Marilynn Marcvjopme / AP & Paula J. Caplan / Tikkun.org – 2007-09-12 23:37:29
Thousands of GIs Cope With Brain Damage
Marilynn Marcvjopme / Associated Press
NASHVILLE, Tenn. (September 9, 2007) — The war in Iraq is not over, but one legacy is already here in this city and others across America: an epidemic of brain-damaged soldiers.
Thousands of troops have been diagnosed with traumatic brain injury, or TBI. These blast-caused head injuries are so different from the ones doctors are used to seeing from falls and car crashes that treating them is as much faith as it is science.
“I’ve been in the field for 20-plus years dealing with TBI. I have a very experienced staff. And they’re saying to me, ‘We’re seeing things we’ve never seen before,'” said Sandy Schneider, director of Vanderbilt University’s brain injury rehabilitation program.
Doctors also are realizing that symptoms overlap with post-traumatic stress disorder, and that both must be treated. Odd as it may seem, brain injury can protect against PTSD by blurring awareness of what happened.
But as memory improves, emotional problems can emerge: One of the first “graduates” of Vanderbilt’s program committed suicide three weeks later.
“Of all the ones here, he would not have been the one we would have thought,” Schneider said. “They called him the Michelangelo of Fort Campbell” — a guy who planned to go to art school.
As more troops return from the war, brain injuries are a growing burden — for them, for the few programs to treat them, and for taxpayers who pay for their care and disability if they cannot hold jobs.
Most TBIs are mild, and most of these patients recover within a year. But one-fifth of the troops with these mild injuries will have prolonged or lifelong symptoms and need continuing care, the military estimates. Nearly all of the moderate and severe ones will, too.
Though the full number of those suffering from TBI is still unknown, the problem is straining the U.S. Department of Veterans Affairs. Until now, “they were dealing with a cohort of aging veterans with diabetes, heart disease, lung disease,” said Dr. Jeffrey Drazen, editor-in-chief of the New England Journal of Medicine and a VA adviser.
Now, these young, brain-injured troops need highly specialized care, and how much it will help long-term is unknown, he said.
People with TBI have frequent headaches, dizziness, and trouble concentrating and sleeping. They may be depressed, irritable and confused, and easily provoked or distracted. Speech or vision also can be impaired.
Some sufferers have been misdiagnosed with personality disorders. Others have lost jobs because of unrecognized and untreated symptoms.
“It’s the so-called invisible injury. It’s where a troop takes 10 times the normal time to pack his rucksack … a complicated injury to the most complicated part of the body,” said Dr. Alisa Gean, a neurosurgeon at the University of California, San Francisco.
Diagnosing it is imprecise — damage rarely shows up on CAT scans or other tests.
Treating it is even more difficult. Lacking a cure, doctors focus on symptoms — headaches, anxiety, vision problems, etc. But they lack good treatments for some of these, too, and are considering some experimental approaches being pushed by private companies with little proof they work.
Many troops get no care at all. Some are sent back to fight with their brain injuries undetected, especially if they had no obvious wounds.
What happened to Eric O’Brien and Bryan Malone shows the scope of this problem.
O’Brien, a 32-year-old Army staff sergeant from Iowa’s Quad Cities, was teasing Malone, 22, a specialist from Haughton, La., in a Baghdad gym last summer.
“I told him and his workout partner: ‘Put some more weight on it,'” prompting the men to get up. Seconds later, a rocket hit where they had sat. They survived, but a pressure wave from the blast coursed through their brains.
“I patted myself down head to toe, making sure I wasn’t missing a limb,” and felt odd, like “I must be missing a chunk of my head,'” O’Brien said. He remembers little else except walking through debris to pick up his iPod and sunglasses.
As for Malone, an air conditioning vent had fallen on his head and he had shrapnel wounds. He had multiple surgeries, spent several months in Walter Reed Army Medical Center and now has titanium mesh reinforcing his skull.
O’Brien, however, had shrapnel removed from his scalp and then was sent back to his unit — “no antibiotics, no pain medication or anything. They just sent me on my way.”
When he later complained of pain, doctors gave him Motrin. When he discovered a trickle of blood from his hip, they said he would be fine. Six weeks later, when he could barely walk, tests revealed shrapnel in his hip. By then, he was having headaches and trouble sleeping.
O’Brien had been through multiple previous explosions — troops average one a month, a study found — and each raises the risk that the next one will do harm. Soldiers and Marines are proud and reluctant to go “off mission” just because “they get their bell rung,” said Dr. Michael Kilpatrick, a top Defense Department physician.
“Most of the treatment is explaining the situation and giving the tincture of time — giving it time to heal,” he said. If no big symptoms appear in eight to 12 hours, “they’re probably ready to go back.”
Officers also face pressure to return troops to duty, said Jordan Grafman, a neuroscientist who studies TBI at the National Institutes of Health.
“People don’t want to lose these guys from their command — they can’t replace them fast enough,” he said.
During a surprise visit to Iraq with President Bush on Labor Day, Gen. Peter Pace, chairman of the Joint Chiefs of Staff, said the military was “much smarter about this now,” and urged troops to watch for signs of TBI and post-traumatic stress.
“They are every bit as much battle injuries as is a bullet or shrapnel. It is OK, it is OK to seek help for those kinds of war wounds, and I ask you all to help your buddies understand what you see in them,” he said.
But that was long after O’Brien was hurt. His TBI was not diagnosed for months, until his hip injury landed him back at Fort Campbell in Kentucky. By then, the Army needed help treating TBI and was contracting with private rehab centers like Schneider’s at Vanderbilt.
Malone and O’Brien had become friends, helping each other cope with wounds.
“They were sent to us together,” Schneider said.
“I’ll need to get milk and bread and eggs. Milk and bread and eggs. Next thing you know, I drive right by Wal-Mart,” O’Brien said.
“I can vaguely tell you what we talked about at the beginning of this conversation,” Malone said.
Memory trouble is a common sign of TBI. It isn’t like Alzheimer’s disease, where people are so disconnected from reality that they forget things like how a key works or where they live. It isn’t like amnesia, where a chunk of the past is missing.
“I don’t have any problem remembering the past. I have trouble with now,” O’Brien said.
Multiple or complex tasks confound and irritate people with TBI. Therapists challenge them through exercises, like a computer game where they run a hot dog stand and must manage inventory, set prices, do banking and anticipate demand according to the weather.
Other therapy focuses on life skills like following directions while paying attention to something else.
“I counted three trash cans,” O’Brien announced after a scouting mission to find landmarks using a map and tally cans along the way.
“I counted five,” said therapist Jenny Owens.
Improving these skills is key to living a normal life, especially driving.
“Most of them don’t drive. A van brings them down. They were hitting mailboxes, they’d get lost. We draw them maps and they forget when they’re supposed to be here,” Schneider said.
The Army gives some injured soldiers Palm Pilots — handheld computers to help manage their lives.
“It costs them more for us to miss two appointments than to give us one of these,” O’Brien explained.
But devices and mental exercises do only so much. Troops must be able to use information and reason, but TBI keeps many from being aware of their gaps.
“They don’t realize their judgment is impaired,” said Vanderbilt neuropsychologist Elizabeth Fenimore.
The training that helped them in combat situations is hurting them now.
“These guys are taught to be alert all the time,” so they sleep poorly, Schneider said.
“Their nervous system becomes acclimated to being constantly on alert — fight or flight,” Fenimore said.
Malone knows it well.
“I worry about every little thing — people breaking into my house, loud booms … I’m jumpy,” he said.
“I’m going to Afghanistan next year,” said O’Brien, determined to stay in the Army and support his two daughters, who live with his ex-wife in Texas.
“I’m trying,” added Malone. “They’re telling me they don’t think my brain can take it. I think, ‘Why don’t you let me decide?'”
Doctors don’t know whether either will return. But after all they’ve been through, if one does and the other does not, “it’s going to be tough,” Malone said. “It’s going to be tough for whichever one stays back.”
Associated Press writer Christine Simmons in Washington contributed to this report.
Posted in accordance with Title 17, US Code, for noncommercial, educational purpsoses.
Vets Aren’t Crazy — War Is
Paula J. Caplan / Tikkun.org
I think I must be crazy,” said the Iraq War vet. “At a welcome-home ceremony the city arranged, I didn’t know they were going to fire ceremonial cannons. I was holding a bottle of champagne, and when they started firing, over and over and over, I went nuts! I hurled the bottle at a tree, stuck my head between my knees, and shook until it stopped. Crazy, right?”
As a psychologist, I can report that after telling me how they feel, most people end with some equivalent of, “That means I’m crazy, doesn’t it?” But the veterans of the wars in Iraq and Afghanistan ask this question with an intensity that is especially disturbing, whether they speak with me in my capacity as a professional, a journalist, or just an interested citizen.
The degree of their anguish and alienation from their loved ones makes it especially hard to persuade them when the word crazy does not apply to them. Their words reveal the vividness of their torment and their despair.
Julia had been home for six months after the year she spent in Baghdad, where she heard half a dozen explosions every day. Since her return, not one night had brought restful sleep. She awoke every day in a state of complete exhaustion.
All her life a sociable person, Julia was stunned to be filled with rage “at friends and family who had done nothing to me” and at herself. Driving her car, she was seized by the impulse to swerve and crash into a mountain. Only digging her fingernails into her palms until they bled and yanking hunks of hair from her head kept her from making that swerve.
“Iraq was terrifying because I had no idea how to explain my feelings,” Julia said. “There were all those explosions, and my regular assignment was doing pat down searches of Iraqis who might have been friends or might have been wearing explosives. If a pat had located a bomb,” she explained, “before my mind registered it, I’d have been dead.
And it was rough when this larger-than-life soldier we all loved died from a roadside bomb. But I keep thinking how many thousands of soldiers have gone through this and been just fine. Not a single soldier in Iraq ever told me they were scared or angry or crazy. They were sad when the big guy died, but nobody lost control.”
The thought of “maybe if I kill myself, I’ll stop feeling so angry and will be able to get some sleep” churned constantly through her mind. Julia considered therapy but feared “seeing a military shrink, because that could wreck my plan to retire on a nice pension when my twenty years in the Army National Guard are up.” Julia’s family never had much money. “If I tell an Army therapist all this crazy shit, they’ll kick me out.”
Private therapists are expensive, but for six weeks, Julia saw “a very nice psychologist” and talked about her emotional numbness, which alternated with rage and despair. The therapist encouraged her to let her guard down. But Julia clung to the numbness, believing it protected people from her irrational anger. She also thought, “If I’m redeployed, I can’t have my feelings exploding all the time.”
Military ethos discourages soldiers from talking about their fear, frustration, helplessness, and uncertainty about the progress of the war. Julia only once told someone about her feelings. While doing pat searches, she had said to a soldier, “Any of those people could kill us.” He responded, “Aw, no, they won’t!” Never again did she say anything less than gung-ho about her work. In no official or unofficial instruction did her sergeant or commanding officer say these reactions were normal.
Someone would occasionally say that anyone who felt depressed or anxious should tell their squad leader, who would send that person to a chaplain or counselor, but the nonverbal message was that needing help was unsoldierly. For the men, it was unmanly. For the women, it proved that women should not be soldiers.
Officially, the military recognizes that going to war can be upsetting. But for the most part, they have not found solutions to its resulting emotional carnage. Their top priority is to produce soldiers who, above all, continue to function. During World War II, when a soldier broke down after seeing his buddy blown to bits, the armed services usually sent him far from combat and gave him time to recuperate. In recent years, asserting the importance of protecting soldiers from “survivor guilt,” they switched to the PIE approach: proximity, immediacy, and expectation.
In practice, this means keeping soldiers in proximity to the combat zone when they are overwhelmed by war’s horrors; getting them back to the combat zone immediately, perhaps after a few days’ rest; and conveying the expectation that they will soon be fine. Of course, soldiers sent back are even more likely to see still more comrades die, thus increasing the chances they will have survivor guilt.
Often, anti-depressants are handed out liberally to soldiers. Yes, the pills can distance the soldiers from their feelings. But those feelings do not vanish, and if they don’t come out immediately, they will later.
Transition times are excruciating, according to Ray, a vet who flew home on a two-week leave after being holed up near Kabul for six months. In preparation for leave, he was called to a one-hour group meeting where the soldiers were told not to hit their wives. (No parallel instruction was given to women soldiers.) Ray says, “That’s all the advice we got.” When he landed in his small hometown, everyone asked, “What’s it like over there?” Ray was dumbfounded. How could he possibly convey to the citizens of this peaceful, Midwestern place what he had seen?
The power of the warlords, the constant, battering uncertainty about friends and enemies and the life-and-death stakes of a wrong guess. Even if he could convey it, should he? “Soldiers have a duty to protect folks back home by fighting wars abroad but also to protect them from our emotional nightmares,” he said. People thought Ray was weird because he wouldn’t speak when asked about the war. Chasms grew. His best friend stopped calling. Family interactions were awkward.
Julia was grateful that emotional numbness made it so much easier to protect her loved ones from both the horrors of the war and the dangers she felt within herself. She stopped going to therapy, partly because she wanted to remain numb and partly because she needed to feel like her old self. “I’ve always been independent and strong and I thought, ‘I don’t need a shrink. I can do this myself.’ ” But do what? She didn’t know where to begin.
A college professor invited Julia to speak to her class. The previous year, home from Iraq on a brief leave, she had spouted what she now calls “the Army’s book, what they want you to say.” This year was different. Though trying to stay calm, she spoke freely about what she had seen, the sleep that brought no rest, the numbness.
She described the self-hatred she felt when watching a TV series about the war and seeing a character handle a situation better than she had. One student asked why she was so hard on herself and why she liked staying numb. Struck by the student’s compassion and the directness of the question, Julia felt it was time to tell the whole truth. “I feel like if I kill myself, maybe I can get some sleep.” That night, she slept soundly for the first time in months.
What made the difference? Someone, a virtual stranger, had wanted to understand, and twenty other students were also present, listening. It was easier to talk to strangers than to the loved ones she felt more responsible to protect.
In our culture, we send traumatized people behind the closed doors of therapists to seek help that presumably only experts can provide. And, after all, who else really wants to hear about the real horrors of war? It’s easier all around if we send vets to professionals, asking them to close the door behind them. In this way, we avoid the emotional carnage of war. But is that healthy for the vets or for us?
Good therapists can help. But soldiers and vets have been held to impossible standards of concealment of deeply human, natural feelings, and sending them to therapists carries the message that they are mentally ill, that they should be “over it” by now. And although Posttraumatic Stress Disorder accurately implies that their anguish results from trauma, PTSD is located in the official listing of mental disorders, thus branding their response to war as abnormal and marginalizing them even more than the war experiences have.
Furthermore, decades of experience with veterans from Vietnam and the first Gulf War indicate that providing psychotherapy and/or drugs may help, but the suffering of many persists, wreaking havoc with relationships and jobs and often leading to addictions and eventually homelessness.
Every American can help. We can tell vets that it’s not crazy to feel rage, despair, self-hatred, and self-doubt in response to being helpless in the face of constant danger, ambiguity, and ever-changing explanations of why Americans are in Iraq, of trying to match a John Wayne image that even John Wayne never matched in real life. If vets’ emotions about those circumstances are signs of mental illness, then what, exactly, would be a healthy, human response?
In his new book, What Really Matters, Harvard University psychiatrist and anthropologist Arthur Kleinman proposes that what we should ask is how someone could not have such feelings, a question that is all the more important the greater the deception and doublespeak involved-as in the wars in Iraq and Afghanistan-in the initiation and prosecution of the war.
On September 11, 2001, Drew went straight from high school to enlist in the military, consumed with avenging all those deaths and defending his country. What he had not counted on was the part of basic training when they order you to run around a field aiming a gun, yelling “Kill! Kill!” Horrified, he became obsessed with images of suicide. Compared to the thought of killing “the enemy,” he found it easier to think of killing himself.
One night, the pull toward suicide became so powerful that he panicked, went AWOL, and flew home. The military court-martials for such conduct, but Professor Kleinman would say that Drew was exhibiting moral, caring behavior. If this is a humane world, then it is important to feel fear and horror about violence. Not to feel such emotions, Kleinman says, is to have a moral disorder.
A psychologist who is asked to assess a person who compulsively lies, whose lies repeatedly lead to devastation and death, and who appears to feel no remorse about the lying or its consequences will readily diagnose that person as a psychopath. It should be obvious that George W. Bush, Dick Cheney, Donald Rumsfeld, and their cronies fit that description, that that is where the true psychopathology lies, although the scale of their misconduct actually leaves psychopathology in the dust and leaps to the realm of evil.
The same goes for the psychologist who is asked to assess a person who repeatedly claims that X is true, when it is patently obvious that X is false (e.g., “We’re bringing democracy to the Middle East,” or “They love us over there”). The psychologist would likely conclude that the person is out of touch with reality to the point of psychosis. When arrogance or greed impel the distortion of reality, rather than cognitive or emotional factors beyond the person’s control, it makes more sense to call it not mental illness but villainy.
War can transform a soldier into someone they have never been and never thought they’d be. Think what it would do to most of us to live for a year in constant mortal danger with no real way to protect oneself or one’s comrades; to hear many times a day the sounds that signal the deaths of other living beings, many of them your fellow citizens; and to know that these might be the sounds of your own death.
If you have always had a nurturant nature, a sociable character, a peaceful soul, what happens to your sense of identity when you are expected to relish the order “Kill! Kill!”? No matter how you feel about “the enemy,” at what cost does one forget that that enemy is composed of human beings?
The war is all the more crazy-making for the many soldiers who joined up for reasons other than the wish to overpower and to kill, like the ones who told me they signed on right after September 11, 2001 because they wanted to protect their country. These then-seventeen-year-olds imagined that they would be guarding airports and harbors, checking for explosives, or perhaps learning codes to work in the intelligence sphere to spot and head off attacks on the United States.
Others joined the reserves or the National Guard when this country was not at war, because they were too poor to pay for college or job training, and the reserves or the Guard gave them these opportunities. And every soldier who told me they signed up while in or soon after high school was devastated to learn that their recruiter blatantly lied to them, assuring them that they would never see combat and that they would have the job opportunities they most desired.
When soldiers come smack up against the realities of war, turning to military therapists for help may be useful for some but has compounded the damage and danger for others. One young man who later went AWOL said a military psychiatrist reviled him for wanting out of the service, called him a coward, and said he could be locked up for a long time for trying to fake a mental illness in order to get out.
Of the many soldiers I have interviewed who went AWOL, every one described first their struggle with shame and self-blame, thinking they must be overly sensitive to the military’s obsession with violence and the frequent humiliation of those who are less than gung-ho about it, and feeling viscerally the emotional and sometimes physical dangers of speaking within the military about the lies and hypocrisy of these wars.
For soldiers to overcome the lifelong indoctrination-intensified in basic training-into the belief that America does no wrong is a monumental task, especially after being told that they face life terms in military prisons if they try to leave.
“When my Sergeant told me that’s what would happen, I believed him,” Drew told me. Not until he went AWOL and, months later, having hidden in a relative’s home in almost total isolation and fear, happened across the American Friends Service’s GI Rights Hotline, was he on the way to learning that the sergeant had misinformed him.
The truth that soldiers know about going AWOL is that the military contacts civilian police forces with the names of those who are AWOL and instructions to pick them up on sight and return them to their bases. Describing a close call he had when a policeman rang the doorbell of the place where he was in hiding, Drew’s terror was palpable, even though he has been officially discharged from the Army for months.
The purposeful terrorizing of soldiers who hate these wars and want to leave the military keeps many of them on their bases until, as many have told me, for the first time in their life they have massive panic attacks or, often, consider suicide. Drew was off the base at a sandwich shop when his first panic attack hit. He was headed for Iraq within days.
He said that nothing in his life-not his parents’ divorce, not major personal problems with which he had grappled-had ever made him think of killing himself, but at that moment, he knew that suicide was the only alternative to the path he took: He walked out of the shop, hailed a taxi, flew home, and went into hiding.
Then there is Neal Howland, who was promised training as a videographer, only to learn when it was too late that he was headed for Iraq and that his job would keep him in combat zones, repairing exploded vehicles. Neal began to have vivid images of driving a car into a tree, hoping to be so maimed that he would be discharged.
Only when those images became nearly irresistible did he go AWOL. Why hadn’t he left before? Because the military psychologist he saw had told him that “faking a mental illness” would likely lead to court martial, and a long incarceration that would keep him from home, family, and friends until his hair turned grey.
Despite such attempts at intimidation, it appears that the phenomenon of going AWOL is more extensive than most people realize. When Neal turned himself in at Fort Knox, one of the two soldiers guarding the gate as he approached asked why he had come. After Neal said, “I’ve been AWOL, and I’m turning myself in,” that guard turned to his fellow and said, “We got another one!”
And in the one week that Neal was there, he met more than fifty soldiers who had come to Knox for the same reason. According to Pentagon figures, more than 28,000 soldiers “deserted” between the beginning of 2002 (the war in Afghanistan began the previous autumn) and the end of 2006.
To call the devastating effects of war “mental illness” is to make the colossal mistake of thinking that the problem springs solely from within the person’s psyche. Individuals vary in how they react to horror, but it would be absurd to think that everyone traumatized by war was mentally ill, rather than understandably devastated.
Are Ray and Drew mentally ill? No, they’re just compassionate. Are Julia and Neal masochists, who, unlike the rest of us, enjoy suffering? No, they want what we all want: life, safety, and tranquility.
If we ignore vets’ numbness and silence, helping them to protect us, who then will protect them? Connection with and care from one’s community have enormous power to heal. A wealth of research shows that social support is often the most important factor in emotional healing.
Better still, it heals without adding to the sufferer’s burden the shame of being considered crazy. We need to decrease vets’ emotional isolation by creating opportunities for plentiful human interactions that will remind them that they are more than the sum of their reactions to war, thus reminding them of who they were and who they still can be.
What helped Julia, Ray, Drew, and Neal can help other vets while also helping heal a country divided by these wars. Without discouraging them from also seeking professional help, we all can offer vets a chance to speak their truth to us, to tell them that, for as long as they want to talk, we will listen. We can say that we would have reacted the same if we had been there. Just hearing those words can bring a person back toward connection and personhood and can broaden their repertoire of ways to cope.
Disconnection and fear of being insane are major risk factors for severe depression and unbridled rage against oneself and others. To tell vets that we are open to hearing the horrors and shame that plague them is to take some of that poison away, to take what they have seen and felt out of the realm of “too awful to be spoken, except to a therapist who is used to craziness.”
We can say that as citizens of this country and as human beings, we take seriously our obligation to help veterans reconnect with those who were lucky enough to have escaped deployment, to help them back to a place of greater physical and emotional safety than perhaps they ever hoped to find again. And in reaching out to these vets, we learn and teach others the full measure of the devastation wrought by war and therefore make it less likely that, as a nation, we will go to war quickly and unthinkingly again.
All vets’ names in the article have been changed to protect their privacy, with the exception of Neal Howland, who gave his permission to use his name and photographs.
Paula J. Caplan, Ph.D., is a clinical and research psychologist at Harvard University and the author of They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.
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