Caring for the Invisible Wounds of War

Earlier this month, the world reacted in horror to reports that a large number of Afghan civilians — primarily women and children — were killed by an American soldier. According to the US Army, Staff Sergeant Robert Bales twice left his outpost in a remote part of southern Afghanistan and shot or stabbed 23 innocent persons, 17 of whom died, in a series of nighttime ambushes. Sergeant Bales has since been charged with 17 counts of premeditated murder and six counts of assault and attempted murder, for which he will likely face the death penalty.

Not only is this a tragedy for the families involved, but this latest massacre has severely damaged the already strained relationship between US military forces and their Afghan partners — a relationship that is essential to the success of American ground forces in Afghanistan. But it also highlights the failure of the US military to care for the psychological and social needs of those who serve in uniform.

Many of the US soldiers currently fighting overseas have served multiple tours of duty. Over 100,000 troops have served three tours of duty, and 50,000 have served four or more. Sergeant Bales himself was on his fourth tour of duty in eight years despite multiple combat-related wounds, including the partial loss of one foot and a mild traumatic brain injury sustained when his vehicle was hit by an improvised explosive device in Iraq. Stretched thin by two wars, the Pentagon often has little choice to send those with valuable combat experience back into the field, even if they’ve been injured or are showing signs of mental illness.

According to the Army’s own statistics, more than 75,000 cases of post-traumatic stress disorder (PTSD) have been diagnosed among US soldiers over the last decade. 65,000 of these cases were identified among those actively deployed in a combat zone. Many of those soldiers returned to the field after receiving treatment. While supporters of this practice correctly point out that PTSD can be treated successfully, many critics have accused the Army of rushing troops back into combat because of the logistical demands of fighting two wars with relatively small, all-volunteer military.

PTSD results from experiencing or seeing a traumatic event, such as being injured in a car crash, being sexually assaulted, or witnessing the accidental or combat-related death of another.  Not everyone who experiences a severe psychological trauma develops PTSD, but those who do often feel detached or estranged from family and friends. They may have difficulty sleeping due to recurrent nightmares and flashbacks. They may also experience episodes of extreme anxiety, or fly into an uncontrollable rage when angered.

Not all soldiers and veterans suffering from PTSD are “ticking time-bombs” — a common and stigmatizing misconception that may lead some to hide their diagnoses or to avoid seeking treatment — but violent behavior is more common among those with the condition.

While Sergeant Bales was never formally diagnosed with PTSD, his legal team believes that he may have slipped through the cracks in the Army’s mental health screening program. That argument will likely not help him in court, as military tribunals do not recognize PTSD as a legitimate defense. But perhaps his rampage could have been prevented if his alleged mental illness had been properly diagnosed and treated.

Given the public and political outcry in the wake of this latest tragedy, the military is likely to step up its efforts to provide adequate screening and treatment for mental illness. It’s about time. While the Army has invested nearly $1 billion in mental health care and has doubled the number of mental health workers it employs since 2007, it has a history of giving short shift to the needs of those suffering from behavioral disorders.

For example, a recent report suggests that the Army has been systematically reversing diagnoses of PTSD among soldiers and veterans in an effort to reduce the cost of providing care for the wounded. As was revealed at a Congressional hearing just last week, over the last five years a psychiatric team has reversed nearly 40% of PTSD diagnoses at the Madigan Army Medical Center in Washington. It can be challenging to diagnose PTSD definitively as there are no clear tests for the condition, but many psychiatrists believe that this rate of reversal was abnormally high.

While a great number of our soldiers and veterans have been physically injured as a result of combat in Iraq and Afghanistan, an even larger number are suffering from the invisible psychological wounds of war. Many are undiagnosed and untreated, despite (and perhaps because of) current efforts by the US military to provide mental health screening and treatment.

Current rates of suicide and substance abuse among active and retired members of the military — not to mention the tragic shootings of civilians in Afghanistan, Iraq and here at home — demonstrate that our current efforts to provide comprehensive mental health screening and treatment are not good enough. Our troops deserve better, not only to honor them for their sacrifice, but also to improve the health and safety of their families, their friends and those with whom they serve.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 29, 2012. It is also available on the WAMC website.]


About Sean Philpott-Jones

A public health researcher and ethicist by training, Sean holds advanced degrees in microbiology, medical anthropology, and bioethics. He is currently Chair of the Bioethics Department at Clarkson University's Capital Region Campus and Director of the Bioethics Program of Clarkson University-Icahn School of Medicine at Mount Sinai, and Director of two Fogarty-funded programs to provide research ethics education in Eastern Europe and in the Caribbean Basin. Until his term expired in August 2012, he served as Chair of the US Environmental Protection Agency’s Human Studies Review Board, an advisory panel that reviews the scientific and ethical aspects of research involving human participants submitted to the EPA for regulatory purposes.
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One Response to Caring for the Invisible Wounds of War

  1. Thank you – as ever, thoughtful and thought provoking. We must find another way.


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