Source: The KKK Recruiting Veterans
More than a decade of war in the Middle East has pushed post-traumatic stress disorder (PTSD) to the forefront of public health concerns. The last several years have seen a dramatic increase in the number of Iraq and Afghanistan war veterans seeking help for PTSD,1 shining a spotlight on this debilitating condition and raising critical questions about appropriate treatment options and barriers to care.
While PTSD extends far beyond the military—affecting about eight million American adults in a given year2—the problem is especially acute among war veterans. Not only are recent veterans at higher risk of suffering from PTSD than those in the general population,3 they also face unique barriers to accessing adequate treatment.4 These include the requirement that they have either an honorable or general discharge to access Department of Veterans Affairs (VA) medical benefits, long waiting lists at VA medical centers, and the social stigma associated with mental illness within military communities.4,5 According to a study conducted by the RAND Center for Military Health Policy Research, less than half of returning veterans needing mental health services receive any treatment at all, and of those receiving treatment for PTSD and major depression, less than one-third are receiving evidence-based care.5
PTSD in Combat Veterans
The existence of war-induced psychological trauma likely goes back as far as warfare itself, with one of its first mentions by the Greek historian Herodotus. In writing about the Battle of Marathon in 490 b.c., Herodotus described an Athenian warrior who went permanently blind when the soldier standing next to him was killed, although the blinded soldier himself had not been wounded.6 Such accounts of psychological symptoms following military trauma are featured in the literature of many early cultures, and it is theorized that ancient soldiers experienced the stresses of war in much the same way as their modern-day counterparts.7
The symptoms and syndrome of PTSD became increasingly evident during the American Civil War (1861–1865).8 Often referred to as the country’s bloodiest conflict, the Civil War saw the first widespread use of rapid-fire rifles, telescopic sights, and other innovations in weaponry that greatly increased destructiveness in battle and left those who survived with a myriad of physical and psychological injuries.
The Civil War also marked the start of formal medical attempts to address the psychological effects of combat on military veterans. Jacob Mendez Da Costa (1833–1900), a cardiologist and assistant surgeon in the U.S. Army, undertook research on “irritable heart” (neurocirculatory asthenia) in soldiers, and during the Civil War, this PTSD-like disorder was referred to as “Da Costa’s syndrome.” 9 Da Costa reported in the American Journal of Medical Science that the disorder, marked by shortness of breath, rapid pulse, and fatigue, is most commonly observed in soldiers during times of stress, especially when fear is involved.9
Over the next century of American warfare, PTSD would be described by many different names and diagnoses, including “shell shock” (World War I), “battle fatigue” (World War II), and “post-Vietnam syndrome.” An estimated 700,000 Vietnam veterans—almost 25% of those who served in the war—have required some form of psychological care for the delayed effects of combat exposure.10 The diagnosis of PTSD was not adopted until the late 1970s, and it became official in 1980 with inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.11
Prevalence of PTSD in Veterans
Estimates of PTSD prevalence rates among returning service members vary widely across wars and eras. In one major study of 60,000 Iraq and Afghanistan veterans, 13.5% of deployed and nondeployed veterans screened positive for PTSD,12 while other studies show the rate to be as high as 20% to 30%.5,13 As many as 500,000 U.S. troops who served in these wars over the past 13 years have been diagnosed with PTSD.14
It is not clear if PTSD is more common in Iraq and Afghanistan veterans than in those of previous conflicts, but the current wars present a unique set of circumstances that contribute heavily to mental health problems. According to Paula P. Schnurr, PhD, Executive Director of the VA National Center for PTSD, the urban-style warfare tactics in Afghanistan and Iraq, marked by guerrilla attacks, roadside improvised explosive devices, and the uncertain distinction between safe zones and battle zones, may trigger more post-traumatic stress in surviving military members than conventional fighting.15
In addition, Dr. Schnurr notes, improvements in protective gear and battlefield medicine have greatly increased survivability—but at a high price. “Between the way we’re protecting the troops and responding to injuries on the ground, a lot of soldiers are surviving with very significant injuries who would not necessarily have survived before,” she says. “And they’re returning stateside with both the physical and psychological trauma.”
Comorbidity of PTSD in Veterans
Complicating the diagnosis and assessment of PTSD in military veterans are the high rates of psychiatric comorbidity.2 Depression is the most common comorbidity of PTSD in veterans. Results from a large national survey show that major depressive disorder (MDD) is nearly three to five times more likely to emerge in those with PTSD than those without PTSD.16 A large meta-analysis composed of 57 studies, across both military and civilian samples, found an MDD and PTSD comorbidity rate of 52%.17
Other common psychiatric comorbidities of PTSD in military veterans include anxiety and substance abuse or dependence.18–20 The National Vietnam Veterans Readjustment Study, conducted in the 1980s, found that 74% of Vietnam veterans with PTSD had a comorbid substance use disorder (SUD).21 In one study of recent veterans, 63% of those who met the diagnostic criteria for alcohol use disorders (AUDs) or drug use disorders had co-occurring PTSD, while the PTSD prevalence among those who met criteria for both AUDs and drug use disorders (e.g., alcohol dependence and cocaine abuse) was 76%.22
Studies also suggest that veterans with comorbid PTSD and SUD are more difficult and costly to treat than those with either disorder alone because of poorer social functioning, higher rates of suicide attempts, worse treatment adherence, and less improvement during treatment than those without comorbid PTSD.23,24
PTSD is associated with physical pain symptoms, as well. For veterans returning from Iraq and Afghanistan, chronic pain continues to be one of the most frequently reported symptoms.25,26Approximately 15% to 35% of patients with chronic pain also have PTSD.27
Risk Factors for PTSD in Veterans
A number of factors have been shown to increase the risk of PTSD in the veteran population, including (in some studies) younger age at the time of the trauma, racial minority status, lower socioeconomic status, lower military rank, lower education, higher number of deployments, longer deployments, prior psychological problems, and lack of social support from family, friends, and community (Table 1).28 PTSD is also strongly associated with generalized physical and cognitive health symptoms attributed to mild traumatic brain injury (concussion).29
Female gender has also been implicated as a potential risk factor for PTSD in veterans.28,30 A number of factors may account for these findings, including a history of military or civilian sexual assault, which may increase a woman’s risk for PTSD.31 According to one study, during 2002–2003, approximately 22% of screened female veterans reported military sexual trauma (MST), a term adopted by the VA to refer to sexual assault or repeated threatening sexual harassment that occurred while the veteran was in the military.32
Despite numerous studies, according to Dr. Schnurr, whether PTSD is a greater risk to female veterans than male veterans is still largely unknown. However, she says that as women continue to play more active roles in the wars in Iraq and Afghanistan and are increasingly exposed to combat situations, their likelihood of experiencing PTSD rises.
More research is needed to better understand these and other risk factors for PTSD and to help clinicians and other care providers offer the necessary treatment before symptoms become chronic.28 Several large VA studies are under way that include both psychological and neurobiological measurement, Dr. Schnurr says. She notes the benefit of studying the effects of war-related acute stress in real time, using both pre- and post-deployment assessments, as well as data from military members currently in theater. “These wars have given us the best opportunity to longitudinally track what happens to people and to examine the risk and resilience factors associated with the outcomes,” she adds.
Defining and Redefining PTSD
The VA defines PTSD as “the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury.” 29 In addition to military combat, PTSD can result from the experience or witnessing of a terrorist attack, violent crime and abuse, natural disasters, serious accidents, or violent personal assaults.
In 2013, the American Psychiatric Association revised the PTSD diagnostic criteria in the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5),33 moving PTSD from the class of “anxiety disorders” into a new class of “trauma and stressor-related disorders.” As such, all of the conditions included in this classification require exposure to a traumatic or stressful event as a diagnostic criterion. DSM-5 categorizes the symptoms that accompany PTSD into four “clusters”:
Intrusion—spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress
Avoidance—distressing memories, thoughts, feelings, or external reminders of the event
Negative cognitions and mood—myriad feelings including a distorted sense of blame of self or others, persistent negative emotions (e.g., fear, guilt, shame), feelings of detachment or alienation, and constricted affect (e.g., inability to experience positive emotions)
Arousal—aggressive, reckless, or self-destructive behavior; sleep disturbances; hypervigilance or related problems.33
PTSD can be either acute or chronic. The symptoms of acute PTSD last for at least one month but less than three months after the traumatic event. In chronic PTSD, symptoms last for more than three months after exposure to trauma.34
PTSD Diagnosis and Assessment
Two main types of measures are used to help diagnose PTSD in veteran populations and assess its severity: structured interviews and self-report questionnaires.34 The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is considered the gold standard for PTSD assessment in both veterans and civilians.35 The detailed 30-item interview has proven useful across a wide variety of settings and takes approximately 30 to 60 minutes to administer.
The well-validated PTSD Checklist for DSM-5 (PCL-5) is one of the most commonly used self-report measures of PTSD.36 Administration of the 20-item questionnaire is required by the VA for veterans being treated for PTSD as part of a national effort to establish PTSD outcome measures. The PCL-5 can be completed in five to seven minutes.36
Another widely used self-report measure for veterans is the Mississippi Scale for Combat-Related PTSD, a 35-item questionnaire in which respondents are asked to rate how they feel about each item using a five-point Likert scale (e.g., “Before I entered the military, I had more close friends than I have now.” [1 = not at all true to 5 = extremely true]).37
Nonpharmacological Treatment Of PTSD in Veterans
The use of psychological interventions is regarded as a first-line approach for PTSD by a range of authoritative sources.38–40 Of the wide variety of psychotherapies available, cognitive behavioral therapy (CBT) is considered to have the strongest evidence for reducing the symptoms of PTSD in veterans and has been shown to be more effective than any other nondrug treatment.41
Two of the most studied types of CBT—cognitive processing therapy (CPT) and prolonged exposure (PE) therapy—are recommended as first-line treatments in PTSD practice guidelines around the world, including the guideline jointly issued by the VA and the Department of Defense (DoD).29,38–42
First developed to treat the symptoms of PTSD in sexual assault victims,42 CPT focuses on the impact of the trauma. In CPT, the therapist helps the patient identify negative thoughts related to the event, understand how they can cause stress, replace those thoughts, and cope with the upsetting feelings.
PE therapy has been shown to be effective in 60% of veterans with PTSD.43 During the treatment, repeated revisiting of the trauma in a safe, clinical setting helps the patient change how he or she reacts to memories of traumatic experiences, as well as learn how to master fear- and stress-inducing situations moving forward. PE and CPT treatments each take approximately 12 weekly sessions to complete.44,45
Once highly controversial, eye-movement desensitization and reprocessing (EMDR) has been gaining acceptance and is now recommended as an effective treatment for PTSD in both civilian and combat-related cases in a wide range of practice guidelines.29,40,46,47 In EMDR, the therapist guides patients to make eye movements or follow hand taps, for instance, at the same time they are recounting traumatic events. The general theory behind EMDR is that focusing on other stimuli while revisiting the experience helps the patient reprocess traumatic information until it is no longer psychologically disruptive.
Pharmacotherapy of PTSD in Veterans
Some patients do not respond adequately to nondrug treatment alone, may prefer medications, or may benefit from a combination of medication and psychotherapy. In these cases, pharmacotherapy is also recommended as a first-line approach for PTSD.38–40
Selective Serotonin Reuptake Inhibitors
Antidepressants are currently the preferred initial class of medications for PTSD, with the strongest empirical evidence available to support the use of the selective serotonin reuptake inhibitors (SSRIs).48Currently, sertraline and paroxetine are the only drugs approved by the Food and Drug Administration (FDA) for the treatment of PTSD.49
All other medications for PTSD are used off-label and have only empirical support and practice guideline support.49 These include the SSRI fluoxetine and the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine, which are recommended as first-line treatments in the VA/DoD Clinical Practice Guideline for PTSD. Venlafaxine acts primarily as an SSRI at lower dosages and as a combined SNRI at higher dosages.
Although SSRIs are associated with an overall response rate of approximately 60% in patients with PTSD, only 20% to 30% of patients achieve complete remission.50 In a study of extended-release (ER) venlafaxine, the response rate was 78%, and the remission rate was 40% (both assessed with an abbreviated version of CAPS) in patients with PTSD.51 Hyperarousal, however, did not show significant improvement. The ER formulation of venlafaxine is approved for patients with major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder.52
Second-line therapies for PTSD are less strongly supported by evidence and may have more side effects. They include nefazodone, mirtazapine, tricyclic antidepressants, and monoamine oxidase inhibitors.53–55Prazosin has been found to be effective in randomized clinical trials in decreasing nightmares in PTSD. It blocks the noradrenergic stimulation of the alpha1 receptor. Its effectiveness for PTSD symptoms other than nightmares has not been determined at this time.56,57
Antidepressants have been the central focus of pharmacotherapy research in PTSD, but better treatments are greatly needed. “Right now, the interest is in novel medication development rather than simply relying only on the SSRIs that we have because we only get so far with them,” Dr. Schnurr says.
Researchers are looking closely at the role of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and the excitatory neurotransmitter glutamate in PTSD. Both GABA and glutamate play a role in encoding fear memories, and therapeutic research targeting these systems may open new avenues of treatment for PTSD. For example, the novel multimodal anti depressant vortioxetine (Trintellix, Takeda) modulates GABA and glutamate neurotransmission.
According to ClinicalTrials.gov, several ongoing studies are investigating the efficacy of vortioxetine and another new multimodal antidepressant, vilazodone (Viibryd, Allergan), in PTSD. Both drugs have been approved by the FDA for the treatment of depression but not for PTSD.
Anticonvulsants or antiepileptic drugs, which affect the balance between glutamate and GABA by acting indirectly to affect these neurons when their neuronal receptor sites are activated, could also provide a useful option in treatment of PTSD symptoms in patients who fail first-line pharmacotherapy. Topiramate, an anticonvulsant used to treat certain types of seizures, has demonstrated promising results in randomized controlled trials with civilians and veterans with PTSD.58 Topiramate is currently listed in the VA/DoD Clinical Practice Guideline for PTSD as having no demonstrated benefit, and further studies are needed regarding the place of this drug in PTSD treatment.59
Clinical research also suggests that smoking cannabis (marijuana) is associated with reduced PTSD symptoms in some patients. One study indicated that PTSD patients reported an average 75% reduction in CAPS symptom scores while using cannabis.60
Although the use of medical marijuana to treat PTSD remains controversial, recent actions by the federal government have brought veterans closer to being able to obtain medical marijuana. In April 2016, the Drug Enforcement Administration approved the first-ever controlled clinical trial to study the effectiveness of cannabis as a treatment for PTSD in military veterans, and in May, Congress voted to lift a federal ban that has prevented veterans’ access to medical marijuana through the VA in states that allow it. Medical marijuana is legal in 23 states and the District of Columbia for the treatment of glaucoma, cancer, human immunodeficiency virus, and other conditions.
Suggested nonpharmacological and pharmacological treatments for PTSD are listed in Table 2.
Combined Pharmacotherapy and Psychotherapy
Medications and psychotherapies are used both separately and in combination to treat the symptoms of PTSD, as well as related comorbid diagnoses. Guidelines suggest a combination may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either approach alone.61 For example, studies have shown combined SSRIs and psychotherapy appear to be more effective than treatment with either intervention used alone.62
Reducing Benzodiazepine Use Among Veterans
The VA/DoD Clinical Practice Guideline for PTSD cautions against any use of benzodiazepines to manage core PTSD symptoms because evidence suggests that they are not effective and may even be harmful.29However, despite this guidance, almost one-third of VA patients being treated for PTSD nationally were prescribed benzodiazepines in 2012, says Nancy Bernardy, PhD, Associate Director for Clinical Networking at the VA National Center for PTSD.
According to Dr. Bernardy, the rates of benzodiazepine use among veterans with PTSD are declining, but focused interventions are needed to achieve further reductions. She says the VA is studying the use of an academic detailing approach to share decision support tools around the appropriate use of these drugs.63The initiative targets subgroups of veterans with PTSD in which there are increased rates of benzodiazepine prescription, including those with comorbid substance use disorders and those with comorbid traumatic brain injury. Designed to be used by providers with their patients, the decision support tools incorporate safety concerns related to the targeted subgroups and offer tapering guidance and information on alternative, evidence-based treatments for PTSD.
“It’s taken a while, but we’re beginning to see success,” Dr. Bernardy says of the initiative, adding that the involvement of family members is an integral part of the tapering process. The VA is also looking at other models for increasing engagement in evidence-based PTSD treatment through shared decision-making.
“Shared decision-making has not been used widely,” Dr. Bernardy says. “So we are trying to create a culture where providers meet with patients and discuss PTSD treatment options—the pros and cons of each—and then let patients and family members make the best decisions for their care.”
For patients with PTSD who do not respond to initial drug treatment, it may be necessary to explore additional pharmacotherapy options to control their symptoms. A number of pharmacological agents, including antipsychotics, antiadrenergic drugs, and anxiolytics, have also demonstrated some efficacy in treating PTSD.64,65
However, for most pharmacological therapies, there is inadequate evidence regarding efficacy for PTSD, pointing to the need for more clinical studies in this area.66 According to Dr. Schnurr, psychotherapy remains the most effective treatment for PTSD. “Antidepressants may be effective,” she says, “but we see more results—and we also see more durable results—with the psychotherapies because they essentially go to the heart of helping the patient address the problem.”
Economic and Societal Burden of PTSD
The need for better solutions is shown by the immense economic and societal burden of PTSD. First-year treatment alone for Iraq and Afghanistan veterans treated through the VA costs more than $2 billion, or about $8,300 per person.67 Health care costs for veterans with PTSD are 3.5 times higher than costs for those without the disorder.67 According to the VA, PTSD was the third most prevalent disability for veterans receiving compensation in 2012 (572,612 veterans), after hearing loss and tinnitus.68
PTSD and Suicide
Veterans now account for 20% of all suicides in the U.S., with the youngest (18–24 years of age) four times more likely to commit suicide than their nonveteran counterparts of the same age. An estimated 18 to 22 veterans die from suicide each day.69 According to a recent study published in JAMA Psychiatry, the likelihood of suicide increases once a person leaves active military service, and that risk is further increased in veterans whose service time was less than four years.70
The association between PTSD and suicide has been a subject of debate, with some studies showing that PTSD alone is associated with suicidal ideation and behavior,71,72 and others indicating that the higher risk is due to comorbid psychiatric conditions.73
Barriers to Effective PTSD Treatment
Despite efforts to increase access to appropriate mental health care, many military veterans continue to face barriers to getting PTSD treatment. The largest single barrier to timely access to care, according to a VA audit, is the lack of provider appointment availability.74 An acute shortage of doctors in the VA, particularly in primary care, combined with the rising population of veterans seeking treatment, has led to months-long waiting times.75
Poor availability of mental health services in many parts of the U.S. also presents a significant barrier for Iraq and Afghanistan veterans and their families.76 Mental health specialists tend to concentrate in larger urban areas, and even in those areas, there are disparities in the per capita number of psychiatrists. Some rural areas have none.77,78 According to the VA Office of Rural Health, veterans from these areas are less likely than urban veterans to access mental health services, in part because of the greater distances they must travel.79
One of the most frequently cited barriers to veterans getting timely and adequate care for PTSD is the social stigma associated with mental illness.80,81 Research indicates that service members may feel ashamed and embarrassed to seek treatment, perceive mental illness as a sign of a weakness, or feel that it is possible to “tough it out.”81
According to Dr. Schnurr, considerable effort has been made to destigmatize seeking mental health treatment among military veterans. For example, the VA is developing initiatives to enhance collaborative care services that integrate mental and physical health, which is thought to help minimize the stigma associated with PTSD. Additionally, the VA has implemented various outreach initiatives, such as the “About Face” awareness campaign, a series of online videos that introduces viewers to veterans who have experienced PTSD and provides guidance on seeking care.
“It’s a culture change,” Dr. Schnurr says. “By working at both the community level and within the system, we are trying to comprehensively make the changes that will make it easier for veterans to recognize that they need help and then to seek help.”
In an effort to address access to care issues, the VA is focusing on telehealth or the use of tele communications technology to provide behavioral health services to veterans diagnosed with PTSD. Telehealth, which can be both convenient and destigmatizing, has particular potential in rural areas, where a large portion (38%) of VA enrollees diagnosed with PTSD live. A recent study of rural veterans with PTSD showed that receiving psychotherapy and related services via telephone or video conferencing can have positive effects, including the initiation of and adherence to appropriate treatment.82
In another study of rural veterans in VA care, patients who received treatment remotely had greater reductions in PTSD scores at six months and at one year than those who were offered on-site care. According to the researchers, participants in the telemedicine group were much more likely to engage in their own care, a critical component of recovery.82
Community-Based PTSD Care
Research indicates that community-based mental health providers are not well prepared to take care of the special needs of military veterans and their families, including evidence- based treatment of PTSD and depression.83 According to Dr. Schnurr, there has not been sufficient dissemination and implementation of the most effective psychotherapies in community-based settings, such as primary care practices, behavioral health centers, substance-abuse treatment facilities, and hospital trauma centers. To help meet these needs, the VA developed the PTSD Consultation Program for Community Providers (vog.av@tlusnocDSTP), which offers free education, training, information, consultation, and other resources to non-VA health professionals who treat veterans with PTSD.
A number of initiatives across the country provide training and/or treatment support to providers who offer services to veterans with PTSD. The Center for Deployment Psychology, a nationwide network of medical centers, trains military and civilian behavioral health professionals to address the emotional and psychological needs of military personnel and their families through live presentations, online learning resources, ongoing consultation, and education.84 Star Behavioral Health Providers is a resource for veterans, service members, and their families to locate behavioral health professionals with specialized training in understanding and treating military service members and their families.85 The service is currently offered in California, Michigan, New York, Indiana, Ohio, Georgia, and South Carolina.
Challenges and Opportunities Ahead
While many important advancements have been made over the past few decades in understanding and treating symptoms of PTSD, the rising number of American veterans who suffer from the disorder continues to be a serious national public health problem. Cognitive behavioral therapy is a widely accepted method of treatment for PTSD, but there is clearly an urgent need to identify more effective pharmacological approaches for the management of symptoms, as not all patients will respond adequately to psychotherapy or evidence-based/first-line pharmacotherapy. Further understanding of the underlying physiological and neurological processes will be helpful in developing new and effective therapies to treat PTSD.
Research also suggests further opportunities for the VA and other health care systems to develop new and innovative ways to overcome barriers to treating veterans with PTSD. With veterans and their families increasingly seeking care outside of the VA system, community providers play a key role in helping to address these challenges. It is critical they receive the education, training, and tools to improve their understanding of and skills for addressing the needs of this unique population.
Link to article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047000/
Post-traumatic Stress Disorder (PTSD) and Veterans Resource Guide
These resources focus on PTSD as a result of combat or military exposure. Many voices are calling for the church to be a significant partner in the complex readjustment process of returning home.
Post-traumatic Stress Disorder (PTSD) is an anxiety disorder that can occur after one has been through a traumatic event. The resources on this page focus on PTSD as a result of combat or military exposure.
Recent reports indicate that one of the major consequences of all warfare is PTSD. Some studies indicate that as many as 18% of returning combat veterans struggle with some significant mental health issues. Department of Defense medical authorities now estimate that as many as 30% of returning Army Reserve and Guard members struggle with such issues four to six months after returning.
Many voices are calling for the church to be a significant partner in the complex readjustment process of returning home. Leaders now tell us that awareness of this need should be heightened, and we can prepare to more effectively walk with a veteran who is making the transition home from war. Those who understand the need advise: become informed, pay attention to what is happening, avoid judging the veteran, gently shepherd the veteran to resources available, and hold them in love.
These materials are provided to enable the church and families to be more alert to the needs of veterans and to understand how to help.
- My Refuge and Strength – Psalm 46
- The God of Healing – 2 Kings 5
- What A Friend We Have in Jesus – Isaiah 61, Matthew 11
- Worship service idea from Reformed Worship
- Hymns focused on healing
- Guiding Questions for Planning a Service of Worship During a Time of War
O God, you are the one who looks way down deep inside of all of us. You see and know what no one knows, no one at all except we ourselves. And, not only do you see us and know us, but you also feel things along with us, even the very painful stuff, the deep stuff along with us, and we feel a strange kind of healing taking place. For it’s like you care and you understand…and we’re no longer left alone with our burdens.
Today, those of us who are struggling inside—who’ve been broken and hurt and still feel the tears within—we thank you for being there and sharing with us what we cannot bear alone.
– from a prayer by VA Chaplain Richard A. Lutz
Mission: Travis Manion Foundation (TMF) empowers veterans and families of fallen heroes to develop character in future generations. In 2007, 1stLt Travis Manion (USMC) was killed in Iraq while saving his wounded teammates. Today, Travis’ legacy lives on in the words he spoke before leaving for his final deployment, “If Not Me, Then Who…” Guided by this mantra, veterans continue their service, develop strong relationships with their communities, and thrive in their post-military lives. As a result, communities prosper and the character of our nation’s heroes live on in the next generation.
Target demographics: Veterans, families of the fallen, and our nation’s youth.
Direct beneficiaries per year: 150,000+ YOUNG ADULTS, 60,000+ VETERANS & SURVIVORS, and 4,000+ VOLUNTEERS
Geographic areas served: We are a national foundation.
Programs: THE TRAVIS MANION FOUNDATION (TMF) EMPOWERS VETERANS AND THE FAMILIES OF FALLEN HEROES TO DEVELOP CHARACTER IN FUTURE GENERATIONS. IN 2007, 1ST LT TRAVIS MANION (USMC) WAS KILLED IN IRAQ WHILE SAVING HIS WOUNDED TEAMMATES. TODAY, TRAVIS’ LEGACY LIVES ON IN THE WORDS HE SPOKE BEFORE LEAVING FOR HIS FINAL DEPLOYMENT, “IF NOT ME, THEN WHO…”
Mission: Soldiers’ Angels is a volunteer-led 501(c)(3) non-profit organization providing aid and comfort to the men and women of the United States Army, Marines, Navy, Air Force, Coast Guard, and their families. Founded by the mother of two American soldiers, we have hundreds of thousands of volunteers assisting veterans, wounded and deployed personnel and their families in a variety of unique and effective ways. Soldiers’ Angels responds quickly to requests for support and provides individualized, immediate assistance. It is a “one-on-one, get it done quickly” organization. Our volunteer Angels at home adopt individual deployed troops and stay in touch throughout their deployment. Wounded soldiers and their families are asked what they need, and Soldiers’ Angels responds in a hundred different ways: voice-activated computers; financial assistance for loved ones to stay with their wounded family member; phone cards to call relatives who can’t visit as often as they wish, etc. Both the organization and the program have grown, but, unfortunately, the needs of our deployed soldiers and their families are growing even faster. This is especially true for our young men and women who are wounded. The government is providing first-class medical care for our wounded soldiers, but it will never be able to provide all of what they deserve and so many services desperately needed by their families. Soldiers’ Angels works closely with the Department of Defense, the nation’s major veterans groups and a variety of other military support organizations to make sure these brave young men and women who are being helped.
Target demographics: the men and women of the United States Army, Marines, Navy, Air Force, Coast Guard, their families, and Veterans of all eras.
Geographic areas served: the United States and around the world
Programs: – Adopt a Soldier: Individualized support throughout deployment – Angel Bakers: Homemade treats for the deployed – Chaplain Support Team: Help chaplains support the troops – Ladies of Liberty: Extra TLC for deployed females – Letter Writing Team: Personal letters for the deployed – SA Germany: Supporting medevac’d wounded/ill and medical staff at Landstuhl – Valour-IT: Providing adaptive laptops for the severely wounded or injured – VA Hospital Support – Living Legends: Comforting the loved ones left behind when a warrior falls on the battlefield – Operation Top Knot: Handmade gifts & virtual baby showers – Adopt-A-Family: Holiday adoption program to support a family’s holiday needs – Women of Valor: Support to female caregivers of Post 9-11 wounded, ill and injured service members. – Sewing Team: Handmade blankets, scarves and pillowcases – Cards Plus Team: Extra TLC for soldiers and families
Perl’s findings, published in the scientific journal The Lancet Neurology, may represent the key to a medical mystery first glimpsed a century ago in the trenches of World War I. It was first known as shell shock, then combat fatigue and finally PTSD, and in each case, it was almost universally understood as a psychic rather than a physical affliction. Only in the past decade or so did an elite group of neurologists, physicists and senior officers begin pushing back at a military leadership that had long told recruits with these wounds to “deal with it,” fed them pills and sent them back into battle.
If Perl’s discovery is confirmed by other scientists — and if one of blast’s short-term signatures is indeed a pattern of scarring in the brain — then the implications for the military and for society at large could be vast. Much of what has passed for emotional trauma may be reinterpreted, and many veterans may step forward to demand recognition of an injury that cannot be definitively diagnosed until after death. There will be calls for more research, for drug trials, for better helmets and for expanded veteran care. But these palliatives are unlikely to erase the crude message that lurks, unavoidable, behind Perl’s discovery: Modern warfare destroys your brain.
The physics behind blast forces was almost unknown until the modern era, and it remains so mysterious and terrifying that scientists sometimes invoke the word “magic” when talking about it. A blast begins simply: A detonator turns a lump of solid matter into a deadly fireball. Within that moment, three distinct things happen. The first is the blast wave, a wall of static pressure traveling outward in all directions faster than the speed of sound. Next, a blast wind fills the void and carries with it any objects it encounters. This is the most manifestly destructive part of the blast, capable of hurling cars, people and shrapnel against buildings and roadsides. The remaining effects include fire and toxic gases, which can sear, poison and asphyxiate anyone within range.
The effects of all of this on the human body are myriad and more complicated than the blast itself. People who have been exposed to blasts at close range usually describe it as an overpowering, full-body experience unlike anything they have ever known. Many soldiers do not recall the moment of impact: it gets lost in the flash of light, the deafening sound or unconsciousness. Those who do remember it often speak of a simultaneous punching and squeezing effect, a feeling at once generalized and intensely violent, as if someone had put a board against your body and then struck it with dozens of hammers. From a distance, a blast makes a distinctive thump, the sound of air pressure clapping outward. When I lived in Baghdad, reporting for this newspaper, I would sometimes be awakened by that sound early in the morning. I would sit up in bed, instantly alert, with a surreal and awful realization: Someone who was just as healthy as me 30 seconds ago has been shredded to pieces.
Credit Greg Kahn for The New York Time.
Trinitrotoluene, or TNT, was first used in artillery shells by the German Army in 1902. Soon after the First World War started in 1914, a rain of these devices was falling on the hapless men on each side of the front. It was a level of violence and horror far beyond the cavalry charges of earlier wars. Very quickly, soldiers began emerging with bizarre symptoms; they shuddered and gibbered or became unable to speak at all. Many observers were struck by the apparent capacity of these blasts to kill and maim without leaving any visible trace. The British journalist Ellis Ashmead-Bartlett famously described the sight of seven Turks at Gallipoli in 1915, sitting together with their rifles across their knees: “One man has his arm across the neck of his friend and a smile on his face as if they had been cracking a joke when death overwhelmed them. All now have the appearance of being merely asleep; for of the several I can only see one who shows any outward injury.”
For those who survived a blast and suffered the mysterious symptoms, soldiers quickly coined their own phrase: shell shock. One period lyric went like this:
Perhaps you’re broke and paralyzed
Perhaps your memory goes
But it’s only just called shell shock
For you’ve nothing there that shows.
One British doctor, Frederick Mott, believed the shock was caused by a physical wound and proposed dissecting the brains of men who suffered from it. He even had some prescient hunches about the mechanism of blast’s effects: the compression wave, the concussion and the toxic gases. In a paper published in The Lancet in February 1916, he posited a “physical or chemical change and a break in the links of the chain of neurons which subserve a particular function.” Mott might not have seen anything abnormal in the soldiers’ brains, even if he had examined them under a microscope; neuropathology was still in its infancy. But his prophetic intuitions made him something of a hero to Perl.
Mott’s views were soon eclipsed by those of other doctors who saw shell shock more as a matter of emotional trauma. This was partly a function of the intellectual climate; Freud and other early psychologists had recently begun sketching provocative new ideas about how the mind responds to stress. Soldiers suffering from shell shock were often described as possessing “a neuropathic tendency or inheritance” or even a lack of manly vigor and patriotic spirit. Many shell-shock victims were derided as shirkers; some were even sentenced to death by firing squad after fleeing the field in a state of mental confusion.
This consensus held sway for decades, even as the terminology shifted, settling in 1980 on “post-traumatic stress disorder,” a coinage tailored to the unique social and emotional strain of returning veterans of the war in Vietnam. No one doubted that blasts had powerful and mysterious effects on the body, and starting in 1951, the U.S. government established the Blast Overpressure Program to observe the effects of large explosions, including atomic bombs, on living tissue. One of my uncles recalls standing in the Nevada desert as an Army private in 1955, taking photographs of a nuclear blast amid a weird landscape of test objects: cars, houses and mannequins in Chinese and Soviet military uniforms. At the time, scientists believed blasts would mainly affect air pockets in the body like the lungs, the digestive system and the ears. Few asked what it would mean for the body’s most complex and vulnerable organ.
Only after yet another European war broke out did scientists begin looking again at blast’s effects on the brain. When the Balkans collapsed into fratricidal violence in the early 1990s, Ibolja Cernak, a small, tenacious woman who grew up in the countryside of what is now Serbia, was working as a doctor and researcher at a military hospital in Belgrade. She soon began seeing large numbers of soldiers with blast trauma, usually from mortars and artillery fire, a common feature of that war. As in World War I, the men often suffered from striking mental impairments but few visible wounds. Cernak, whose colleagues call her Ibi, has an appealing blend of briskness and warmth, along with a clinician’s conviction that you must listen to your patients. It is easy to imagine her running around the battlefields of Bosnia and Serbia, collecting blood samples from soldiers. That is what she did for several years, at no small risk to her life, for a study cataloging the neurological effects of blast on 1,300 recruits. “The blast covers the entire body,” she told me. “It has a squeezing effect. Ask soldiers what they felt: The first thing they say is that their ears were popped out, they were gasping for air, like some huge fist is squeezing them. The entire body is involved in that interaction.”
Cernak became convinced that blast ripples through the body like rings on a pond’s surface. Its speed changes when it encounters materials of different density, like air pockets or the border between the brain’s gray and white matter, and can inflict greater damage in those places. As it happens, physicists would later theorize some very similar models for how blast damages the brain. Several possibilities have now been explored, including surges of blood upward from the chest; shearing loads on brain tissue; and the brain bouncing back and forth inside the skull, as happens with concussion. Charles Needham, a renowned authority on blast physics, told me post-mortems on blast injuries have lent some support to all of those theories, and the truth may be that several are at play simultaneously.
A decade after her initial battlefield surveys in the Balkans, Cernak took a position at Johns Hopkins University in Baltimore, where she did animal research that bolstered her conviction about blast’s full-body effects. She found that even if an animal’s head is protected during a blast, the brain can sustain damage, because the blast wave transfers through the body via blood and tissue. Cernak also came to believe that blast injuries to the brain were cumulative and that even small explosions with no discernible effects could, if repeated, produce terrible and irreversible damage. Much of this would later be confirmed by other scientists.
Even Cernak’s limited conclusions about blast injuries were heresy to much of the military-medical establishment at the time. She presented some of her findings at a conference in Vienna in the late 1990s, and before she was even finished, “an older gentleman stood up, a military doctor from the U.S.A.,” she recalled. “He said: ‘Stop with this nonsense. If you give soldiers fluid replacement, they’ll do fine after 24 hours, so it’s not this.’ … I was taken aback. It’s been an uphill battle.”
Credit Australian War Memorial
It was not until 2001, when America embarked on what became an era of constant warfare, that doctors began to move slowly toward Cernak’s way of thinking. A new generation of more powerful roadside bombs — improvised explosive devices, or I.E.D.s, in military parlance — became a signature of the fighting in Iraq and Afghanistan, yielding an epidemic of blast injury. Medics soon noticed an oddity of blast: It reflects off hard surfaces and multiplies, so that people who appear to be protected inside an enclosed space like a Humvee often suffer much worse brain injuries than those outside. Military and civilian researchers began focusing their work on the brain rather than just the body. But it was still very difficult to isolate blast from all the other physical and mental effects of being exposed to an explosion in a combat zone.
A landmark advance came in 2007, when an engineering firm called Applied Research Associates received a call from the SWAT team of the Arapahoe County Sheriff’s Office in Colorado. The officers were worried about possible neurological effects from breaching, the practice of blowing open doors with small explosive charges. Almost every major city in the United States has breacher teams, as do militaries in war zones. The Applied Research team quickly recognized that monitoring breachers would allow them to observe blast in its pure form, because the charges are too small to knock soldiers over or give them concussions; they are subject to the blast wave only. Plus, the researchers could bypass any ethical concerns about running tests on human subjects, because the breachers were doing it anyway.
The Applied Research team quickly designed and led a study on military breachers, rigging its own blast gauges and subjecting the recruits and trainers to neuropsychological tests at the beginning and end of a two-week breaching course. The resulting report, circulated in 2008, found a small but distinct decline in performance among the instructors, who are exposed to far more blasts than students. It was only a pilot study, but one author, Leanne Young, told me it added to “converging evidence that there is a cumulative effect with chronic exposure to blast,” even at relatively low levels.
The military was still reluctant to take blast seriously or even to concede that the symptoms it caused were a matter of physical harm. As late as 2008, researchers at the Walter Reed Army Institute of Research published a paper suggesting that the symptoms of traumatic brain injury could be caused in large part by PTSD and brushing off “theoretical concern” about neurological effects of the blast wave. By that time, American doctors who had gained Cernak’s unusual blend of medical expertise and battle experience were starting to draw their own conclusions.
One of the first to challenge the military from within was a 44-year-old Army lieutenant colonel named Christian Macedonia. In March 2008, Macedonia was in Arlington, Va., listening to a group of scientists and government bureaucrats talk about roadside bombs. The talk was dry and technical, and finally Macedonia, a square-jawed man with an air of urgent candor, could no longer contain himself. He lashed out against the military’s inaction on brain injury, using what he recalls as “some pretty salty language” to make his point. “I see no movement, and I’m kind of sick of it,” he concluded. As the meeting broke up, Macedonia expected other participants to politely avoid him. Instead, a younger aide approached, gave him a business card and urged him to get in touch with Adm. Michael Mullen, then chairman of the Joint Chiefs of Staff. Macedonia contacted Mullen and repeated his pitch. To his surprise, Mullen hired him.
At the time, “you had an entrenched military-medical community that did not want to go down that road,” Macedonia told me. “They didn’t want to give any credence to the idea that these symptoms were anything other than emotional difficulty.” Macedonia, an obstetrician as well as a soldier, knew otherwise. He did a tour in Anbar province in Iraq in 2004 and 2005 with soldiers who were being targeted frequently by mortars and roadside bombs. As an officer and doctor, he felt responsible for younger soldiers and their injuries. “Kids exposed to explosions were asking for help, and I was mouthing the party line: ‘You’ll be O.K.’ I was part of the machine that didn’t help. That’s what haunts me.”
Like Macedonia, some senior officers, including Gen. Peter Chiarelli of the Army and Gen. James Amos of the Marines, were also frustrated. They had seen too many soldiers discharged for disciplinary issues that were related to brain injury. Mullen hired several other experts to join Macedonia, asking them to monitor and improve the treatment of brain injury across the entire military. They called it the “Gray Team” — partly a play on gray matter and partly because the men were mostly in their 40s and going gray. They were an extraordinary group: mostly military officers, all of them had advanced degrees in medicine or science. And almost all of them had seen combat.
One of them was Jim Hancock, an emergency physician and Navy captain whose main qualification, he told me, was that he had suffered a traumatic brain injury himself, in southern Afghanistan. He also suffered concussions twice as a college athlete, so he had a basis for comparison. “The theory at the time was, it was a concussive event,” Hancock told me. “I said, ‘B.S.’ I’ve been concussed. I’ve never had anything like blast.” Like other members of the team, Hancock had noticed that soldiers exposed to blasts often had memory and focus problems that did not go away and that seemed distinct from battlefield trauma. If the blasts were repeated, the lapses sometimes devolved into career-ending mental and behavioral struggles. The Gray Team shared a gut-level belief that a blast wave’s effects on the body were far more extreme, and more complex, than the concussion model could account for. But their main task was to push the military to take brain injury more seriously, whatever its causes.
In early 2009, the Gray Team’s first five members traveled to military bases in Iraq and Afghanistan, meeting with trauma surgeons and other doctors to see how they handled brain injury. They found a wildly inconsistent picture. There were three extraordinary doctors who understood brain trauma and how to handle it. But “our fear was, those three rotate out, and it disappears,” said Dr. Geoffrey Ling, another member of the Gray Team.
Credit Nick Oza for The New York Times
When they got home, the team identified the most valuable practices and, along with Chiarelli and Amos, had them codified. Any soldier who was within 50 meters of a blast or who was in a vehicle behind or ahead of one struck by a bomb would have to be screened for brain injury. Anyone who suffered a concussion would have to be pulled out of combat. The Gray Team used a checklist to help identify concussed soldiers, although they were soon forced to write six different versions of it, because so many Marines memorized the correct answers to avoid being pulled out of combat. They also found a civilian contractor to build blast gauges, like the ones used in the breacher study. Every recruit or officer in a combat zone now wears three of these tiny devices, which weigh 20 grams each. The gauges are designed to turn red if they register a force of more than 12 pounds per square inch, the lower limit indicating a possible concussion or brain injury. The soldiers can no longer brush it off: If your sensor is red, you must be screened for brain injury.
The military has taken the new rules seriously. Less than a year after its first tour, the Gray Team went out to the field again and found that 90 percent of the bases they visited were in compliance. Still, the larger question of blast’s residue inside the skull remained a mystery.
Brandon Matthews is built like a tank, with huge humps of muscle outlining his back and shoulders. Ugly scars run down his biceps and forearms, cutting deep creases into the muscle. Others line his legs and sides, the legacy of an 11-year career as an Army Ranger. Matthews, registered with the military as Brandon Matthew Sipp, was exposed to so many blasts, in Iraq and other places, that he cannot count them all. The worst was a suicide bombing that sent him flying down a corridor and left him in a coma. He was hospitalized for months, and his military career was over. But his struggles with brain injury were only starting.
“I have moments when I forget everything: who I am, where I am, what I’m doing,” he told me. “It happens almost every day,” sometimes while he is driving. Decisions, once easy, have become impossible. He turns the kitchen burner on and then walks out, returning to discover a fire raging.
Matthews has 24 names tattooed down the center of his back. Eighteen are former war buddies who were killed in action. The more painful losses, in a sense, are five others: friends who have killed themselves since returning from the war. One of them, another Special Operations veteran with an undiagnosed traumatic brain injury, threatened his wife and children with a gun six months ago, Matthews told me, then shot himself in the head. Matthews spoke at the funeral. Undiagnosed blast injuries are common among the Special Operations soldiers, he said, because members of this military elite prize their toughness and do not want to risk losing their careers. “Here’s the harsh reality,” another veteran told me. “In the Special Forces especially, if I fail my physical, I’m done. That’s all there is to it. My cool-guy stuff is done.” So they keep their heads down, say nothing and suffer more blasts. Until one day, like Brandon Matthews, they are too damaged to fight.
I met Matthews at a hotel in Scottsdale, Ariz., where he now lives, and within an hour he had consumed several vodka-and-waters. He was warm and talkative, but every now and then he got a lost, plaintive look in his green eyes; I had the impression of a man who is clinging to a precipice. Before I could turn in, he insisted on steering me to a series of nightclubs, where he drank round after round and regaled strangers with his war stories. I asked him about friends, and he told me that almost all of them were dead. He lives on his military pension, and at 33, seems to have given up on holding down a job.
All this is fairly typical of service members and veterans who have suffered serious or repeated blast injuries, I was told by Susan Ullman, who runs an outreach network called Warrior2Warrior. (Ullman’s own husband, a Green Beret who suffered a traumatic brain injury, killed himself in 2013.) When I asked Matthews about other veterans and suicide, he grimaced and unleashed a string of obscenities about the cowardice of taking your own life. It felt cruel, and a little unnecessary, to ask if he had been tempted that way himself. (He has his own name tattooed on his back after those of friends who have killed themselves.)
Even if the underlying wounds of men like Matthews cannot be treated, the symptoms of brain injury, like those of trauma, can often be alleviated. The distinction between organic and emotional injury can be very blurry; trauma changes neuronal patterns, and therapy can alter a brain that has been physically damaged. “Everything we know suggests that people with structural lesion will also respond to pharmacological and psychological treatment,” said David Brody, a neurologist who has worked extensively with the military. Finding the right treatment is the key. Many veterans told me that they had gone to the V.A. and been handed pills indiscriminately. A number of mostly untested treatments have gained traction in the past few years, from hyperbaric chambers to ergonomic mouth guards, and some veterans swear by them.
For all his mental confusion, Matthews told me that he thinks he can now distinguish between the emotional wounds he suffered — the survivor’s guilt, the bad dreams and night terrors — and the more concrete cognitive problems that he traces to his blast exposure. A number of Special Operations soldiers said the same thing. They also said it makes a big difference to be told they have a physical wound rather than a mental one, even if it is incurable. Some brain injuries can now be seen on M.R.I.-type brain scans of living people, though precise diagnoses remain elusive. Matthews told me he would find some solace in simply being able to see what was going on inside his head.
Daniel Perl is continuing to examine the brains of blast-injured soldiers. After five years of working with the military, he feels sure, he told me, that many blast injuries have not been identified. “We could be talking many thousands,” he said. “And what scares me is that what we’re seeing now might just be the first round. If they survive the initial injuries, many of them may develop C.T.E. years or decades later.”
Perl takes some solace from the past. He has read a great deal about the men who suffered from shell shock during World War I and the doctors who struggled to treat them. He mentioned a monument in central England called “Shot at Dawn,” dedicated to British and Commonwealth soldiers who were executed by a firing squad after being convicted of cowardice or desertion. It is a stone figure of a blindfolded man in a military storm coat, his hands bound behind him. At his back is a field of thin stakes, each of them bearing a name, rank, age and date of execution. Some of these men, Perl believes, probably had traumatic brain injuries from blasts and should not have been held responsible for their actions. He has begun looking into the possibility of obtaining brain samples of shellshocked soldiers from that war. He hopes to examine them under the microscope, and perhaps, a century later, grant them and their descendants the diagnoses they deserve.
The support of friends and family members is critical for servicemembers experiencing symptoms of posttraumatic stress disorder (PTSD), especially when many service members choose not to get the help they need because of the stigma that surrounds psychological health care. Paul Rose, the author of this Navy Medicine Live blog post knows this firsthand. Read about how he helped his brother, a U.S. Army veteran, get the help he needed for his combat-related PTSD. And then explore the resources identified at the end of this post to support military members and those who support them.
When my kid brother left for Iraq he was just that — a kid. He returned home shattered inside. The “dark pit,” as he calls it, was hidden underneath his gruff, infantry-tattooed exterior. No one in our family could have predicted what he would experience or the after-effects that continue to haunt him today.
Many sailors, soldiers, Marines and airmen return from deployments with posttraumatic stress disorder. As a family member of a person suffering from PTSD, we must be strong for them in a variety of ways to help them combat the disorder. I received an up-close and personal look at how it can affect a person, when my younger brother came to live with me after separating from the U.S. Army.
Shortly after graduating from the U.S. Army Infantry School at Fort Benning, Ga., my younger brother found his newly-issued boots on the sandy ground in Mosul, Iraq — during a time that would turn out to be one of the bloodiest during the war. His main duties were to provide infantry support to convoys, security detail, and to locate and apprehend insurgents.
He came home with an inescapable burden on his back. He continually woke up, drenched in sweat, with nightmares so real he could still see the terrifying images in his dark room. His mind was filled with the lives he had to take, the friends he lost — some to the enemy, some to suicide — and the near-misses of death’s cold, bony grip on his own neck.
He talked to no one about the sleepless nights and the recurring feelings of depression and hopelessness. The stigma associated with being diagnosed with PTSD kept him from seeking help. The disorder eventually caused him to exit the Army before his enlistment was up. A short time later he’d be living in my finished basement, as my wife and I adjusted to life with our two kids and a newly discharged war veteran.
My brother would continually become overwhelmed with routine things like paying his bills, getting up for work or dealing with relationships. PTSD was winning the battle against him, and he did not know how to fight back. Even after he hung up his uniform, he still carried himself like an invincible infantry soldier. Deep down he knew he needed help, but was still too afraid, ashamed and overwhelmed to seek it.
The year he spent with us was an extremely trying time. As he was learning how to get better, we were learning how to help him. Being a family member of someone who has been diagnosed with combat-related PTSD can be difficult, but the most important thing we did was to provide a stable support system for him.
There were times my brother could be so frustrating that we would get into screaming matches. He would peel out of the neighborhood, the screech of his car tires echoing through the house, and I would pray he came home that night. His behavior became more erratic. I helped him apply for jobs. He would hold one for a short time and then quit, normally after losing his temper or becoming fed-up with it. All of these actions are a correlation to the internal fight he was struggling with.
After much convincing by my wife and I, he finally overcame his fear of the stigma associated with the disorder and went to the local Department of Veterans Affairs (VA) medical center, where he was evaluated and given a service-connected disability for PTSD, as well as for injuring his back while deployed, but most importantly access to the tools and programs to fight it.
The nightmares still remained. We continued our support. I gathered research on the subject, finding that a mix of therapy, medication and a healthy lifestyle could decrease the effects. He started taking a prescribed medication and spoke with social workers at the VA hospital regularly. I dragged him to workouts with me and created healthy athletic competition for us, including intramural sports, which was something he enjoyed and looked forward to all week. We made sure he remembered his appointments, encouraged him in his work and most importantly, ensured that he knew he was a valuable part of our family dynamic. I tried to keep him from getting overwhelmed by telling him to take things “one day at a time.” It became a mantra for us.
It’s been a few years since my brother was in Iraq with an M4 slung over his shoulder. And he’s a long way from the 8-year-old who dug foxholes in my mother’s backyard while dreaming of being a soldier. He would never take back his time in the Army and believes very much in his mission in Iraq. When he eventually made me one of the few people he shared his experiences with, he confessed with tear-filled eyes of times he came close to taking his own life. He assured me that war is not glorious or heroic. He did what he had to do because the soldiers serving beside him needed him, and each one of them would have done the same thing, he said.
After a year with us, he had gotten his PTSD under control, with help from the VA and support from his family. He continues to maintain his appointments, take his medication, work out on a regular basis and has a steady job. He is living on his own and is still fighting hard.
While there is no clear cut route to helping a family member with combat-related PTSD, the one thing we can do for those close to us who are suffering, is to offer support. Without his family, I don’t know where my brother would be today — if he would even be alive. But I do know that he is winning the war — one day at a time.