By Dr. Elspeth Ritchie

Best Defense guest columnist

Psychiatric Annals recently published the second in a series on new and innovative treatments for PTSD. The series focuses on so-called complementary and alternative medicine (CAM) used in the Department of Defense. I say "so-called" because no one quite agrees on the name; it is also called integrative medicine and/or holistic medicine. CAM generally includes acupuncture, herbal techniques, and meditation. I add canine-assisted therapy, virtual reality, and other innovative therapies in this series in Psych Annals, of which I am the guest editor.

PTSD is an immense problem in the military after 11 years of war. The military is also leading the way in developing new therapies. This article focuses on stellate ganglion block, which is an anesthetic technique traditionally used to treat pain. In brief, an anesthetic is injected into the peripheral nerves. In some cases, it has been found that this technique drastically reduces symptoms of PTSD.

One of the many things that are exciting about this treatment it is that it is biologically based. So, if anyone still thinks that PTSD is "all in their head," or totally psychological, the success of this technique would seem to refute that. Another interesting point is that it seems to work in refractory PTSD that has not responded to other treatments.

This is not yet an evidence-based treatment. In other words, it has not yet been subjected to randomized clinical trials (RCTs), which are the gold standard in research in medicine. However, in the days since the on-line version was published, funders from the Medical Research and Material Command (MRMC) have been reaching out to researchers to see if they can do some of the RCTs. So exciting times in new approaches to treating an age-old problem.

Retired Army Col. Elspeth Ritchie, MD, MPH, is the chief clinical officer, Department of Mental Health, for the District of Columbia. She also is a professor of psychiatry at the Uniformed Services University of the Health Sciences.

Friends say Peter Linnerooth came home from Iraq with heavy PTSD. He had written about the burnout of military therapists.

By Jim Gourley

Best Defense department of physical fitness and national security

Obesity and weight-related health conditions have become a prevalent concern to American policy in the last decade. National military leadership was also exposed to obesity's potential risks to national security with the release of the report "Too Fat to Fight" by Mission Readiness in 2010. The group's primary message is that a burgeoning population of overweight American children will drastically reduce an already diminished pool of viable candidates for military service in the next ten years. However, these reports indicate only the most general aspects of the problem and focus on projections of future implications. When the scope of the American obesity epidemic is examined specifically within the context of its impact on the armed forces, data shows clearly that the threat is not imminent, but existential.

At present, 62 percent of active duty military members over the age of 20 have a body mass index that falls into either the overweight or obese category. For personnel under the age of 20, the number stands at 35 percent. That is actually an improvement from a 2005 rate of 46 percent. These statistics are often challenged due to the disputable methods of calculating Body Mass Index (BMI). However, the 2011 Annual Summary of the Armed Forces Health Survey Center cites 21,185 medical diagnoses for overweight, obesity and hyperalimentation (overeating). Research also dispels service culture stigmas. No service is immune to overweight issues. Comparing the relative percentages of overweight/obese service members, the Navy is the fattest service at 62.7 percent, followed by the Army at 61 percent, the Air Force at 58.8 percent. The Marines register the fittest at 55.1 percent, still substantially more than half overweight. Closer examination shows that more than 12 percent of active duty service members in each service are obese. The Marines break the trend more significantly in this category with a 6.1 percent obesity rate.

The increase of girth in the military progressed at a linear rate between 1995 and 2005, but has remained fairly consistent since then. However, emerging data indicates that the overweight population may rise further in the next ten years if the military is to meet recruiting goals. A new study by the Trust for America's Health predicts that more than half of Americans in 39 states will be obese by 2030. This is disturbing enough, but it becomes even more troubling for the armed forces when individual state recruitment trends are compared to their childhood obesity rates. All ten states that contributed the most military inductees in 2010 have childhood obesity rates greater than 15 percent. Three of them (including Texas, which was second in total recruitment with over 15,000 new military members) exhibit rates between 20-25 percent. The preponderance of our young military members come from the most ponderous states.

The problem is not simply one of cosmetics or intangible metrics of combat performance. The costs of an unfit military carry a real-dollar value. A 2007 joint study by The Lewin Group and TRICARE management activity estimated that the Defense Department spends $1.1 billion annually on medical care for obesity and overweight conditions. This study included dependents and retirees who qualified for TRICARE Prime coverage. More restricted to the active duty component are the costs to manpower. The AFHSC report tallied 245 "bed days" for medical treatment directly linked to weight issues, and 4,555 service members were involuntarily separated for failing to meet weight standards in 2008. The recruiting and initial entry training costs alone represent a loss of $225 million. Adding in specific military job training, logistics, equipment and the cost of lost duty days brings the annual price tag of overweight service members to about $1.5 billion. That exceeds the military's budget for Predator drones in 2010. The military still fails to grasp the true scale of the problem so long as comorbidities of overweight and obesity remain unexamined. There were more than 42,000 service members affected by hypertension and another 5,700 by diabetes in 2011. Hypertension alone ranks in the top thirty conditions affecting active duty service members. Also overlooked is the expense of XXL chemical warfare suits and development of other plus-sized uniform items.

The military's response to the problem has been mixed. The Army provided waivers to 1,500 new recruits who failed to meet weight standards in 2007. The program remains in place but the numbers of waivers issued in subsequent years have not been published. The Navy had a similar program until 2010. The Air Force never offered such a program and the Marines actually tightened standards in the 2009-2011 time period. Trends suggest that weight standards are on a sliding scale driven largely by manpower requirements and retention problems in a wartime military.

Therein lies the greatest problem. It seems all but certain that American society will continue gaining weight over the next decade. In this regard, the military may be a kind of canary in the cave given its emphasized dependence on physical fitness for mission success. However, without an established position on the matter of physical fitness standards and given the likelihood that leaders at every level will themselves be at an unhealthy weight, it is possible that the military will experience substantial increases in operating costs and diminished capability in the next decade.

Jim Gourley is a Best Defense jolly good fellow.

While Tom Ricks is away from his blog, he has selected a few of his favorite posts to re-run. We will be posting a few every day until he returns. This originally ran on July 28, 2010.

This was posted yesterday by Jim Gourley in response to Blake Hall's guest column. Like Blake's terrific essay, this comment really struck me as thoughtful. I told my wife about the cave analogy over dinner. 

Of Lepers and Caves
By Jim Gourley

I'm going to say quite a few things that I can't immediately qualify, because the views build on each other. I wish I could give you a clear line of reasoning, but if I could then PTSD wouldn't be a problem. So I'm going to do this the only way I know how -- create the ball of twine and then unravel it. Bear with me.

I am an expert on PTSD. So is every other Soldier/Sailor/Marine/Airman (avoiding diatribes against the all-inclusive "warrior" here) who has felt and/or suffered (because feeling and suffering are distinct from each other) from PTSD. I know we are all experts because no one else does, or can, understand the condition without having gone through it. Army psychologists and counselors who have not felt it or suffered from it only scratch the surface of the problem.

PTSD is very difficult to deal with for two reasons. One reason is the misconception that it is a psychological condition. It's not. It's a spiritual condition. Yes, I know that you cannot anatomically identify the human spirit or sedate it with valium and that, for all its complexities and mysteries, we find the brain much easier to "treat", but I'm telling you right now that trying to understand PTSD under a psychological paradigm is like trying to conduct an ACL surgery at an auto-body shop. I've met David Grossman, and even he speaks about it in metaphysical terms on a frequent basis. If you don't believe me, I'll go dig up the quotes from all the shrinks-in-chief that declare the cause for spikes in suicides in 2008 and 2009 and 2010 was "due to the weather." I give all due respect to the shrinks and counselors. They're doing their best. But with all due respect, their best is nothing but best guesses. Because this isn't scientific. It's spiritual.

The second reason it's difficult is that, even when we acknowledge the spiritual nature of this condition, we are woefully inept at dealing with it. Blake Hall hits on all the things we do wrong -- ridicule, ostracize, and ignore those with the disease. Treat the guy like a leper.

You want to know why we do that? Because deep down underneath all that type-A, testosterone-driven, state-of-the-badass-art Spartan warrior bravado that we exude, we are scared to f---ing death that we'll catch it. PTSD in the Army is like cooties in a third-grade classroom.

If we want to treat PTSD, we've got to do exactly what Blake did. We've got to learn how to hug lepers. We've got to get past the condition and see the man or woman we've always known. We've got to embrace them and hold them tight, tell them that we're here and we're not leaving them. And we've got to mean it. We have to be there. At the office, on the steps of their house, on a swollen riverbank out back of a Chili's on a Saturday night, on the floor of a living room where there used to be furniture at 2 o'clock in the morning. These people don't need us 24/7, but when they do, we've got to answer the call. And we've got to be the kind of leaders and peers that instill enough confidence in them that they'll pick up the phone and call us.

Hotlines and VA administrations can't help. They weren't there in the s--t with you when it was all going down. They don't know. They didn't see. And they don't really care. Yes, I know that many of these people really DO care, but I only know that now. When you have PTSD, you DON'T know that. You certainly won't believe it. Let me back up.

Here's what PTSD is like, and why people kill themselves over it. Think of life like a cave. If I send you into a cave with a lantern and tell you there are no bears in the cave, you feel safe. You will walk around the cave and enjoy yourself. Now what if I give you a lantern and a gun and tell you that there is a bear in there? You can still go down, but you'll be careful to look for the bear and ready to run or shoot if you see it. Now, what if I send you down there with a gun but no lantern and simply say "bear" to you? Pretty soon, you're in there, you can't see the way out, and every rock you bump into feels like a bear. After a long enough time being down in the cave, you realize you don't have enough ammo to shoot everything that might be a bear. It has nothing to do with running out of food or water or feeling like you're fighting some unwinnable battle with the bear. You just get sick and tired of the uncertainty. Are you going to live through the night? Are you going to wake up to a bear gnawing your intestines? You get to the point where you just wish the bear would come along and end it. And when he doesn't come, you decide to do it yourself.

Suicide isn't a surrender, it's a reassertion of power. These guys' lives have spun out of control, and the decision over whether they live or die is the last thing they have the power to determine. Think about it. You ever met a Soldier that wasn't a "take charge kind of guy?" That's my warning bell. I've seen lots of "cries for help" where a guy said "life is meaningless." I don't put much stock in those. But when he says "life is scary"? That's the guy that's going to do it.

So, back to the moment of choice. You've got that gun on your bed or your car keys in your hand and a good cliff in mind. What's going to get you out of that? Some slick-sleeve doc you've never seen before asking you how many times you've been deployed, or a buddy putting his hand on your shoulder and saying "you alright, bro? you look like you're hearing bears."

I'm out with a buddy a while back. We're talking about brands of beer. He hears a car backfire, and suddenly he's scanning ridgelines. He's not here anymore. He's all the way in Afghanistan, and he takes me halfway back to Iraq with him. I think about saying something, telling him that he's here, not there. That I'm with him. That everything is okay. But that would be the wrong thing to say. A couple of minutes pass as we walk. He keeps scanning, I just stay by him. After that, we go back to talking about beer. We don't mention anything about the event.

A couple of days later we're walking along and he says "you know, I really freaked out the other day." I tell him that I know, and I was right there with him. That's all that needs to be said. He knows my story. We don't need any elaborate cathartic rituals or long discussions about it. It's no different than strapping on armor and walking outside the wire. I trusted him to be able to take care of himself, and he trusted me to catch him the moment he couldn't. We're Ranger buddies, not baby-sitters. Giving him dignity and letting him fight the battle on his own is just as important as helping him get up when he gets knocked down.

Our best therapists are our brothers and sisters. The medicine is the very spritual bond of the profession of arms. But you've got to give that medicine in a heavy, constant dose. I'm talking about full-on morphine drip here. When you're in the cave with that bear, you're aware that something is wrong with you. You can't help but feel that. Because of that, you become acutely suspicious of EVERYONE around you. You begin to hate yourself. You have very good, rational reasons for hating yourself. You don't understand why everyone else can't see these reasons and why they don't hate you. Or maybe they do. Maybe they're secretly drafting personnel action memos to move you somewhere else. Maybe they're talking behind your back. It seems like the only people who don't hate you are your wife or kids or parents. Well, it's obvious why. They weren't out there with you. They didn't see. They're all idiots. You start to hate them for not understanding you and not hating you. They keep telling you it's going to be okay and to calm down, and if they say that one more time you're going to scream and wring their necks because it's just not true because so help-me-god-i'm-down-inthiscavewiththisbearandit'sgoingtogetmeAAAARGH!!!

"Jim, where's your furniture? Where's your wife? What's going on?"

"I've ruined my life, Sir."

A Lieutenant Colonel sits down on the tile floor of an empty house beside a sobbing Captain. He's a Brigade XO who's had a long week and only has about a month before he takes Battalion Command and goes to Iraq. His wife is waiting outside in the car and his kids are waiting for him at home. But he takes time for this guy, because he's been down in the cave. He knows this guy is terrified of bears right now, and the Captain might not make it through the night if he doesn't show him there's no bear. He doesn't just refrain from ridicule. He starts telling stories. Stories he'd rather not remember. Stories told in confidence that probably won't be told many more times in his life, but will never be forgotten. That Lieutenant Colonel says lots of things, but it all adds up to one important message.

"There is nothing wrong with you."

He doesn't mean that in a "you ain't hurt, drive on", Patton way. He means it in a very genuine, spiritual way. There is nothing wrong with that Captain because EVERYONE feels that way. We are either all lepers or we're all fine. Either way, there is no reason for that Captain to feel like he's untouchable, outcast, damaged goods. The Lieutenant Colonel chooses to believe we're all okay. On this night, he's successful in convincing the Captain that this is true.

"Is there a gun in the house?"

It's the right question to ask. There isn't one. But the Captain is holding his car keys in his hand and has a bridge in mind. That the Lieutenant Colonel cares enough to ask is all it takes to remove the notion.

"I'll see you at work tomorrow. We'll figure this out-- together."

And that's how my long, slow crawl out of the cave began.

That Lieutenant Colonel said all the right things in all the right ways. You can't train a doc to do that, or write it down in a field manual. You can't teach it to Cadets at West Point or illustrate it on a power point slide. How do you get more leaders to be like that Lieutenant Colonel? The answer, sadly, is that we've got to save as many people going through it as possible, and keep them in the fight. They're the ones who are innoculated against it. They can recognize it, acknowledge it, and help others to fight it. They possess a compassion and empathy no one else can. How do we save the ones currently dealing with it when we have so few who are innoculated? I don't know, but I wish to God someone figures it out. In the meantime I keep watch over my buddy while he watches ridgelines. So much for the extent of my PTSD expertise.

I know how people here feel about Sassaman's memoir, but there was one passage in it that is worth reading the whole book to see.

"A part of me will always be a broken-hearted 40-year-old Battalion Commander."

He says that in reference to the death of Captain Eric Paliwoda, an event that shook him to the core. I suppose it resonates with me because part of me will always be a broken-hearted 26-year-old Captain. I've learned how to keep that part of me from causing the great suffering that nearly destroyed my life, but I still feel it. I feel it every time I see a friend scan ridgelines, or listen to someone talk about watching another human being bled out and die in some godforsaken wheat field that no one will ever remember or care about. I feel it, and by feeling it I'm able to relate. And while we relate to each other and share the heartbreak, that person is able to breathe easy in the cave, because there's one thing in there that they can be sure isn't a bear. It's another leper holding onto them. Life isn't scary, and it's worth living another day.

By Mark Hammel

Best Defense guest columnist

As in all human endeavors, knowledge is power. Therefore, in treating an individual unfortunate enough to be suffering from Posttraumatic Stress Disorder (PTSD), I begin by explaining that PTSD is neither an illness nor a weakness, but rather, an injury. As with all injuries, it is due to exposure to a force that undermines the integrity of a biologically adaptive system of the body. In the case of an injury to the musculoskeletal system, the force is typically of a kinetic nature, such as with a badly sprained ankle. In the case of PTSD, the force is initiated by the perception of mortal danger giving rise to a wave of neurological activity so great that the stress response system of the brain is damaged. Think of this as a power surge.

The stress response system is one and the same as the system that responds to the perception of danger with the fight-freeze-or-flight response. I've found it useful over the years to refer to this system as the danger-monitoring-and-response system of the brain. It is the malfunctioning of this injured system that gives rise to the symptoms that we have come to know in the aggregate as PTSD.

Under normal conditions, our five senses work tirelessly in the background, monitoring the environment for any change in ambient conditions that might represent danger, such as a novel sound or smell, or perhaps movement on the periphery of our visual field. When such a change occurs the system initiates an immediate IFF, consulting its own knowledge base of previous experience, i.e. memory, and at the same time readies itself to unleash the fight-freeze-or-flight response should our memory turn up a match for something that could do us harm.

When the system is impaired, as in the case of PTSD, it enters a sort of safe mode, where the danger-monitoring-and-response function supersedes all other normal functioning. The victim becomes preoccupied with danger, accompanied by an impaired ability to muster the attention and motivation to engage in the myriad of biopsychosocially adaptive activities that uninjured humans accomplish with relative ease.

I hope this explanation makes it easier to grasp the source of two major groups of PTSD symptoms: hyperarousal (e.g. hypervigilance, exaggerated startle response, sleep disturbance, etc.), and avoidance and numbing.

A third group, reexperiencing symptoms, among them so-called flashbacks, is perhaps less easy to grasp, but surely the most salient to victim and clinicians. Normally, when we experience something it brings about a change in the brain that results in the formation of a memory. When we recall it, it is clearly in the realm of having occurred in the past, the there-and-then. In the case of a traumatic experience, the transformation into a memory is incomplete. It exists in a kind of limbo where it is maddeningly reexperienced as occurring in the here-and-now.

Read on

I know, that didn't make sense to me at first. I mean, how can getting bitten by a mosquito measure anything but the nettlesome persistence of the insect? But a footnote to the 1972 article in the American Journal of Psychiatry article I mentioned the other day says that the 1st Infantry Division in Vietnam used the rate of malaria in a given unit as an indicator of command performance "because the incidence of vivax malaria directly reflected whether or not the men had taken their chloraquin primaquine tablets, a function of discipline and morale." (P. 699)

By Rebecca Frankel
Best Defense Chief Canine Correspondent

It was only a few years ago that Lex, a German Shepherd, was patrolling the streets of Fallujah sniffing out roadside bombs with his handler, 20 year old Corporal Dustin J. Lee. The two made quite a pair and were said to be inseparable. But during an attack on March 21, 2007 a rocket-propelled grenade killed Cpl. Lee. Lex sustained serious shrapnel wounds to his hindquarters including a piece still lodged in his spine.

Cpl.'s Lee's family, knowing how much their son had cared for his canine partner, lobbied to adopt Lex. Getting Lex released into their custody, however, was no easy feat. Undeterred by military regulations, the family "launched an Internet petition and enlisted the aid of a North Caroline congressman..." and by December Lex was at home with the Lees in Mississippi. It was, apparently, the first time the military has "granted a dog early retirement to be adopted by someone other than a former handler." Dustin's father said he and his wife were only acting in their son's stead. "He knew that we would take care of Lex and love him, just like our own."

But once Lex arrived, there was no escaping the depth of his injuries -- the nine-year-old dog could barely walk on his own.

Read on

My CNAS colleague Nancy Berglass has a good new study on how we need to bring together the efforts of the Defense Department, the VA and the non-profit sector:

The U.S. government can draw upon an emerging network of nongovernmental organizations to form a model of public-private partnerships that will greatly enhance the care and services provided to those who have served the nation.

There are a lot of private outfits that want to help, she notes:

By working largely within the confines of governmental structure, both DOD and VA fail to take advantage of private-sector resources. Both agencies could fulfill their missions more quickly, effectively and with a desperately needed personal touch by leveraging the exceptional promise of community partners to help them meet their charges.

I was impressed by this video in which more than 30 people who received the Medal of Honor talk about the need to get counseling when, as one puts it, the enemy comes home with you. It portrays seeking care as an act of strength. Take two minutes to check it out -- you won't regret it.

I am told that Gen. Pete Chiarelli, the vice chief of staff of the Army, was one of the people who made this video happen. A job well done.

Military spouse Alison Buckholtz proposes an "It Gets Better" campaign that speaks to suicidal service members, akin to the current campaign reaching out to gay teens. "Stoicism and name-calling doesn't work," she writes. "Nor do stand-downs and speeches. Individual Americans can help close the military-civilian divide by demonstrating the belief that suicides among service members demand our immediate attention as a society. Soldiers and sailors need reassurance that it gets better for them too."

Oh man. Take a minute to read this widow's account of watching her Marine sergeant husband fall apart after he came home from Afghanistan. Two quotations that really struck me: 

"I knew that we had run out of time."

And, as he contemplated suicide:

"There is no way I can stop you from doing this, is there?" she said she asked her husband.

"No."

If you know someone who seems suicidal, here is a phone number:

1-800-273-TALK

(HT to BD)

My e-mail lately brings notice of two organizations doing good things:

First is the National Action Alliance for Suicide Prevention, which rolls out this morning. This one involves a bunch of bigwigs, like the defense secretary, the Army secretary and the VA secretary, but what caught my attention was the participation of the Rev. Robert Certain, who before becoming a minister was a PoW in Hanoi.

By the way, here is the recent Defense Health Board report on the issue. 

Second is Spirit of America. A friend of a friend writes that it is

a 501c3 nonprofit that helps our troops help the people in Afghanistan, Iraq and Africa. Since 2003 we've responded to needs identified by U.S. Soldiers and Marines for things that will help the local people -- sewing machines, school supplies, solar water pumps, solar radios, sandals, blankets, mosquito nets, playground equipment, saffron bulbs... any kind of humanitarian or economic development assistance that is needed. This support improves relations and increases trust and cooperation. it is especially helpful in counterinsurgency operations now in Afghanistan. Ultimately, SoA support helps our troops be safer and more successful in their mission.

Spirit of America's support is fast, flexible and decentralized. We fill gaps in military and US government assistance programs. In Afghanistan, it can be difficult to get aid to the remote villages -- far from Kabul -- where much of the war is being fought and where little things can make a big difference. That's where SoA is most active. You can think of this as grass roots public diplomacy. We help the troops be effective unofficial ambassadors... ambassadors of the goodwill of the American people. Most NGOs keep their distance from the military. Spirit of America takes a different approach that offers a new model for military-NGO collaboration.

Everything we do is supported by private-sector donations. We provide Americans with a meaningful way to help and to connect with the service of our troops. People can choose where their money goes and 100% goes to provide what those on the front lines say is needed.

This blog is probably not the best place to run this column, because many of you will know instantly what Blake is talking about here. But I am happy to have him start here, and I hope others, outside of those who pay steady attention to our wars, will hear what he has to say.

I am turning the whole column over to him today.

By Blake Hall
Best Defense guest columnist

Every day is a national tragedy. This is not hyperbole. Eighteen veterans kill themselves every day, a figure that represents twenty percent of the suicides in this country, and veterans constitute twenty-three percent of this nation's homeless population. Veterans represent nine percent of America's population, so those numbers, to me, are staggering.

Last month, I sat down for dinner with my former battalion commander. I brought up these numbers and he responded with valid questions, "How much of that is self-selection? Were these vets already struggling with problems before the military? Were they already pre-disposed to engage in high-risk activity? How many of them fought in combat?" I noted that the figures don't include the veterans who kill themselves with alcohol or who kill themselves on motorcycles or in single-car accidents, because those types of fatalities don't fit into neatly quantifiable categories. But, ultimately, I do not have the academic knowledge or expertise to respond authoritatively to his queries. I can only comment on my former scouts and snipers, who call me from time to time, as they fight their demons.

I led twenty-four scouts and five snipers in Iraq from July 2006 to September 2007. Our mandate as a platoon was to kill/capture High Value Targets -- typically Al-Qaida or Iranian backed militants. We were in some rough spots, and, as you can imagine, we saw some terrible things. It affected all of us. As the prophet Isaiah noted, "Behold, I have refined thee, but not with silver; I have chosen thee in the furnace of affliction."

I've had two calls from my men in the last month and a half. One of them was from a sniper team leader I nominated for the Bronze Star with Valor for his actions in combat. The other was from a sniper I consider one of the bravest men in my platoon. Both men told me they considered killing themselves either during deployment or when they returned home from war.

In Mosul, the sniper team leader, "David," rescued the crew of a Stryker Reconnaissance Vehicle taking heavy fire from three different directions. He exposed himself to that fire in order to secure a winch to the vehicle, which was in danger of rolling over into a draw. He saved the crew after he had emplaced and directed his sniper teams to engage insurgents firing four mortar tubes on a combat support hospital -- an action senior commanders credit with saving twenty American lives, for ten coalition service members, some of them nurses, had already been critically wounded at the base from the mortar fire. And then he subdued an Al-Qaida militant in hand-to-hand combat inside of a building.

In Baghdad, another sniper, "Jonathan," was on the rooftop of a building with my company commander during a firefight. Afterwards, the company commander walked up to me with shaky legs and said, "Blake, your snipers are crazy. They were walking around on the roof, bullets everywhere, just pointing and shooting. I was huddled behind the wall taking cover. You might tell them to get down once in awhile."

Both men are brave. I want them by my side in a firefight -- the highest compliment a soldier can give. So it breaks my heart when a soldier like Jonathan calls me and tells me that he wants to kill himself. Jonathan was brave in some of the scariest situations I can imagine, but it is the way that he is being treated now that he is back home that is breaking him down.

When Jonathan returned home from Iraq, he exhibited classic signs of PTSD, a term I hate, for PTSD is a disease that every veteran suffers from to some degree or another. He had trouble sleeping. He was nervous and hyper-alert in normal everyday situations. He couldn't concentrate on a task for longer than a few minutes.

When he went to the chain-of-command for support, he was removed from the sniper section and placed into an administrative role while the command figured out what to do with him. I had moved to the battalion staff, but I took him to lunch one day and he told me, "Sir, I'm not even in the platoon anymore. I feel like a shitbag."

That Jonathan could be treated this way, even by Infantry officers, many of whom have not seen combat to the degree that he has seen it, is unacceptable to me. There is a very real dilemma facing commanders who must decide whether they can allow a soldier to train with live weapons while they are dealing with psychological trauma, but, ultimately, the narrative needs to change. All of us hit lows from time to time, everyone who has experienced heartbreak in a relationship knows how utterly depressing the next few weeks after that cut can be, but, with the help of family and friends, you can make a full recovery and heal.

To understand the current narrative, read this quote from General George S. Patton:

The greatest weapon against the so called ‘battle fatigue' is ridicule. If soldiers would realize that a large proportion of men allegedly suffering from battle fatigue are really using an easy way out, they would be less sympathetic... If soldiers would make fun of those who begin to show battle fatigue, they would prevent its spread and also save the man who allows himself to malinger by this means from an after-life of humiliation and regret.

From the moment a soldier enters basic training to the day he takes off the uniform, he is taught that to admit weakness is to invite ridicule. In The Things They Carried, Tim O'Brien noted how the fear of embarrassment is the greatest motivator of valor. He focused on the negative. Certainly, a hunger for admiration can also enable bravery. But they both center on a certain primal desire for respect we all retain. When I was scared in combat, I knew that I could not shrink from danger, for I would never be able to stand in front of my men again with credibility. So I stood and fought.

We soldiers have been conditioned to never, ever admit we are hurt or suffering. But dealing with the aftermath of war, when you are no longer surrounded by the men who fought with you, when you are no longer working for a chain of command that can give you feedback from a position of authority, when you are alone -- is a battle that far too many of us lose. When some of the bravest guys that I know can't admit weakness, or do admit weakness, and then are subject to ridicule, then I posit that the narrative for the "after," for the persistent battle that we veterans fight for the rest of our lives, should be distinct and separate from the Army's normative weakness -- ridicule relationship that is appropriate for combat.

I told Jonathan that he was brave when it counted. I said that when the chips were down, he faced the bullets and he moved forward, often at the head of the platoon. I let him know that I thought it was far more manly and heroic to admit weakness back here at home because it defies everything we have been taught in our culture that celebrates strength and filters out weakness lest it corrupt the unit.

After a long pause, he said, "Thank you so much for talking to me sir. I already feel a lot better." He shouldn't have to thank me, the nation should thank him. He should feel the respect and gratitude of the country every day by the way he is treated, not just in the popular culture that celebrates America's service members, which all of us who have served appreciate.

Sadly, some of the articles I have read on this blog from the systematic mismanagement and scope creep that have ruined the Army's Warrior Transition Units to single anecdotes about a veteran living alone with PTSD to op-eds that note some businesses are afraid to hire vets due to PTSD and TBI concerns (your article about Obamacare), reinforce the broken nature of the ecosystem of programs design to re-integrate American veterans. David visited a VA counselor three times to talk about the issues he dealt with every day. On his fourth visit, his normal counselor wasn't there, so a new counselor saw him. The counselor asked, "Why are you here?" Then, the counselor sat back and expected David to fill him in on everything that he had already covered with his normal counselor. David got up and left, without treatment, because he got the sense that the therapist didn't care. No one tried to stop him from leaving.

When you go to sleep tonight, eighteen more veterans will be gone by their own hand. Many more will lay their heads down without shelter, because they have lost their way. The thought that one day David and Jonathan could join their ranks is more than I can bear.

Veterans need to know that it is okay to admit weakness after dealing with the trauma of war. They need to know that they won't be judged for opening up about their pain. They need to know that Americans care.

I am willing to keep up this discussion. So is Noel Koch,
who this morning sent along this reply to General Cheek's comments posted
yesterday:

By Noel Koch
Best Defense wounded warrior columnist

General Cheek has
kindly suggested I might offer my vision of how the Army's Wounded Warrior
program should be run, and I shall in due course. In the interim, one useful
start might be to adopt the General's own vision of a tiered system in which
Wounded Warriors are managed separately from those camping in the WTUs for as
long as they are able to game the system. I believe this notion came up during
one of our discussions involving his consternation over an Army Colonel who was
managing to squat in one of the WTUs for something on the order of 600 days,
resorting to various subterfuges, including threats of suicide, to defeat
efforts to move him on. 

Regarding the
matter of satisfaction surveys, which seem to be a running point of contention,
the following is an excerpt from a report by the US Government Accountability
Office: 

"The Army's feedback mechanisms include its Warrior Transition Unit
Program Satisfaction Survey, which collects information from servicemembers in
WTUs on a number of issues, including the primary care manager and nurse case
manager. However, the surveys response rates for the WTUs have been low (13 to
35 percent) and the Army has not determined whether the results obtained from
the respondents are representative of all WTU servicemembers. An Army official
told GAO that the Army does not plan to conduct analyses to determine whether
the survey results are representative, because it is satisfied with the
response rates. In GAO's view, the response rates are too low for the Army to
reliably report satisfaction of servicemembers in WTUs." 

Read on