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.