Tell My Folks I'm Dead

by Molly Ivors

I've blogged before about post-traumatic stress disorder, but it still seems to be an infuriatingly invisible issue to the vast majority of Americans. And that's far from accidental. Like the the secret coffin returns and the nonexistent military funerals,  we hide our vets away, only really seeing them when George Bush comes a-courtin', as he did last week.

Last spring, the Boston Globe did an excellent piece on PTSD in which they note, among other things, that the Iraq/Afghanistan war is unprecedented in American history for the number of wounded soldiers to every dead soldier. In World War II, two soldiers were wounded for every one killed. In Iraq/Afghanistan, it's 16:1. The military disputes these figures, preferring, as the Globe's Charles Sennott notes, "to calculate only those wounded in direct combat, which would make the ratio in Iraq 1 dead to 8 wounded, and still place it as the highest killed-to-wounded ratio in American history."

One of the reasons for the wide area of disputed numbers is that battlefield injuries tend to be visible, like these. Mental effects, which can be equally debilitating, are all but invisible. Also, they tend to have delayed onset: if you lose a limb, you pretty much notice right away, but you can go on without your soul for months sometimes without anyone else being able to tell, sometimes even yourself, if you're numb enough.

In a recent HuffPo post, veteran Jon Soltz takes on a recent Army study which finds that soldiers serving in this clusterfuck of a war are far more likely to report problems six months after coming home than right away. Estimates vary between active-duty soldiers and Reservists, but they're between 20 and over 40%.

That's a really fuck of a lot of people.

Soltz points to the visible/invisible divide I've been noting:

Just because mental injuries cannot be seen, it doesn't mean they are less severe. And yet, as a nation, we treat mental injuries like that, when it comes to our veterans. Imagine if we had veterans in the streets with untreated third-degree burns, blown off limbs that weren't sewed up, and gaping open wounds with organs hanging out. This country would never forgive this Administration and those in Congress who voted against increased VA funding. And yet, we have a very similar situation, when it comes to untreated mental injuries, and a system that allows our veterans to deal with it on their own.

Let's define terms: "On their own" means through drugs--legal and illegal--and alcohol, private psychiatric help (if they can afford it--the effects of PTSD tend to impact employability and thus insurance coverage), the VA (if they can wait six months), spouses, girlfriends and boyfriends (if they can stand to stick around--many can't), family, friends (though I'm assured by one young vet I know that you don't talk about "that stuff" in front of people your own age because they'll "think you're crazy"), and sometimes, through suicide (Iraq and Afghanistan vets commit suicide at about twice the national rate).

What's weird, as Soltz notes, is that this seems to be news to the people in charge of planning for VA services. In The Boston Globe story linked above, Paul Sullivan, a former researcher for the VA, tried desperately to sound the alarm.

In 2004, Sullivan led an effort to create a more seamless way to track veterans through their transition from active military duty to the VA system. The so-called Seamless Transition Taskforce also sought to project costs and kinds of needed care. Sullivan said his report, published in January 2005, was watered down in the editing, but that its core message was clear.

"This was bureaucratese for, 'Hey, we've got a train wreck coming!' " he said.

By summer 2005 the warnings were growing louder. One all-out alarm was sounded in a July 25, 2005, memo to the VA's under secretary for health from the Committee on Care of Veterans with Serious Mental Illness.

The committee, comprised of a panel of specialists in PTSD and VA mental health providers, presented a plan to increase funding for mental health programs.

But the plan was not implemented, according to members of the committee and consultants who worked for it. The funding for mental health has not kept up with the onslaught of veterans reporting psychological problems.

The VA spokesman, Phil Budahn , said that Sullivan's research at the VA was solid, but that his interpretation of data and much of the criticism he and others are voicing is "alarmist."

Well, we're now eight months down the road from Sullivan's "alarmist" criticism, and where do we find ourselves? According to that Army study, cited in the Washington Post, just about where you'd think.

Initial screenings "substantially underestimate the mental health burden," according to the study, which adds to growing evidence that more than a quarter of recent Iraq combat veterans are grappling with various psychological problems.

"Soldiers reported more mental health concerns and were referred [for treatment] at significantly higher rates" several months after their return, says the study, written by Col. Charles S. Milliken and Col. Charles W. Hoge of the Walter Reed Army Institute of Research and Jennifer L. Auchterlonie of the Army Center for Health Promotion and Preventive Medicine.

The study concludes that the Army should intervene earlier with mental health care for combat veterans -- reservists, in particular -- and their family members "before symptoms become chronically entrenched." But it also casts doubt on the effectiveness of the treatment for PTSD in what it calls today's "overburdened" military medical system, finding "no direct relationship of referral or treatment with symptom improvement."

I'm with Soltz: it seemd like this issue should be a no-brainer for anyone with anything like a decent moral compass. "Where's the outrage?" he asks.  I would add "where are the leaders willing to take this issue on?"

Well, here's one.

Presidential contender John Edwards is introducing a $400 million plan Monday to help veterans with post-traumatic stress disorder, including those recently returned from combat in Iraq and Afghanistan.

Under Edwards' plan, veterans could seek counseling for post-traumatic stress disorder outside the Veterans Health Administration system; the number of counselors would increase; and family members would be employed to identify cases of PTSD.
........
A recent study of Veterans Affairs records showed that the number veterans with PTSD increased by almost 20,000 during the last fiscal year _ a nearly 70 percent jump.

Edwards said the Bush administration's extension of tours to 15 months has only exacerbated the situation, and he promised to increase the time given to service members between deployment. A Defense Department study earlier this year showed that inadequate time stateside led to higher rates of PTSD or aggravated mental stress from service in the field.

Edwards' campaign said there are too few trained counselors in the networks available to veterans. As such, they avoid seeking care because of the wait or the stigma. Instead, Edwards said he would increase counseling and training for counselors and allow veterans to seek treatment outside of the existing system.

The VA currently has a backlog of as many as 600,000 claims, increasing delays for initial treatment by up to six months, according to the campaign. Edwards pledged the entire backlog would be eliminated by Memorial Day 2009 _ four months after he might take office _ and would cut the processing time by half.

I've been digging on John Edwards lately, though admittedly for sort of a silly reason. Still, he's talking about issues that matter, like this, and like poverty, and to me, that's dead fucking serious.

(For some interesting historical readings of shell shock in WWI, read this 1917 paper by W.H. Rivers, who served at Britains Craiglockhart War Hospital during WWI and the wide variety of documents on "shell shock," as it was then known, at The World War I Document Archive, the baby of our beloved fellow Atriot GWPDA.)

Mac tells it like it is.

Comments

[SteveB]

I'm assured by one young vet I know that you don't talk about "that stuff" in front of people your own age because they'll "think you're crazy"

I wonder what the effect on military enlistment would be if young people were aware of PTSD and the likelihood of coming home with it. When you're 18, the prospect of being killed in battle doesn't really mean much - how can you even imagine it? But the prospect of having panic attacks so severe that you can't leave your apartment is both real and horrifying.

How many fewer would sign up? Every year, the Army alone needs to persuade 80,000 young people to risk their lives (and mental health) by enlisting. What would happen if they could only get 40,000, or 20,000? Would they be able to continue the war?

[eRobin]

Thanks for writing this. I've been on the issue of hidden vets for a while - ever since I started trying to find out how many vet and other military families use programs like SCHIP, WIC, food stamps, LIHEAP. Those stats are kept secret - even Kennedy's office can't find out how many mil fams use SCHIP. If we knew the answer, it would be much harder to (as I've said before) paint the face of need as the Cadillac-driving Welfare queen or as the thieving illegal.

I've been doing lots of work recently on the Labor-HHS-Education appropriations bill. For the first time in six years, programs included in it will get very modest increases. The bill stinks - don't get me wrong - but it's better than the drastic cuts that the lunatic president proposed. Now here's how this ties in to what you wrote: there are at least three programs in Labor-H dedicated to helping vets like the ones you describe - and, of course, we know but can't prove that the other programs in it help mil fams too. Labor-H was vetoed this week by Dear Leader and we have a real fight on our hands to override it. I wrote about it yesterday here.

Bottom line for now: Please call your members of Congress NOW - the vote to override happens in the House later today - and tell them to override the Labor-H veto NOW - no excuses. If you have a GOP rep, then get ten friends to call too.

[eRobin]

P.S. That's cool about Edwards and all, but I wish that he'd use his megaphone to educate people about programs that already exist and which are facing cuts at the hands of BushCo and his minions in Congress. I'm not a small government gal but we may not need more programs as much as we need to fund the ones we have adequately and drag this issue into the sunshine.

One example of what I'm talking about is the Philadelphia Veterans Mulit-Service and Education Center. GREAT people doing god's work and they need funding help.

[eRobin]

Sorry - me again. I keep re-reading that Ewards bit. What does this mean? allow veterans to seek treatment outside of the existing system. I'm afraid that he's demonizing the VA (something we don't need) for political gain. The guy drives me crazy - then again, I may be wrong. It's just that all I've learned makes me bristle at at that statement. And it sounds dangerously close to privatization talk. Also, $400M is chump change. I'm still thinking that it would do better to be put into existing programs than held out as a way to forge a brand new path.

Okay - no more comments. It's just that this issue is a heart-tugger for me personally and professionally.

[DrDick]

Good post. This really is the hidden cost of war - all wars. My father was a WW II vet (Pacific) and many of my friends were in Viet Nam. PTSD in varying degrees and forms affects all combat veterans. My father would still wake up screaming in the middle of the night in the 1960s, 20 years later. All my friends who were in Viet Nam suffered a variety of problems (drug and alcohol abuse high on that list) based on their experience there. As a nation, we need to embrace the reality that no one ever comes home from war intact. Some are just more injured than others. Perhaps this would make us more cautious in deciding to go to war in the first place.

[SteveB]

Here's another question: how do we educate the public about the nature and extent of PTSD without reinforcing the "crazy vets" stereotype?

We know how harmful this stereotype was to vets after Vietnam, so how can we prevent something similar from happening this time around?

[Molly Ivors]

Wow, eRobin, thanks for the great input!

I do wonder whether Edwards' move to privatize psychiatric care is ripping the rug our from under the VA or simply acknowledging that the problem is too big for them to deal with in their current form. It's a fair debate, I think, and much more complex than the soundbites indicate. (To listen to the head of the VA, service delays are "anecdotal" and "a glitch," so suck it up and be patient, guys!) I wonder if the VA could license independent social workers the way the Red Cross does in order to deal with the tsunami of damaged guys they have to deal with. But PTSD has such a long half-life, they might as well bring permanent people on board.

Like Thers, I work at a community college, and we really are the front line of treatment for a lot of these guys coming back and trying to readjust to life here. Our Veteran's Affairs office, I am told, had 7 full-time employees in the late sixties and through the seventies in order to deal with the practical and psychological issues those guys faced. Now we have one part-time person, with the expected results.

[Molly Ivors]

SteveB,
An excellent question, and one for which I don't have an answer. Appropriate mental health treatment, easing financial and health burdens, and providing places where they could meet and talk would be a start. One of my colleagues, a Vietnam vet, is a playwright and is creating a course in writing about the war specifically for vets.

[eRobin]

I didn't know that community colleges dealt with this issue. That's an excellent lead for me. I also taught at a community college for a while (Go Mercer County! Woo!) so I have some numbers I can call right now. THANKS.

[Molly Ivors]

eRobin,
Well, we're not supposed to, technically. But CCs are the place where you transition in life: from high school to adulthood, from your outsourced factory job to your soon-to-be-outsourced IT job, from the military to civilian life. And so we see a lot of young guys just out and somewhat unmoored.

[DoubtingThomas]

eRobin says: The guy drives me crazy - then again, I may be wrong.

I hear this a lot. Edwards takes up the issue that no other candidate will dare to, and yet those who the issue is dear to (eRobin) are "wary" and wonder what he means. It seems to me that if no one else is addressing your issue, than the one guy who does address it should get kudos. What is it about Edwards that drives you crazy, eRobin? he seems to drive the Democratic establishment crazy as well. He appeals to my middle class sensibilities but the Beltway and the Press hold this disdain for him. Same thing with Dean in '04. Maybe you can let me know what it is? Thanks...

[TS]

PTSD primarily affects soldiers with physical wounds, but in fact touches everyone who serves for extended amounts of time in any forward area, including but not limited to combat zones.

You don't need to be wounded; seeing someone who has been hit will do just fine. And for our troops, rotated again and again back to Iraq, it's a continual re-immersion in an environment where you expect that anything can happen -- where you're encouraged to maintain a "healthy paranoia", and it's concurrent high adrenalin levels, as a survival skill.

Day after day of that means that many will end up with some level of PTSD, even without extreme trauma.

[actor212]

This problem becomes even more dramatic when you realize that there are far more brain injuries in this invasion than all the previous conflicts combined.

[Jake T. Snake]

...and if I might add fuel to the fire...it is crucial to have qualified clinicians treating PTSD or you run the risk of actually making the condition worse than it was prior to treatment. Much of what currently passes for treatment actually serves to further develop the neural pathways that trigger the aroused physiological response typical of PTSD i.e. elevated resting pulse and blood pressure, increased startle response etc.

Also a very interesting animal in this age of "all mental illness is biological or genetic", because this disorder is created by the environment or nurture, if you will.

[Molly Ivors]

Jake,
I did some reading about this in WWI--you know me & Freud--and he basically came to the conclusion that shell shock (or "War Trauma") could not be usefully treated on a somatic level. (Granted, 1918 treatments tended to be electroshock, if anything.) These days the guys get bucketloads of meds to calm them down and zonk them out, but I'm not convinced that's better than electroshock.

Rivers was a sort of non-libidinal Freudian who worked in what I guess we'd now call trauma theory. Craiglockhart, which was in Scotland, was where Wilfred Owen and Siegfried Sassoon met, so it's a bit important in literary studies. Because it was only for officers (that is: educated gentlemen), they didn't get electroshock, they got the talking cure. For Sassoon, at least, it seemed to work. They were encouraged to write, to channel their anger about the war and the generals, and to communicate. It was one of the most fertile literary scenes of the 20th c.

Now, soldiers having trouble coping are not even allowed to be seen in public.

[protected static]

You don't need to be wounded; seeing someone who has been hit will do just fine.

Actually, you don't even need that. Just living long enough with the continual threat of being killed or wounded can bring on PTSD.

[protected static]

Molly --

There's some good research being done on (and good clinical results coming from ) non-drug treatments for PTSD right now. My wife is involved in a massive treatment-dissemination program being run by the VA to get one of these treatments out to as many clinicians as possible.

[hamletta]

There's a documentary about the Universal Studios horror films of the '30s, and one of the commentators brings up WWI as an influence.

He says that medical science had advanced to the point where men who would have died lived, but with horrible, disfiguring injuries.

He cites Abel Gance's J'Accuse! with its scene of ghostly, disfigured soldiers rising from the grave.

And how much has science advanced now? And these brain injuries? Do we know what they are? How they affect these men and women?

No, of course not.

Will we do anything about it? Probably not much.

Every society pisses on the veterans after they're used up.

[flawedplan]

Jake makes the crucial point. PTSD as a legitimate Axis I DSM construct is under attack due to the dominance of the biological model of mental illness. The psychiatrist Sally Satel, advisor of Bush's New Freedom Commission on Mental Health is the most visible and powerful consultant who is behind the lack of funding for vets with PTSD, a disorder she, and many, many other *experts* insist does not count. Here in groovy, progressive Austin, there is no funding for vets, our local mental health authority just this Summer moved from the "psychosocial" model to the medical model of mental illness, and no longer recognizes PTSD as a legitimate mental illness. Vets are completely dependent on the underfunded VA, and victims of non-combat trauma
are SOL. Biopsychiatry has a long arm, it's ideologically and pharma-driven and hurts everyone. The irony is in that vets gave us PTSD, and now all their hard work is being undone for the sake of a thoroughly speculative genetic ideology.

And Steve, the only shame in being crazy occurs in the prejudice and stigma you express. Which is something you can change.

[Jake T. Snake]

Flawed Plan,

I'm confused that the biologically oriented mental health (business) establishment doesn't want to recognize PTSD, because the other fascinating thing about it is that traumatic experiences severe enough to cause PTSD actually cause physical changes as I pointed out in my first post and in some studies changes in the way the brain works structurally i.e. interprets environmental data. This does however shoot to shit the nice neat genetic theories about mental illness which while widely researched HAVE NEVER BEEN PROVEN!

You are correct about the pharmaceutical companies dominating the discourse in psychiatry and mental health. It is just so sad, because at the end of the day, the medications we give people for mental illness just don't work that well and they have horrendous side effects.

Thorazine, for those with an interest in the history and a dark sense of humor, was distributed in this country in the 1930s to farmers by the department of agriculture to????? kill the parasites on their pigs.

This would be amusing if the medications were much better than this now...but they aren't, all the marketing aside.

[Batocchio]

Thanks, Molly. Well done. I've been plotting a new PTSD post, and was actually looking for more WWI material, since several of the accounts I've read of how shell shock was treated are pretty horrific.