Linda Blum - Washington Post (June 29, 2008)

Treating Wounds You Can't See

By Linda Blum
Sunday, June 29, 2008; B01

On the wall in my office at Fort Dix, N.J., hung a row of nature photos and some historical documents for my patients to look at: a land grant signed by James Madison, another signed by Abraham Lincoln's secretary in his name, a Lincoln campaign ballot. The soldier from Ohio studied the wall carefully. It was amazing, he said, how much the layout of those picture frames resembled the layout of the street in Tikrit that was seared in his memory; the similarity had leapt out at him the first time he came in for a session. He traced the linear space between the frames, showing me where his Humvee had turned and traveled down the block, and where the two Iraqi men had been standing, close -- too close -- to the road.

"I knew immediately something was wrong," he said. The explosion threw him out of the vehicle, with his comrades trapped inside, screaming. Lying on the ground, he returned fire until he drove off the insurgents. His fellow soldiers survived, but nearly four years later, their screams still haunted him. "I couldn't go to them," he told me, overwhelmed with guilt and imagined failure. "I couldn't help them."

That soldier from Ohio is one of the nearly 40,000 U.S. troops diagnosed by the military with post-traumatic stress disorder after serving in Iraq and Afghanistan from 2003 to 2007; the number of diagnoses increased nearly 50 percent in 2007 over the previous year, the military said this spring. I saw a number of soldiers with war trauma while working as a psychologist for the U.S. Army. In 2006, I went to Fort Dix as a civilian contractor to treat soldiers on their way to and return from those wars. I was drawn by the immediacy of the work and the opportunity to make a difference. What the raw numbers on war trauma can't show is what I saw every day in my office: the individual stories of men and women who have sustained emotional trauma as well as physical injury, people who are still fighting an arduous postwar battle to heal, to understand a mysterious psychological condition and re-enter civilian life. As I think about the soldiers who will be rotating back home from Iraq this summer as part of the "pause" in the "surge," as well as those who will stay behind, I remember some of the people I met on their long journey back from the war.
'We Are Marked'

A high-ranking noncommissioned officer had waged tank warfare during both the 1991 Persian Gulf War and the Iraq war. This soldier remains in immense distress, like many of the people I treated who needed to grieve for lives they had taken in combat. Once, after he killed at least nine people in one week, he experienced acute anxiety and depression and was taken off work for a week. "They had me pet a dog," he said.

Pet a dog? That struck me as fairly mild treatment, although association with pets has been shown to lower blood pressure and other stress indicators.

"How was that, petting the dog?" I asked.

"It was okay, I think it helped some," he said. "I don't know how it was for the dog."

* * * Another soldier, a sergeant, seemed to be living under a thick, dark cloud. He would come in every week, talk some, then periodically stare off into space. He had injured his back and shoulder and was trying to accept that many of his favorite activities were over: He couldn't run, play tennis, play basketball with his son.

He was always lucid, on point, but since his return from Iraq, he had been having auditory hallucinations in which he'd hear his name being called.

He seemed so lost in his own world that I nagged him to come to a group to try to open him up. When he finally did join us, he was transformed -- talkative, funny, smiling, strikingly different than I'd ever seen him. But later, he told me he'd hated the group: He couldn't stand hearing everyone's problems; he had felt that he had to cheer everyone up; it had been unbearable. He never went back.

Shortly before he left Fort Dix, he said to me: "We [combat vets] are marked. People see us and they know. . . . They know we're different."

Sadly, he was leaving with guilt-driven thoughts. He was in chronic pain, partially disabled, but the thought of separation from the National Guard left him deeply dejected.

He joined when he was 18. The Army had given him years of memories, an identity, a sense of belonging and purpose, a way of life. "My military career is over," he said sorrowfully.

He was medically discharged with a 60 percent disability rating. He came up to say good-bye with his papers in hand. "I'm on my way," he said.
'You Have PTSD, Full-Blown PTSD'

The lieutenant refused to fill out the paperwork and wouldn't sit in the waiting room in case someone in his unit saw him. Recently returned from the war zone, he was visibly shaky. He was in his 30s and had worked in the mental-health field as a civilian. When he went home, he had felt only numbness, a chilling emptiness, when he saw his wife and young children. He'd touched his wife's arm and been flooded with memories from the past year in Iraq: a neck wound, blood, severed body parts. He couldn't have sex with her.

In my office, he seemed bewildered, almost shocked. "Why is this happening?" he asked.

"You have PTSD, full-blown PTSD," I told him. And I wondered how he could have missed his own diagnosis. He had given combat-stress briefings and counseled hurting soldiers.

We went back over his Iraq deployment, which had involved bloody rescue missions and constant mortar fire at his unit's base. He'd been protective of his troops. "I didn't like sending people out on missions," he said, "so I went out myself." As the months rolled on, he felt increasingly remote from his family, who seemed to be going on with life without him. And the vortex of war trauma ultimately engulfed him so fully that he lost the capacity to observe himself.

The unwarranted sense of shame, of depleted self-esteem he conveyed, troubled me. "If you went out on missions instead of sending other people out, you're a hero," I said the second and last time I saw him. He finally smiled.

* * *An older soldier came in, looking pale, a couple of days after getting off the plane. The hardest part of his deployment? "Just riding in a tank," he said. "The confinement. I was afraid we'd get hit from above."

I hadn't heard that before. "Did it remind you of anything?"

He reflected for a moment. "Khe Sanh," he said. "We were in underground bunkers. I thought they'd blow out the entrance, and we were all going to die." He had been 19 when he went to Vietnam; 38 years later, he was in Iraq as an officer in the National Guard, his hair gray, his face seamed and rough. "My wife said, 'It took you 20 years to get over the last war,' " he told me. " 'How long will it take this time?' "

In the 1980s, years after Vietnam, he and his wife had attended a talk on PTSD at their local Veterans of Foreign Wars post. "They were talking about me, that was what I had," he told me. "But before then, we just didn't know."

Years of treatment followed. But the military kept its hold on him; he stayed in the Guard and became an officer after getting his college degree. In Iraq, he recalled, uneasiness and sometimes grief gripped him, rooted in his current experience but also emerging ghostlike from the past.

* * *

The young soldier had been at Rustamiyah, known as perhaps the most mortared U.S. base in Iraq; two months after coming home, when he closed his eyes, he would hear the whish-boom of the mortars coming in. "The clarity is phenomenal," he said, as if describing a recording.

* * *Another soldier, a captain, choked up in my office, describing a day in Iraq nearly two years earlier. "They were just kids, 18, 19 years old," she said. "They were playing like kids all day, jumping, swinging from a rope. And then that night, just a few hours later, they died."

"Did you send them out?" I asked.

Silence.
'Am I Going to Get Better?'

I was continually struck by the different coping techniques, including humor and irony, that my patients employed.

* * * Three soldiers were sightseeing in a Philadelphia park when a water main ruptured nearby, making a noise like an explosion. They recounted that one soldier dove for the wall, another hit the ground and the third ran. "People must have thought we were crazy," one told me. They felt safer indoors, so they went to the Betsy Ross House. "We spent two hours at the Betsy Ross House," another said. "We saw everything."

* * *Another soldier had PTSD and probably a traumatic brain injury; his injuries and the array of medications he was taking had seriously impaired his short-term memory and concentration. Like an amnesiac in the movies, he had notes posted all over his room detailing his appointments and medication schedule.

"Am I going to get better?" he asked urgently. He was just back from the war and would likely improve significantly in the months to come. But I couldn't tell him with any certainty whether he would one day function at his prior level. He was having so much difficulty concentrating that it took him eight hours to watch a movie. "It saves money on DVDs," he said.

* * * When the command for the Warriors Transition Unit -- for the soldiers who were at Fort Dix on medical hold -- scheduled a mandatory holiday party, some recently returned soldiers were terribly anxious about the crowd and noise. They worried for the whole week before the party. I was considering writing waivers to excuse them from going, but I hesitated to reinforce their anxiety. A former squad leader from Iraq resolved the issue: "We will get a table in a quiet corner," he told them. "We will all sit together and we will make it through this party."

* * *One soldier, a medic, recalled a particularly traumatic deployment that had involved collecting numerous bodies of both Iraqis and members of his own unit.

He brought his wife in to see me one day. She complained that he was cold, withdrawn, hostile; he would sit in the darkened bedroom all day. She wanted to know why I wasn't helping him more. I'd been working with him for four months; what was I doing?

There had been some gains, I told her. His mood was brighter, and he was no longer weeping daily, but he was still in great distress. "Your husband has had severe trauma," I said. "It's going to take a long time."

'All You Have To Do Is Stay Alive'

Something that still surprises me is the fact that many soldiers wanted to go back to war. Some thought of the inexperienced soldiers who needed their guidance; some talked about providing for their families. But mostly, they told me the same thing about why they wanted to go back: "You get up every day, and all you have to do is stay alive."

Ordinary daily life -- sustaining once-stable relationships, seeing old friends, paying bills, shopping -- could seem excessively burdensome when they returned. Minds that had been on high alert for so long had become better adapted to war than life at home.

"We're subject to state, federal and military law here [on post]," a soldier said in group one day, though he had never been arrested and was considering going to nursing school. He feared both other people's unpredictability and his own reactions, and he was not alone. Generally, my patients had more control than they thought they did. But in that group, one person had received a recent DUI charge, and another had been demoted after a verbal confrontation with a Department of Defense police officer.

"But what do you think would happen?" I asked the soldier who was worried about running afoul of the law.

"It could be anything," he said. "You let your guard down in the States."

I pressed: "But what might happen?"

"Anything. You just don't know."

Like other soldiers, he was troubled by the changes he noticed in himself.

I told him then what I have said to my patients again and again, trying to explain what had happened to their brains in battle: "If you put enough stress on your back, 10,000 pounds on your back, it doesn't matter how strong your back is. It's going to break. The brain is the same way -- it can only take so much stress." A broken back may not seem like a reassuring analogy, but at least it addresses the shame that my patients so often harbor.

"The brain can't just change the channel, like a TV remote," I tell them. Why do people expect their brains to be endlessly pliable, to be able to heal rapidly and perfectly after such trauma? Perhaps it's because a mental injury is invisible, which encourages the fantasy that it will go away overnight. But the change in emotional reactions and behavior cuts so close to the sense of self. For my patients, the trauma isn't something that happens to you. It is you.

lblum101@verizon.net

Linda Blum is a clinical psychologist in New Jersey.