I just finished reading Erica Goode's Times story on the suicides of four soldiers who served together in a small North Carolina-based Guard unit in Iraq from 2006 to spring 2007. This is a witheringly painful story. Goode, who has done quite a bit of science writing as well as substantial reporting from Baghdad, tells it with an unusual freshness of perspective and clarity of vision.
She starts where I suppose she must:
On Dec. 9, 2007, Sergeant Blaylock, heavily intoxicated, lifted a 9-millimeter handgun to his head during an argument with his girlfriend and pulled the trigger. He was 26.
"I have failed myself," he wrote in a note found later in his car. "I have let those around me down."
Over the next year, three more soldiers from the 1451st -- Sgt. Jeffrey Wilson, Sgt. Roger Parker and Specialist Skip Brinkley -- would take their own lives. The four suicides, in a unit of roughly 175 soldiers, make the company an extreme example of what experts see as an alarming trend in the years since the invasion of Iraq.
But this isn't another routine PTSD story. Though an IED explosion that killed two comrades near the end of the unit's deployment plays a large role, Goode doesn't bolt the men's distress down to standard-narrative reactions to this traumatic event. By acknowledging early and outright the complex multiple problems that faced these men both in Iraq and back at home, she adds dimension to their lives -- and gives a cleaner look at the forces that drove them to end them.
Suicide is a complex act, a convergence of troubled strands. Researchers who have examined military suicides find not a single precipitating event but many: multiple deployments, relationship problems, financial pressures, drug or alcohol abuse. If decades of studies on civilian suicides are any indication, soldiers who kill themselves are also likely to have a history of emotional troubles like depression, post-traumatic stress disorder or another illness.
And so it was with these soldiers. Their problems are multifaceted, self-compounding, and brutally stubborn.Do read the story.It's long for a news story, but it doesn't seem so. It reads short -- but you know you've been somewhere.
I want to point out a couple central issues this story raises, at least implicitly, but which need far more attention in public and policy discussions.
The first is the spectacular failure of the military's predeployment screening. Why -- why o why o why -- are we deploying people whose mental state and/or histories clearly suggest they're poor candidates for weathering its stress? Of the four soldiers who committed suicide, two seem to be easily identifiable as poor candidates to send into a combat zone.
The more obvious case is Blaylock, whose suicide is described above. Blaylock had actually been discharged from the military in 2002 for a personality disorder. But in 2005, when we were short on troops, he was activated and deployed even though, as Goode reports,
[Blaylock's] ups and downs [at the time] were noticeable enough that three soldiers separately approached a mental health screener at Camp Shelby in Mississippi and warned that he was too unstable for combat.
"This kid does not need to be going to Iraq," Staff Sgt. Brian Laguardia, another of the [1451st], remembers saying.
But an Army evaluation found him fit, and in May 2006, Sergeant Blaylock boarded a military transport along with the other soldiers of the 1451st.
This is just stunning.
Meanwhile, Blaylock's comrade Sergeant Roger Parker had a history of bipolar disorder in his immediate family. a well-known significant risk for that very difficult disorder. Conceivably the military didn't know this. But if they knew -- hoo boy.
The military has made various excuses for not screening out more soldiers with the sort of mental -health vulnerabilities that Blaylock and Parker had. But as I wrote a few weeks ago, in "What if you could predict PTSD in combat troops? Oh, who cares...," a major study by DOD researchers suggests that we already have tools and the data to readily screen out and divert from combat at least half the soldiers who end up with PTSD and other post-combat mental illness rates (and presumably, their accompanying suicides).
Might we already have measures of mental and/or physical health that let us predict which service members are most likely to get PTSD from serving in a combat zone?
The answer is a fairly emphatic Yes. The study found that the least healthy 15% of the troops in the study who saw combat accounted for well over half -- 58% -- of the post-combat PTSD cases, as indicated by either the study's own criteria or by self-report of a PTSD diagnosis from the soldiers during follow-up.
This ... certainly suggests that, as the study put it, "more vulnerable members of the population could be identified and benefit from interventions targeted to prevent new onset PTSD....
[But] strangely, .... this finding has gotten virtually no press. One reason may be that it was published in a British journal -- the British Medical Journal, or BMJ. Why is a study funded by the United States, conducted by an ace team of US Department of Defense researchers, and having to do with the physical and mental health of US soldiers, published in a British journal rather than an American journal? This is a rich and dangerous question. I'll offer one possibility: this study appeared in the British Journal because its more fundamental finding -- that the overall PTSD rate caused by service in Iraq and Afghanistan was much lower (7.3%) than the rates that, though based on questionable studies and contaminated by the conflation of symptoms with disorder, have been reported and insisted upon by those who dominate the study and treatment of combat PTSD. (I noted this discrepancy in my Scientific American feature on PTSD this April; that story has much more on this tension about PTSD rates in our soldiers.)
The other question I wish Goode's story had addressed -- and possibly she wanted to but lacked room, for the story is unusually long as is -- is why the VA does so poorly at treating these soldiers. Granted, psych disorders are hard to treat. But despite pouring billions into the VA's PTSD system over the last 25 years or so, we don't have nearly as much information on either the nature of effectiveness of the VA's methods as we should -- and what data we have shows the VA gets poor results. As I noted in my SciAm article,
In civilian populations, two thirds of PTSD patients respond to treatment. But as psychologist Christopher Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, "In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own."
Right now we're hosing money at the VA to treat PTSD, and there's little evidence we're getting much for it. The VA has some dedicated, skilled therapists (and some not so good.). But their efforts are undermined by bureaucratic, cultural, and structural problems that are going willfully ignored, while ideas to solve some of the most obvious, such as restructuring the disability system to create stronger incentives to heal, meet fierce and dismissive resistance. As my story points out, the overdiagnosis of PTSD in people with other problems has so overloaded the system that it can't give the attention it needs to give to the genuinely and deeply distressed. There are hints in Goode's story that such failures might have played a role in some of the men in her story.
So at the front end, the DOD is sending to war soldiers who obviously shouldn't be sent. And at the back end, awaiting soldiers who return, is a VA response that is clearly wanting.
This ain't working.
I'm now reading Tom Ricks' The Gamble, about the surge in Iraq. We won't know how well the surge really worked until we leave. But one thing the book makes clear: When it finally became deadly obvious to even George W. Bush that Rumsfeld and Co's approach in Iraq was failing, there was enough of an opening even in the echo chamber around W that a few people with alternative ideas -- most notably David Petraeus and retired General Jack Keane -- could gain his ear, expose some faulty assumptions, displace those who had stubbornly pushed a strategy based on those assumptions even as it was clearly failing, and bring some fresh thinking and better tactics to bear.
Our current approach to post-combat distress is failing just as completely as the Rumsfled approach did. But in the halls that count, there's no sign a change in thinking.
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Would I be correct in thinking that an expansion of the definition of PTSD -- ie, a dilution -- that the treatment offered is also diluted?
The most disturbing part of the story was that Blaylock was offered help to stop smoking rather than help with his real problem.
Is it possible that smoking has been too concentrated as an evil? How absurd is it to even think... at least he wasn't a smoker when he killed himself.
Perhaps I should note that my opinions are those of a retired serviceman's dependent and mother or mother-in-law of active duty, National Guard, and reserve children, both officers and enlisted. And my father is a 100% disabled WWII vet.
I'm about as sympathetic to the military as one can be... but there are things that need to be addressed, not only in the military community but the psychiatric and psychological communities as well.
While it was certainly traumatic to returning Vietnam Vets that the country was against what they'd been fighting for, that may have been easier to cope with than the ambivalence... the simply not caring or knowing... that returning Iraq and Afghanistan vets deal with.
Couple that with the current reigning opinion that our troops should not quite defend themselves against what they know are the enemy because the enemy looks like a civilian.
Some of this happened in Vietnam - My Lai - being the most egregious example of an over-reaction. My question is... is an under-reaction not as damaging to the psyche of our troops?
I wish I had some answers.
Donna B,
Thanks for writing. You raise some difficult questions and issues - which is certainly appropriate, as the subject is difficult.
Some I want to ponder. But I'll take a stab at a couple:
Q Does an expansion of the def of PTSD lead to a dilution of the treatment?
A. In a sense, yes. As I note in my story in SciAm, having a diagnosis categroy grow so broad and baggy that people with other problems get included in it leads to confusion all around, and, in some cases, a focus on a problem that may not be really the most important problem, or use of a technique or treatment aimed at A when the problem is B.
Q (if I understand you correctly): Might an underreaction to ambiguous threats from civilians be as damaging to the psyche of troops as an overreaction?
A. Fuzzy ground here. Certainly it's stressful to feel helpless to respond to threats. And the specifics that might apply here are so various and potentially complex that it's hard to generalize. But: Many, many individual accounts and cases, as well as some studies and a fair amount of psych theory, hold that one of the most troubling and psychically taxing things in war is killing in general, and killing innocents (or people who might or might not be innocents) in particular. So I'd wager that restraint in such situations, even if frustrating, is generally far less traumatic and psychologically risky, as it were, for the soldier.
I very much appreciate your note and thoughtful questions, the more so coming from soneone who has so many close family members who have been on the line or stand ready to be called. And you're right -- this war is astonishingly invisible and unspoken, and returning from it must be strange indeed.
Though there are moments where you see people at least try to acknowledge a service the depth of which they know they can't understand. On a recent flight back home to Vermont from DC, I sat next to a captain in the Army Reserve, a man around 50, I would guess, who told me he'll be shipping out for his third tour in Iraq this November, and who has two sons over there, one in Iraq, on in Afghanistan, each on his second tour. As we were walking through the Burlington, Vt., airport after landing -- he was a few feet ahead of me as we navigated crowds and doors -- two people thanked him for his service, and when he went through the double doors that separated the scure departure/return waiting area from the public receving area, a little boy about 5 or so, waiting with his dad for someone else arriving, excitedly pointed at this captaion (who was in uniform) and said, "Daddy! Daddy! Look!" -- as excited as if he'd seen Spiderman. His dad turned and said, "Yes!" to his son, and he too quietly thanked the captain for his service. A few yards down the hall, I asked the captain if he got a lot of that.
"I do here," he said, smiling. "Vermonters love their soldiers."
Donna B,
Thanks for writing. You raise some difficult questions and issues - which is certainly appropriate, as the subject is difficult.
Some I want to ponder. But I'll take a stab at a couple:
Q Does an expansion of the def of PTSD lead to a dilution of the treatment?
A. In a sense, yes. As I note in my story in SciAm, having a diagnosis categroy grow so broad and baggy that people with other problems get included in it leads to confusion all around, and, in some cases, a focus on a problem that may not be really the most important problem, or use of a technique or treatment aimed at A when the problem is B.
Q (if I understand you correctly): Might an underreaction to ambiguous threats from civilians be as damaging to the psyche of troops as an overreaction?
A. Fuzzy ground here. Certainly it's stressful to feel helpless to respond to threats. And the specifics that might apply here are so various and potentially complex that it's hard to generalize. But: Many, many individual accounts and cases, as well as some studies and a fair amount of psych theory, hold that one of the most troubling and psychically taxing things in war is killing in general, and killing innocents (or people who might or might not be innocents) in particular. So I'd wager that restraint in such situations, even if frustrating, is generally far less traumatic and psychologically risky, as it were, for the soldier.
I very much appreciate your note and thoughtful questions, the more so coming from soneone who has so many close family members who have been on the line or stand ready to be called. And you're right -- this war is astonishingly invisible and unspoken, and returning from it must be strange indeed.
Though there are moments where you see people at least try to acknowledge a service the depth of which they know they can't understand. On a recent flight back home to Vermont from DC, I sat next to a captain in the Army Reserve, a man around 50, I would guess, who told me he'll be shipping out for his third tour in Iraq this November, and who has two sons over there, one in Iraq, on in Afghanistan, each on his second tour. As we were walking through the Burlington, Vt., airport after landing -- he was a few feet ahead of me as we navigated crowds and doors -- two people thanked him for his service, and when he went through the double doors that separated the scure departure/return waiting area from the public receving area, a little boy about 5 or so, waiting with his dad for someone else arriving, excitedly pointed at this captaion (who was in uniform) and said, "Daddy! Daddy! Look!" -- as excited as if he'd seen Spiderman. His dad turned and said, "Yes!" to his son, and he too quietly thanked the captain for his service. A few yards down the hall, I asked the captain if he got a lot of that.
"I do here," he said, smiling. "Vermonters love their soldiers."
I find your take on the issue of screening for PTSD to be somewhat narrow focused. It is important to recognize that the practice of screening has already been done during WW2 and The Spanish civil war by Mira.
Whatever effectiveness the screening had could be easily overshadowed by the benefits of forward treatment in the manner advocated by Salmon and the logistical handicap of immediately eliminating a percentage of recruits during wartime.
While one may say a reimplementation of such a policy today would be justified by our greater understanding of mental disorders, It would be a stretch to say that any decision policy concerning PTSD could be made with great confidence.
I would argue that instead of a screening policy, efforts should be made in the manner of PIE...which is probably the most effective tool against PTSD. An immediate, proximal treatment has proven time and time again to be the best. The reason why the VA has trouble with PTSD years after a traumatic event is because that's the worst time to treat it.
The reason why PIE has failed in recent conflicts is due to the rapid nature of warfare, and the lack of a clear front line. As shown in the Lebanon-Israeli, such high intensity conflicts with no front line produce a disproportionate number of PTSD cases.
The proverbial cherry is the boredom and drug abuse (inhalants) of rear echelon troops adding a Vietnam like behavioral problem strain on the mental health facilities in the armed forces.
Rather than focusing on before or after, efforts placed on rapid response and the creation of a safe, forward treatment area will show much greater return.
I have no idea what you guys are talking about! The VA is doing an outstanding job with PTSD treatment - if you consider over medicating our Veterans "treatment." Certainly is much easier to write a 'script and tell the Vet to go home and take his medications and relax, than to actually help the Veteran.
And unfortunately the label "PTSD" has gathered 'baggage' that does dilute the significance of combat related PTSD. Big difference in surviving a hurricane (for which you were told to evacuate the area before it hit) and surviving the trauma of war.
It all makes 'perfect' sense to me - over medicate the Veterans, and throw them into the same 'category' as a hurricane survivor - yep, perfect sense.
I believe the problem is worse for National Guard soldiers. These folks are expected to transition from the full-on military combat culture directly back into the civilian life. Further compounding the difficulty is the fact that many of these soldiers signed on in order to protect their country in emergencies or invasions. They chose to be citizen-soldiers, rather than full-time soldiers but now they find themselves in the position of occupying a foreign land where they are being shot at by children in many cases. And the National Guard is often considered second class in the military culture. They don't get the support of the military community when they return home and their families are not supported by the military culture very well.
Hi David: I think you're doing an important service in pushing peoples thinking regarding PTSD treatment. I'm curious: you quote Dr. Frueh as stating
"In civilian populations, two thirds of PTSD patients respond to treatment. But as psychologist Christopher Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, "In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own"
The 2/3rds number is pretty well established in PTSD outcome research and psychotherapy outcome research generally. However, I'm wondering if you could provide links to the two studies noted by Dr. Frueh. I've had trouble finding them on my own. Thanks again.
z
zi: You asked for the refs for the papers Chris Frueh cited:
"In civilian populations, two thirds of PTSD patients respond to treatment. But as psychologist Christopher Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, "In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own.:"
They are:
Schnurr et alia, "Randomized Trial of Tramua-Focused Group Therapy for Posttraumatic Stress Disorder," Arch. General Psychiatry 5 Nov 2003, online at http://archpsyc.ama-assn.org/cgi/content/abstract/60/5/481
Friedman et al, "Randomized, Double-Blind Comparison of Setraline and Placebo for Postraumatic Stress Disorder in a Departmeent of Veterans Affair Setting," J Clin Psychiatry, May 2007.
On other comments:
BJ: Indeed, some studies show higher rates of mental distress and readjustment problems in National Guard soldiers, and the reasons you cite are often offered in explanation, and seem viable to me. But into that mix you have to stir the (statistically) lower occurence in older people, and if memory serves me well, Guard cohort is generally older -- so that may ameliorate some of the vulnerabilities. But Yes, Guard soldiers are showing more signs. But in some cases they have more secure and supportive environments to return to, and that can be a great help.
Mike Manion: I don't mean to ignore the question of how in-theater measures could be better. I imagine they could -- and by some accounts, some units there have made improvements, though PIE hasn't been instituionalized as such. I'd be v interested to see a good study on how post-deployment readjustment arcs might differ between soldiers who have served mainly or exclusively in the post-surge operations, when instead of venturing out from isolated bases they stayed in smaller bases in neighbhorhoods and ventured out constantly, so they became familiar with the neighborhoods, and switched their mission from hunt-and-kill (or draw fire and return) to knowing and protecting the populace. This has not only worked well in undermining the insurgency, but give the soldiers both a much clearer sense of mission and a much richer and more coherent sense of context in which any action takes place. I suspect that would help a great deal. It would also be hard to separate, in a study, from a) the lower attack and casualty rates that those measures have generally produced and b) the possible scarcity of soldiers who have served only in those operations, since so many at this point are on 2d or 3d tours.
Context is hugely important in these issues. The surge has created an in-theater context and sense of mission that is much more coherent. But soldiers still return to a domestic context in which few Americans understand much at all about the war. And little wonder. The press badly misreported the first half or two-thirds of the war -- and didn't really understand the surge. And by that time, we had far fewer reporters over there anyway -- and those who read their stories back home were understandably skeptical about what they read. After reading for 3 years how some breakthrough or new way of operating or new feel on the streets was changing things, people here -- the few paying attention - were naturally slow to accept that we really WERE doing things differently, and getting different results.
Those changes may not leave Iraq at peace when time comes to leave. But they (and other changes, such as Safr's militian standing down) certainly changed the context in which US soldiers have been operating, in a way I suspect would be helpful to mental health there and afterwards.
Any vets out there who could speak to this, I'd love to hear from you.
Thanks,
David Dobbs
Wow, this is all really interesting, and sad to me. I guess I can only look at this from my perspective (as we all do), and that tells me that as you have pointed out, there are some serious holes in the mental health system in the VA. Furthermore, the fact that they are letting people go into combat who are already at very high-risk to develop PTSD is shocking to me. I actually read this New York Times story and was asking myself, "but, I thought they were really trying to work on this?".
Again, from, my own perspective, I find myself wondering if part of the problem is that the army (and for that matter much of the world) still don't view mental illness as a legitimate concern. In my mind, many people probably see PTSD as a non-legitimate concern, especially those who are raised that think that being in the army is manly etc. I know that the general healthcare system doesn't seem to think that depression, bipolar disorder, and personality disorders merit the same coverage, so it's likely the VA has also fallen into this line of thinking.
Thanks for the great insight!
I finally got around to reading the SciAm article and offer my apologies for not reading it before commenting.
I first became acquainted with PTSD in the late 90s as part of a grant being written to assure proper counseling for policemen who had shot someone or been shot in the line of duty. Even then, I had my doubts about its "reality" as far as an illness. But, the grant idea seemed sound -- if, as soon as possible after the event -- the officer was debriefed and counseled, PTSD was either prevented or greatly reduced.
The grant was not funded.
Sue L. -- services and quality of care vary widely depending on the VA center. This is a problem, but I fear it's going to be addressed by bringing them all down to the level of the worst.
David Dobbs -- I think my question was more along the lines of how the demonization of possibly killing an innocent civilian has been greatly increased. Because of My Lai, in this country it has been deemed that killing a civilian (innocent or not) is the greatest wrong the military can do. Coupled with the fact that more civilians are participating as combatants and that combatants are more likely to hide behind the facade of a civilian, I would think this would increase the stress greatly.
In Afghanistan and Iraq, our uniformed soldiers are not fighting other uniformed soldiers. Even though there were exceptions in Vietnam, normally the other side could be readily identified as the other side.
Does that clarify my question a bit?
But don't ask me my opinion of the VA right now. I'm currently filling out the forms to claim disability for my husband's service in Vietnam and on Christmas Island. His third primary cancer was the tipping point. The forms are tedious, even asking about previous marriages I might have had. If you know why this is relevant, I'd wish you'd tell.
As for National Guard/reserve unit activations, my daughter worked (for pay) with the Army to organize Family Resource Groups these units. She was hired because of her education, Army service, and experience in organizing (without pay) Family Resource Groups for regular Army units sent to Iraq.
Perhaps one of the reasons veterans do not get well from PTSD like civilians do is that they are paid as long as they are sick... Civilians are not rewarded for ptsd . Also there is no incentive for the therapists either as they are paid as long as they have patients. I have a friend who is considered disabled from PTSD by the VA and has gotten paid for this disability for 40 years. Meanwhile he is able to do anything that anyone else does. travel skydive ski, entertain.