06 October 2011

Combat Stress and Moral Injuries...Or, PTSD.

Stephen Sherwood returned from Iraq in the summer of 2005, along with the rest of his brigade combat team which included the 506th Infantry Regiment.  You know of this regiment from the mini-series "Band of Brothers." 
          
"Longtime friends said Sherwood came back from Iraq a changed man.  After a few days, he took down the American flag in front of his house and scraped the SUPPORT OUR TROOPS sticker off his car.  On the day of the argument [with his wife, 03 August 2005], Sherwood's wife told him about an affair she had started while he was in Iraq.  Hours later, he shot her five times in the face and neck, then killed himself with a single shotgun blast.  In his pocket, police found a newspaper clipping stating that 30 percent of troops returning from Iraq developed mental-health problems.  Fort Carson assured the media it carefully screens every soldier and Sherwood's postdeployment health assessment did not indicate he was "high risk."  - "Lethal Warriors," David Phillips, pg 97.

Sherwood's screening didn't indicate that he was high risk because he, like many (perhaps most) in his unit and others, lied on that screening.  Some senior soldiers suggested that filling the screening out truthfully would give Sherwood and his comrades a one-way ticket to the shrink, that they would be denied their block leave, and perhaps be kicked out of the infantry.  It was also perceived as being contrary to the Soldier's Creed.

I am an American Soldier.
I am a Warrior and a member of a team. I serve the people of the United States and live the Army Values.
I will always place the mission first.
I will never accept defeat.
I will never quit.
I will never leave a fallen comrade.
I am disciplined, physically and mentally tough, trained and proficient in my warrior tasks and drills. I always maintain my arms, my equipment and myself.
I am an expert and I am a professional.
I stand ready to deploy, engage, and destroy the enemies of the United States of America in close combat.
I am a guardian of freedom and the American way of life.
I am an American Soldier. [Emphasis added by author.]

The Soldier’s Creed makes it hard to ask for help.  If the creed doesn’t, the motto of the 506th is "Stands Alone." By all accounts, this motto was taken to heart by the soldiers of the 506th.  But there are some things during which our soldiers shouldn't stand alone.  Are we failing our combat veterans?  Are we giving them the support they need when they return from doing what it is we sent them to do; to kill and be killed on our behalf?  I ask myself these questions daily. 

I have been doing a great deal of reading about combat stress injuries, or moral injuries as Dr. Jonathan Shay calls them.  Or PTSD, as you likely know it.  This began, ostensibly, as research for character development for a novel that I’m writing, and that's what I continue to tell myself. The more I read, however, the more engrossed I became in the subject, and convinced that we need to do more.

As an aside, the problem with the name PTSD is that it suggests that it's simply a disorder.  I don't think it's a disorder.  I think, as do many mental health professionals, that it is an injury.  And like a shattered leg, it should be treated, and treated comprehensively.  Unfortunately, you can't see moral injuries at first glance.  But the hell they wreak on both the returning combat veterans and society is readily visible.  Or at least it should be, if only we were looking.  Very few seem to be looking.  In his book, quoted above, David Phillips shows us what it’s like when we do look.  Maybe that scares us and we continue to pretend that everything is well.  Maybe combat veterans scare us.  All part of the same problem, no?

You don't have to understand what it's like to be in combat (or have been in combat) to understand how a man or woman can be changed by that experience.  You don't have to have "walked a mile in his shoes" to be empathetic.  To suggest that would be foolish.  But I feel that it is our duty as Americans to at least try to understand and empathize.  I don't want you to patronize veterans with shows of faux sympathy.  But you should try to understand. 

You can easily see the missing limbs and burned skin from IED attacks, but as it stands right now, we can barely recognize the legitimacy of the psychic scars that many of our veterans bear.  They could by lying after all.  They could be malingerers.  They could be trying to shirk their duty.  They could be, as we called them in the Marine Corps, “shitbags.”  If so, they should be ostracized and discharged.  Better to err on the side of caution, right?  To banish them?  To cast them off?  

Here is an SNCO talking to a junior enlisted man:

"Soldier, you got hit by five IEDs, countless ambushes, and saw your entire squad killed.  Your best friend bled out and died in your arms.  You couldn't tell who the enemy was; everyone there seemed to hate you.  But other than the brain fluid that seeped out of your ears that one time your Humvee was launched 10 feet in the air by a buried 155mm round, you didn't suffer a scratch.  You're fine.  So you have nightmares?  We all do.  Suck it up.  Don't be a wimp.  Here's a fat reenlistment bonus.  Go get drunk and get laid and blow off some steam.  Oh, and by the way, we're going back in 8 months.  Dismissed." 

Suck it up.  But what if they can’t just “suck it up”?  What happens when they are in distress, psychologically and emotionally, and the above SNCO is their support system?  The answer is: Nothing positive.

Consider this: If you're going to tell yourself and others that these men and women are protecting your freedom and protecting your way of life, you should want understand that the ramifications of them doing that duty go far beyond physical disabilities.  Shouldn't you? 

We have this image of victorious WWII veterans returning home and stoically and smoothly transitioning from warriors to peaceful civilians.  That vision, through decidedly rose colored glasses, is the gold standard.  The problem is it's not really true.  Moral injuries were present in WWII veterans (just read some of the autobiographies of the aforementioned Band of Brothers) and have been present in returning veterans since antiquity.  In fact, Homer's Iliad and the Odyssey, which I take from Dr. Shay, could be interpreted as a brilliantly crafted metaphor for moral injuries.  This is not a new phenomenon, but is instead as old as warfare itself. 

Furthermore, it is nothing to be ashamed of, and we need to change the way we think about moral injuries.  We're doing this.  We're getting there.  But we're not there yet.  I don't know if we'll ever really get there, and I offer no solutions other than to ask that you inform yourself and your loved ones, even if they haven't been touched by the long tendrils of war.  I offer no solutions because I, well, I'm not that smart.  But this is a burden that we all share, like it or not.  And we, like our veterans, should shoulder that burden.

Not all combat veterans have moral injuries, PTSD, combat stress injuries, etc.  I'm not saying that.  So all you uninformed arm chair generals (and even a few of you combat veterans) can refrain from telling me that our warriors are just that; WARRIORS with no room for such touchy-feely mental weakness ("OOH RAH, HOO AH, STANDS ALONE!").  I don't want to hear that and I won't hear it because it's not weakness.  It's reality.  If you don't believe that combat changes the brain, and in turn the man, I simply point you to one of the dozens of studies that show real, concrete changes in the way the brain works after prolonged exposure to combat and other stressful situations.  Some people are changed more than others, and rarely is this change for the better.  Inform yourself.  Read.  Learn.  We all stand to gain from it.

If you are a veteran and you feel like there is something wrong, but don't understand what, educate yourself as well and seek help.  We haven't always done enough for you, and those like Stephen Sherwood and countless others, as well as their families, have paid for it.  But help is out there.  I ask that you stop worrying about what it will do to your career, and worry about what it will do to your existence as a human being. 

What to read?  Where to start?  There are thousands of books on this subject.  Some better than others.  My recommendations, which I've personally read, are as follows, in no particular order.

  • "Achilles in Vietnam" and "Odysseus in America" by Dr. Jonathan Shay.
  • "On Combat" and "On Killing" by Col. David Grossman.
  • "An Operators Manual for Combat PTSD" by Dr. Ashley R. Hart II.
  • "Lethal Warriors" by David Phillips.

When you're done reading them, check out their bibliographies.  If you want more suggestions, contact me or your local Veterans Advocate.

I'm not advocating the neutering of our fighting men.  I'm just advocating that we take some responsibility when we turn our men into trained killers and unleash them upon our enemies.  Even Lethal Warriors sometimes need help.  Who's going to give it to them?