The Invisible Wounds of War
A plague that has haunted soldiers for centuries
By Judy Beaupre
Long misunderstood, too often ignored, and repeatedly misdiagnosed, it has gone by a multitude of names. World War II veterans struggled with the symptoms of “battle fatigue,” while their fathers and uncles spoke in whispers of “shell shock,” the mysterious malady that for many defined the months—even years—following the First World War. And five decades before, men in Confederate grey and Union blue returned from the bloodiest war in American history, forever burdened with memories of death and devastation, an enigmatic syndrome that became known as “soldier’s heart.”
It was not until the Vietnam War that post-traumatic stress disorder (PTSD) began gaining recognition as the real and debilitating affliction it is. No longer dismissed as an indicator of personal weakness, cowardice, or damaged nerves, PTSD captured the attention of the mental health community—making its way into the third edition of the Diagnostic and Statistical Manual in 1980. Not far behind came the attention of the media, the Pentagon, and the public at large.
“It’s taken us a long time to recognize that an elevated level of stress as a result of combat is really the norm,” says U.S. Navy Commander John Ralph, director of mental health services for the National Naval Medical Center in Bethesda, Md. “It is universal; no one can deploy and not experience it. Our focus now is to distinguish temporary stress from PTSD and to let troops know that it’s important to deal with.”
Today, some seven years into the Afghanistan and Iraq wars, the prevalence of post-combat psychological and cognitive problems has reached unprecedented levels, sounded new alarms within the military and veterans’ communities, and led to a myriad of initiatives designed to understand, diagnose, and heal these invisible wounds of war. A 2008 study by the Rand Center for Military Health Policy Research estimated that 20 percent (more than 300,000) of soldiers returning from Middle East deployments had met the screening criteria for PTSD and/or major depression, and that 320,000 had experienced a probable traumatic brain injury (TBI). Overall, Rand speculated, one in three U.S. servicemen and women were returning from combat duties with significant psychological problems. Worse, only half had sought or received treatment for their injuries.
It took years to realize that the cumulative impact of treating those who had experienced the horror firsthand could be just as traumatizing.
As the longest-running wars fought by an all-volunteer United States military, the current conflicts have resulted in the deployment of almost 2 million troops and, for many, prolonged and repeated periods of combat-related stress or traumatic events. Evidence gathered by the Rand Center suggests that the psychological toll of the deployments may be disproportionately high compared with physical injuries.
“We found that the single biggest risk factor for PTSD and major depression was exposure to trauma,” said Terri Tanielian, co-director of the study. “The more exposures a soldier experienced, regardless of number or length of deployments, the more likely he was to return home with psychological problems requiring treatment.”
The study identified 23 experiences—including 11 that were rated highly predictive—that contribute most often to post-combat anxiety and depression. They range from engaging in hand-to-hand combat to having a friend killed to being responsible for the death of a civilian. The study represented the first large-scale nongovernmental assessment of the psychological and cognitive needs of troops serving in Iraq and Afghanistan and representing all branches of the armed forces.
Robert Diosdado, who served as a platoon leader and brigade training officer, and more recently, as a civilian organizational consultant to the U.S. Army, believes direct combat exposure is not a required determinant of PTSD. Different kinds of wars call for different definitions of trauma, he says, and today’s typical combat tour is characterized by “months of boredom, followed by a few moments of sheer terror and chaos.
“There are no front lines in Iraq and Afghanistan, which has changed the combat dynamic,” says Diosdado, who, from his post in Afghanistan, is pursuing a Ph.D. in Organizational Leadership at The Chicago School of Professional Psychology in an effort to integrate psychological theory into the work he currently does for the Army. Because all troops deployed to these countries work under a constant threat of mortar attacks, suicide bombers, or encountering improvised explosive devices (IEDs), the projected threat is often far worse than the actual event, he explains. “The fear of being attacked is almost unbearable for some people. I’ve seen soldiers attempt to substantiate their continued fears by creating a reality in which they were actually involved in combat.”
The upside is that the military has taken huge strides in understanding and treating the PTSD and/or major depression that so often accompany deployment to a battle zone. While diagnoses of these conditions far exceed those of previous wars, military mental health professionals readily acknowledge that the trend can be attributed in part to their increased capacity to recognize and address the symptoms than ever before in history.
Since Civil War days (when mustered soldiers bearing obvious symptoms of what today would be diagnosed as PTSD were put on trains home with only the name of their hometown pinned to their uniform) and early 20th century wars (when mental health professionals were used primarily for intelligence and “sanity” testing of recruits), the military has made steady progress in its incorporation of psychology into wartime healthcare strategies.
It was during the 1960s and 1970s—as the war in Vietnam was escalating—that an understanding of combat-related trauma was beginning to take hold, psychology professionals agree. But while the problem was gaining acceptance, it would be years before evidence-based treatments were available to provide the early and aggressive therapy that is often recommended as a result of today’s post-deployment screening.
“Back in Vietnam, a soldier had to be involved in something horrific to even be considered for a diagnosis of PTSD,” says Dr. Larry James, a clinical psychologist and retired Army colonel who directed mental health services at both Walter Reed and Tripler Army Medical Centers during his 22-year military career. “It took years to realize that the cumulative impact of treating those who had experienced the horror firsthand could be just as traumatizing and require similar levels of therapy.”
Further complicating the mental health environment of that era was the fact that troops were returning from an unpopular war to homecomings that were often anything but welcoming. While the previous generation had returned from World War II and Korea heralded as heroes, Vietnam veterans “were afraid to wear their uniforms through the airport for fear of being spit upon,” says Dr. James, who is now president of the American Psychological Association’s Society for Military Psychology (Division 19) and dean of the Wright State University School of Professional Psychology. “This just added to the stress and depression that many had experienced during their months in Southeast Asia.”
But gradually times have changed. Today initiatives taken by all service branches, as well as the Departments of Defense and Veterans Affairs, have dramatically altered the ways in which troops are assessed and treated during all phases of deployment and its aftermath. Dr. Ralph points to the Navy’s decision 15 years ago to begin putting clinical psychologists on every aircraft carrier.
“This represents a total change in the outlook of the Navy at large,” he says. “Commanding officers used to have to make the difficult and expensive decision to send sailors with psychological problems off the ship, but we have gotten that number down to almost zero. Psychologists are now on board and available to help sailors talk through problems and resolve personal issues. It’s a very different model for us.”
The Navy also provides medical services for the Marine Corps, which for the first time in the coming fiscal year will embed clinical psychologists in units serving in Iraq and Afghanistan.
“Before, psychologists were primarily attached to hospitals. It made the whole idea of mental health more mysterious and much more prone to stigma,” says Dr. Eric Getka, national training director for navy psychology. “By having them available to marines in the field and as an actual part of their unit, we’ve come a long way in dispelling the myths around mental health care.”
Dr. Ralph attributes changes in the healthcare focus of the Navy to a combination of compassion and pragmatism on the part of senior officers. It’s the right thing to do for our men and women in uniform, he says, but it also reflects officers’ sense of responsibility to doing their jobs well.
“Officers need to make sure their men are ready to fight. They have to be attuned to anything that could degrade that readiness,” he says. “Losing people to mental health problems has an adverse effect on everyone involved.”
Now we have crusty generals talking about their own issues to troops. I can remember a time when no admiral or general would ever admit to having problems like that.
The Army, too, has increased its focus on the mental health of its troops. In collaboration with the University of Pennsylvania, it offers a pilot program in master resilience training as part of a newly launched Comprehensive Soldier Fitness program, which prepares troops for the physical and psychological challenges of sustained operations. Army Chief of Staff Gen. George Casey recently pinned his hopes on the new fitness program as a means of reducing the continuing rise in suicides in the Army.
“We’ve increased by about 18 suicides a year since 2004 and this past year, after all the effort we made, we increased by another 20,” he told the Senate Appropriations defense subcommittee in March. “I’m personally frustrated that we haven’t stemmed the tide.”
Despite the proactive stance that the military is taking toward the psychological health of its troops, however, barriers that are hard to overcome remain. Stigma is still a central issue, even as the armed services struggle to convey the message that combat stress is universal, inevitable, and not necessarily an indication of disorder. A big deterrent to coming forward for screening or treatment, they say, is the fear of sabotaging their careers, forfeiting the next promotion, or losing their security clearance. A big step forward was taken in 2008 when a Defense Department policy was revised to allow a way around what U.S. Defense Secretary Robert Gates called “the infamous Question 21.”
Question 21—long a standard part of the Questionnaire for National Security Positions—asked if the applicant had ever sought mental health care. Fearful that an affirmative response would jeopardize their future in the military, respondents frequently avoided admitting to symptoms of combat-related stress so they could answer “no.” The 2008 change allows applicants to respond “no” if the care they received was not court-ordered and was “strictly related to adjustments from service in a military combat environment.”
“Now we have crusty generals talking about their own issues to troops,” Dr. James says. “I can remember a time when no admiral or general would ever admit to having problems like that.”
For veterans, services and resources have also increased steadily and in fact, rather dramatically. Dr. Antonette Zeiss, deputy chief for mental health services at the Department of Veterans Affairs, says her office has responded to its growing awareness of the need for comprehensive mental health services for veterans by almost doubling the number of VA psychologists in recent years, from 1,800 in 2005 to almost 3,500 today. Although VA services were originally reserved for low-income veterans, that also has changed for troops who have served in the Afghanistan and Iraq wars, she adds. All are eligible for lifetime medical and mental health care as long as they initially access services within the first five years after separating from the military.
Access doesn’t necessarily translate to services, though. Dr. Zeiss echoes the findings of the Rand report, saying that fewer than half of the 1.9 million veterans who have returned from active duty since 2002 have taken advantage of VA services.
“Almost half of those who did come in presented with a strong suggestion of PTSD or other psychological disorder,” she says. These numbers do not include possible diagnoses of TBI, which is handled by another office at the VA, she added.
Mirroring changes that have taken place in the civilian world, both the armed forces and the VA have integrated mental health services into primary care settings, which allows them to reach many more patients. Troops and veterans resistant to seeking out the help of a psychologist will often open up about anxiety and depression symptoms in a primary care setting, again underscoring the pervasive role that stigma plays in mental health issues, experts say.
“Our services are so much better than they were for previous wars,” Dr. Zeiss says. “But it’s not because the war is different or the VA is different—it’s because psychology is different. We have so much more information available about the best treatment for PTSD and depression. We can offer a whole range of evidence-based psychosocial therapies that work.”
Women in the Military
One group that stands out in their vulnerability to combat-related stress, research shows, is women.
Despite the increased presence and more versatile use of women in all service branches (no longer are their options limited to nursing and clerical positions), accommodations for them have not kept up.
“They will report for duty in a combat zone to find that only one tent and one shower has been allotted for all of them,” says Capt. Kathryn Serbin, a psychiatric clinical specialist with the Navy Reserves, explaining why women’s hygiene and physical health suffer during deployment. “Urinary tract and vaginal infections are common during deployment where resources for self care and appropriate primary care for women are scarce or unavailable.”
Capt. Serbin agrees with others interviewed for stories in this issue in identifying sexual harassment as one of the biggest—and under-addressed—challenges that women face when mobilized.
“Sexual assault in the military is greatly underreported,” she says. “Often it’s the women themselves who won’t report it. If they do, they find themselves revictimized— ostracized and further harassed. Anecdotally, I’ve heard from women that they’re encouraged not to bring their concerns forward.”
In addition to her reserve role for the Navy, Capt. Serbin serves in a voluntary capacity with the Returning Warriors Program, and co-facilitates a workshop specifically for women warriors to tell their stories. She also works as a civilian at the Naval Health Clinic Great Lakes, where she heads the gynecology clinic.
“We are recognizing the strain on our returning women,” she says. “Whether they are serving as MPs, or out with a convoy, they are supposed to just suck it up, rather than show how they’re feeling. The Returning Warriors Program gives women an opportunity to tell their stories, often the first chance they’ve had,” Capt. Serbin says. If they’re not comfortable sharing their story with a group they can write it.
“I see myself as an advocate for women—encouraging them to speak up and seek the medical care they need,” she says. “The expanding role of women in combat operations presents both an opportunity and a challenge. Further research is needed to assess the impact of war zone deployment on service women in order to narrow the knowledge gap on protection and enhancement of health and performance of military women.”