| 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.
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