February 2011 Philadelphia Chapter of Pax Christi U.S.A.

The One Percent Who Bear the Burden of War

My career in medicine, my first job, was as a captain in the Army. Now, 43 years later near the end of my career I again work with soldiers. In 1967 President Lyndon Johnson sent a letter drafting me into the US Army. A long path left me at the medical Field Service School at Fort Sam Houston, Texas. My job was teaching medical colleagues the diagnosis and treatment of tropical diseases in soldiers serving in Vietnam. Some of my soldier trainees were former medical school classmates. Now nearing the end of my career I have a two-day a week job in tele-psychiatry at Walter Reed Army Medical Center. I see 15 to 20 soldiers a week. Many are on their way to Iraq or Afghanistan or have just returned from deployment. Some have been deployed four or five times.

Sometimes I think this work is a curious path for a physician who explored being a conscientious objector during the Vietnam War. I have my reservations about all these wars but have no reservations about helping soldiers. And yet isn’t that contributing to the war effort? I help make decisions as to whether soldiers are suitable for returning to combat.

As I watched my colleagues go and return from Vietnam they, like the entire American society, were changed by the experience. By contrast today 1% of society, soldiers serve in Iraq and Afghanistan and their families are carrying the burden of these wars. 99% of us are virtually unaffected as we watch the war and know little about it.

For the last few years I have watched these two new wars. I read a lot about the war, debated its merits, and viewed a weekly list of names and photos on TV. I didn’t’ know anything about these men and their experiences, those who give their life in service of our country. Opportunities over the years to give an hour a week in my private office taking care of soldiers passed me by. I, like many of my colleagues, declined feeling that a single person private office was ill-equipped for the task.

And then in 2009 an opportunity to work in tele-psychiatry at Walter Reed Army Medical Center came my way. The complexity of clearing the security and competence hurdles is hard to exaggerate. More than three months of time and countless e-mails, letters, and phone calls were required. Once hired it took an equal amount of time to complete army educational programs and become credentialed at military bases throughout the United States.

Walter Reed Army Medical Center is an impressive organization. It is certainly a government bureaucracy but after the Washington Post exposé on soldier treatment a few years go leaders made a decision to hire a top executive from Disney World. His job was to teach the Walter Reed community about graciousness, courtesy, and hospitality. After six months, so impressed with his Walter Reed exposure, he agreed to move his family from Florida to Washington, DC, to take a full time job at Walter Reed.

One of the many indoctrination courses at Walter Reed was the required "dreaded” information course on hospitality. The Disney executive was a key speaker. His lecture on how to create a hospitable environment was fabulous. As a result I went right back to my private office to change the way it was arranged and set up. I got rid of a lot of clutter which is a distraction to patients. Courtesy and graciousness make a difference in an environment whether large or small.

He illustrated a major point about hospitality by asking the audience what was the most frequently asked question at Disney World. The answer, “What time is the three o’clock parade?” The three o’clock parade in Disney World occurs at various

times depending on where you’re standing when the parade passes you by - it might be 3:30 it might be 3:45. His point – there are no stupid questions.

His work and that of others shows. Almost everyone at Walter Reed greets each other and speaks to one another. The cafeteria is crowded sometimes mobbed. Throughout are many soldiers in wheelchairs some with two or three limbs missing. It’s a sobering sight and yet they all look like they’re managing well. Modern surgery produces many effective artificial limbs and appendages. I learned, however, physical trauma is one thing, psychic trauma is another.

After I completed an extensive number of indoctrination and credentialing courses I was scheduled to see my first soldier. While I was scheduled to do the interview over closed circuit tele-psychiatry, a medium unfamiliar to me, I noticed in myself an unusual degree of apprehension. Checking with colleagues they confirmed a similar reaction. It wasn’t just the technology or the complexity of the electronic medical records. It was also the enormity of the task. I knew these soldiers suffered. Yet I had no idea of the complexity of their past and present lives. The first soldier was beyond my expectations.

He was very depressed both chronically and acutely. He had a suicide plan which I was able to confirm was plausible and possible. I proposed three options for working on this problem. I suggested he could make a choice of which plan we work on. Frustrated he picked up a trashcan and threw it at me and walked out of the room. The hundreds of miles between us insulated me from the flying trashcan but created a logistical problem in how to save him from himself. Fortunately the Army’s enlightened suicidal prevention program allowed me to contact personnel on his base to help me with the situation.

A few days later came a soldier brandishing a knife. A routine question in the waiting room, “where does your spouse live?” prompted the response, “if you find out let me know.” As the soldier pulled the knife and walked into the viewing room I began receiving telephone calls saying that security had surrounded the booth and was prepared to arrest him following my interview. All of this and I had not even seen the soldier. Needless to say I felt obligated to ask him his plans and he responded by giving me a detailed description of how he intended to kill his wife and do it in a way that would make her suffer in the most extreme manner. This soldier has suffered though his multiple deployments and now was going to make his wife suffer for the pains that he believed she was causing him. I knew immediately that he was going to test all that I had learned in 40 years of practicing psychiatry.

We spent an hour talking about a variety of issues. He explained the necessity of carrying the knife. He couldn’t sleep and he had a hard time eating because he had no appetite. He couldn’t shop for groceries because he couldn’t be in crowds. The knife was necessary in case he was bumped by somebody.

He tried alcohol to numb his psychic pain. Beating up a policeman, an arrest, and a long hospitalization helped him realize alcohol was not the solution. He was denied admission to an anger management course because he so frightened the intake worker. She determined that the other members of the course would be too intimidated by his comments.

By the end of the hour I decided to tell him simply that his plan to kill his wife was not a good idea. I explained that no matter how angry he was at her it was not a good way to treat people and it could create a lot of trouble for him. I further explained

that he simply couldn’t come back with a knife because it makes people too upset. Although he protested about his need for self-defense, he understood how the presence of the knife might be upsetting to others. He agreed to return to discuss how

to more effectively deal with the real problems his wife was presenting. I have no doubt that the course on hospitality was a part of my response. No one should treat or be treated this way.

I explained to the soldier that if he could agree to come back and work on these problems, I would call his base and tell the security police outside of the video boot that he should be free to go. He agreed and he has been returning for months to work on these matters. He has decided he cannot be an effective soldier, cannot be deployed in a combat zone and therefore should leave the Army. He has come a long way in dealing with his trauma but adjustment in civilian life will be complicated.

These evaluations are multifaceted. In one hour the soldier is introduced to video conferencing, a history is taken, a plan is formulated, medications and psychotherapy are discussed, and an electronic medical record of this discussion is made. When the soldier plans to commit suicide or kill one of his commanders, it is difficult to “pull it all together” in one hour. An

entire systemic plan needs to be in place. After a while PTSD can be infectious. Listening to and dealing with the accumulated trauma of one or many soldiers can be traumatizing to the person listening. No wonder soldiers often find others only superficially interested in their problems. Many say I can only talk to someone who really understands what happened.

This accumulated trauma creates traumatized relationships with their intimate others. How do spouses, separated for months, often caring for their mutual children find the strength and resolve to be supportive and understanding? Some soldiers awaken by noises in the middle of the night misidentify a sleeping spouse as an enemy. More commonly, nightmares lead to flailing in bed at whomever is nearby.

One of the most difficult listening problems I had is the following story. A soldier related that he and two or three of his colleagues were on patrol. Suddenly the others were “vaporized” by an explosion. After dealing with the emergency, he and others were left to collect body parts into a bag. He complained of nightmares about this experience seven nights a week, week after week. It is difficult to know what to say. “Thank you for your service” seems inadequate. I listened.

Frankly, I dreaded his return. He was absent a long time. When he did return, I asked him how he was. He reported that he had just returned from being with his mother and father. His mother was dying from metastatic breast cancer and he had spent two weeks with them while she was in hospice. He noted he had never seen a death from natural causes. He found the hospice experience very comforting. He was helpful to both parents and gained great comfort from them in return. He said the nightmares were going away. Upon further questioning he said that being part of a natural dying process helped him put his war experience in a different perspective. Much later after a long vacation with his surviving father he again reported how helpful he thought the experience had been in discussing denial, anger and grief with his father. The nightmares? They were gone! I learned that not many twentysomethings have had much experience with death as a natural process.

One can read more about these experiences in the book War by Sebastian Jungar (author of the Perfect Storm) or see the movie Restrepo based on the book the Hurt Locker. The intensity of prolonged conflict leaves many to be fearful of the “silence of American civilian life.” The adaptation to “normal life” is difficult and many long to return to battle.

Although soldiers do fight for each other as much as anything, they also speak of the addiction to battle. The book demonstrates and soldiers confirm that the adrenaline “high” of intense combat is better than a cocaine high and lasts longer. The author ably notes the biological and evolutionary roots of this addiction supported by society and amply reinforced by “older men”, past their prime, making decisions to send in younger men in proxy battles.

Although many point out the apparent futility of the current strategy of this war, I think both these wars and the current and future effect it will have on our society is a far more complex problem. We need to ask ourselves what will hundreds of young men addicted to fighting do when they return to “normal” society. Some describe the irony of their inability to participate in a simple July 4th “Independence Day” celebration because the noise of fire crackers exploding startles them into battle. The book and the movies are good places to begin thinking about these issues.

Remember these so young men and women, caught in a maelstrom beyond their wildest expectations, and pray for them daily.

Ted Beal on the faculty of Georgetown Medical School – and a psychiatrist with the Department of the Army.

War, Sebastian Jungar, 2011, First Trade Edition

The Hurt Locker, Mark Boal & Kathryn Bigelow, Harper Collins Publisher, 2009

Ted Beal, MD,