So Sad our Soldiers & PTSD

Mad, Bad, Sad
What’s Really Happened to America’s Soldiers
By Nan Levinson
"PTSD is going to color everything you write," came the warning from a stepmother of a Marine, a woman who keeps track of such things. That was in 2005, when post-traumatic stress disorder, a.k.a. PTSD, wasn't getting much attention, but soon it was pretty much all anyone wrote about. Story upon story about the damage done to our guys in uniform -- drinking, divorce, depression, destitution -- a laundry list of miseries and victimhood. When it comes to veterans, it seems like the only response we can imagine is to feel sorry for them.
Victim is one of the two roles we allow our soldiers and veterans (the other is, of course, hero), but most don't have PTSD, and this isn't one of those stories.
Civilian to the core, I've escaped any firsthand experience of war, but I've spent the past seven years talking with current GIs and recent veterans, and among the many things they've taught me is that nobody gets out of war unmarked. That’s especially true when your war turns out to be a shadowy, relentless occupation of a distant land, which requires you to do things that you regret and that continue to haunt you.

Theoretically, whole countries go to war, not just their soldiers, but not this time. Civilian sympathy for “the troops” may be just one more way for us to avoid a real reckoning with our last decade-plus of war, when the hostilities in Iraq and Afghanistan have shown up on the average American’s radar only if somebody screws up or noticeable numbers of Americans get killed. The veterans at the heart of this story -- victims, heroes, it doesn’t matter -- struggle to reconcile what they did in those countries with the "service" we keep thanking them for. We can see them as sick, with all the stigma, neediness, and expense that entails, or we can recognize them as human beings, confronting the morality of what they've done in our name and what they’ve seen and come to know -- even as they try to move on.
Sacred Wounds, Moral Injuries
Former Army staff sergeant Andy Sapp spent a year at Forward Operating Base Speicher near Tikrit, Iraq, and has lived for the past six years with PTSD. Seven if you count the year he refused to admit that he had it because he never left the base or fired his weapon, and who was he to suffer when others had it so much worse? Nearly 50 when he deployed, he was much older than most of his National Guard unit. He had put in 17 years in various branches of the military, had a stable family, strong religious ties, a good education, and a satisfying career as a high-school English teacher. He expected all that to insulate him, so it took a while to realize that the whole time he was in Iraq, he was numb. In the end, he would be diagnosed with PTSD and given an 80% disability rating, which, among other benefits, entitles him to sessions with a Veterans Administration psychologist, whom he credits with saving his life.

Andy recalls a 1985 BBC series called "Soldiers" in which a Marine commander says, "It's not that we can't take a man who's 45 years old and turn him into a good soldier. It's that we can't make him love it." Like many soldiers, Andy had assumed that his role would be to protect his country when it was threatened. Instead, he now considers himself part of "something evil." So at a point when his therapy stalled and his therapist suggested that his spiritual pain was exacerbating his psychological pain, it suddenly clicked. The spiritual part he now calls his sacred wound. Others call it “moral injury.”
It’s a concept in progress, defined as the result of taking part in or witnessing something of consequence that you find wrong, something which violates your deeply held beliefs about yourself and your role in the world. For a moment, at least, you become what you never wanted to be. While the symptoms and causes may overlap with PTSD, moral injury arises from what you did or failed to do, rather than from what was done to you. It's a sickness of the heart more than the head. Or, possibly, moral injury is what comes first and, if left unattended, can congeal into PTSD.

What we now call PTSD goes way back. In Odysseus in America, psychiatrist (and MacArthur "genius" grantee) Jonathan Shay has traced similar symptoms to Homer’s account of Odysseus’s homecoming from the Trojan War. The idea that a soldier may continue to be haunted by his wartime life has had a name since at least the Civil War. It was called "soldier's heart" then, a lovely name for a terrible affliction.
In World War I, it went by the names “shell shock” and “war neurosis” and was so widespread that Britain devoted 19 hospitals solely to treating soldiers who suffered from it. During WWII, it was called “battle fatigue,” “combat neurosis,” or “gross stress reaction,” and the problem was severe enough in the U.S. Army that, at one point, psychiatric discharges outpaced new recruits. The Vietnam War gave us the term “post-Vietnam syndrome,” which in time evolved into PTSD, and eventually the insight that, whatever its name, it is probably neurologically based.

PTSD’s status as an anxiety disorder -- and as the only mental health condition officially defined as caused by a single, external event -- was established in 1980, when it was enshrined in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. The diagnostic criteria have expanded since then and will probably be altered again in next year’s version of the DSM. That troubles many therapists treating the ailment; some don't think PTSD is a disease, others argue that the symptoms are just a natural response to being at war or that, in labeling it a disorder, political and cultural norms are being invoked to reinforce what is considered orderly. As Katherine Boone, writing in the Wilson Quarterly, put it, "If you react normally to trauma, you have a disorder; if you act abnormally, you don't."
Most PTSD is short term, but perhaps one-third of cases become chronic, and those are the ones we keep hearing about, in part because it costs a lot to treat them. For a variety of reasons, no one seems to have an exact number of recent combat veterans with PTSD. The Veterans Administration estimates that between 11% and 20% of the 2.3 million troops who have cycled through Iraq and Afghanistan suffer from it, and the Congressional Budget Office calculates a cost of $8,300 per patient for the first year of treatment. Do the math, and you could be talking about as much as $3.8 billion a year. (What we're not talking about nearly enough is the best way to prevent PTSD and other war-caused psychic distress, which is not to put soldiers in such untenable situations in the first place.)

Since the early days of diagnosis -- when you were either sick with PTSD or you were fine -- the medical response to it has gained in nuance and depth, which has brought beneficial funding for research and treatment. In the public mind, though, PTSD still scoops up everything from risky behavior and aggression to substance abuse and suicide -- kind of the way “Alzheimer's” as a catch-all label stands in for forgetfulness over 50 -- and that does a disservice to veterans who aren't sick, but aren't fine either.
“What you come into the war with will dictate how you come out of war,” Joshua Casteel testified about a soldier’s conscience at the Truth Commission on Conscience and War, which convened in New York in March 2010. He had spent five months as an interrogator at Abu Ghraib shortly after the prisoner abuse scandal broke there. He later left the Army as a conscientious objector after an impassioned conversation about faith and duty with a young Saudi jihadist, whom he was supposed to be questioning, led him to conclude that he could no longer do his job. Casting a soldier’s experience as unfathomable to anyone else was not only inaccurate, but also damaging, he said; he had never felt lonelier than when people were afraid to ask about his life during the war.

Our warriors today are all volunteers who signed up and are apparently supposed to put up with whatever comes their way. As professionals, they're supposed to be ready to fight, but as counterinsurgents they're supposed to be tender-hearted and understanding -- at least to kids, those village elders they’re fated to drink endless cross-cultural cups of tea with, and their buddies. (Every veteran has a kid story, and mourning lost friends with tattoos, rituals, and drunken sorrow are among the few ways they're allowed to grieve publicly.) They're supposed to be anguished when they hear about the "bad apples" who gang-raped, then murdered and set fire to a 15-year-old girl near Mahmoudiya, Iraq, or the “kill team” that hunted Afghan civilians “for sport.”

Maybe it’s the confusion of these mixed signals that makes us treat our soldiers as if they’re tainted by some special, unwanted knowledge, something that should drive them over the edge with grief and guilt and remorse. Maybe we think our soldiers are supposed to suffer.