Neuroplasticity is a concept that should have huge implications for victims of combat stress because it suggests that the events that change someone’s brain can be changed again. Although something cannot be undone, perhaps there are ways to alleviate dramatic changes.

To me, that suggests there can be hope for victims of post-traumatic stress disorder (PTSD).

In his remarkable book, The Brain That Changes Itself, Dr. Norman Doidge mounts a compelling argument that the brain is plastic. By that, he means that the brain adapts to the events that it encounters; in effect, it shifts its resources to meet changing conditions.

That’s something most of us have encountered. For example, we may have known or heard about a blind person whose sense of hearing is remarkably keen. But Doidge takes that concept a step further. He writes about implanting electrodes into a monkey’s brain and watching different electrodes fire up as the monkey’s fingers explore an abject. Then all the fingers are taped together. After a few days of confusion, a new pattern emerges from among the electrodes as the monkey’s brain recognizes that all the fingers are now acting as a single unit.

Doidge also writes about a woman whose vestibular system had been destroyed by an infection some years before, leaving her with virtually no sense of balance. She could not stand upright because she kept falling down. Then one of the pioneers of neuroplasticity, Paul Bach-y-Rita, devised a special construction-style hat that took the spatial measurements from her optical nerves and relayed them to a device in her mouth that transmitted them to her tongue. It not only allowed her to learn to stand erect again, but it also showed her brain how to rewire itself to allow the woman to keep her balance without the mechanical hat.

The concept of a brain evolving destroyed the earlier theory that the brain is a machine, a sort of super-computer that couldn’t really change or grow.

“The idea that the brain can change its own structure and function through thought and activity is, I believe, the most important alteration in our view of the brain since we first sketched out its basic anatomy and the workings of its basic component, the neuron,” Doidge writes in the preface of his book. “The neuroplastic revolution has implications for, among other things, our understanding of how love, sex, grief, relationships, learning, addictions, culture, technology, and psychotherapies change our brains. All of the humanities, social sciences, and physical sciences, insofar as they deal with human nature, are affected, as are all forms of training. All of these disciplines will have to come to terms with the fact of the self-changing brain and with the realization that the architecture of the brain differs from one person to the next and that it changes in the course of our individual lives.”

Just think of the implications for combat vets!

PTSD is all about a brain being changed during combat. It’s about that heightened awareness that comes to a soldier who knows he’s in danger. His frontal cortex is analyzing all the signals from his eyes and ears, trying to sense the threat. That information is instantly passed along to the amygdala and the hippocampus, which are gearing the body up for a fight or a flight. The heart is pounding, the adrenaline is flowing, and the nerves are so tight they feel like they could snap under the strain. This is a normal response to danger. And when the threat subsides, it’s normal for the body to return to “normal.”

But when you get wave after wave of danger, the brain stays on high alert … and that becomes “normal.” But when the danger disappears and the brain remains on high alert, that’s what we call PTSD.

So far, our ways of treating PTSD haven’t been very effective. Drugs such as psychotropic medications can dull the pain, but leave patients numb. Talk therapy can let a vet know he’s not alone with his emotional wounds and can help him understand that what he’s going through is a natural response to combat, but that probably won’t alleviate the nightmares or the flashbacks or the instinctive response to hit the deck when a car backfires.

Now Doidge, who is on the faculty of the University of Toronto’s Department of Psychiatry and Columbia University’s Center for Psychoanalytic Training and Research, is telling us that we should be able to change a brain back again. Obviously, we can’t erase an event, particularly such a compelling one as combat, from our memories. But we might be able to weaken the combat images by changing the way the brain processes them.

More on that in my next blog.

After nearly nine years, America closed out its mission in Iraq last week with an official death toll of nearly 4,500 soldiers, plus another 30,000 wounded. Now most of the remaining soldiers there are returning home, and the Pentagon is gearing up to provide hundreds of thousands of them with a new congressionally mandated safeguard: individual screenings for mental/emotional wounds caused by combat.

But the military suicides – on average, one soldier has taken his or her own life every 36 hours between 2005 and 2010 – aren’t slowing down yet, according to an alarming new report this fall that says the suicide rate could threaten the nation’s continued hopes for an all-volunteer fighting force.

Troubled in large part by those suicides, Congress passed legislation two years ago requiring three mental-health screenings for each soldier within the two year period after he or she returns from combat.

“We have been working for years to develop better screening for signs of post-traumatic stress disorder, or PTSD, in our combat troops and veterans,” said the bill’s chief sponsor, Sen. Max Baucus, D-Mont. “The Montana National Guard led the way on this front with a successful pilot program. And in 2009 we passed a law to take the Montana model nationwide.”

As of October, the Pentagon had hired nearly 3,500 health-care providers to screen its returning combat vets for elevated stress levels. The Army has already provided its initial examinations of the first 400,000 troops, although it hasn’t announced the results of those exams yet.

“Before this law, many of our troops received only a paper questionnaire, and never received an individualized assessment,” Baucus said. “Thanks to this law, they are now getting personal, and private, one-on-one attention from a trained health-care provider. And they get follow-up assessments for at least two years after they return.”

The Congressional Budget Office estimated that enacting the legislation would cost taxpayers $60 million over a 10-year period.

Montana’s junior senator, Jon Tester, also a Democrat, added a provision that the Department of Defense also provide a baseline mental-health exam for all troops before they deploy into combat arenas.

That followed a study reported in the American Journal of Psychiatry in which doctors screened more than 10,000 infantry soldiers from three brigades heading into combat in Iraq in 2007. The 74 soldiers at highest risk were barred from deployment, and doctors tracked another 96 at-risk soldiers and provided them with coordinated care. The study then compared the screened brigades’ mental health problems with another 10,000 unscreened soldiers from three other brigades.

“Soldiers in screened brigades had significantly lower rates than those in unscreened brigades for suicidal ideation, combat stress, and psychiatric disorders, as well as lower rates of occupational impairment and air evacuation for behavioral health reasons,” it concluded.

A study released last October by the Center for a New American Security found that approximately 14 percent of our military population is currently taking a prescription opiate. Furthermore, when military doctors change a civilian prescription, they’re barred from requiring that soldiers turn in the excess medications. And it said 29 percent of our military suicides involve drugs or alcohol.

When a combat vet named Chris Dana took his own life in March 2007 (see my previous blog, Military Suicides), it shook Montana, a highly patriotic state with one of the nation’s highest rates of veterans per capita.

Gov. Brian Schweitzer quickly demanded answers and appointed a commission to detail how Dana had slipped through the cracks of the state’s military mental health care system. The commission came up with 14 recommendations for reform, and Gen. Randy Mosley, the adjutant general of the Montana National Guard, promised to implement all of them.

He did, and Montana became the model for providing mental health care to its vets. Now, many of the lessons learned through those reforms are now being implemented nationwide just in time for the return home of the remaining 170,000 troops from Iraq (That will be the subject of my next blog).

Most important was a pledge to have every soldier receive a mental health examination every six months for the first two years after his return from combat and another every year thereafter. Previously, soldiers had been given a questionnaire during their debriefings asking them whether they suffered from post-traumatic stress disorder (PTSD). For some, those symptoms didn’t appear for months after their return, but even the vets already having nightmares and flashbacks tended to check the box “no” because they wanted to get home and see their families and because   they feared they might jeopardize their military careers if they admitted high levels of post-combat stress.

All that changed under the new system. Soldiers are required to sit down with trained counselors every six months to discuss how they are feeling, how they are sleeping, anger or irritability issues, abnormal alcohol use and/or marital issues.

At the 120^th Air Wing of the Montana National Guard, deployment resiliency assessment screenings of about 1,000 airmen over the past year triggered 88 individual red flags, including 5 critical cases and 10 priority cases, according to the Montana National Guard’s personnel chief, Col. Jim Oehmcke. That’s about 17 percent of those who had been deployed.

“A critical case might be someone currently threatening to harm himself or others, while a priority case might be someone who had considered it in the past,” explained Master Sgt. Mary Montag.

Those numbers are lower than in previous years because the number of deployments has dropped from about 400 airmen a year to 100, Montag said, adding that “a lot of our cases involve alcohol abuse or medication mixing.”

During 2011, the Montana Army National Guard screened 1,147 soldiers, including 510 who had previously been deployed, and referred 111 (nearly 22 percent of those who had been deployed) for further mental health counseling, according to Oehmcke.

Both the Army National Guard and the Air National Guard developed crisis response teams made up of the unit’s commander, first sergeant, personnel officer, a chaplain and health professionals. They can be convened almost immediately to provide help when a soldier is in trouble. The crisis response team for the 120^th Fighter Wing, based in Great Falls, handled five crisis situations in its first year.

Another major change involved broken bonding. After returning from combat, soldiers were traditionally given a three-month vacation from their weekend drills, but members of the Montana Guard said they really missed being away from their combat buddies and they were having difficulty talking with their families.  So Guard officials got permission from the DoD to continue holding monthly drills immediately after deployment. But there was a catch: drills were held in hotels or convention centers in civilian clothes with wives and families in attendance. There were seminars for soldiers and spouses on mental health, anger management, personal finance and civilian driving laws. That turned into the Yellow Ribbon Program that has been adopted by the National Guard nationwide.

In addition, TriWest Healthcare developed a plan of embedded counselors that it tested in
California and Montana. It sent a counselor to join the Army National Guard and another to join the Air National Guard on base during each drill weekend. Counselors were available to talk with soldiers, their buddies or their families with or without an appointment. They also mingled with the Guardsmen and observed interactions. At the end of the first year’s pilot program, the embedded counselors were clearly so useful that the Montana National Guard adopted it permanently.

“I can’t say enough for what they tried to do,” says Dana’s stepbrother, Matt Kuntz.  “There’s no doubt that PTSD created a huge challenge for the Montana National Guard and other military units, but it started when they flat-out admitted that they had been wrong, and that’s what it takes for an organization to change and make the reforms they need.”

Based on that track record and a congressional mandate, the Pentagon has also adopted the mental health screening program for returning combat vets … just in time to help 170,000 troops returning home from Iraq by the end of this year. And that will be the subject of our next blog.

The VA’s real surprise is the low number of diagnoses for traumatic brain injury (TBI),
which has become one of the signature injuries in the Iraqi/Afghanistan
conflict due to the large number of roadside bombs, mortars and
rocket-propelled grenades.

Four years ago, the Rand Corp. interviewed 1,965 vets and projected in its controversial
2008 report that 18.5 percent of all returning service members would meet the
criteria for either PTSD or depression (14 percent for each, but there’s some
overlap), and that another 19.5 percent would experience a probable TBI while
overseas. Again after taking into account that overlap, it said 31 percent of
all returning troops would suffer from one or all of those ailments.

The VA’s actual treatment figures show 28.5 percent of the returning vets are seeking
mental health care, which is right on track with the Rand Report. But while the
Rand Report projected that some 320,000 American soldiers would need help for
TBI, the VA says only 54,070 vets (a little over 4 percent of the returning
vets) qualified for that diagnosis.

“That’s absurd, preposterous, erroneous,” snorts Mike Zacchea, a Marine Corps
lieutenant colonel retired on a medical disability after service in Iraq, where
he survived a bomb in a mess hall, almost daily sniper attacks, mortar attacks
on his unit’s convoy, and a rocket wound during intense combat in Fallujah. All
of those took a huge physical and emotional toll on Zacchea.

As of last June, the VA had data on 544,481 vets whose brains might have been affected by
battlefield explosions, according to Dr. David Cifu, national director of the
VA’s Physical Medicine & Rehabilitation program. Of that number, he says,
“19.8 percent have screened positive for a mild TBI (concussion), that is were
exposed to explosions that might have caused traumatic brain injury.

“When those 19.8 percent of veterans were evaluated by one of the 100 TBI specialty
teams across the nation, approximately one third (or 7.8 percent of the original
544,481) tested positive for TBI with persistent symptoms,” says Cifu. “Another
approximately 2 percent were found to have a TBI that pre-dated their military
service. Those two figures (the 7.8 percent plus the 2 percent) add up to
54,070 veterans.”

The difference, says Cifu, is that the Rand Report used the total number of
injuries as its TBI figure while the VA used only the number of vets still
showing TBI symptoms a year after their injuries.

“The Rand Report was pretty accurate on the number of those who may have had injuries due to a
blast, but didn’t take into consideration that many of those may have injuries
that will fairly quickly get better over time,” says Cifu. “We know that up to
97 percent of those who experience concussions are normal without symptoms
within a year. So we’re tracking just the people who continue to have
difficulties.”

But Zacchea, a staunch member of Veterans for Common Sense, charges that the VA is trying hard to deny this
disability. “Today’s cutting edge neurology is that any symptoms that last
longer than two weeks indicate traumatic brain injury,” says Zacchea. “They’re
using the one-year time frame because that benefits them, but that’s just
medieval.”

Zacchea says he was quickly diagnosed with post-traumatic stress disorder after returning from combat, but
that he had to fight for his TBI diagnosis. “They wouldn’t even let me see a
neurologist,” he says. So he took his case to the Yale Medical School, got a
private diagnosis of TBI and challenged the VA to disprove it. After a number
of verification tests, he was finally granted a TBI diagnosis by the VA in
2008.

His ongoing symptoms include migraine headaches, sensitivity to light and noise, and loss of fine motor
skills. “My fingers are numb, and I’m always dropping things,” he says. “I have
difficulty tying my shoes so I usually wear slip-on shoes.” He also has a
distinct taste in his mouth. “I’ve lost most of my taste sensation,” he
explains, “so I put hot sauce on pretty much everything.”

A new book, The Concussion Crisis, concludes that even minor concussions repeated regularly can be
harmful, leading to impaired cognition and ultimately early-onset dementia
among athletes such as boxers and football players, as well as among soldiers.
In reviewing the book, Connie Goldsmith wrote: “There is no such thing as a minor
concussion. Every concussion is a potentially devastating injury. These stories
focus on concussions among athletes of all ages, as well as concussions among
soldiers and victims of auto accidents. Some of the stories are heartbreaking:
adolescents who suddenly die after what appear to be minor head injuries;
boxers and football players with early-onset Alzheimer’s disease and dementia;
and returning veterans left to wander through the medical system seeking
treatment for their unrecognized or misdiagnosed concussions.”

Dr. Allen Brown, head of the Mayo Clinic’s Brain Injury
Unit, defines a TBI as an external mechanical force impacting a body and
creating a brain injury. Thus, by definition, every concussion is a TBI and should
be part of the medical record.

But in the civilian world, he says, only about 8 percent
of brain injuries are severe enough to be labeled a “definite TBI,” as opposed
to a “probable TBI” which is milder or a “possible TBI” which is symptomatic. A
“definite TBI” involves any of the following: loss of consciousness for more
than 30 minutes, post-traumatic amnesia for more than 24 hours, significant
loss of motor skills as measured on the Glasgow Coma Scale, or intracranial
bruising or bleeding.

Brown agrees with Cifu that “an overwhelming majority” of brain injuries resolve themselves, although
repeated injuries increase the risk of significant damage. “It’s pretty clear
to me that the cumulative effect of any injury increases the risk for secondary
problems, including repeated TBIs that could lead to loss of cognition later in
life,” he told me. “It may not happen in every case, but the risk is whoppingly
high.”

And he calls the disparity between the Rand Report and the VA’s definitions of TBI “one of the most
argued-over controversies in medicine.”

More than half of America’s former warriors in Iraq and Afghanistan are returning home with medical and mental problems that need treatment, according to new statistics from the VA.

 “These are unprecedented numbers,” says Dr. Sonja Batten, assistant deputy chief of patient services care for the Department of Veterans Affairs Mental Health Division

But they’re surprising numbers, in some ways.

While they bear out the controversial 2008 Rand Report that one soldier in three will return home with post-traumatic stress disorder (PTSD), major depression and/or traumatic brain injury (TBI), the TBI component is dramatically lower than had been predicted. We’ll look at the reasons for that specifically in my next blog.

By last June, Batten said, 1.3 million of the 2 million-plus soldiers serving in Iraq and Afghanistan since 2002 had left military service and were eligible for VA health care. About 700,000 of them (53 percent) have sought health care from the VA.

While this reflects the difficulties facing today’s vets after 24-7 combat and multiple tours of duty, it also reflects the new resources provided the VA by the Obama administration. The president’s 2012 budget request for the VA was $132.2 billion, which would be a 23 percent increase since he took office in 2009. That’s even more remarkable, considering the collapse of the economy in that period. 

But it’s still not enough, according to Mike Zacchea, a Marine Corp lieutenant colonel now retired on a medical disability after serving in Iraq and a staunch member of Veterans for Common Sense. “Wait times for VA treatment are still way too long,” he told me. “And this is just the beginning. The VA is going to be overwhelmed by vets from Iraq and Afghanistan for health care, and if the VA can’t handle the demand it has now, it’s going to be powerless against the tsunami that’s yet to come.”  

            Among the returning soldiers, the main complaint was joint pain (neck, back, hips and knees), all consistent with the kinds of injuries you would expect to find among soldiers with heavy packs jumping in and out of big trucks, said Batten. The VA has treated 396,552 vets for musculoskeletal complaints, about 30.5 percent of the returning soldiers.

But the second largest complaint has been with mental health issues.

According to the VA’s not-yet-published statistics, 367,749 Iraqi and Afghan vets have sought mental health care treatment.  That’s 51.7 percent of the total caseload – and also 28.2 percent of the returning 1.3 million vets – a number that’s sure to grow larger as those who returned home recently begin acknowledging cases of delayed PTSD. It’s common for vets not to begin experiencing combat stress until after the euphoria of being home has waned, typically six months to a year or more.

PTSD was the most common mental health complaint with 197,074 vets receiving treatment, which is about 15 percent of the returning vets.  The second most common complaint was depression with VA treatment provided to 147,659 vets, 11.3 percent of the total returning. Third was anxiety disorder with treatment provided to 126,673 vets, 9.7 percent of those returning. There’s some overlap, with some vets being treated for more than one disorder.

These figures seem to bear out the Rand Corporation Report, issued in 2008 and updated in September 2010, which had estimated that 30 percent of America’s servicemen/women would require mental health care after returning from Iraq and Afghanistan.

But VA diagnoses for traumatic brain injury are far fewer than predicted. More on that in our next blog.

Vets with wounded souls have been self-medicating themselves for centuries to dull the pain of what they’ve done – or what they’ve not done. And many psychologists have followed suit by prescribing anti-depressants or anti-anxiety drugs.

But there has to be a better way to help. “Pharmaceuticals are just a mask because they don’t deal with a problem,” says Hardie Higgins, a retired Army lieutenant colonel who served 20 years as a chaplain. He has written a book, To Make the Wounded Whole: Healing the Spiritual Wounds of PTSD.

Note the use of the word “spirit” (pnuma) rather than “soul” (psyche). Since man is made in the image of the spirit (pnuma) of God, Higgins believes a spiritual wound is deeper than a wounded soul. One may be cognitively aware of a wounded soul, but unable to deal with spiritual wounds without God’s help.

Higgins argues that the battlefield strips away the belief system that soldiers grew up with, leaving them empty. “The key to recovery for victims of PTSD is, I believe, to assist them in discovering the redemptive meaning of their suffering and how to use that suffering to add meaning to their future life,” he says.

One of the vets he has been counseling was crippled emotionally for decades by the memory of clubbing a Vietnamese boy to death with a rifle butt. Higgins reached out for healing by setting two chairs in a room, then asking the vet to sit in one and explain why he did what he did to the boy, then move to the other chair to let the boy talk with the soldier.  “He explained to the kid that he was just a soldier doing his job and he was sorry,” Higgins says. “Then I put him in the other chair and said, ‘Now you’re the little kid. What do you want to say to the soldier?’ And it was amazing how much more forgiving that little kid was. He said, ‘I know you were just a soldier and you didn’t know what you were doing.’ When you hear that kid talking about forgiveness, there’s some real healing going on.”

Higgins also uses the Bible to help vets lift their levels of guilt. He reminds them of that familiar verse in the Lord’s Prayer: “Forgive us our trespasses as we forgive those who trespass against us.”  That’s a deceptively simple phrase, but it really means that God will forgive me if I forgive others. And if God forgives me, I have to forgive myself, too. 

Drawing on the Native American culture, Ed Tick, founder of Soldiers’ Heart and author of War and the Soul, also counsels a path of atonement to healing. He notes that the Lakota Sioux have a term for combat stress that can be translated as “his spirit has left him” or “his spirit has been emptied.”  And he cites a Flathead Indian “victory song” in which a returning warrior asks forgiveness for the damage he has done to the cosmos.

War creates an identity crisis for returning vets, Tick told me; they initially transform from civilians to warriors, but they never can return to being civilians again, So healing involves asking atonement for what they have done, creating a new post-warrior identity for themselves, and sharing their experiences with the community. That lifelong journey can lead to acceptance and spiritual peace again. Failure to do that leads to nightmares and flashbacks as the suppressed combat experiences struggle to be recognized, but also fear it. “Holistic medicine looks for true healing, not just symptom management,” says Tick.

In the years to come, we must also recognize and provide special help to vets whose souls have been wounded by what they’ve done – or not done.

I remember talking with the grieving family of a young Marine killed in Iraq five years ago. As we stood in the cemetery, a snow-swept knoll in northeastern Montana, his mom recalled her son’s last visit home a few months before and how devastated he’d been by an incident there.
            The 20-year-old had told his family that he and his friends had been tossing candy to a bunch of Iraqi kids when one pressed too close. Warned to stay away, one kid kept advancing. And finally, remembering the stories of bad guys who carried knives or guns or bombs strapped across their chests, this young Marine shot the kid.

When they checked the kid’s body, he was unarmed. “Mom, I killed an innocent Iraqi goat-herd,” her son had said over and over again.

 That trauma is what some psychologists are calling a “wounded soul,” a moral injury that pierces a person’s sense of himself, his relationship to society and his relationship to God

Killing goes against the moral code of virtually every society, so what a soldier does in a combat situation redefines him in his own mind. He knows he has crossed a moral line. And he knows that having done it once, he can always do it again.

Worse, he knows that his family and friends will also know that about him.

As a Christian, there’s only one thing that’s worse. I believe that God handed down a set of laws written in stone that say very explicitly: “Thou shalt not murder.” Later, that commandment was imprinted on our hearts, hard-wired into our psyche, as it were. So breaking that law also separates me from my Creator, providing a triple whammy.

Ed Tick, a psychotherapist who heads the private group Soldier’s Heart, says conventional medicine doesn’t take that aspect into account. “I’ve talked with a number of vets who say they are treated as victims, but that they know they were the perpetrators,” he said.

It’s no wonder that the mental health casualty rates are so high for warriors.

In September 2010, the Rand Corporation updated its 2008 report which had estimated that 30 percent of America’s 1.64 million servicemen/women would require mental health care after returning from Iraq and Afghanistan. The Rand Corporation stands by its projection of nearly one vet in three needing help, which to me is a staggering number.

Still, I think that number should be broken apart for better understanding.

Fear of being injured or killed remains a significant part of the vet’s psyche, even in a supposedly safe civilian world, but his soul can also be wounded by what he has done – or failed to do. There’s an unseen but very real wound when your buddy dies beside you; could you have steered him clear of danger, could you have shot the enemy first, could you have stepped in front of the bullet yourself, could you have stopped his bleeding faster and saved his life? And as you question yourself, you also begin to question the leaders who put you in that position.

Tick, author of War and the Soul, told me that the “wounded soul” half of PTSD actually includes a number of traumas. After killing someone, love and intimacy and attachment are altered; perhaps a war buddy is more important than family because a vet feels his buddy can understand what he had to do in combat.  Killing wounds the heart and violates a vet’s moral code. “A chaplain at Walter Reed (Medical Center in Washington, D.C.) told me once that healing involves renegotiating your covenant with God,” said Tick.

Those are some very different traumas, and they require very different therapies. We’ll examine those next.

I remember talking with the grieving family of a young Marine killed in Iraq five years ago. As we stood in the cemetery, a snow-swept knoll in northeastern Montana, his mom recalled her son’s last visit home a few months before and how devastated he’d been by an incident there.
            The 20-year-old had told his family that he and his friends had been tossing candy to a bunch of Iraqi kids when one pressed too close. Warned to stay away, one kid kept advancing. And finally, remembering the stories of bad guys who carried knives or guns or bombs strapped across their chests, this young Marine shot the kid.

When they checked the kid’s body, he was unarmed. “Mom, I killed an innocent Iraqi goat-herd,” her son had said over and over again.

 That trauma is what some psychologists are calling a “wounded soul,” a moral injury that pierces a person’s sense of himself, his relationship to society and his relationship to God

Killing goes against the moral code of virtually every society, so what a soldier does in a combat situation redefines him in his own mind. He knows he has crossed a moral line. And he knows that having done it once, he can always do it again.

Worse, he knows that his family and friends will also know that about him.

As a Christian, there’s only one thing that’s worse. I believe that God handed down a set of laws written in stone that say very explicitly: “Thou shalt not murder.” Later, that commandment was imprinted on our hearts, hard-wired into our psyche, as it were. So breaking that law also separates me from my Creator, providing a triple whammy.

Ed Tick, a psychotherapist who heads the private group Soldier’s Heart, says conventional medicine doesn’t take that aspect into account. “I’ve talked with a number of vets who say they are treated as victims, but that they know they were the perpetrators,” he said.

It’s no wonder that the mental health casualty rates are so high for warriors.

In September 2010, the Rand Corporation updated its 2008 report which had estimated that 30 percent of America’s 1.64 million servicemen/women would require mental health care after returning from Iraq and Afghanistan. The Rand Corporation stands by its projection of nearly one vet in three needing help, which to me is a staggering number.

Still, I think that number should be broken apart for better understanding.

Fear of being injured or killed remains a significant part of the vet’s psyche, even in a supposedly safe civilian world, but his soul can also be wounded by what he has done – or failed to do. There’s an unseen but very real wound when your buddy dies beside you; could you have steered him clear of danger, could you have shot the enemy first, could you have stepped in front of the bullet yourself, could you have stopped his bleeding faster and saved his life? And as you question yourself, you also begin to question the leaders who put you in that position.

Tick, author of War and the Soul, told me that the “wounded soul” half of PTSD actually includes a number of traumas. After killing someone, love and intimacy and attachment are altered; perhaps a war buddy is more important than family because a vet feels his buddy can understand what he had to do in combat.  Killing wounds the heart and violates a vet’s moral code. “A chaplain at Walter Reed (Medical Center in Washington, D.C.) told me once that healing involves renegotiating your covenant with God,” said Tick.

Those are some very different traumas, and they require very different therapies. We’ll examine those next.

I think it’s time for us to refine PTSD (post-traumatic stress disorder).

Thirty years ago when PTSD was added to the Diagnostic Manual of Mental Disorders, it was a break-through for psychologists to recognize what less-professional observers had known for millennia: that war causes emotional damage, just as it causes physical damage. To confirm that, you need only to go back to the Greeks, the tragedies of Homer, Aeschylus and Sophocles, as well as the history of the Peloponnesian War by Thucydides. As Jonathon Shay, a psychiatrist who works with Vietnam vets, says: “Athenian theater was created and performed by combat veterans for an audience of combat veterans; they did this to enable returning soldiers to function together in a democratic polity.”

But over the past three decades of working with PTSD, it seems as though our stressed-out vets are demonstrating two distinctly different symptoms that should be treated differently.

Stress caused by combat is a logical disorder. It’s a natural defensive mechanism, a shield that the brain dons when it knows someone or something is trying to kill it. One result is long-term  hypervigilance, the state of high alert to forestall and survive the next attack.

But as currently defined, PTSD also includes the guilt that some psychiatrists are calling “wounded souls.”  This stems not from what others are trying to do to them, but from what they have done to others.

Therapists such as Shay, a recipient of a MacArthur Foundation “genius” grant; Edward Tick, director of the private group Soldier’s Heart; and Brett Litz, a VA psychologist, argue that what happens in war may more accurately be called a moral injury — a deep soul wound that pierces a person’s identity, sense of morality and relationship to society.

My friend Jack Jager fits the latter diagnosis perfectly.

A dog handler during the war in Vietnam, Jager came home and tried to live a normal, civilian life, but couldn’t. And when his mom asked what had happened to him over there, he couldn’t tell her. Instead, he fled to Montana, got an isolated job as a long-haul trucker, drank heavily and fell in and out of marriages.

“I felt very guilty,” he told me a few years ago. “There are things I did that I feel very guilty about. I was brought up right, brought up to do right, but in war the compassion is not there. Human beings were not made to kill each other. I saw some soldiers who just could not pull the trigger on an adversary face to face, and they died. After all the depravity of war was over, I was afraid people would know what I was, so I just ran away from it.”

Jager is what I would call a wounded soul.

And I think psychology would be better served to break the PTSD diagnosis in half. There will always be overlap, but it makes sense to provide one kind of relief to those traumatized by what was done to them and another therapy to those traumatized by what they did to others.   

Dr. Tick, author of War and the Soul, agrees. He told me that combat stress/anxiety is a logical half of the PTSD diagnosis, but that spiritual injuries form the other half. “We really don’t have the words in our language to express our spiritual loss, but when I describe it to combat vets, they understand it immediately,” he said.       

Next we’ll look at what causes wounded souls.

So what will the Army do with Sgt. John M. Russell, accused of killing five fellow soldiers last week at a military stress clinic in Baghdad?
Or, more to the point, what should it do?
Five deployments into combat zones created more stress than Russell could handle, his family’s chaplain told me in a phone conversation from Germany.
“If this individual could have had some objective way of measuring the stress he was un-der, the outcome would have been different,” Phil Davis said in a telephone interview from the big Army base in Bamberg, Germany. “And that’s why I say to his wife and everyone else that this was a very avoidable tragedy.”
Now Russell has been charged with five counts of murder.
According to the Army Times, Russell, of Sherman, Texas, was scheduled to return home in three months from his third tour of duty in Iraq.
He previously was deployed for six months in 1996 to Serbia and for seven months in 1998 to Bosnia.
“When the full story comes out, we’ll see that he was just a normal guy put into an abnor-mal situation,” Davis told me.
The Army has initiated an AR 15-6 investigation to determine whether there are adequate mental health care resources available in Iraq, the Army Times reported.
“From all accounts, he was not showing any signs of stress (before his last deployment),” Davis said. “His family is a happy family, and everything had been going well.
“The Army inquiry is under way because — from all accounts — there was no indication of the tragedy about to happen.”
Davis said stress can disorient a deployed service member’s mind, increasing the perceived magnitude of problems.
“It’s a pretty accurate guess that he felt threatened by someone and that his thought proc-ess made the unreal real,” Davis said. “As he played and replayed the requirements he had in a place where he was not being treated well, it became more and more intolerable.
“He had no way of putting a perspective on it, (or) the tools he needed to distance himself from those problems,” Davis said. “They became a personal affront to him.”
Davis is working with soldiers at Bamberg to provide those tools.
One of them is the mind-body bridging technique advocated by Stanley Block in his book, “Come to Your Senses.” Davis worked with Block at the University of Utah in Salt Lake City.
One aspect of that technique is using the senses — listening, smelling, seeing and touching your environment instead of wrestling with your thoughts.
A second aspect is accepting the things that a person can’t change and consciously lower-ing expectations of what to expect in certain situations.
Davis said he is seeking a grant that will allow military health professionals to create a mental health database at Bamberg. The database will show the prevalence of combat-induced disorders and the success of various therapies in treating them.
But the final question is ultimately the first: What should the Army do with Russell? Should he be locked away for murder by a military system that trains its members to kill? Or should he be treated for the emotional disorders that resulted from five tours of duty in combat zones?
You know the answer as well as I do: treatment.

While Montana continues to have one of the nation’s highest rates of alcoholism and drug abuse, the recovery rate after treatment is nearly twice as good as it was when I was writing the “Alcohol: Cradle to Grave” series of stories a decade ago.

And it was wonderful to see that several of the problems identified by those stories have been fixed. I suspect that’s one of the reasons for the improved success rate.

For one thing, counselors have found that the one-size-fits-all treatment method doesn’t work for alcoholics either.

“One big change is putting wrap-around services into the mix and allowing people the amount of treatment they need,” said Joan Cassidy, chief of the state Chemical Dependency Bureau. “One individual may need two weeks of treatment versus the next one who might need one year of treatment.”

The state now offers three tiers of treatment options: full hospitalization, two eight-bed facilities with full medical attention 24-7 in a home-based environment, or 11 supportive living centers based around the state.

In addition, the state is providing assistance in other living skills that alcoholics may be deficient in — things like education or financial planning or anger management.

These are the programs that Cassidy calls wrap-around services. They are designed to give alcoholics the social skills they need to survive in society.

Those two elements have nearly doubled the success rate of treatment, which used to see only about 40 percent of the patients still abstaining from drugs and alcohol six months after treatment. I noted at the time that the Hazelden Foundation in Center City, Minn., boasted a success rate of around 60 per cent at the time, largely on the basis on assigning local mentors. i.e. recovering alcoholics, to each patient leaving their facility.

Since 2003, the state of Montana has been checking its former patients every quarter, and it has found that six months after treatment:

ã 75 percent of its patients remained abstinent from alcohol and other drugs;

ã 63 percent were employed full time;

ã 86 percent remained clear of the criminal justice system;

ã 0.2 percent reported homelessness.