If a soldier’s brain has been so traumatized by combat that he cannot control some of the things that he does, how can he be held legally accountable for his actions?

But then again, how can he not?

“Do we have the legal and moral right to judge and sentence soldiers who have diminished capability due to actions taken on behalf of the American public?” asked University of Pennsylvania Law Professor Stephen Morse, who is also a prominent forensic psychologist, during a PTSD conference hosted by the Center for Ethics and the Rule of Law in Philadelphia.

Morse’s questions were highlighted by the observation of Dr. Bessel van der Kolk that “after combat, vets have to live with an altered neural network.” For more on van der Kolk’s lecture on neurobiology, see my previous post.

Let’s start, as Morse did, by looking at the legal definition of what is needed to be liable for one’s actions.

Morse said that all crimes include the requirement of being a “voluntary act” (i.e., an intentional action or omission) done in a state of reasonably intact consciousness. That provides a basis for being acquitted or convicted of murder, for example. Thus, if a defendant is in a state of divided or disassociated consciousness, the act requirement is not met and the defendant will be acquitted. Such cases are relatively infrequent.

But how else does the law deal with impaired consciousness?

In 46 states and in the federal system, there is also a plea of not guilty by reason of insanity if the defendant’s mental disorder produces a sufficient cognitive deficit or, in a minority of states, a control deficit.

How should the law deal with PTSD, a disorder in which the victims are operating with a reasonably intact consciousness until something triggers in some sufferers an altered state of consciousness? Should this be treated as a cognitive or control deficit in appropriate cases?

For example, smells go directly to the amygdala, the limbic brain’s fight-or-flight center. I know a vet in Montana whose flashbacks were probably triggered by a nearby oil refinery that produced odors that reminded him of diesel fumes in his Iraqi forward operating base. During one of those flashbacks, he tackled a mailman, pinned him to the ground, and was screaming for his rifle. The vet’s consciousness seems clearly to have been altered in this case.

There are vets’ courts in some states, but not all states, that accept a vet’s diminished capacity. So the system is unfair to vets without that option.

I remembered a former Army Ranger who created a disturbance on an airliner. The prosecutor and the defender worked out a deal for him to plead guilty to a misdemeanor, then be sentenced to treatment in a VA hospital. But judges have considerable discretion in sentencing, which also makes the outcome unfair for others.

Professor Morse had a suggestion. He proposed a fourth plea, in addition to innocent, not guilty by reason of insanity, or guilty. That would be a plea of guilty, but not fully rational, which would give the legislatures or the courts an option for reduced sentences. Sufferers from PTSD who met the voluntary act requirement and who were not sufficiently affected to succeed with an insanity defense would then have a genuine opportunity to present a claim that they had diminished rationality and diminished culpability.

At one point, our discussion shifted to atrocities like revenge killings that could lead to moral injuries. Would they also be considered as not fully rational?

That led to heated discussion, with one former Army judge advocate insisting there was no such thing and demanding a retraction of the charge. But three other Army commanders also weighed in on the issue.

One said he had pored over the records from Abu Ghraib and was appalled to find how many soldiers from how many different units had employed enhanced interrogation techniques (like waterboarding).

Another military prosecutor said he had seen cases in Iraq in which American soldiers should have been charged with war crimes since there was compelling evidence they had shot civilians and planted weapons near the bodies. Instead, he said, they were charged with Article 15s and busted one rank in the unlikely event they were convicted.

And another commander said atrocities are still a minority of what soldiers do, but that they are a significant minority and greater than most people realize.

This seminar was made up of top military personnel, legal scholars and mental health experts, with a couple of journalists thrown in for good (or bad) measure. So we debated the issue at some length, without resolution.

Finally, one of the participants summed it up for all of us, saying, “I think we’re all morally conflicted for what we are sending soldiers out to do, what we are willing for forgive them for, and what they can forgive themselves for.”

Trauma changes not only the way we think, but also the way our brains work.

“After combat, vets have to live with an altered neural network,” said Dr. Bessel van der Kolk, founder and medical director of the Trauma Center at the Justice Resource Institute in Massachusetts.

And that has profound implications for combat vets with PTSD. If neurological reasons prevent them from controlling some of the things they do, how can we hold them accountable? And what therapies work best for these damaged brains? We’ll look more closely at those two issues in subsequent blogs.

But first, let me tell you about a remarkable lecture that van der Kolk gave at the Center for Ethics and the Rule of Law at the University of Pennsylvania in Philadelphia last week.

Early in his career, one of van der Kolk’s patients told him that he had killed some Vietnamese children, shot an innocent farmer and raped a woman to avenge the deaths the previous day of all the members of his platoon, including his best friend. So van der Kolk used revenge killings as one example of moral injury at the PTSD conference.

“After something like that happens, vets don’t feel safe with themselves anymore,” he said. “And they may not feel safe being around their wife and kids.”

One problem is desensitization. As a soldier becomes numb to the chaos around him, he also loses his sense of compassion for others.

Even worse, it’s as though those traumas get stuck in a vet’s brain and he can’t get on with his life. “That’s because PTSD emerges from a part of the brain over which we have no control,” van der Kolk explained.

In the past few decades, neurologists have been able to use brain scans to determine how people’s brains respond to various stimuli and to memories. Van der Kolk showed several slides to illustrate how a traumatized brain operates differently from a so-called “normal” brain.

When a combat vet remembers traumatic events from his past, the prefrontal cortex of the brain – the center of rational thinking – shuts down. That makes it impossible to try to use logic to confront his memories, van der Kolk said.

In particular, one part of the left frontal lobe of the brain called the Broca’s area shuts down when confronted by trauma. “Without a functioning Broca’s area, you cannot put your thoughts and feelings into words,” van der Kolk said in his newest book, The Body Keeps the Score. “Our scans showed that Broca’s area went offline whenever a flashback was triggered….

“Under extreme conditions, people may scream obscenities, call for their mothers, howl in terror or simply shut down,” he wrote. “Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children ‘lose their tongues’ and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void.”

At the same time, the brain’s limbic system – the seat of emotions – is ramped up, and the amygdala sends out hormones and neurochemicals that drive up blood pressure, heart rate, and oxygen intake to ready the body for fight or flight.

There’s no known neural pathway to allow reason to moderate the emotions stemming from the limbic system, van der Kolk told the PTSD conference.

Trauma victims also have a harder time focusing because they’re distracted by everything around them.

“The left anterior cingulate filters out distractions around us,” said van der Kolk, “but trauma disables it. So traumatized people are unable to filter out outside influences, which makes it hard for them to learn new behaviors.”

Childhood trauma makes an adult more susceptible to being re-traumatized, he said. That’s especially troubling he added, because more than 12 million American women have been the victims of rape, with more than half of all rapes being forced upon girls younger than 15 years old. And each year, around 3 million children are abused and neglected, one third of whom so severely that local child protective services or the courts are required to take action.

“So if you want to eliminate PTSD in the military, only let people with perfectly safe childhoods serve in your army,” he added. “Of course, it would be a very small army.”

Van der Kolk closed his lecture by illustrating two dramatically different responses to the terror attacks of 9-11.

One was a 5-year-old child’s drawing of the plane slamming into the World Trade Center. It showed what looked to be a fireball explosion, people screaming and jumping out of the windows. It portrayed all the sights and sounds of the attack that had been registered by the limbic system.

But there was also one important element of rational thinking: the young artist had added a trampoline on the ground beside the World Trade Center so that the people who were jumping would not be hurt.

By contrast, the response from Washington, D.C., was completely limbic, van der Kolk said.

“After 9-11, the president said we’re going to bomb them alive or dead,” he said. “And that was totally a limbic response, not a rational one. Because our government operated on a limbic response instead of a rational one, more than 2,000 Iraqis who had nothing at all to do with 9-11 have been killed.”

So what kind of therapy does this neuroscientist favor?

“We need to bring that portion of the traumatized brain back online if we are to provide effective therapy for PTSD,” van der Kolk told the group.

In many ways, that involves the same techniques that a mother uses to comfort a frightened child: rocking, holding, soothing and singing. It’s also important that the vet, like the child, feel a sense of safety.

“Man is a social animal,” said Aristotle, and that concept is key to van der Kolk’s therapy. We connect with others by working in synchronicity, building rhythms that connect us with others, he said. That’s why breath exercises, chanting, martial arts like qigong, drumming, group singing and dancing are so important.

All rely on interpersonal rhythms, visceral awareness and vocal and facial communications that help shift people out of their fight-or-flight stages, reorganize their perception of danger, and increase their capacity to manage relationships, he said.

“Americans use alcohol and drugs to treat PTSD,” said van der Kolk. “But other cultures turn to dance, song, music and drumming. Yoga shows greater effectiveness than any pill you can take.”

Some psychologists are gung ho about using prolonged exposure therapy to treat PTSD, but others are more skeptical.

“It’s a terrible therapy, just terrible,” Dr. Bessel van der Kolk, medical director of the Trauma Center at the Justice Resource Center, exclaimed as we walked to a PTSD conference at Penn Law’s Center for Ethics and the Rule of Law. “It merely re-traumatizes vets who have previously been traumatized. You can quote me on that – and you should.”

Other vets and counselors were less outspoken, but equally troubled by this therapy.

“It’s very intense,” observed Cathy Coppolillo, a staff psychologist for nearly a decade at the Clement J. Zablocki VA Medical Center in Milwaukee. “I’d guess that half the people we try to treat with PE get a few sessions into the protocol and disappear. Not only do they go away untreated, but they think all therapy looks like that.

“In those cases, we’ve probably lost the person for good, which feels like the worst way possible to fail a patient,” Coppolillo added. “So if I’m unsure at all about their ability to tolerate PE, we do something else.”

Coppolillo said other VA hospitals around the country have also been reporting a 50 percent dropout rate for PT patients. But Dr. Edna Foa, who invented the therapy, insisted that the attrition rate is no more than 20 percent, which she said was about average for all therapies.

Coppolillo screens her patients for the ones that might benefit from PE because it can reduce the intensity and frequency of nightmares and flashbacks, she said. But not all qualify. Some can’t deal with intense emotions involved in reliving traumas.

“The combat vets I see have learned (via combat experiences and military training before that) that emotions are potentially life threatening, given their ability to destabilize and distract from the tasks at hand,” she told me. “So emotions are more than just unpleasant and unfamiliar – they feel life threatening. And that’s one of the reasons so many vets drop out of treatment.”

Many vets show up at the VA medical center suffering from PTSD as a result of the roadside bombs that blew up their buddies and forced them to begin filling body bags with pieces of their comrades, Coppolillo said. And PE can work for those vets.

But PE is not very effective in treating the wounded soul syndrome, Coppolillo said.

“So many of these vets are suffering with a moral injury because they were forced to do things that violated their moral code,” she explained. “Revisiting these horrible memories can habituate vets to traditional PTSD, but it can’t touch that sense of guilt.

“I think about one vet who had some pretty rough stuff done to him during his year in Iraq, but he’d also done some pretty rough stuff to others,” she said. “”We tried PE, but habituation doesn’t do much for moral wounds. Finally he said to me, ‘I’m just a monster, and I’m going to have to live with that fact for the rest of my life.’”

Without atoning for their actions and forgiving themselves, many vets become stuck – kind of like the “dry drunk” who throws away the bottle, but never finds anything to replace it.

“So many veterans feel they don’t deserve to move forward and live happier, more fulfilling lives, given the ‘monster’ they feel is lurking within them,” said Coppolillo. “This limits the effectiveness of any kind of treatment (including PE) if someone feels they deserve their suffering and that to fix it would be morally wrong. In my experience, this is unbelievably common.”

At the PTSD conference, Foa said she didn’t believe the concept of moral injury was a particularly helpful one.

About a quarter of her patient load at the VA medical center in Milwaukee involves military sexual trauma, Coppolillo said, and they are a little easier to treat than moral injuries.

“My experience has been that PTSD symptoms that arise from sexual trauma seem to resolve a bit more quickly than do symptoms related to moral injury,” said Coppolillo. “My gut sense is that that’s probably because there isn’t the same sense of moral injury holding the symptoms in place.

“Certainly, sexual assault survivors feel a deep sense of guilt/responsibility because of any number of choices they might have made at the time, but that seems to be a really different animal from the deep soul injury many combat vets face,” she added. “‘I made a bad choice and that resulted in my assault’ is very different from ‘The choices I made prove to me I’m a monster.’”

Another observation is that traumas from the distant past are about as treatable as more recent ones, but they may take longer to treat.

“I think about our Vietnam vets and how lengthy their treatment tends to be,” said Coppolillo. “”They’ve spent years suffering and generally not doing well in jobs and relationships that they end up building their identity around their brokenness. Like moral injury, that identity creates a scaffolding that holds the PTSD symptoms firmly in place, and disassembling that scaffolding tends to be quite a bit of work.

“So is therapy less effective with stuff that’s 40-plus years old?” she asked. “I wouldn’t say that, as much as I would say it’s more effortful and takes longer because there’s more you have to drill through before they’re really ready for help.”

One VA counselor, who’s been working with vets since 1970, said he actually tries to steer vets away from dwelling on past traumas.

“People come to me with their slop buckets and try to dump them on me all the time,” he said. “But I don’t see the need for them to sit and tell me their problems for an hour a day every week for 10 years – that just builds mental memory and reinforces the slop.

“They don’t have to tell me, and I don’t have to listen” said the counselor, who asked that his name not be used because he hadn’t cleared the interview with the VA public information office. “I ask them what their specific problems are and what resources they need to overcome those problems. Then we stack the resources together and allow the vet to process his problems with new resources to collapse the threat.”

Another Vietnam vet told me of his experience with exposure therapy while undergoing PTSD treatment at the Tomah (Wis.) VA Medical Center.

“It was very intense,” he said. “Guys were literally on their knees in tears.” This vet said he told the class how he mistakenly killed two South Vietnamese men that he encountered in the jungle where no one should have been, then checked their bodies and found they were civilians with no weapons.

“It was very relieving (to get that story out),” he said, ‘but I wouldn’t want to do it again.”

One of the major limitations of most therapies, including prolonged exposure therapy, is that they fail to provide vets with a sense of purpose similar to the mission they experienced in the armed services, said Coppolillo.

“If we’re talking about recovery writ broadly for these veterans – not just from PTSD as a narrowly defined diagnosis, but from ways that their military experience has wounded them – this question of meaning and purpose is huge,” she explained. “I spend hours each week discussing it in both group and individual sessions.

“The loss of belonging to something bigger than the self, and of a defined mission, is so painful, and it’s one of the biggest barriers I see for folks trying to recapture/create a life that makes sense,” Coppolillo said.

I’ve been a little skeptical about using prolonged exposure therapy to treat post-traumatic stress disorder. Revisiting a trauma over and over again to become habituated to it seems fine in theory, but it has to be agony for vets already traumatized by those events.

So I was pleased to participate in a keynote panel at a conference, Preventing and Treating the Invisible Wounds of War: Combat Trauma and Psychological Injury, at the University of Pennsylvania Law School’s Center for Ethics and the Rule of Law. It featured Dr. Edna Foa, the professor of clinical psychology who invented the therapy.

PE therapy has been embraced by both military psychologists and the Veterans Administration, and Foa insisted that was because it is effective in treating PTSD. So far, about 1,300 mental health professionals have been trained in PE, she said.

She cited statistics showing that 1.8 percent of men in the civilian population have PTSD compared to 5.2 percent of the women, 9 percent of the Vietnam vets and 20 percent of the Iraqi/Afghan vets. There’s no real explanation for the difference between the two vets’ groups except that PTSD didn’t become a diagnosable disorder until 1980, five years after the war in Vietnam had come to an end.

She noted that the military suicide rate, which had traditionally been lower than the civilian rate, has nearly doubled during the Iraqi/Afghan war, exceeding the civilian rate in 2010. One service member kills himself nearly every day, she added, while male veterans are twice as likely to commit suicide as men in the general population

Then Foa addressed treatment, which she said is likely to be either prolonged exposure therapy (PE) or cognitive processing therapy (CPT) in the military and the VA.

PE involves repeated revisiting and recounting traumatic memories that are otherwise avoided because they cause so much pain. After remembering the traumas, there’s a period of processing them, including a recognition of changes of perception that might have occurred as a result. Therapists focus on fear and anxiety, but also on shame, guilt and anger. A second part of the treatment is approaching situations that the vet has been avoiding to show that they are safe in a post-combat world.

CPT involves changing a vet’s thinking in four major ways: learning about PTSD symptoms, becoming aware of thoughts and feelings, learning skills to help question or challenge feelings, and understanding changes of belief that commonly occur after undergoing trauma.

Both therapies may take 10 to 12 sessions – or more, depending on the severity and number of the traumas.

Foa cited one 2007 study of 284 female vets that showed PTSD severity dropped from 80 percent on the PCL scale to 50 percent after PE treatment. PCL is a 20-item, self-report list that measures the 20 symptoms of PTSD that are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

She also cited a 2013 study of 1,931 vets being treated by the VA that showed 62.4 percent exhibited significant improvement of at least 10 points over their baseline PCL scores, with 49 percent dropping below the 50 PCL threshold for diagnosing PTSD.

Her conclusion was that PE and CPT are both more effective than just counseling, although she noted that a few studies have shown military personnel didn’t do as well.

“Some experts suggest that military traumas include more moral injuries than civilian traumas,” said one slide in her powerpoint. “Moral injury is associated with more severe PTSD and with suicide.”

In an aside, Foa told me she didn’t believe the concept of moral injury was a particularly useful one.

She also addressed the issue of inflicting too much emotional distress on patients in a paper published last year in the journal of Cognitive and Behavioral Practice.

“A concern that some clinicians may have with providing PE is patient overengagement, which is excessive emotional distress resulting from imaginal exposure,” she wrote. “Some patients may initially experience significant distress when reviewing their trauma narrative. Should overengagement occur, clinicians can modify exposure procedures to help patients remain grounded while describing their traumas.”

Nonetheless, she said patient dropout was only about 20 percent, about the same as other therapies.

More on this in our next blog.

I’m indebted to Jonathan Shay for showing me a new dimension of moral injury, or a wounded soul, as I prefer to call it.

For years, I’ve argued that the traditional definition of post-traumatic stress disorder only covers half the problem. It diagnoses and treats what others are trying to do to you: typically working very hard to maim or kill you. But the other half of PTSD isn’t recognized by the mental health community yet. That’s the moral injury: what you are doing to others, or what you have failed to do for others.

That might include shooting and killing a boy who looks like he’s carrying a grenade, but it turns out to be something totally innocent. Or it might be misreading the tactical situation and blundering into a fierce firefight in which a couple of your buddies were killed.

But I had dinner in Philadelphia a few nights ago with Shay, the retired VA psychiatrist who coined the term moral injury. We had both been invited to participate in a conference, Preventing and Treating the Invisible Wounds of War: Combat Trauma and Psychological Injury, at the University of Pennsylvania Law School’s Center for Ethics and the Rule of Law.

And Shay suggested a whole new aspect of moral injury that I’ve seen repeatedly … but never really recognized.

Shay argued that moral injury is also present when there has been a betrayal of what is right by a person in a position of legitimate authority in a high-stakes situation. “Both forms of moral injury impair the capacity for trust and elevate despair, suicidality and interpersonal violence,” he wrote in an article, “Moral Injury,” published last year in the journal of Psychoanalytic Psychology.

It’s a major step forward because it involves betrayal, something I’ve witnessed often over the years, but never really connected the dots. I’ve noticed that when patriotic soldiers sent into a battle begin to realize the conflict is unjust, they develop anger, bitterness and cynicism. They no longer trust authority in government or in their workplace. That often leaves them unemployed and homeless, with a marriage shattered beyond repair.

And it’s something that usually happens after the soldier returns home because military morality differs from civilian morality.

Take the lead driver in a military convoy who has been told to stop for nothing because it might be a trap leading to an ambush. He sees a small boy sitting in the road and hesitates because this seems so wrong, but then obeys the order and drives over the boy. In Iraq, he’s a good soldier, but at home, he’s a baby-killer.

Nancy Sherman, a philosopher and psychologist at Georgetown University, cited another example in an article, “Recovering Lost Goodness,” also published last year in the journal of Psychoanalytic Psychology.

She cites a civilian family in Iraq driving home from church which got caught in the crossfire of a U.S. attack on a high-value target. The father was killed instantly, and the mother and son were thrown from the car and also killed. A major who was first on the scene and gathered body parts was ordered to find the family and make amends.

However, Paul Bremer’s American occupation administration stymied the officer at every turn, convinced that the family members were insurgents. They sent him to deliver $750 to the family for damages, an insulting amount that the family rejected by throwing the bills on the floor and stalking out. The bodies sat in the heat for a month or more awaiting death certificates to authorize the burials. When the certificates came, they were marked in red ink “ENEMY.”

That moral injury can be devastating to a soldier, much more so than bullets and bombs.

“How does moral injury change someone?” asked Shay. “It deteriorates their character; their ideals, ambitions and attachments begin to change and shrink. Both flavors of moral injury impair and sometimes destroy the capacity for trust. When social trust is destroyed, it is replaced by the settled expectancy of harm, exploitation and humiliation from others.”

And that may be one of the reasons for the soaring suicide rates among veterans and active-duty service members.

Writing in “Vietnam Magazine,” my friend Neal Ulevich tells the story of a former combat vet who restored his own sense of honor by honoring his fallen comrades in arms, particularly the long-forgotten soldiers of Southeast Asia.

Stuart Allen Beckley, a retired lieutenant colonel, spent a decade teaching counterinsurgency tactics to the Thai armed forces, as well as serving in Laos and Bangkok. After his retirement, however, he remained bitter and angry at the outcome of the War in Vietnam.

“That I did not die with the last to die is a source of great shame to me,” he wrote later. “My country ‘died’ on that bleak April day in 1975 when the last helicopter lifted off from the American Embassy in Saigon.”

In particular, he was haunted by the published image of a young South Vietnamese Ranger whose wrist was tattooed with the question: “When I die, who will build my tomb?”

Beckley decided that he would build that tomb.

Slowly, his anger became a mission to build a monument called Soldierstone that would be a tribute to every man of arms who fought in Indochina in the three decades from France’s fight to save its colonies in Indochina at the end of World War II to the close of the American War in Vietnam in 1975.

He placed that monument in a remote section of the Continental Divide called Sargent’s Mesa in Colorado’s Rocky Mountains. At 10,800 feet above sea level, it’s accessible only after the snow melts in an alpine pasture of the Rio Grande National Park in late spring.

The monument is a 10-foot tall obelisk of stacked blocks inscribed with words like “sacrifice” and “courage.” Surrounding the obelisk are 30 “quotestones,” each with sad insights from soldiers who fought in Indochina.

Its remoteness was deliberate. “I do not want this to become ‘Stu’s project,’ it’s for those tired, spent dusty soldiers that march through my nights,” he wrote to the Forest Service about five months before his death from cancer in 1995.

Ark Valley Memorial Co. at Rocky Ford in eastern Colorado crafted and engraved the granite blocks, which came from a quarry in Georgia. It erected the tower, using a big six-wheel-drive truck with a crane on it. Engraving the stones with quotations in foreign languages was a special problem.

Each of the quotestones weighed about 300 pounds. Mike Donelson, the monument company’s owner, recalled his astonishment as Special Forces soldiers shouldered the granite blocks and carried them to random locations surrounding the obelisk.

The monument cost just under $100,000, and Beckley put up most of the money himself. But he refused to put his name on it. “Soldierstone will be starkly beautiful in its simplicity,” Beckley wrote. “It will stand alone … as did those soldiers in the seasons of death.… Soldierstone makes no political statement … except for the horrific tragedy of war.”

Since its completion two decades ago, Soldierstone has been largely unknown, accessible only by about 15 miles of extremely rough logging roads. But not long ago, a group of bikers happened on it, filmed it, and posted their film on the Internet.

“Stu’s dearest wish was that this site not become a tourist attraction or be publicized in any way but by word of mouth, but he and we didn’t envision social media or YouTube in 1995,” one Forest Service official told Ulevich, who worked with me half a century ago on the University of Wisconsin’s student newspaper, the Daily Cardinal. A photojournalist for The Associated Press, Ulevich was aboard the last chopper out of Saigon and won the Pulitzer Prize in 1977 for his photographs of street violence in Bangkok.

There’s yet another research study out that confirms what Charlotte Porter told us recently: Reporters and photojournalists covering combat are nearly as prone to PTSD as soldiers. (For background, see my blog of Sept. 9.)

“We hope that this study will encourage news organizations in Kenya and other African countries that send journalists into harm’s way to look out for their psychological health and offer confidential counseling as a matter of course,” the study’s main author, Anthony Feinstein, was quoted as saying.

The study, just published in JRSM Open, sampled 57 Kenyan journalists. It noted that “intimidation, assault, mock execution and witnessing death and destruction are just some of the occupational hazards that come with the job.”

“These hazards can explain why the lifetime prevalence for post-traumatic stress disorder in journalists who have worked for over a decade in zones of combat approaches that seen in combat veterans and exceeds fivefold the rates in the general population,” it said.

Researchers looked at journalists who had covered two traumatic events: first, the election violence of 2007 that pitted ethnic groups against each other and left more than 1,000 Kenyans dead, and second, the 2013 attack in the Westgate Mall by insurgents that left 67 Kenyans dead.

“The post-election violence was experienced firsthand as neighbor turned upon neighbor, communities were destroyed and the media in some cases became the focus of mob rage,” it said. “Here, the risks of covering the violence were life-threatening.”

Eleven journalists were wounded or injured on the job, it said.

“Being wounded emerged as the most robust independent predictor of emotional distress,” said the study. “Journalists covering the election violence reported significantly more PTSD-type intrusion and arousal.”

Thirteen journalists received counseling, although those wounded were not any more likely to receive counseling than other colleagues, it added.

“Good journalism, a pillar of civil society, depends on healthy journalists,” said the study. “”It is hoped that these data act as a catalyst encouraging news organizations encouraging news organizations sending journalists into harm’s way to look out for their psychological health in doing so.”

Santiago Lyon, director of photography and director of Asian news coverage for The Associated Press, said The AP has had a policy of helping its employees process their traumatic professional experiences for more than a decade.

“We assess everybody on a case-by-case basis, and when we find individuals who need assistance in processing their professional experiences, we have an informal network of mental health professionals around the world that we can tap into,” he told me. “Our job is to put them in touch with mental health officials who have a specialized knowledge of the issues that they are dealing with.”

Lyon noted that the “macho culture” of journalism had begun changing 10 or 15 years ago and that journalistic organizations like The AP have been more focused on how best to help their professionals cope with the emotional stresses of their jobs. AP is the world’s largest news-gathering cooperative, employing about 2,000 journalists and 300 photojournalists.

To show how widespread that realization has become, the National Center for PTSD now has a special section on journalists and PTSD.

“Although most journalists do not report chronic distress associated with their jobs, several recent studies have documented increased rates of psychological stress for journalists, especially those, such as war correspondents, whose assignments involve life threat and witnessing death, dying and human suffering,” said the National Center for PTSD. “These studies highlight that journalism can be a profession bearing some risk of physical harm and long-term emotional distress and that the greater the level of exposure, the greater risk of distress.

“Yet the literature also indicates that few employers of photojournalists recognize the stress and negative impact on mental health that is associated with some assignments,” it concluded. “Even fewer employers offer counseling services and education about PTSD symptoms.”

BETHEL, CONN. – Kewon Potts was beaming broadly as he flung open the door to his “fitting room” and stepped out in a new suit that perfectly fit his broad torso.

“OOOOHs” and “AAAAHs” greeted the Navy vet, who hopes to get back into the job market after some tough years since leaving the military. “Looking sharp, man!” someone called.

The “fitting room” from which Potts stepped forth was actually an office of Save-a-Suit, a nonprofit foundation in Connecticut that was giving free suits, dress shirts and ties to more than 25 vets that morning.

It’s the brainchild of Scott Sokolowski, talent acquisition manager for The Barnum Group, a division of MetLife. “I want these people to walk into their job interviews with confidence and dressed for success because I know the importance of first impressions and that the first 30 seconds are critical,” he explained later.

Potts needed that confidence. Since he never had a father figure in his life, “I relied on the military to teach me how to be a man. It was tough,” he said.

After four years of active duty, he left with a full-blown case of post-traumatic stress disorder. For the next two decades, he struggled with alcohol and drug addiction, he said.

“I suppressed a lot of issues, and they caused a lot of trouble for me when they surfaced,” said Potts. “I’d like to become a drug and alcohol counselor now because I hope I could help others alleviate some of the pain I went through.”

Since Sokolowski founded the nonprofit in 2009, it has given suits, shirts and ties to more than 2,200 vets, said Jessica F. Ewud, executive director of Save-a-Suit. Some are purchased with cash donations, while others had been gently used before being donated.

“We hand-sort through all our donations to make sure everything is in mint condition before we give it to our vets,” she said.

Another vet receiving a suit that morning was Diana L. Brasselle, an Army vet who says she also developed PTSD after experiencing trauma on active duty. Nightmares and flashbacks have been all too common, she said.

“It became harder and harder to be around people and harder and harder to work,” said Brasselle, who has been a physical therapist in the Yale-New Haven Hospital. Now she wants to look professional when she begins orientation as a substitute teacher next week.

“My No. 1 goal is to remain living independently in the community,” she added.

Save-a-Suit hosts up to five give-aways a year for vets who ask for help. You can learn more about the program at http://saveasuit.org/. But that help isn’t limited to those who walked through its doors that crisp September morning.

“One man had been living in vet housing in Milford (Conn.) for three years with his daughter,” remembered Ewud. “He called in a panic one night to tell us he had a job interview the next morning, and he needed appropriate clothing to wear. We got his clothing sizes and drove a suit, a shirt and a tie to his home that night.

“He called later to thank us and to tell us that he gotten the job as an administrator, I think,” she added.

But that’s not all. For a $50 donation, Save-a-Suit will ship a suit, dress shirt and tie (which average about $400 in value) to vets in other states. You can learn more about that program at http://saveasuit.org/ship-a-suit/ .

“We’ve shipped suits to 36 states since the foundation was founded,” said Sokolowski, an Air Force vet from a military family. “Last week, we shipped a suit to a vet in Alaska, so that makes 37.”

Save-a-Suit was founded after Sokolowski asked a job interviewee why he wasn’t dressed appropriately, and the college graduate answered he couldn’t afford one. Vets quickly became the focus, however, and now the foundation gives more than 90 percent of its suits to veterans who need to get jobs.

“This day is a blessing for me, a super-duper blessing,” said Potts. “This suit they gave me will help me build the confidence to get back into the job market. This is just a blessing from God.”

PTSD isn’t just about combat vets. It affects many of us for many different reasons. Let me share with you this column written by a friend of mine, Charlotte Porter, to commemorate the 10^th anniversary of Hurricane Katrina. At the time, Porter was chief of bureau in New Orleans for a major national news organization.

I know the anniversary (of Hurricane Katrina) is over, but I wanted to share this. There are a lot of people out there who may think they should “get on with it” after a natural disaster. It’s not so simple.

Here’s my story:

I lied.

When anyone asked how I survived Katrina, I replied that nothing happened to me. My house didn’t flood; no one I loved was hurt or killed. I wasn’t even in town when the streets filled up with toxins and bodies. I got out soon afterward for a new job far away. I was lucky.

Now, 10 years later, I can say Hurricane Katrina is the worst thing that ever happened to me. Under the weight of depression and what I later came to realize was post-traumatic stress disorder, something in me broke. After struggling with guilt, shame and withdrawal, I’ve started to understand I’ll never be quite the same.

It’s taken centuries for people to come to grips with the fact that soldiers are often victims of “shell-shock,” or PTSD, and it still carries the sting of stigma. PTSD can happen to people who have survived tornadoes, or childhood abuse, or being mugged. And the journalists who bear witness suffer as well.

By August 2005, I had lived in New Orleans for 11 years and was no stranger to tropical storms. As we had before, I and many of my co-workers at a major news agency moved our essential operations out of harm’s way, leaving a small group behind to gather on-the-ground detail.

When Katrina’s storm surge drowned much of New Orleans, I was watching it on TV miles away, my heart cracking, wondering if the city I loved was gone forever. It was days before I knew if my home had survived. It was weeks before I could go see for myself.

Friends and colleagues who evacuated, as I did, sometimes spent days trying to find places to stay, locate open stores and gas stations, get calls through to loved ones, make sure elderly relatives had shelter and power. Those who stayed in the city saw bodies floating in the streets, children screaming for lost families, houses stinking of things decomposing inside, people — so many people — without help, with no sign that help was even coming.

Some of these colleagues broke, hard. They found comfort in drugs and alcohol. One, in despair, tried to get police to shoot him. One had an elderly relative who killed himself when he returned to town and saw the ruins of his life.

I was lucky. Nothing happened to me.

It was years before I told even those dearest to me that Katrina had been a soul-shattering experience. And it was more years before I admitted my own soul was still damaged.

What right did I have to feel sorrow? What right did I have to pull away, cocoon in my new apartment, keep contact with people to a minimum? I didn’t suffer the way that my beautiful old city did, I didn’t have to beg housing from indifferent bureaucrats or distant cousins far from home, I didn’t have to rebuild, search for missing relatives, identify loved ones in the morgue. I hadn’t patrolled the streets in a rowboat, looking for people stuck on rooftops and finding corpses. I hadn’t sweltered for days in the sun on an interstate overpass, the only high ground for miles. I hadn’t fought for space or food or a working toilet in the Superdome or the Convention Center. All I had done was worry, fight down fear, try not to cry and pretend I was holding together. I had a good job and friends and family who loved me. What was my problem?

I grieved for New Orleans, the place I adored and had hoped to spend the rest of my life in. I grieved at my weakness in coping. I grieved for the hardships my friends went through. I grieved because, a few months after the storm, I left them behind.

It’s funny how grief works. There’s no “deserve” or “not deserve.” You grieve, or you don’t. But if you feel you don’t deserve to, shame piles on. And then, for some of us, comes withdrawal.

I finally stuck my head up after about five years and realized how small and cold my life had gotten. I began making amends to friends I had long neglected, began trying to re-engage with life, find something besides pain to fill my days. It’s a work in progress. Some days are easier than others, and there are still some apologies to be made.

There’s a Japanese aesthetic called wabi-sabi that celebrates the imperfect in design, finding beauty in flaws. Another involves mending beloved objects with gold or silver, making beautiful the damage that occurs over the years.

I’d rather not have been damaged. These past 10 years would have been so much happier. But as the great poet Leonard Cohen sings, “There’s a crack in everything. That’s how the light gets in.”

Charlotte Porter’s intensely personal account of the emotional damage inflicted on her by Hurricane Katrina is an object lesson for all of us. We’re accustomed to link PTSD to combat, but it runs much deeper than that.

I talked with a soldier a few years ago who couldn’t understand why he had PTSD because he’d never been in combat himself; when I asked him what he did in the army, he told me he was a mortuary specialist, stuffing pieces of dead soldiers in body bags. So soldiers can experience trauma second-hand. We also know cops and deputies can suffer from PTSD. Drone operators who kill people a continent away can suffer a similar trauma. And their families can also suffer from second-hand PTSD.

But now Charlotte reminds us that journalists who feel powerless in the face of disaster are equally at risk. That’s something all news organizations should address, if they already haven’t. Reuters has a counseling program in place for its war correspondents, according to an editor with whom I spoke a few years ago while we were judging Pulitzer Prizes together at Columbia University.

Grief, guilt and shame are all part of the mix. A lot of soldiers suffer from what I call the “wounded soul syndrome,” caused when actions that they took (or didn’t take) violate the moral code they were raised with.  There’s a huge emotional wound caused by killing others, or failing to prevent a buddy from being killed.

That’s true for journalists, as well. In addition to being impartial observers, we’re also human. And it’s not easy to walk away from people who are suffering. We know that experiencing a disaster like Katrina can be life changing, but we also know that the trauma is cumulative — it builds up over the years.

Charlotte’s account of the progression of that disorder is fairly typical. Grief, guilt and shame create depression. Depressed people hide out and lick their wounds. Isolation is common because you don’t want people to know about you what you know about yourself.

One of the things I’ve learned from the vets is that atonement is a huge part of healing. A lot of vets feel better about themselves when they reach out to help others.

Recognizing the problem and dealing with it are critical, and I applaud Charlotte for reaching out to those she’d been hiding from. I also applaud her for her honesty and courage in writing about it.  But then, as her friends know, that’s just who she is.

OVAPA, WV — “Agriculture saved my life!” exclaims Eric Grandon, a retired staff sergeant who struggles with Gulf War Syndrome and post-traumatic stress disorder.

Three years ago, Grandon bought his father’s farm for a buck and put in his first crop of sorghum to make molasses. It failed miserably.

But the next year, with some mentoring by James McCormick, director of the state’s Veterans to Agriculture program, the sorghum crop came in nicely. So Grandon and his wife Mary named their farm the Sugar Bottom Farm.

Only about four of the 93 acres have been cultivated, but the production is amazing. Two acres of sorghum stood about seven feet tall last week, although a vicious storm blew down about three quarters of it the evening after my visit, costing the Grandons between $5,000 and $7,000.

In the garden, Grandon has added about 500 lunchbox pepper plants and another 250 grape tomato plants, so that he can sell fresh produce to the Clay County schools to supplement student lunches.

“We were very successful because everyone loved our home-grown vegetables,” he said. “We couldn’t grow enough to meet the demand.”

Next to the garden is a humming beehive. Bees pollenate his cane, but also provide honey. Grandon has 10 more beehives sitting in his garage awaiting delivery of new bee colonies, which will be a major focus early next summer.

Fifteen hens were busily laying eggs in their henhouse during my visit, and the Grandons are incubating a new batch of chicks in an upstairs bathroom. As we sat talking in their living room, Mary heard a flurry of excited peeps and ran upstairs to prevent a mass breakout by the chicks.

Raspberries, blueberries, watermelons and strawberries take up a portion of their hillside, and Grandon plans to expand that dramatically next summer. He’s also planning to turn a big portion of their yard into an orchard.

“Peaches, pears and apples,” murmured Mary happily.

Mary has her own greenhouse, in which she starts all her vegetables from seed. And the Natural Resources Conservation Service has just provided the Grandons with a big seasonal tunnel. Essentially it’s a huge plastic greenhouse, 30 feet wide by 72 feet long. Best of all, it was free.

“That will extend my growing season from February until December,” said Grandon.

Currently, Grandon farms for five days, then spends a day each selling his produce at two area farmers’ markets. But by extending his growing season, he can take better advantage of area farm-to-school programs, which provide a more predictable income.

“The goal is to set up Sugar Bottom Farm as a satellite farm for training vets in agriculture,” Grandon said.

Frankly, what the Grandons have accomplished in just two years is nothing short of amazing.

“Agri-therapy has been hugely helpful for Eric,” said his wife, adding that he needed it badly.

During a 20-year career in the Army, Grandon served six tours of duty in the Middle East. “But the strange behavior problems started right after (the terrorist attacks on) 9-11,” Mary said. He told me that he would end up going back, and that started a downhill spiral. He just sat on the couch and waited for the call, and it came in 2003. In 2005 when he came back, I told him it was time to seek some help.”

Grandon’s last deployment was back to Iraq again, but he was severely depressed and kept leading his unit into unnecessary firefights. Finally, he was reassigned to work with the CIA interrogating suspected members of the Republican Guard, the elite military forces reporting directly to Saddam Hussein, at prisoner-of-war camps similar to Abu Grhaib.

He has never talked about what he did during those interrogations, he said, because a two-star general threatened him with severe reprisals if he ever said anything.

“So when I cracked, I cracked wide open,” he said.

Focus was a major problem. “I was just spinning around and getting nowhere,” said Grandon, adding that their young daughter had to stay with her grandparents when her mother wasn’t around to take care of her. He also lost several cars, and his wife wouldn’t let him go anywhere alone.

Then in 2011, he had some surgery done, and a botched catheterization created excruciating pain. That triggered a three-week flashback in which he tried to write on hospital room walls, convinced he was recording mission assignments on a mission board in a military headquarters.

Ultimately, he says he was rated at 160 percent disabled – 60 percent for Gulf War Syndrome and 100 percent for PTSD.

“James (McCormick) introduced me to farming,” said Grandon. “We talked for four straight hours the first time we talked because we had a lot in common: We were both dealing with PTSD. He saw I needed something because I was just spinning around and going nowhere. James put me on task. It brought me into focus for the first time in years.”

Mary said she saw the change after he came back from a veterans’ conference on small farms in Arkansas. “He came back with a spark,” she said. “He said ‘This is what I want to do,’ and I said ‘Go for it.’ For Eric, it was a way to structure himself, and it was also a way to give something back.”

Counseling taught him some lessons. “The first step to recovery – and the most important one – is to forgive yourself for everything you did,” said Grandon.

But farming took that to a whole new level. “When you’ve got all that guilt and anger, three weeks on a rototiller will take a big chunk of that away,” he chuckled.

And he continues to be active in the West Virginia Vets to Agriculture program because it gives him a chance to help other vets. “We’re all about teaching someone who has no farming skills to become a successful farmer,” said Grandon. “Because as I’ve demonstrated, agriculture is tremendously therapeutic.”