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Injured veterans don't want to be pitied, they want respect along with appropriate, timely treatment for wounds incurred in the service of their country. While amputees evoke both sympathy and respect, growing numbers of servicemen and women with invisible psychological injuries face obstacles to treatment, sometimes with contempt for their emotional vulnerability. Psychologist Paula Caplan, Fellow at the Women and Public Policy Program at Harvard, concentrates on two issues: the unmet needs of veterans, and a psychiatric establishment that offers too little help for a growing problem. Despite its upbeat title, her book is full of disturbing facts about the personal costs of war--including post-traumatic stress disorder (PTSD), depression, and suicide--and the failure of the Defense Department and the Veterans Administration to cope with them. More upbeat and controversial is Caplan's claim that caring friends (even strangers) are more helpful than trained therapists in dealing with PTSD and related consequences of war.
Can there be informed consent for soldiering? It is required for military service. Enlistees agree to risk life and limb, and to relinquish many rights. Though defending democracy, they have no vote on who leads them, and little to say about where they go and what they do. They are not free to express certain ideas. They can and should refuse an illegitimate order, but have no right to sue, despite any damage caused by leaders' errors of commission or omission. Most soldiers who die while serving--except suicides-- are called heroic. Some amputees adept with artificial limbs are shown on television, but those with less visible physical and psychiatric disabilities have to prove that their problem is service related, not pre-existing. The Veterans Administration (VA) has reexamined thousands of claims to prevent fraud, despite evidence that the overwhelming majority of veterans are honest. The backlog of over 600,000 claims (doubled since the Iraq War began) will take years to settle. These are some of the grim facts that energize the author of this important book.
Caplan defines Eight Plagues of Combat, based on what veterans from World War II onward have told her or expressed publicly: trauma; grief and sadness; fear and anxiety; guilt and shame; rage; conflicts of values and crises of meaning; betrayal and mistrust; isolation, alienation, and numbing. She illustrates each category with case examples, including soldier's written prose and poetry. Conflicts of values and crises of meanings, for example, represent a clash with the war zone mentality of "tight focus and black-and-white thinking." To question a mission that is backed by military chaplains as well as commanding officers, "is at best a luxury and at worst a dangerous sign that one is un-American..." (p. 52). Soldiers have learned in training that "fear is your enemy" and to "act reflexively" rather than reflectively. That does not always spare them from feeling like murderers. "Modern combat training conditions soldiers to act reflexively to stimuli," says Lt. Col. Peter Kilner, a professor of philosophy and ethics at West Point, "and this maximizes soldiers' lethality, but it does so by bypassing their moral autonomy. Soldiers are conditioned to act without considering the moral repercussions of their actions; they are enabled to kill without making the conscious decision to do so. If they are unable to justify to themselves the fact that they killed another human being, they will likely -- and understandably -- suffer enormous guilt." (p. 53, from 2008). In his blog, Kilner reports research showing that PTSD occurs more often among soldiers who have killed in war than those who have not. Doubtless their suicide rate is higher, too.
In Chapter 3 Caplan addresses problems restoring traumatized soldiers to health. A therapist herself, she argues that empathic, thoughtful nonprofessionals do better than licensed therapists because academic training creates barriers to normal, humane communication. To me (a retired psychiatrist) this overstates the issue, though I grant that amateurs are often than professionals, and that personal qualities and life experience trump academic degrees. However, the difference between psychoanalytic training in the heyday of Sigmund Freud and the humanistic/existential approaches of Carl Rogers, Clara Thompson, Irvin Yalom, et al, is significant, though academic programs over-emphasize the mechanics of therapy to make it respectable and researchable (as with the Cognitive-Behavior approach). Caplan points out that PTSD masks some problems while introducing new ones, concluding that it's wrong to diagnose veterans as psychiatrically ill, and, worse, to drug them with anti-depressants and anti-psychotic medication. Polypharmacy (multiple medications for one patient), unsupported by research, is all too common.
Veterans face existential, ethical, and relationship issues, and no two people are alike. In good psychotherapy, science and humanism must be reconciled so that trustworthy relationship determines technique. The use of drugs should be an adjunct to talk therapy and not replace it. The prevalence of psychological problems related to combat ranges from 9 to 31 percent. More than one in six service members are taking at least one psychiatric drug; psychiatric casualties account for more hospitalizations than any other medical condition, and also for over ten percent of medical discharges. (p. 141). Compounding the problem are assumptions that war is necessary and that soldiers' emotional issues and ethical reservations are signs of weakness to be suppressed, not examined and dealt with.
Caplan encourages citizens to make contact with veterans, and how to do it. She lists questions to ask (and to be avoided, like "Did you kill anyone?"). Crucial parts of the story cannot come out until trust is established. Each person's story is a treasure to be shared, though it has explosive aspects to be defused by empathic listening and response. Some of her guidelines: pace the dialog but don't judge; allow silence; trust your own power of respect and compassion; consider that a vet feels like a victim and a perpetrator of violence; when guilt comes up, ask also about shame and fear. (p. 194) She warns that good listeners will lose ther innocence: even a experienced VA psychologist got so distressed he said "Please, stop!" to a veteran, who then left. Caplan's guidelines would help therapists and counselors in many difficult situations.
She concludes Chapter 6 with a list of dozens of organizations, publications, web sites, and films, from Acupuncturists Without Borders to Wounded Warrior Project (but missing are Center on Conscience & War, and Citzen Soldier). Caplan relates an event after a performance of her own play, "War&Therapy." A World War II veteran in his eighties said, "war is not in human nature...once you know you have killed another human being, it haunts you." A younger vet then left in a huff, saying the previous speaker had desecrated the memories of those who had fought for liberty.
It makes sense for lay therapists to get involved in part because they are not limited by an institution that has to justify the damage and protect the institutions of war. "Closeting vets behind therapists' doors and silencing them with drugs makes all of us morally sick." (pp. 211-12). Less than 0.5 percent of Americans take part in the wars in Iraq and Afghanistan compared with 12 percent in World War II, so very few of us know someone in the service today, or even know that half the 200,000 women soldiers are mothers, and 12 percent of deployed women and four percent of men are single parents.
This book approaches large, complex set of socio-psychological issues with intelligence and compassion. Caplan's counseling guidelines would be helpful in many situations, and should be taken to heart by graduate students and their teachers as well as by lay therapists. She encourages and enables "all of us" to help distressed recruits who carry out national policy in our name, only to find that Government assistance is faulty and late. Her research and documentation is thorough; for historical perspective I would add No Victory Parades: The Return of the Vietnam Veteran by Murray Polner (1971): "Most of them have retained complicated forms of guilt, associated with death encounters--guilt because they survived and their buddies did not, guild for having killed other human beings...an enemy they never hated.... There is always guilt in battle but it is particularly unbearable when few know why the battle is being fought." (p. 163). The after-effects of killing and/or witnessing death and maiming of individuals on either side of a conflict are lasting, burdensome and sometimes debilitating.
Recent research by Dave Grossman and Pete Kilner at West Point compel us to rethink the psychology, ethics and personal consequences of war. We are social beings, living in large and small groups. Like wolves and apes we have strong inhibitions against intraspecies killing, but with humans these can be overcome with conditioning and medication. We can turn normal, mostly peaceable young adults into serial killers. Once the inhibition is released, getting the killer genie" back in the bottle may be a difficult, even life-threatening problem. The chaplains who bless and counsel them, the therapists who try to repair them, and of course the politicians who authorize wars, are mostly insulated from the experience of face-to-face combat. Military disciple requires that individuals accept the will and direction of superior officers, who may or may not be superior in judgment, ethics, human relations, or even leadership.
Grossman documents that it is easier to kill dozens with artillery and thousands with bombs than just one person face-to-face. (It's relatively easy to kill retreating troops whose faces are not visible.) In airplane dogfights, where pilots often see each other, one percent of pilots made 30 percent of kills and many pilots make none. Machine gunners and others in pairs or teams, or closely supervised, will fire their weapons. This squares with Stanley Milgram's famous experiments showing how average people will do cruel, harmful, possibly lethal things if directed by a legitimate authority. Grossman notes that two percent of recruits have no killing inhibition, and they score high on measures of "aggressive psychopath." They generally make good soldiers and adjust easily in returning to civilian life; another one percent like them don't do well because they can't tolerate military discipline. Grossman writes that studying killing is like studying sex: men have always lied about both sex and combat to cover up the inhibitions that rule all but three percent of males. With training--including conditioning and psychotropic drugs--we achieved 90 percent ability to shoot at a recognizable human being in the Vietnam War--up from only 20 percent in WW II and before.
In 2009 and 2010 more active duty troops killed themselves than died in combat in Iraq and Afghanistan. In 2009 the numbers were 434 and 381, respectively. (The services reluctantly release the data, and vets who left service are not counted.) Rep. Rush Holt (Dem., N.J.) wrote a bill included in Defense authorization legislation to require phone contacts with returning reservists every 90 days. Conferees removed the provision from the final bills in both 2010 and 2011. (CQ Jan. 24, 2011). The cost of phone contacts would be trivial, and warranted for suicide prevention. Cutting the provision represents denial of the issue, a kind of Congressional cover-up.
I attribute the high suicide rate among vets to a mixture of guilt and fear. Returning home to normal life, veterans will sometimes find themselves angrier at family and friends than they were at the enemy in combat. The fear of harming a loved one or co-worker, or aggressive stranger could spark unbearable fear of one's own destructiveness. The killer genie won't go away. It has to be killed.
One last thought. Let our phamaceutical companies--among the most successful financially--make drugs available at cost to the DoD and the VA. That significant patriotic gesture would also remove any suggestion that profits are driving over-prescription of expensive medicines to soldiers in distress.
© 2012 E. James Lieberman
E. James Lieberman, M.D., Clinical Professor of Psychiatry, Emeritus, George Washington University School of Medicine