Hidden Battles on Unseen Fronts

by Patricia Driscoll

  Give an Hour is a nonprofit organization that consists of a national network of mental health professionals who provide free mental health services to US troops and their families. Our plan is to continue recruiting mental health providers so that anyone affected by the current war who is in need of mental health support or care will be able to access it easily. Currently we have providers in every state, with the network growing daily. In addition to providing direct service to returning troops and family members, we assist with phone support, public education and consultation to veterans’ organizations, private employers, schools and other state and local agencies.

  According to a Rand Report released in April 2008, approximately 320,000 of the men and women who had returned from combat at that time indicated that they had experienced a Traumatic Brain Injury, or TBI. Only a small percentage of these individuals suffered TBI as a result of a penetrating wound. The vast majority of these men and women suffered potentially disabling neurological wounds from the blast waves of IEDs (improvised explosive devices), mortar shells or other explosive weapons—all without so much as a scratch of physical evidence.

  Since founding Give an Hour, I’ve spoken with a number of veterans and family members. One family member I talked to was a physician in Texas who reported what has become a very typical story. His son was deployed to Iraq and spent several months riding around in one of the Army’s Bradley fighting vehicles. Although he wasn’t wounded in the traditional sense of the word, he was in the immediate vicinity of multiple blasts. This father told me that upon his return his son had chronic headaches, difficulty sleeping and hearing loss. Despite these concerning symptoms of possible Traumatic Brain Injury, this young soldier shipped out for another deployment to Iraq soon after I talked with his father.

  I have also met many people in the military who are trying to stay in front of these issues. Indeed, they are working tirelessly to address the psychological and neurological needs of the troops through a variety of excellent programs within the military culture. In addition, they are reaching out to organizations like Give an Hour to partner in this critical effort.

  Fortunately we have the knowledge and the human resources to attend to these deserving men and women and their families. In fact, we have over 400,000 mental health professionals in our country—many of them eager to help. Through collaborative efforts with the Department of Veterans Affairs, the Department of Defense, state and local governments and other nonprofit organizations, I believe that we can create a comprehensive support system that ensures proper care for our military community.

  In order to reach those in need, however, we need to educate the public and the entire military community. Most people—both civilian and military—do not understand how a strapping young man or woman, courageous and full of life, can return from a deployment so psychologically damaged. The soldiers themselves don’t understand what is happening to them. Those suffering symptoms of combat stress often feel ashamed; they are afraid they are losing their minds, and are also afraid of losing their families and careers. They don’t talk about it—they try to go on.

  Those suffering from traumatic brain injuries often feel confused; frequently, their conditions are not accurately diagnosed. They return home to find that they have trouble concentrating, focusing and carrying out the tasks of daily life. They may also experience frequent headaches and difficulty controlling their moods.

  Sadly, it is not uncommon for this new generation of veterans to have multiple physical, psychological and neurological injuries with which they must cope. As a nation, we must prepare for the return of these men and women. We must assist in their recovery and—when needed—plan for their long-term care.

  “The number of troops with new cases of post-traumatic disorder jumped by roughly 50 percent in 2007 amid the military buildup in Iraq, increased violence there and in Afghanistan. Records show roughly 40,000 troops have been diagnosed with the illness, also known as PTSD, since 2003. Officials believe that many more are likely keeping their illness a secret.”

  —“Wartime PTSD Cases Jumped Roughly 50 Percent in 200,” Pauline Jelinek, AP, January 2008

  7

  DEEPER THAN WAR

  The Story of Marine Corps Captain Tyler Boudreau

  “Their trauma, it seems, was not all based strictly on those moments of powerlessness when they’d been shot at, mortared or IED’d. There were clear incidents of moral distress, too. As many Marines as I dealt with who were agitated by the dangers they encountered, there were as many more agitated by their own actions. Most often, I suspect, veterans contend with some varying blend of the two.”

  In 2004 Tyler Boudreau was a rifle company commander in the US Marine Corps. “Our battalion had just returned from Iraq and would be heading back exactly nine months later. In Iraq our area of operations had been dubbed by the media “The Triangle of Death.” Many of our men were wounded or killed. The violence was heavy on all sides. Those who returned home had much to consider. We weren’t stateside for long before Marines started trickling into my office to talk about the turbulence brewing inside them.” This was his introduction to the world of post-traumatic stress.

  At the time, Tyler had been in the Marine Corps for about eleven years. “I knew of post-traumatic stress, of course. I’d read about it in the books. I’d even seen it portrayed in the movies. But I’d never been confronted with it face to face, especially not as an officer. What those outside the military must appreciate most is the predicament this creates for a commander. In the military the mission always comes first; troop welfare comes after. It doesn’t mean a commander doesn’t care about his troops or that he can’t love them—he can and he should—but he must love the mission more. It’s doctrine, it’s written, and quite frankly it’s common sense; the mission—that is, the greater good—must always take precedence over the individual.”

  Within the doctrinal texts and the stuffy tomes of military history, that sounds reasonable enough. Even on the battlefield, as one imagines a line of soldiers assaulting an enemy strongpoint, the notion of “the unit” and “the mission” being a life-or-death priority makes sense. But to Tyler, in the context of soldiers coming home from war with post-traumatic stress, it began to sound a little bit less sensible.

  “With no enemy bearing down, it was certainly difficult for me not to give my full compassion to every Marine who experienced the slightest distress. But as a commander, I needed to always bear in mind that my unit would soon be back in the combat zone and, further, that manpower was not an inexhaustible spigot. There is an expectation that a commander preserve his force to every possible extent. There will come a point when the spigot runs dry and the deployment date arrives; when it does, you go. Whether you’re ready or not, whether you’re full strength or shorthanded, when D-Day arrives, you go. Of course, going to war shorthanded or mentally ill-prepared is not only dangerous for the unit; it is inherently detrimental to the mission.” And therein lay Tyler’s predicament.

  He had nine short months to prepare 150 Marines for battle. “I had to process out the departing Marines and train from scratch the arriving ones. I had to inventory weapons and equipment, plan training, draft orders, conduct inspections, and continually petition for all those things in short supply. Some Marines have specialized skills; they’re hard to find, and the good ones are even harder. The best ones often go to the most effective advocates.” A commander’s business is as much about scrounging, bargaining and downright fighting for the best personnel and equipment he can find as it is about leading his men in battle.

  “These were the issues that occupied the bulk of my time and thoughts during the months before our second deployment. So when my armory custodian (an essential figure) showed up in my office with the Company Gunnery Sergeant to explain that he wanted an appointment with the Division Psychiatrist, I’ll admit I was dismayed. When one of my best machine-gunners came in with the same request, I was concerned.” When nearly a dozen more Marines pou
red in, all looking to “get out,” Tyler was downright alarmed. “It struck me almost instantly as a negative trend—a method to avoid our deployment, and I grew worried that this trend would catch on.”

  A rash of men suffering from post-traumatic stress can bear a striking resemblance to general low morale within the unit. “I suspect this is hard for those outside the ranks to really understand. This is one of the primary struggles for a commander—to maintain the esprit de corps of his men so that they perform well together on the battlefield. Breakouts of “malcontent” can be devastating to a unit, and furthermore extremely contagious. While rampant instances of discernible apathy or melancholy, or even flagging discipline among the troops may very well be symptoms of a post-traumatic stress epidemic, they may occur to a commander instead as fatigue or buckling will. Unfortunately, the remedy for one is quite contrary to the remedy for the other.”

  Tyler had to ask himself, how he could balance the needs of the Corps and country with the needs of an individual Marine in pain? How could he prevent himself from slipping into the habit of viewing all such men as shirkers or malingers?

  “I can say from my own encounters with this dilemma, it is difficult. What I found even more difficult to fathom at the time was the non-uniform nature of their reports. Their trauma, it seems, was not all based strictly on those moments of powerlessness when they’d been shot at, mortared or IED’d. There were clear incidents of moral distress, too. As many Marines as I dealt with who were agitated by the dangers they encountered, there were as many more agitated by their own actions. Most often, I suspect, veterans contend with some varying blend of the two.”

  “Collateral damage” is a term used in the military to describe the unfortunate, unintentional and often unavoidable destruction that occurs on the battlefield in the execution of a mission. “In Iraq, collateral damage was not uncommon, particularly because, in most cases, those who we fought were indistinguishable from those who we meant to protect. Mistaken identities were simply inevitable, and when they resulted in death, it was truly heartbreaking for all of us, especially for the unlucky Marines who’d pulled the trigger. What I discovered about their anxiety was that it did not include any context whatsoever. In other words, justifications were never permitted by their conscience.“

  “I made more speeches that I can count defending Marines to themselves—those who had fired their weapons in self-defense, but because the situation had been unclear (as so many situations in Iraq tended to be), they’d inadvertently killed non-combatants. Occasionally those non-combatants were very young indeed, and that made their memories all that much more tenacious. I argued to them that the circumstances had compelled them to fire. Their lives and the lives of their fellow Marines depended very much on them having done what they did.

  “But all my reasoning had little effect. Their moral consternation existed in a vacuum beyond the scope of reason. The killing of people, combatant or non-combatant, can for many men be a trying event, and sometimes an utterly devastating one. All the justifications in the world, legitimate or not, cannot sever them from their pain. This was a reality I found hard to accept. I must admit, once I’d explained the situation to these Marines, I rather arrogantly expected them to just “snap out of it.” But they didn’t snap out of it. I couldn’t understand why such cogent logic, presented by me, their own commander, was not enough to get them back on track. Thinking on it now, I tend to believe that my very position as commander induced a certain myopia within me, which I could not shed until I shed my uniform and relinquished my command.”

  The greatest irony of his resistance to truly understanding their condition was that, at the very same time, Tyler was experiencing his own share of post-traumatic stress. “I too was agitated. I wasn’t sleeping. When I did sleep, I was prone to some incredibly violent dreams. I was jumpy, excitable, downright volatile. I could flip to rage at the slightest provocation, and the rage was difficult to subdue. On top of it all, I did bear an undeniable regret for the violence that I’d inflicted in Iraq. All of this festered inside my body and mind until those crucial preparations for our deployment were utterly edged out of my consciousness. After a while, the stress owned virtually all of my thoughts. I would arrive at work at one or two o’clock every morning and I’d sit alone in a darkened building and just stew until dawn. Throughout our training exercises, I had trouble concentrating on the tasks at hand. My duties as a commander became an afterthought. Finally, after months of deterioration, after I’d really begun to lose confidence in myself as a leader of Marines, I made the most difficult decision of my life—to relinquish my command and resign my commission.”

  After Tyler left the Marine Corps he began to see the inherent conflict presented to a commander who must care for his men suffering from post-traumatic stress while simultaneously preparing his unit for combat. “It was not until I ceased to function optimally as a Marine myself that I started to really acknowledge that those Marines in my company who’d come to me seeking help were not, in fact, malingerers, but just men in pain.”

  Tyler Boudreau served 12 years in the Marine Corps infantry. He enlisted in 1989, was commissioned a 2nd Lieutenant in 1997, and was deployed to Iraq as a Captain in 2004 with 2nd Battalion, 2nd Marines. Boudreau resigned his commission in 2005 and is the author of Packing Inferno: The Unmaking of a Marine. He currently lives with his family in western Massachusetts.

  “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 feel. ‘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. For my patients, the trauma isn’t something that happens to you. It is you.”

  —“Treating Wounds You Can’t See,” Linda Blum, Washington Post, June 29, 2008

  8

  THE VA’S SUICIDE PREVENTION HOTLINE

  Saving the Lives of Veterans

  By Janet Kemp, VA National Suicide Coordinator

  The VA program for suicide prevention is based on a public health approach utilizing universal, selective, indicated strategies. The VA recognizes that suicide prevention requires ready access to high quality Mental Health Services, supplemented by programs that address the risk of suicide directly. For veterans this means that the VA understands the need to make the right care and support available for those who need it, when they need it and for as long as they need it. To accomplish this goal a vital resource has been made available to Veterans: the VA National Suicide Hotline—1-800-273-TALK—with the option to push “1” if the caller is “a veteran or someone who cares about a veteran.”

  The VA National Suicide Hotline is located in a large room inside an older brick building on the campus of the VA Medical Center in Canandaigua, New York. The room is simply furnished with workstations that contain phones, headsets and computers. The walls are decorated with clocks that give the time in various time zones across the country and posters that state the VA Suicide Prevention message: “It takes the courage and strength of a warrior to ask for help.”

  There are pictures of the workers’ families on the desks and the requisite bowls of snacks and candy. The workers are calm, quietly answering the phone twenty-four hours a day, seven days a week. Health technicians are busily calling for local rescue people to help, or searching medical records, or following up on callers to make sure that they have been seen at their local VA as promised.

  The hotline is unique and differs from community-based “Crisis Lines” in several ways. It is staffed with VA Mental Health professionals who have the ability to make immediate referrals to local Suicide Prevention Coordinators and also do checks to determine that the callers get the care a
nd follow-up that they need. Utilizing all aspects of the VA system, the responder is able to provide the caller with far more than just an answer to a phone call. The staff is trained in both crisis response and VA issues. They understand that it is equally as important to help those who are not yet in crisis as it is to help those who are already in dire trouble. Their work is critical because calls come in to staff at the center where action can be taken immediately. The follow-ups are done at the local levels afterward. When it comes to suicide prevention, these call center workers are unique within the military in providing veteran-specific care.

  A few individual cases may illustrate the complexity of the task, as well as the capability of these dedicated workers.

  “A female veteran called the hotline in extreme distress. She stated she had pills and was going to walk into the woods and take them all. She stated that no one believed her and she couldn’t go on. She just wanted to talk to someone while she did it. I could hear her park her car and start walking through the words. She refused to give any identifying information other than her first name. We were able to determine the area code she was calling from on her cell phone and called the VA in that area code. The Suicide Prevention Coordinator (SPC) quickly reviewed her high-risk list and was able to identify the person by her first name. The hotline stayed on the phone with her—repeatedly calling her back when she would end the call. Her husband was found by the SPC and he was able to identify the make and model of her car, and he and the local police began a road-by-road search in the area for the vehicle. Several hours later her car was located and the police found her deep in the woods sobbing and holding the bottle of pills and the phone. The local SPC stayed at the facility late into the evening until she was brought in. She is now receiving intensive therapy.”