| As
they take their seats in the movie theater,
Eric and Raquel Schrumpf could be any young
couple out on a summer night in Southern California.
No one notices as Schrumpf, 31, a former Marine
sergeant who served in Iraq, scans the rows
for moviegoers who may be wired with explosives
under their jackets. No one pays attention as
a man who appears to be Middle Eastern, wearing
a long coat with bulging pockets, takes a seat
in the same row as the Schrumpfs and Eric starts
watching him intently. No one listens as Schrumpf
instructs his wife to "get as low to the
ground as you can if something happens."
Then something does. Schrumpf hears metal jangling
as the man reaches into his pocket. Convinced
he is a suicide bomber about to strike, Schrumpf
lunges at him. The man jerks away and his deadly
weapon falls to the floor: a can of Coke.
Schrumpf has
everyone's attention now, as he and his wife
quickly leave the theater. The Schrumpfs can't
even remember what movie they went to see. Not
that it would have mattered. Eric Schrumpf had
room for only one movie in his head, the one
where he is in Iraq. Now, more than two years
later, Schrumpf has a good job, a strong marriage,
a couple of pets, and a life that looks startlingly
like everyone else's in Orange County, Calif.
But he is still never more than a sound, smell,
or thought away from the war. He gets anxious
in a crowd, has been known to dive for cover,
even indoors, at the sound of a helicopter,
reaches for nonexistent weapons to be used in
nonexistent circumstances, and wakes up screaming
from nightmares about burning bodies and rocket-propelled
grenades. "I'll never be the same again,"
says Schrumpf, who as a weapons and tactics
instructor with the 5th Marine Regiment was
part of the initial push into southern Iraq
in 2003. "The war will be part of my life
and my family's life forever."
Reliving
the war. Like thousands of soldiers
who have returned from Iraq and Afghanistan,
Schrumpf is suffering from post-traumatic stress
disorder, a chronic condition whose symptoms
include rage, depression, flashbacks, emotional
numbness, and hypervigilance. It can be brought
on by a single event, such as when a grenade
landed next to Schrumpf, ticking off his death
and then failing to explode. Or it can be the
result of repeated exposure to trauma such as
house-to-house firefights or the accidental
killing of civilians. "Soldiers who are
routinely exposed to the trauma of killing,
maiming, and dying are much more likely to bring
those problems home," says Army Col. Kathy
Platoni, a clinical psychologist and leader
of a combat stress-control unit that works with
soldiers on the battlefield. At its most basic,
PTSD is the inability to flip the switch from
combat soldier to everyday citizen and to stop
reliving the war at so high a frequency that
it interferes with the ability to function.
The problem
is as old as war itself. But this time, American
soldiers have been assured by the government
and the military that the solution will be different:
Iraq will be nothing like Vietnam, with its
legacy of psychologically scarred veterans whose
problems went unrecognized, undiagnosed, and
untreated. "The hallmark of this war is
going to be psychological injury," says
Stephen Robinson, a Gulf War vet and director
of government relations for Veterans for America
in Washington, D.C. "We have learned the
lessons of Vietnam, but now they have to be
implemented."
Since the war
began, the departments of Defense and Veterans
Affairs have stepped up efforts to address the
mental health needs of soldiers before, during,
and after they are deployed. And more effective
treatments for PTSD have been developed. But
as the war drags on, the psychological costs
are mounting and so is the tab for mental health
care. Troop shortages are driving already traumatized
soldiers back into combat for three and sometimes
four tours of duty. Those who make it home often
feel too stigmatized to ask for treatment lest
they jeopardize their military careers. And
if they do ask, they often can't get the care
they need when they need it.
In addition,
there are concerns among veterans groups that
the Bush administration is trying to reduce
the runaway cost of the war by holding down
the number of PTSD cases diagnosed (and benefits
paid), and that the promise to protect the mental
health of nearly 1.5 million troops is not being
kept. "Throughout this war, everything
has been underestimated-the insurgency, the
body armor, the cost, and the number of troops,"
says Paul Rieckhoff, an Iraq war vet and founder
of Iraq and Afghanistan Veterans of America
in New York. "Now, the psychological problems
and the needs of these soldiers are being underestimated,
too."
Just how many
troops will bring the war home with them is
impossible to know at this point. But the numbers
could be substantial. In a study published in
2004 in the New England Journal of Medicine,
researchers at the Walter Reed Army Institute
of Research found that nearly 17 percent of
soldiers who have returned from Iraq, or nearly
1 in 6, showed signs of major depression, generalized
anxiety, or PTSD. A report in the Journal
of the American Medical Association earlier
this year found that 1 in 5 soldiers met the
risk for concern. And those numbers are virtually
certain to grow as the war enters its fourth
year. "I do think we're going to see a
whole lot more PTSD as time goes on," says
Platoni.
The VA, short
of doctors, therapists, and staff in some areas,
is straining to meet the mental health needs
of the troops who have already returned from
Iraq and Afghanistan. Soldiers often wait weeks
or even months to see a psychiatrist or psychologist.
A 2004 study by the Government Accountability
Office found that six of the seven VA medical
facilities it visited "may not be able
to meet" increased demand for PTSD. "I
don't think anybody can say with certainty whether
we are prepared to meet the problem because
we don't know what the scope is yet," says
Matthew Friedman, a psychiatrist and executive
director of the VA's National Center for PTSD
in White River Junction, Vt. "What we do
know is that the greater the exposure to trauma,
the greater the chance that someone will have
PTSD."
Danger
zone. There may be no war better designed
to produce combat stress and trauma. Operation
Iraqi Freedom is a round-the-clock, unrelenting
danger zone. There are no front lines, it's
impossible to identify the enemy, and everything
from a paper bag to a baby carriage is a potential
bomb. Soldiers are targets 24-7, whether they
are running combat missions or asleep in their
bunks. "There is no moment of safety in
Iraq," says Andrew Pomerantz, a psychiatrist
and chief of the Mental Health and Behavioral
Science Service at the VA Medical Center in
White River Junction. "That's one of the
things we're seeing in people when they come
back-a feeling of an absolute lack of safety
wherever they are."
Stories of
vets who sleep with guns and knives and patrol
the perimeters of their homes obsessively are
as common as tales of valor. Marine Lt. Col.
Michael Zacchea, 38, who trained Iraqi troops
and was in about 100 firefights, knows that
paranoia all too well. "Every time I get
on the road," says Zacchea, who commutes
from Long Island to Wall Street, "it's
like I'm back in the streets of Baghdad in combat,
driving and running gun battles, with people
throwing grenades at me." Zacchea, a reservist,
is now being treated for PTSD at a VA hospital,
but had it not been for chronic dysentery, migraines,
and shrapnel wounds in his shoulder, he says
he probably would have been redeployed in September,
emotional scars and all.
And he still
may be. The military's need to maintain troop
strength in the face of historic recruiting
lows means many service members, including some
suffering from psychological problems like Zacchea,
have no choice but to return. President Bush
recently authorized the Marine Corps to call
up inactive reservists, men and women who have
already fulfilled their active-duty commitment.
"They're having to go deep into the bench,"
says Robinson, "and deploy some people
who shouldn't be deployed."
Multiple
tours. Robinson is referring to the
increasing number of reports of service members
who stock antidepressants and sleeping pills
alongside their shampoo, soap, and razor blades.
The Defense Department does not track the number
of soldiers on mental health medications or
diagnosed with mental illnesses. But the military
acknowledges that service members on medication
who may be suffering from combat-induced psychological
problems are being kept in combat. "We're
not keeping people over there on heavy-duty
drugs," says Army Surgeon General Kevin
Kiley, who estimates that 4 to 5 percent of
soldiers are taking medications, mostly sleeping
pills. "Four to five percent of 150,000,
that's still a lot of troops. But if it's got
them handling things, I'm OK with that."
Handling things
is a relative term. Army Pvt. Jason Sedotal,
21, a military policeman from Pierre Part, La.,
had been in Iraq six weeks in 2004 when he drove
a humvee over a landmine. His sergeant, seated
beside him, lost two legs and an arm in the
explosion. Consumed by guilt and fear, Sedotal,
who suffered only minor injuries, was diagnosed
with PTSD when he returned from his first tour
in early 2005 and given antidepressants and
sleeping pills. Several months later, while
stationed at Fort Polk, La., he sought more
mental health care and was prescribed a different
antidepressant
Last November,
Sedotal was redeployed. "They told me I
had to go back because my problem wasn't serious
enough," Sedotal said in an interview from
Baghdad in mid-September. Sedotal says he started
"seeing things and having flashbacks."
Twice a combat stress unit referred him to a
hospital for mental health care. Twice he was
returned to his unit, each time with more medication
and the second time without his weapon. "I
stopped running missions, and I was shunned
by my immediate chain of command and my unit,"
says Sedotal, who returned to Fort Polk last
week.
Cases like
Sedotal's prompted Congress earlier this year
to instruct the Department of Defense to create
a Task Force on Mental Health to examine the
state of mental health care for the military.
It is expected to deliver a report to Secretary
of Defense Donald Rumsfeld in May 2007 and make
recommendations for everything from reducing
the stigma surrounding disorders to helping
families and children deal with the traumatized
soldier.
Sending military
members who suffer from PTSD back into combat
goes straight to one of the toughest issues
of the war: how to protect soldiers' mental
health and still keep them fighting. It is well-established
that repeated and prolonged exposure to combat
stress is the single greatest risk factor in
developing PTSD.
At the same
time, there is tremendous resistance to sending
home soldiers who are suffering from psychological
wounds, in all but the most severe cases. "If
a soldier has some PTSD symptoms," says
Kiley, "we'll watch him and see how he
does." The expectation "is that we're
all in this boat together and we need to drive
on to complete the mission," he says, adding
that if the situation gets worse, the soldier
would most likely be given a couple days of
rest to see if he recovers. Once soldiers are
evacuated, "they are much less likely to
come back."
With that in
mind, the DOD has designed a program to manage
combat stress and identify mental health problems
when they occur. It will include so-called battle-mind
training for recruits, which focuses on the
emotional fallout of seeing and contributing
to the carnage of war and how to deal with it.
Once they are in Iraq, there are psychologists
and combat stress-control teams, such as Platoni's,
who work side by side with troops to help them
deal with their emotions and decompress immediately
after battle. "Soldiers suffering from
combat stress do better if they are treated
early, efficiently, and as close to the battlefield
as possible," says Col. Charles Hoge, chief
of the Department of Psychiatry and Behavioral
Sciences at Walter Reed Army Institute of Research.
Currently,
there are more than 200 psychiatrists, therapists,
social workers, and other mental health experts
working with soldiers "in theater."
They lend an ear, encourage soldiers to talk
about their experiences with each other, and
administer whatever short-term remedies they
can, including stress-reduction techniques,
anger-management strategies, or medications.
However, their mission, first and foremost,
is to be "force multipliers" who maintain
troop strength. Their success is judged by their
ability to keep soldiers from going home for
psychological reasons. Soldiers are often their
allies in this effort, as they feel such guilt
and shame over abandoning their units they'll
most likely say anything to keep from leaving.
"It's a very sticky wicket," says
Platoni. "We don't know if our interventions
are enough to help them stay mentally healthy,
or if they'll suffer more in the long term."
Last year,
for instance, Platoni spent four months in Ar
Ramadi, near Baghdad, where her battalion was
under constant attack by insurgents. "They
were watching their fellow soldiers burning
to death and thinking they might be next,"
says Platoni. When a break came, one platoon
was removed from combat for 48 hours so they
could rest, shower, have a hot meal, and talk
to psychologists about what they'd been through.
"When they returned to the fighting,"
says Platoni, "they were able to deal with
their fears better and focus on what needed
to be done."
When soldiers
do return home, the true emotional trauma of
war is often just beginning. They go through
a cursory post-deployment medical screening
and a quick interview with a healthcare worker,
who may or may not specialize in mental health.
And returning soldiers are far more likely to
downplay emotional problems for fear of being
shifted from the "go home" line into
the "further evaluation" line and
being prevented from seeing families and friends.
Macho
warrior. Three to six months after
they return-the time when PTSD symptoms are
the most likely to start becoming obvious-troops
are given another mental health screening and
may be referred for further evaluation, although
the chances are slim. A GAO report issued in
May, for instance, found that of the 5 percent
of returning veterans between 2001 and 2004
who tested as being at risk for PTSD, fewer
than one quarter were referred for further mental
health evaluations. William Winkenwerder, assistant
secretary of defense for health affairs, took
issue with the study: "We're doing more
than any military in history to identify, prevent,
and treat mental health concerns among our troops.
It is a top priority for us." Even with
a referral, many veterans and active-duty soldiers
will not seek help for fear of being stigmatized.
To help break down the barriers, the DOD has
begun encouraging high-ranking soldiers to openly
discuss the effects that combat and killing
can have on a person's psyche. Even so, the
military remains dominated by the image of the
macho warrior who sucks it up and drives on.
According to the VA, the number of PTSD cases
has doubled since 2000, to an all-time high
of 260,000, but fewer than 40 percent of veterans
from Iraq and Afghanistan have sought medical
treatment. "This is the military culture,"
says Schrumpf, who now gets regular therapy
and takes medication to help with his PTSD.
"If it gets out that you even went to see
the medical officer, and it always does, then
you're done as a career marine."
In a surprising
admission, former Georgia Sen. Max Cleland,
who lost three limbs in Vietnam, announced in
August that he is being treated for PTSD in
the hopes of encouraging other vets to do the
same. One of the biggest problems for Vietnam
veterans, for instance, was that their psychological
wounds went unrecognized and unattended for
so long that, by the time they got treatment,
many were past of the point of being helped.
Cleland is one of a growing crowd of Vietnam
vets who are finally seeking help-and competing
for VA services-as a result of long-buried feelings
stirred up by the Iraq war.
In the past
few years, in part because of events such as
September 11, there have been advances in therapies
for PTSD. "Just because you have PTSD,
it doesn't mean you can't be successful in daily
life," says Harold Wain, chief of the psychiatry
consultation and liaison service at Walter Reed
Army Medical Center in Washington, D.C., the
main Army hospital for amputees. Many of the
patients Wain sees have suffered catastrophic
injuries and must heal their bodies as well
as their minds.
Reimagining
the trauma again and again, or what's known
as exposure therapy, has long been believed
to be the most effective way of conquering PTSD.
It is still popular and has been made even more
effective by such tools as virtual reality.
However, therapists are increasingly relying
on cognitive behavior therapy or cognitive reframing,
putting a new frame around a thought to shift
the way a soldier interprets an event. A soldier
who is racked with guilt because he couldn't
save an injured buddy, for instance, may be
redirected to concentrate on what he did do
to help. Other approaches such as eye movement
desensitization and reprocessing use hypnosis
to help soldiers.
For some soldiers,
simply talking about what happened to them can
be therapy enough. When Zachary Scott-Singley
returned from Iraq in 2005, he was haunted by
the image of a 3-year-old boy who had been shot
and killed accidentally by a fellow soldier.
With a son of his own, Scott-Singley couldn't
get the picture of the child and his wailing
mother out of his head and became increasingly
paranoid about his own child's safety. "I
was constantly thinking about how people were
going to attack me and take him," he says.
Scott-Singley twice sought mental health care
from the Army. The first time he says he was
told that since he wasn't hurting anybody, he
didn't have PTSD. The next counselor suggested
he buy some stress-management tapes on the Internet
and practice counting to 10 whenever he felt
overwhelmed. (The VA is legally precluded from
discussing a soldier's medical records.) Ironically,
Scott-Singley found his therapy on the Web anyway,
with his blog A Soldier's Thoughts (misoldierthoughts.blogspot.com).
"It feels so much better to know I am not
alone."
Outcry.
Many veterans say they would also find it therapeutic
to hear Bush acknowledge PTSD and the psychological
costs of the war instead of downplaying them.
Earlier this year, for instance, the Institute
of Medicine was asked by Congress to re-evaluate
the diagnostic criteria for PTSD, which was
established by the American Psychiatric Association
in 1980. Critics claim the review was ordered
by the Bush administration in an effort to make
it harder to diagnose PTSD, which would in turn
reduce the amount of disability payments. The
number of veterans from all wars receiving disability
payments for PTSD, about 216,000 last year,
has grown seven times as fast as the number
receiving benefits for disabilities in general,
at a cost of $4.6 billion a year. And that figure
does not include most of the more than 100,000
Iraq and Afghanistan veterans who have sought
mental health services. The IOM report, released
in June, supported the current criteria for
diagnosing PTSD.
Now the institute
is looking at the accuracy of screening techniques
and how to compensate and treat vets with PTSD,
widely regarded as an easy condition to fake.
And in another move that infuriated veterans
groups, the VA late last year proposed a review
of 72,000 cases of vets who were receiving full
disability benefits for PTSD to look for fraud.
The move prompted such an outcry that it was
called off.
Studies and
reviews aside, there isn't enough help available
to veterans with PTSD. According to a report
from the VA, individual veterans' visits to
PTSD specialists dropped by 20 percent from
1995 to 2005-"a decrease in capacity at
a time when the VA needs to reach out,"
the report stated. Secretary of Veterans Affairs
James Nicholson says the VA sees 85 percent
of new mental health patients within 30 days.
"But that still leaves 15 percent and that's
a big number. Could we do better? Yes."
Bush has called
for a record $80.6 billion in the 2007 VA budget.
That includes $3.2 billion for mental health
services, a $339 million increase over this
year's budget. However, those increases are
being met by increasing demands for care, as
well as rising cost-of-living allowances and
prescription drug prices. "The bigger budget
doesn't really add up to much," says Rieckhoff.
However frustrating
and exhausting the process, most vets can avoid
getting help only so long before friends and
family push them into counseling or they get
in trouble with the law. "It's almost like
your family has its own form of PTSD just from
being around you every day," says a former
Army sergeant who worked as an interrogator
in Iraq and asked that his name be withheld.
"When I came back I was emotionally shut
down and severely paranoid. My wife thought
I was crazy and my son didn't realize who I
was. Because of them, I got help."
Like many soldiers,
he found it at one of more than 200 local Veterans
Centers, which offer counseling for PTSD and
sexual assault, a growing concern for women
in the military. Vet Centers are part of the
VA but operate like the anti-VA, free of the
delays and bureaucracy. There is almost no paperwork,
and the wait to see a counselor is rarely more
than a week. It's no coincidence that when Doonesbury
character B.D. finally went for help with his
PTSD, he went to a Vet Center (story, Page 60).
The centers are small and staffed mostly by
vets, which creates the feel of a nurturing
social environment rather than an institutional
one. The free coffee is strictly decaf, and
the approach is laid back. "Someone may
come in asking about an insurance problem, and
as we answer their questions, we ask them how
are they feeling," says Karen Schoenfeld-Smith,
a psychologist and team leader at the San Diego
Vet Center, which sees a lot of Iraq vets from
nearby Camp Pendleton. "That's how we get
them into it." Many come just to talk to
other vets.
It is that
same need to talk that keeps Schrumpf E-mailing
and phoning fellow marines and returning to
Camp Pendleton every couple of weeks to hang
out. "It is the only place I can talk about
the killing," he says. Next month, Schrumpf
will leave California for his home state of
Tennessee, where he says it will be easier to
raise a family. He's not worried about taking
the war with him. In fact, in many ways he is
more worried about leaving it behind. "The
anger, the rage, and all that is just there,"
says Schrumpf. "And honestly, I don't want
it to leave. It's like a security blanket."
Or a movie, that just keeps on playing.
This story
appears in the October 9, 2006 print edition
of U.S. News & World Report. |
