Posted on: Sunday, September 12, 2004

COMMENTARY
Help returnees heal from the traumas of war

By Paula J. Caplan

In 1996, in his late 20s, Robert joined the Army Reserve to get help with college tuition. The Reserve's demands weren't much of a hardship — until 9/11, when his life was turned upside down.

First assigned to full-time duty as an airport guard, he was sent to Kabul, Afghanistan, eight months later. There, he counted the minutes until he could get back home.

But when he did, half a year later, he found himself "all at sea." The people around him, he felt, "acted like I'd never left. For them, nothing was different."

His feelings of turmoil were exacerbated by an uneasy sense that he had no right to them, as his unit had been shot at only once.

When he couldn't shake feelings of depression after nearly a year at home, his sister finally suggested he see a therapist. It seemed the obvious solution to her, and I can see why. After all, we sent many Vietnam and Gulf War veterans behind psycho-therapists' doors to deal with their anguish, and we've come to think it's the best thing to do.

Unfortunately, in our over-psychologized society, we've also come to think it's the only thing to do.

We've failed to learn what the veterans of previous wars have taught us — that although therapists clearly help some soldiers, there is only so much emotional damage from war they can fix. Leaving this work to psychotherapists alone may not only be harmful to the soldiers but also dangerous for us as a nation, because it helps hide the consequences of combat, making it easier for us to go to war again the next time.

Simply sending frightened, angry soldiers off to therapists conveys disturbing messages: that we don't want to listen, that we're afraid we're not qualified to listen, that they should talk to someone who gets paid to listen.

But it's important for the rest of us to let returnees know that we don't consider them weak or crazy for having problems.

According to Army reports, the suicide rate for American soldiers in Iraq is 17.3 per 100,000, nearly five times the rate for the Gulf War and 11 percent higher than for Vietnam. As of March this year, seven soldiers committed suicide after returning from Iraq.

Clearly, the emotional casualties of this war are already extremely high, and it is likely they will get worse the longer troops remain in Iraq and Afghanistan.

Many soldiers' first instinctive response to witnessing the horrors of war is to repress their feelings and not talk about them. Traditional prescriptions for men to be tough intensify the expectation that no matter how soldiers suffer, they should handle it alone.

As more women take on combat roles, the same expectations apply to them. Having seen a buddy blown to bits or realizing they have killed an Iraqi child, many soldiers choose to suffer in silence. Some do so to protect loved ones. Others fear the pain of telling their stories and not being understood.

That's what happened to one soldier serving in Iraq with whom I talked. He described how hard it was to sympathize with his fiancée in Dubuque, Iowa, when she wrote about daily frustrations like her car overheating, as he was reeling from the shock of being reviled as an invader and occupier by the Iraqis around him.

"It's hard to have any long-distance relationship," he told me, "but from Dubuque to the war in Iraq is impossible."

After a three-week leave, he headed back to the war zone, his engagement ended.

Help for traumatized troops really must begin on the battlefield. Yet the military's response has been largely inadequate, even misguided. When soldiers have breakdowns in combat, military therapists give them a little rest and a chance to talk with a counselor, then send them back into the fray, rationalizing that this helps prevent "survivor guilt."

But sending psychologically fragile soldiers back into combat is wrong-headed. They'll likely feel guilt no matter what. Instead, therapists should advise commanding officers that these are the last people who should be sent back into battle. They also should seek ways to help the soldiers handle survivor guilt, such as pointing out that their deaths would not guarantee that others would live.

One military program, called Operational Stress Control and Readiness, or OSCAR, provides treatment in combat zones that includes antidepressant medication, usually Prozac. Though no one would begrudge a soldier anything that might dull the terror of combat, the truth is that the feelings they experience will have to be dealt with eventually. And there's something Brave New World about sending people into situations where they're endangered and feel helpless, then giving them drugs when they crack, to change their brain chemistry so they can return to battle.

The military touts its debriefings for soldiers heading home. With these programs, which often last 10 days or less, it hopes to decrease the violent behavior some soldiers exhibit when they get back home. The Army increased its counseling after three soldiers back from fighting in Afghanistan were accused of killing their wives in 2002.

Returnees are alerted that they might have nightmares and short tempers, reminded that their wives have been making all the decisions and may not want to give up that power, and warned that their small children might not recognize them. That's a beginning, but for many the debriefings are inadequate, and their brevity can imply that this should be all they need to "get over it."

Even with forewarning, the reality of having your child fail to recognize you can be devastating. Some counseling may work for some soldiers, but other advice — buy some flowers for the wife, take the kids to Chuck E. Cheese — may fail to smooth the troubled waters. It's no easy matter to know what will help, but even though the answers are neither simple nor obvious, the ongoing project of seeking them is a social responsibility.

Every one of us needs to shoulder a bit of the burden of helping our soldiers and our returning civilians with their re-entry into ordinary life.

In June, I was at the bank when I heard a red-haired customer with crewcut boast, "We were with the 82nd that got Saddam." When the bank teller expressed awe, the soldier retreated a little, saying, "Well, I didn't actually see him. But some of our guys did." Another customer said, "Thanks for keeping us safe," and the soldier straightened up and boomed out that he was headed for Afghanistan soon. "Gonna get bin Laden," he declared loudly.

As he walked past me on his way out, I remarked quietly that I was frightened for him. His straight-as-a-board posture vanished, and he said: "I got stabbed in Iraq. We're sitting ducks. And it's weird being home. Can't stop watching my back."

Given a chance to voice anything other than the expected bravado, out came his natural feelings of vulnerability. We need to let returnees say they were scared and let them know that's not crazy. We must also allow them to tell proud war stories. When they wish to talk, we must find nonpsychiatric, nonpathologizing opportunities for them to do so openly, while also supporting them if they choose to see a therapist. And when they need silence, we must respect that, too.

A recent study in the New England Journal of Medicine showed that 38 percent of soldiers thought to be mentally ill did not trust therapists, 50 percent worried that seeing one could harm their careers and a full 65 percent feared being seen as weak. Realistically, these barriers to therapy won't be overcome anytime soon.

So we civilians must accept the social responsibility of telling returnees not only that we will listen, but that we will listen for as long as they want to talk about how it felt to be over there and how it feels to be back. We need to tell them not to censor themselves for fear of upsetting us, offending our sensibilities, making us feel helpless to help them or making us angry at them. If we fail to do this, then we become complicit in concealing some of war's most devastating consequences. And to refuse to face these fully is to increase the chances that we will go to war again.

Paula J. Caplan is spokeswoman for the Association of Women in Psychology and author of "They Say You Are Crazy: How the World's Most Powerful Psychi-atrists Decide Who's Normal." She wrote this article for the Washington Post.