrifices we ask soldiers to make. That Vietnam was "the wrong war," as Muller puts it--a futile, failed effort that the American public would just as soon forget, along with those who fought it--contributed mightily to the mental problems those vets developed, and continue to have, he says. Finding social vindication and an overriding sense of purpose for wartime trauma is critical to recovery. It likely accounts for the lower number of traumatized vets of other wars, especially World War II, which had a clear and indisputable purpose for both soldiers and civilians. When a sense of purpose that gives meaning to wartime sacrifice is missing, the soldiers who actually made the sacrifice can experience an overriding and destructive feeling of betrayal.

War changes a person, says Muller. "You go down a path of darkness. You warp." Back from war, he adds, a person will experience predictable emotions: "Guilt, in part because you've come back--survivor guilt; shame, because, trust me, shameful things happen all over the place in war; and trauma, because when you're dealing with killing and the degradation of human beings that happens when fighting a war, there's a lot of trauma. When you come back, you need society's absolution to help you heal, knowing that what you did had to be done."

Among Vietnam vets, he says, "most came to terms with the horror piece." But once home and "out of that bubble of war," they grew in political awareness, determining that the war was a scam and that the government had lied to them. "You shake your head and start asking questions," he notes. "And you get angry because you realize you've been fucked politically." He calls this the "What the Fuck" syndrome, and he and others predict that soldiers from this war will experience the same reaction, if they haven't already, particularly since more than 60 percent of the American public now oppose the war in Iraq, 55 percent think we made a mistake sending troops there to begin with, and nearly 60 percent believe we were purposely misled in the reasons given for going to war.

"These people are clinging desperately to a sense of purpose to this mission," Muller says, motioning to the staff beyond his office working on Iraq veterans' issues, "just like I saw guys in the hospital with me clinging desperately to the belief that they were heroes. It took them time, but as the inevitability of the outcome of Vietnam registered, and the public verdict that it was not only unnecessary but in fact wrong registered, they really paid a price." He pauses, and speaks slowly: "So. Will. They," he says of Iraq vets. "It hasn't even begun."

The Endless Politics of PTSD

Despite our deep and growing understanding of post-traumatic stress disorder, it remains a controversial diagnosis, which can't overcome its politicized genesis. As cost and criticism for this war escalate, there's a growing movement to knock the diagnosis.

Psychiatrists treating this new generation of veterans are "urged to learn the lessons of Vietnam," according to Simon Wessely, a prominent British combat-trauma researcher, who speaks frequently on the disorder while questioning its prevalence. "But no one is sure what those lessons are," he's quoted as saying. "Do the explanations for allegedly high rates [among Vietnam vets] lie in the jungles of Vietnam, in America's struggle to come to terms with the war, or with symptoms manufactured to fit a cultural narrative and expectation of what kinds of mental stress these veterans would experience?"

In September, Science published a report by Columbia University researchers, who reexamined the widely accepted results of a 1988 government study and downsized the number of Vietnam veterans suffering from PTSD from 31 percent to 19 percent, with about 9 percent still showing PTSD symptoms today. Researchers said they cross-referenced military records unavailable at the time of the original study and corroborated veterans' exposure to combat stress, with the result that some were found to have psychological problems that predated service and others had symptoms that didn't impair daily functioning, which wasn't a criterion for diagnosis then, but is now.

The authors explain that the point of the new study is to offer a clearer picture of what to expect from soldiers returning from Iraq. But in some ways, it does just the opposite, casting doubt on the whole diagnosis of PTSD. One can't help wonder if that wasn't, perhaps, the intention.

It's easy to understand why the federal government and others are concerned about the attention focused on PTSD: for Vietnam veterans alone, PTSD disability payments rose 150 percent between 1999 and 2005--that's about 100,000 new cases among veterans of a 30-year-old war. Some are being diagnosed three decades after service; some are being treated again because the events in Iraq have caused flashbacks of their own experiences, in effect retraumatizing them. Compensation for full disability is about $2,300 a month, and between 1999 and 2004, PTSD benefit payments rose from $1.7 billion to $4.3 billion. As of August 2006, 63,767 discharged soldiers from Iraq and Afghanistan were diagnosed by the Department of Veterans Affairs (VA) with a mental disorder, 34,380 of them with PTSD. Richard Lynch, a retired brigadier general who founded the annual National Tri-Service Combat Stress conference 14 years ago with colleague Bart Billings, a psychologist and now retired colonel, predicts the mental wounds from PTSD and traumatic brain injury will cost the country "a couple hundred billion dollars a year in care" for many years.

Given these potentially huge costs, it's perhaps inevitable that the apparently escalating presence of PTSD is getting close scrutiny. Even with "total buy-in" among top military leadership this time around that PTSD issues are indeed a "clear consequence of war," as Col. Charles Engel, director of the DOD's Deployment Health Clinical Center at Walter Reed Army Medical Center, maintains, many in and out of the military still wonder if the diagnosis is overblown. They worry that every mental health issue coming out of Iraq is being viewed through the PTSD lens.

"It's a diagnosis that invites people to speculate on what has traumatized them," said Sally Satel, a psychiatrist and resident scholar at the conservative think tank American Enterprise Institute, speaking last February at an Institute of Medicine hearing sponsored by the Department of Veterans of Affairs (VA) to review the PTSD diagnosis. Satel, who once worked with the VA, has become the voice of skepticism for the disorder, and many share her views. Two years earlier, testifying before Congress, she speculated that PTSD could provide a "medicalized explanation" for "unhappy but not necessarily traumatized veterans who'd been trying to make sense of their experience."

Veterans, by contrast, contend that it's common to have their mental problems diagnosed as preexisting conditions, such as bipolar disorder and personality disorder, that aren't covered by VA benefits.

The Danger of Overdiagnosis

It's easy to dismiss such comments as political shots, but beneath what may be partisan positioning are some difficult truths: combat PTSD is hard to define; those who have it or are susceptible to it are hard to identify; and not everyone agrees on who should be treated, when they should be treated, or which interventions are most effective for veterans. Another question is whether we should make a distinction between the normal reactions to a highly abnormal and gruesome situation--the emotional and psychological problems we'd expect anyone to have after seeing his buddy ripped apart by an IED--and the pathological symptoms described in the PTSD diagnosis. Figley thinks we should. Most returning soldiers, he says have severe transitional problems, suffering not from PTSD but what he calls "Post Combat Freakout."

For soldiers on constant high alert in Iraq, for example, it isn't easy to turn off the habits of wartime survival, but this may not amount to pathology. Hypervigilance has its place in a world where you're being mortared all day long, but it can interfere with life back home. Likewise, driving fast and aggressively, all the while scanning the landscape for roadside bombs, can keep you from getting blown up in Baghdad, but it'll probably get you ticketed or arrested in your hometown. Even interpersonal relationships must be relearned. During war, soldiers are trained to parse information, but if you can't communicate with your spouse or boss, you become withdrawn and alienated--and probably divorced and unemployed.

"We have to take a careful look at those we're diagnosing with a major medical disorder based on the symptoms they display and wonder if the symptoms wouldn't be there if not for the war," says Figley. "Maybe we need to call it a different name. We may be overpathologizing the combat stress reaction, too quickly perceiving it as PTSD instead of a natural, normal adjustment to recovery." Rushing to pathologize these behaviors as PTSD, he says, keeps veterans from getting the help they need to readjust after service--which can cause the behaviors to fester and, paradoxically, turn into full-blown PTSD.

Others suggest that, as it stands, the PTSD diagnosis is too limited to encompass the many manifestations of postwar reactions. Perhaps, says Garett Reppenhagen, a military expert and Iraq War veteran, the PTSD diagnosis needs to "evolve" to include symptoms, emotions, and behaviors not now associated with it. "Some are addicted to war and want to go back [to Iraq], but feel guilty about it," he says. "Some have severe PTSD from actual incidents. Some have general stress and tension just from the pressures of war. A lot feel alienated from society--not only do they hate the administration, but they hate America for sending them there and allowing them to do the things they've had to do. The emotional experience of war is so intense that it creates a rainbow of mental illnesses. It's hard to classify them in a DSM. And it's hard to treat them."

Trauma Treatment Vacuum

It's impossible to gauge what kind of psychotherapeutic services or interventions a soldier with PTSD will receive in military medical centers, because there are no standard treatment protocols. The DOD and VA have jointly published clinical guidelines for treating PTSD, which recommend four evidence-based therapies: cognitive therapy, exposure therapy, Eye Movement Desensitization Reprocessing (EMDR), and Stress Inoculation Therapy. A fifth therapy, Cognitive Processing Therapy, is expected to be rolled out in a training program for clinicians in 2007.

But therapy providers working the armed forces aren't required to use these therapies, and their use isn't tracked. Therapist training also varies widely. A survey of mental health providers from the VA and DOD conducted by Steven Silver, director of the PTSD program at the VA Medical Center in Coatesville, Pennsylvania, found that 90 percent of the 137 surveyed had no training in any of the four recommended therapies. Of those who were trained, most had gotten it before working in the military, and few had had experience using the therapy to treat PTSD. Many respondents said they didn't treat PTSD at all because they didn't know how. A study in the Federal Practitioner echoes these findings, citing "a paucity of research regarding treatment outcomes and a lack of evidence-based psychotherapies in use within VA PTSD treatment programs."

It's a frustrating situation for many military mental health providers, who want and need the expertise to respond better to an obvious need. Patricia Resick, who developed Cognitive Processing Therapy and now works at the VA's National Center for PTSD (NCPTSD), says VA therapists have been "flooded," and many are playing "catch-up." The central office, she says, is making a concerted effort at training, but it takes time. "You can't possibly teach enough in a two-day workshop," she says. Collaborative learning, online resources, and e-mail groups are all being developed to help speed up the training process.

The obstacles aren't only institutional, says Lee Bridgewater, a clinical psychologist at the Daytona Beach VA Outpatient Clinic who's writing a PTSD treatment manual. While cognitive behavioral and exposure therapies are widely recognized as the "standard of care" for PTSD, within the VA, "there's a lot getting in the way of therapists doing [these therapies]." Veterans with combat PTSD typically don't come for treatment until 10 years after a war. They try everything to distract themselves from the symptoms: marriages, jobs, alcohol, sex. Meanwhile, the condition becomes chronic and resistant to treatment, and usually remains that way. The newest veterans, at 18 to 24 years old, believe they're invincible, and they, too, often don't seek the treatment the VA offers, adds Bridgewater. Many, he says, see it as "Vietnam veterans disease" and don't want any part of it. They also stay away because of negative perceptions about the efficacy of psychotherapy, distrust of providers, and difficulty in scheduling appointments, according to DOD research. In addition, servicemembers in an all-volunteer, professional military worry greatly about the stigma associated with mental illness, and are concerned, with good reason, that it will compromise their standing with unit leaders and their careers. Of the 13 percent of Iraq soldiers diagnosed with PTSD, 80 percent recognized they had a problem. But only 40 percent of those said they wanted help--and a little more than half of them actually got it.

The situation is somewhat ironic: never in the history of the military has so much energy and so many resources been expended to treat troop mental health. The Army now has 200 mental health workers deployed in Iraq and another 25 in Afghanistan who dispense meds and provide counseling. It's instituted post-deployment health assessments (PDHAs), which returning troops are required to fill out to screen them for PTSD. But is it enough? Is the military doing the right things?

Psychotropic meds can get a troubled soldier through his deployment, but prescribing such drugs to troops in combat has become controversial. Likewise, the PDHAs sound like a good idea, but the DOD doesn't put much faith in their results, nor is every positive screen a cause for concern. Of the 5 percent of returning troops who screened positive for risk of PTSD, only 22 percent were referred for further mental health consultation, based on an evaluation made in the primary care system. Even the government's own oversight agency took the DOD to task for the lax follow-up, and questioned whether mental health professionals shouldn't conduct the evaluations.

The DOD says its intent is to draw more servicemembers into mental health treatment by focusing efforts at the primary care level. A pilot program, called "RespectMil"--Re-engineering the System of Primary Care in the Military--is operating at Ft. Bragg, North Carolina, and will be expanded to 15 other sites in the Army medical system. It's designed to improve early recognition and management of PTSD and depression in returned troops, and to reduce stigma by folding the mental health assessments into primary health care visits. Nearly 95 percent of returned troops have at least one health care visit a year within either the DOD or VA systems, Engel points out. Educating primary care physicians to spot mental problems at the "front end" of the medical system seems the logical and least threatening way to flag servicemembers who need psychotherapy--"many of whom, quite honestly, might not want to see a specialist," he says--and direct them to the appropriate mental health provider. Another program, called De-Stress, is a therapist-assisted interactive web base being tested for use with veterans who don't want to see a specialist in person or live in areas where it's geographically difficult.

But many veterans see DOD's primary care focus as another attempt to stall and defer real mental health treatment, a strategy that suits the department's needs, says Robinson. "Honestly? They don't have the doctor-patient ratio, and this is a way to get rid of them and send them down the road to the VA."

Wayne's World

How to deal with these problems once home is the question, and a difficult one. For many soldiers, that's where the real battle begins--a battle that Gary Trudeau aptly titled "The War Within" in a much-discussed collection of cartoons depicting his character B.D.'s struggle with amputation and PTSD on his return from a tour in Iraq.

It's a war few who haven't seen combat can truly understand, and it poses a dilemma in treatment. The most effective therapies for PTSD have been developed and are most widely available in the civilian world, but veterans are least likely to go there for help, according to Charles Figley. Soldiers who've lived the horrors of war believe that unless you've been there, you just don't get it. Many feel shamed by their wartime acts and fear misunderstanding and harsh judgment--even from those who are psychologically trained. Civilian therapists must be extremely knowledgeable about the war experience if they're to help veterans. Says Figley: "There's a cultural gulf between those who've been socialized to survive in combat and those who haven't."

How to bridge that gulf is the challenge. It's an age-old artistic theme: ordinary people are trained and transformed into killers to go to battle, but how do we prepare war-weary soldiers to go to peace? It took Odysseus 10 years to figure out how to get home. By the end of the movie The Deer Hunter, we're still unsure whether Robert De Niro's character will ever fit in again. But Trudeau's B.D., who struggles to find someone who can relate to the residue of his Iraq experience and pull him out of the resulting emotional hell, discovers hope in a single counselor at his local Vet Center--a character named Elias. He's based on a former marine corporal named Wayne Miller, the team leader at the Vet Center in Silver Spring, Maryland. Vet Centers, part of the VA system, started as rap groups created by Vietnam vets for peer support at a time when there were no services for their problems. They're staffed by civilian and military therapists, with a strong emphasis on peer support and clinicians who are veterans.

Trudeau spent time with Miller, witnessing his methods, hearing about his past, and observing the veteran culture. Like Elias, Miller is a burly, gruff, and welcoming Vietnam vet with one leg and tired eyes. Elias lost his leg in a motorcycle accident, but Miller's was blown off in a mortar attack on July 4, 1969. His other leg was "mangled," and his hands and arms disfigured in combat, too. He spent six months paralyzed after coming home from Vietnam. He was 18 years old.

Miller modeled for Trudeau what Elias does for B.D. He seeks out hurting vets where they tend to gather. "Under bridges, inside bars and churches, at disaster areas. We go and pick them up," says Miller. He discreetly passes along his card if he overhears "buzzwords" or conversation that suggests a veteran needs help. Those who walk into the center from the street are greeted quickly and eased in. Once in counseling, he treads softly, reminding veterans that they aren't "crazy" (their greatest fear, he says), but merely experiencing what many returning from combat inevitably go through--and that they aren't alone. He tells them: "PTSD isn't a mental illness: it's an anxiety disorder. 'Crazy' is when you take your K-bar, cut your stomach open, and take your guts out!" He laughs at his own bluntness. But in his speech, one hears traces of Elias: "See, Bro, sometimes combat comes at you so hard, the memories don't get processed properly. They become free floating, like raw footage that hasn't been edited down to make sense."

Miller shares pieces of his past that "trigger" similar experiences and feelings in his patients, which they might then talk about. He lets them know clearly that he's been where they are--and that nothing can shock him. "I'm a Marine, I've seen combat, I'm a social worker, I'm an amputee," he says, sitting back in his chair. Glancing around his cluttered but precisely arranged office, one gets the message loud and clear. In fact, behind him, hovering like a doppelg[Cyrillic KA]nger of his former self, is his neatly pressed Marine Corps uniform with his helmet propped above it. By the shoulder is a hand grenade. His shelves are lined with books on war and psychological healing. His desk, tables, and walls hold war photos and memorabilia, veterans'-group mementos, and family pictures that illustrate how life can still go on when the war is over.

"Everything changes after war. That's the message I give to veterans," he says. "For me, I wake up every morning and put my leg on to walk. I'm constantly reminded--24/7, 365 days a year--of the war and my injuries. A lot of times, you don't think you can survive, especially with PTSD. But I'm living proof that change occurs--that you can still live and breathe and survive after war."

But to do that, says Miller, takes hard work, retraining of mind and spirit, and relearning everyday habits--even how to make small talk or be with your spouse--that were warped in the war zone. To change what have become maladaptive means of survival once back in the civilian world, Miller runs what he calls a "PTSD boot camp." Just like military boot camp, it lasts eight weeks, and Miller plays the badass drill instructor--at least initially.

"Okay you doggies, squids, jarheads," he barks at them at the first meeting. "You won't be called a civilian until you graduate from my boot camp!" On the floor in front of each veteran are two yellow footprints (in front of Miller there's just one), the same type that direct fresh Marine recruits off the bus and into the barracks. These footprints, Miller hopes, will redirect his recruits. "You have 10 seconds to get on the yellow footprints!" he yells at them.

Then he sits and waits before a quiet, stunned group of veterans. Finally he laughs: "Didn't any of you think I was crazy?"

Over the weeks, he leads the group through stages of understanding and recovery that Miller call's "neither the right way, nor the wrong way, but Wayne's Way." He borrows heavily from many schools of psychotherapy and the trauma research literature, while educating vets about PTSD and life post-combat. Those who "graduate" may simply go about their civilian lives, while others may go on to individual, specialized treatment, or get referred to a VA clinic.

Listening to Miller, I'm struck by the grittiness of the therapy. To heal a psychologically wounded vet requires more than developing the perfect screening methods, or prescribing the latest meds, or performing cutting-edge neurobiologically informed protocols. It requires an intimate understanding of what if feels like to have been to hell and not fully come back. It calls for the willingness and ability to reexperience that terror with a veteran, and to reach across the frightening chasm that separates war from peace, soldier from civilian.

Combat trauma is different from other kinds of trauma because the horror of war--the trauma-inducing murderousness of it--is inextricably linked with sacrifice, courage, honor, pride, and patriotism. And the trauma occurs in the context of profound personal loyalty. Some soldiers will never experience bonds as intense as those formed with buddies fighting or dying beside them in the desperation of battle or the confines of an exploding Humvee. No other trauma is so intermingled with our deepest values and strongest fears of overwhelming loss. Is it any wonder that soldiers have a hard time letting it go?

It isn't surprising that those who've been through war feel they possess a terrible, secret knowledge that no ordinary citizen, even a well-meaning therapist, can imagine or understand. But to help, we must imagine it. We must understand the oddly thrilling, adrenaline rush of combat--what Matt Frank called a kind of "drug" earlier in this story--as well as its corrupting horror. We must realize that coming back from such a brutal landscape makes the flatlands of civilian life seem, well, pretty flat--even for someone tortured with PTSD. And that makes recovery all the more difficult.

Of course, only those who've been to war can truly know its devastating effects. But it doesn't follow that only former soldiers can lead other soldiers back. The rest of the therapeutic world has much to offer, but also much to learn. Beyond the bells and whistles of the latest trauma treatments, one must also keep in mind a simple human truth that Wayne Miller models in his outreach and therapy: emotional healing comes in intimate form--the acknowledgment of another's suffering and the willingness and ability to get down and dirty with that person to the point that you can truthfully say, "I get it." To bring a veteran out of Hades requires not so much a collection of methods as a sure-footed personal guide like Miller, who can lead a psychologically wounded soldier back into the light, and all the way home.


"Emotional healing comes in intimate form--the acknowledgment of another's suffering and the willingness and ability to get down and dirty with that person and say, 'I get it.'"