Coping With Combat
The Struggle to Gauge a War's Psychological Cost WOUNDS INSIDE
Stress on the Front Lines
By BENEDICT CAREY
Published: November 26, 2005

It was hardly a traditional therapist's office. The mortar fire was relentless, head-splitting, so close that it raised layers of rubble high off the floor of the bombed-out room.


Since returning home to Madison, Wis., after a tour in Iraq, Abbie Pickett has struggled with symptoms of post-traumatic stress disorder.

Capt. William Nash, a Navy psychiatrist, sat on an overturned box of ready-made meals for the troops. He was in Iraq to try to short-circuit combat stress on the spot, before it became disabling, as part of the military's most determined effort yet to bring therapy to the front lines.

His clients, about a dozen young men desperate for help after weeks of living and fighting in Falluja, sat opposite him and told their stories.

One had been spattered with his best friend's blood and blamed himself for the death.

Another was also filled with guilt. He had hesitated while scouting an alley and had seen the man in front of him shot to death.

"They were so young," Captain Nash recalled.

At first, when they talked, he simply listened. Then he did his job, telling them that soldiers always blame themselves when someone is killed, in any war, always.

Grief, he told them, can make us forget how random war is, how much we have done to protect those we are fighting with.

"You try to help them tell a coherent story about what is happening, to make sense of it, so they feel less guilt and shame over protecting others, which is so common," said Captain Nash, who counseled the marines last November as part of the military's increased efforts to defuse psychological troubles.

He added, "You have to help them reconstruct the things they used to believe in that don't make sense anymore, like the basic goodness of humanity."

Military psychiatry has always been close to a contradiction in terms. Psychiatry aims to keep people sane; service in wartime makes demands that seem insane.

This war in particular presents profound mental stresses: unknown and often unseen enemies, suicide bombers, a hostile land with virtually no safe zone, no real front or rear. A 360-degree war, some call it, an asymmetrical battle space that threatens to injure troops' minds as well as their bodies.

But just how deep those mental wounds are, and how many will be disabled by them, are matters of controversy. Some experts suspect that the legacy of Iraq could echo that of Vietnam, when almost a third of returning military personnel reported significant, often chronic, psychological problems.

Others say the mental casualties will be much lower, given the resilience of today's troops and the sophistication of the military's psychological corps, which place therapists like Captain Nash into combat zones.

The numbers so far tell a mixed story. The suicide rate among soldiers was high in 2003 but fell significantly in 2004, according to two Army surveys among more than 2,000 soldiers and mental health support providers in Iraq. Morale rose in the same period, but 54 percent of the troops say morale is low or very low, the report found.

A continuing study of combat units that served in Iraq has found that about 17 percent of the personnel have shown serious symptoms of depression, anxiety or post-traumatic stress disorder - characterized by intrusive thoughts, sleep loss and hyper-alertness, among other symptoms - in the first few months after returning from Iraq, a higher rate than in Afghanistan but thought to be lower than after Vietnam.

In interviews, many members of the armed services and psychologists who had completed extended tours in Iraq said they had battled feelings of profound grief, anger and moral ambiguity about the effect of their presence on Iraqi civilians.

And at bases back home, there have been violent outbursts among those who have completed tours. A marine from Camp Pendleton, Calif., has been convicted of murdering his girlfriend. And three members of a special forces unit based at Fort Carson, in Colorado Springs, have committed suicide.

Yet for returning service members, experts say, the question of whether their difficulties are ultimately diagnosed as mental illness may depend not only on the mental health services available, but also on the politics of military psychiatry itself, the definition of what a normal reaction to combat is and the story the nation tells itself about the purpose and value of soldiers' service.

"We must not ever diminish the pain and anguish many soldiers will feel; this kind of experience never leaves you," said David H. Marlowe, a former chief of military psychiatry at the Walter Reed Army Institute of Research. "But at the same time we have to be careful not to create an attachment to that pain and anguish by pathologizing it."

The legacy of Iraq, Dr. Marlowe said, will depend as much on how service members are received and understood by the society they return to as on their exposure to the trauma of war.

Memories Still Haunt

The blood and fury of combat exhilarate some people and mentally scar others, for reasons no one understands.

On an October night in 2003, mortar shells fell on a base camp near Baquba, Iraq, where Specialist Abbie Pickett, then 21, was serving as a combat lifesaver, caring for the wounded. Specialist Pickett continued working all night by the dim blue light of a flashlight, "plugging and chugging" bleeding troops to a makeshift medical tent, she said.


Abbie Pickett, of the Wisconsin National Guard, served as a medic. Stationed near Tikrit, Iraq, she treated heavy combat casualties in October 2003.
Sandy Huffaker for The New York Times


THE THERAPISTS Capt. William Nash, right, a psychiatrist, standing next to Lt. Cmdr. Gary Hoyt, a psychologist and a colleague in the Marines' mental health program in which the therapists stationed at a base are deployed with battalions in the field.
Sandy Huffaker for The New York Times


THE VETERAN Benjamin Flanders, a graduate student in mathematics, went to Iraq with the New Hampshire National Guard.
Jodi Hilton for The New York Times

At first, she did not notice that one of the medics who was working with her was bleeding heavily and near death; then, frantically, she treated his wounds and moved him to a medical station not knowing if he would survive.

He did survive, Specialist Pickett later learned. But the horror of that night is still vivid, and the memory stalks her even now, more than a year after she returned home.

"I would say that on a weekly basis I wish I would have died during that attack," said Specialist Pickett, who served with the Wisconsin Army National Guard and whose condition has been diagnosed as post-traumatic stress disorder. "You never want family to hear that, and it's a selfish thing to say. But I'm not a typical 23-year-old, and it's hard being a combat vet and a woman and figuring out where you fit in."

Each war produces its own traumatic syndrome. The trench warfare of World War I produced the shaking and partial paralysis known as shell shock. The long tours and heavy fighting of World War II induced in many young men the numbed exhaustion that was called combat fatigue.

But it is post-traumatic stress disorder, a diagnosis some psychiatrists intended to characterize the mental struggles of Vietnam veterans, that now dominates the study and description of war trauma.

The diagnosis has always been controversial. Few experts doubt that close combat can cause a lingering hair-trigger alertness and play on a person's conscience for a lifetime. But no one knows what level of trauma is necessary to produce a disabling condition or who will become disabled.

The largest study of Vietnam veterans found that about 30 percent of them had post-traumatic stress disorder in the 20 years after the war but that only a fraction of those service members had had combat roles. Another study of Vietnam veterans, done around the same time, found that the lifetime rate of the syndrome was half as high, 15 percent.

And since Vietnam, therapists have diagnosed the disorder in crime victims, disaster victims, people who have witnessed disasters, even those who have seen upsetting events on television. The disorder varies widely depending on the individual and the nature of the trauma, psychiatrists say, but they cannot yet predict how.

Yet the very pervasiveness of post-traumatic stress disorder as a concept shapes not only how researchers study war trauma but also how many soldiers describe their reactions to combat.

Specialist Pickett, for example, has struggled with the intrusive memories typical of post-traumatic stress and with symptoms of depression and a seething resentment over her service, partly because of what she describes as irresponsible leaders and a poorly defined mission. Her memories make good bar stories, she said, but they also follow her back to her apartment, where the combination of anxiety and uncertainty about the value of her service has at times made her feel as if she were losing her mind.

Richard J. McNally, a psychologist at Harvard, said, "It's very difficult to know whether a new kind of syndrome will emerge from this war for the simple reason that the instrument used to assess soldiers presupposes that it will look like P.T.S.D. from Vietnam."

A more thorough assessment, Dr. McNally said, "might ask not only about guilt, shame and the killing of noncombatants, but about camaraderie, leadership, devotion to the mission, about what is meaningful and worthwhile, as well as the negative things."

Sitting amid the broken furniture in his Falluja "office," Captain Nash represents the military's best effort to handle stress on the ground, before it becomes upsetting, and keep service members on the job with the others in their platoon or team, who provide powerful emotional support.

While the military deployed mental health experts in Vietnam, most stayed behind the lines. In part because of that war's difficult legacy, the military has increased the proportion of field therapists and put them closer to the action than ever before.

The Army says it has about 200 mental health workers for a force of about 150,000, including combat stress units that travel to combat zones when called on. The Marines are experimenting with a program in which the therapists stationed at a base are deployed with battalions in the field.

"The idea is simple," said Lt. Cmdr. Gary Hoyt, a Navy psychologist and colleague of Captain Nash in the Marine program. "You have a lot more credibility if you've been there, and soldiers and marines are more likely to talk to you."

Commander Hoyt has struggled with irritability and heightened alertness since returning from Iraq in September 2004.

Psychologists and psychiatrists on the ground have to break through the mental toughness that not only keeps troops fighting but also prevents them from seeking psychological help, which is viewed as a sign of weakness. And they have been among the first to identify the mental reactions particular to this war.

One of them, these experts say, is profound, unreleased anger. Unlike in Vietnam, where service members served shorter tours and were rotated in and out of the country individually, troops in Iraq have deployed as units and tend to have trained together as full-time military or in the Reserves or the National Guard. Group cohesion is strong, and the bonds only deepen in the hostile desert terrain of Iraq.

For these tight-knit groups, certain kinds of ambushes - roadside bombs, for instance - can be mentally devastating, for a variety of reasons.

"These guys go out in convoys, and boom: the first vehicle gets hit, their best friend dies, and now they're seeing life flash before them and get a surge of adrenaline and want to do something," said Lt. Col. Alan Peterson, an Air Force psychologist who completed a tour in Iraq last year. "But often there's nothing they can do. There's no enemy there."

Many, Colonel Peterson said, become deeply frustrated because "they wish they could act out on this adrenaline rush and do what they were trained to do but can't."

Some soldiers and marines describe foot patrols as "drawing fire," and gunmen so often disappear into crowds that many have the feeling that they are fighting ghosts. In roadside ambushes, service men and women may never see the enemy.

Sgt. Benjamin Flanders, 27, a graduate student in math who went to Iraq with the New Hampshire National Guard, recalled: "It was kind of a joke: if you got to shoot back at the enemy, people were jealous. It was a stress reliever, a great release, because usually these guys disappear."

Another powerful factor is ambiguity about the purpose of the mission, and about Iraqi civilians' perception of the American presence.

On a Sunday in April 2004, Commander Hoyt received orders to visit Marine units that had been trapped in a firefight in a town near the Syrian border and that had lost five men. The Americans had been handing out candy to children and helping residents fix their houses the day before the ambush, and they felt they had been set up, he said.

The entire unit, he said, was coursing with rage, asking: "What are we doing here? Why aren't the Iraqis helping us?"

Commander Hoyt added, "There was a breakdown, and some wanted to know how come they couldn't hit mosques" or other off-limits targets where insurgents were suspected of hiding.

In group sessions, the psychologist emphasized to the marines that they could not know for sure whether the civilians they had helped had supported the insurgents. Insurgent fighters scare many Iraqis more than the Americans do, he reminded them, and that fear creates a deep ambivalence, even among those who most welcome the American presence. And following the rules of engagement, he told them, was crucial to setting an example.

Commander Hoyt also reminded the group of some of its successes, in rebuilding houses, for example, and restoring electricity in the area. He also told them it was better to fight in Iraq than back home.

"Having someone killed in World War II, you could say, 'Well, we won this battle to save the world,' " he said. "In this terrorist war, it is much less tangible how to anchor your losses."

Help in Adjusting to Life at Home

No one has shown definitively that on-the-spot group or individual therapy in combat lowers the risk of psychological problems later. But military psychiatrists know from earlier wars that separating an individual from his or her unit can significantly worsen feelings of guilt and depression.

About 8 service members per every 1,000 in Iraq have developed psychiatric problems severe enough to require evacuation, according to Defense Department statistics, while the rate of serious psychiatric diagnoses in Vietnam from 1965 to 1969 was more than 10 per 1,000, although improvements in treatment, as well as differences in the conflicts and diagnostic criteria, make a direct comparison very rough.

At the same time, Captain Nash and Commander Hoyt say that psychological consultations by returning marines at Camp Pendleton have been increasing significantly since the war began.

One who comes for regular counseling is Sgt. Robert Willis, who earned a Bronze Star for leading an assault through a graveyard near Najaf in 2004.

Irritable since his return home in February, shaken by loud noises, leery of malls or other areas that are not well-lighted at night - classic signs of post-traumatic stress - Sergeant Willis has been seeing Commander Hoyt to help adjust to life at home.

"It's been hard," Sergeant Willis said in a telephone interview. "I have been boisterous, overbearing - my family notices it."

He said he had learned to manage his moods rather than react impulsively, after learning to monitor his thoughts and attend more closely to the reactions of others.

"The turning point, I think, was when Dr. Hoyt told me to simply accept that I was going to be different because of this," but not mentally ill, Sergeant Willis said.

The increase in consultations at Camp Pendleton may reflect increasingly taxing conditions, or delayed reactions, experts said. But it may also be evidence that men and women who have fought with ready access to a psychologist or psychiatrist are less constrained by the tough-it-out military ethos and are more comfortable seeking that person's advice when they get back.

"Seeing someone you remember from real time in combat absolutely could help in treatment," as well as help overcome the stigma of seeking counseling, said Rachel Yehuda, director of the post-traumatic stress disorder program at the Veterans Affairs Medical Center in the Bronx. "If this is what is happening, I think it's brilliant."

Tracking Serious Symptoms

In the coming months, researchers who are following combat units after they return home are expected to report that the number of personnel with serious mental symptoms has increased slightly, up from the 17 percent reported last year.

In an editorial last year in The New England Journal of Medicine, Dr. Matthew J. Friedman, executive director of the National Center for Post-Traumatic Stress Disorder for the Department of Veterans Affairs, wrote that studies suggested that the rates of post-traumatic stress disorder, in particular, "may increase considerably during the two years after veterans return from combat duty."

And on the basis of previous studies, Dr. Friedman wrote, "it is possible that psychiatric disorders will increase now that the conduct of the war has shifted from a campaign for liberation to an ongoing armed conflict with dissident combatants."

But others say that the rates of the disorder are just as likely to diminish in the next year, as studies show they do for disaster victims.

Col. Elspeth Cameron Ritchie, psychiatry consultant to the Army surgeon general, said that given the stresses of this war, it was worth noting that five out of six service members who had seen combat did not show serious signs of mental illness.

The emotional casualties, Colonel Ritchie said, are "not just an Army medical problem, but a problem that the V.A. system, the civilian system and the society as a whole must work to solve."

That is the one thing all seem to agree on. Some veterans, like Sergeant Flanders and Sergeant Willis, have reconnected with other men in their units to help with their psychological adjustment to home life. Sergeant Willis has been transferred to noncombat duty at Camp Pendleton, in an environment he knows and enjoys, and he can see Commander Hoyt when he needs to. Sergeant Flanders is studying to be an officer.

But others, particularly reservists and National Guard troops, have landed right back in civilian society with no one close to them who has shared their experience.

Specialist Pickett, since her return, has felt especially cut off from the company she trained and served with. She has struggled at school, and with the Veterans Affairs system to get counseling, and no one near her has had an experience remotely like hers. She has tried antidepressants, which have helped reduce her suicidal thinking. She has also joined Operation Truth, a nonprofit organization that represents Iraq veterans, which has given her some comfort.

Finally, she said, she has been searching her memory and conscience for reasons to justify the pain of her experience: no one, Specialist Pickett said, looks harder for justification than a soldier.

Dr. Marlowe, the former chief of psychiatry at Walter Reed, knows from studying other wars that this is so.

"The great change among American troops in Germany during the Second World War was when they discovered the concentration camps," Dr. Marlowe said. "That immediately and forever changed the moral appreciation for why we were there."

As soldiers return from Iraq, he said, "it will be enormously important for those who feel psychologically disaffected to find something which justifies the killing, and the death of their friends."