Let us strive on to finish the work we are in, to bind up the Nation’s wounds, to care for him who shall have borne the battle and for his widow and for his orphan.
Second Inaugural Address,
Saturday, March 4, 1865
Nearly a century and a half after he said them, Lincoln’s words call us once more. But the nature of combat has changed. The line between combatants and civilians is blurred. The range of weapons exceeds what the eye can see. Even heavy, high-speed vehicles are little protection against improvised explosive devices (IEDs) and rocket-propelled grenades (RPGs) aimed at their most vulnerable spots. IEDs, cheap and easily triggered by a cell phone, have enough power to leave vehicle-size craters in the ground while mixing infectious contaminants into the cauldron of injury.
Unlike the huge numbers lost in the warfare of the last century when, beginning in World War I, millions of young men simply never came back to their homes, these days many more U.S. combatants return from war. More and more of those with terrible wounds—lost limbs, traumatic brain injuries, guilt that cannot be shed, a lost sense of distinguishing right from wrong—now survive. The press keeps track of fatalities; however, swifter responses of more skilled medical care mean that those with life-altering injuries far outnumber those who die. Whereas some 40 percent of those wounded in World War II died and some 30 percent died in Vietnam, in Iraq the fatalities have been reduced to 10 percent.
We are desperately learning how to bind up wounds. Our capacity for averting death far exceeds our ability to restore to health.
A woman who might once have been a mourning widow—but ultimately available for another fulfilling relationship—may find herself now at a military hospital in a strange, distant, expensive city waiting to welcome home a mutilated stranger. She is starting an unanticipated career as an unpaid, overworked, distraught, lifelong caregiver in a life that now is in a shambles. Her likely preparation: little education, a baby on the way, and all the wisdom of 20 years.
Children are orphaned, but far more often they have a father they do not recognize. These discoveries don’t always come at homecoming. Often they may be delayed for months, disrupting with unexplained behavior what everyone had expected would be a prolonged but calm adjustment. Awareness is slowly sinking in, prompted by the invisible wounds of acute combat stress that still abide 40 years after the Vietnam War. And combat still vomits forth more wounded in Iraq and Afghanistan. Combat has changed; the trauma has not.
Time—that we once thought heals all wounds—doesn’t.
The senior medevac dispatcher at San Diego’s Naval Medical Center, where the combat wounded arrive from Iraq and Afghanistan, says: You don’t get back the one you sent. The family members of survivors add: You don’t know how to live with him when he gets here.
And they’re coming. They’re on the way. Many are here. An estimated 20 percent of the 1.7 million men and women who have rotated through Iraq and Afghanistan are back already—or coming back to a land that may no longer know them. We are talking about a third of a million individuals coming back to settle down among us. That’s only so far; more are on the way. Are we going to say that receiving them is someone else’s job?
PTSD (post traumatic stress disorder), made familiar to us by its frequent appearance in the press, is the latest term for what was called soldier’s heart 150 years ago, shell shock 100 years ago, and battle fatigue 40 years ago. But PTSD is a stigmatizing term soldiers and Marines absolutely hate, reject, and deny. Why? It is laden with the term "disorder," implying a permanent maladjustment that is incurable and permanently debilitating.
Even worse, the term is capable of implying an innate condition completely unrelated to combat. The preferable term to replace it is combat stress injury. Our knowledge of stress has changed sharply and "injury" retains the promise of some recovery. If you can’t do anything else, at least refuse to use the term PTSD and say, instead, combat stress injury.
It is almost impossible to overstate the complex emotional toll of combat for those who have not experienced it. Here is what I have learned from two years of close association with returning wounded patients and their families:
The combat veteran who comes home cannot look at daily life in the same way he once did. He has looked death in the eye and the stare abides, it still haunts.
You’re back. You came by medevac helicopter from a combat zone. Then you stopped at a world-class hospital in Landstuhl, Germany, until you were stabilized for the journey. Following that came a long trip by air transport to one of three receiving hospitals in the U.S., likely in a strange city far from home. Perhaps the IED, which lifted your Humvee off the ground and threw you out, killed those on either side of you. Maybe the person you respected most in your unit was mortally wounded and, despite excellent care on the way, died in your arms. You were spared. Others more experienced or even more useful to your unit than you died. You didn’t.
Or you may have fired at the shadowy figure in the direction of the shots aimed at killing you—only to find later that the target you hit was a ten-year-old girl scurrying for cover.
You are still alive yourself only because you were extremely watchful. All the time. On patrol, and off. There was no nuance about the life-or-death interval that you have survived. Nothing was "a little dangerous" or "maybe okay." Everything was either black or white, friend or foe. Staying alive depended on this. Without hypervigilance—constant, highly intensive observation—you were lost. That vigilance kept you alive. You don’t want to let go of it. You can’t.
The simplest hint of danger overlooked could mean death. You might endure a mutilating injury: a jaw shot off, a knee shattered; you were left-handed, but that arm and hand are gone, or even worse, useless; or an eye lost forever along with the depth perception so essential for vigorous physical activity. Disfigurement—for a 20-year-old perhaps more feared than death—could await you if you relaxed.
This adrenaline-fed state, once started, does not shut down easily. Empathy has been switched off. The emotions by which you identify with others—their needs, their helplessness, their vulnerability—have been freeze-dried and set aside. Yet the adrenaline that feeds this elation and keeps it alive is still as present as the air you breathe. You no longer have control of this energizing voltage galvanizing your system.
Daily life at home, meanwhile, now seems as bland as oatmeal seven days straight compared to your favorite breakfast. The past peak experience of adrenaline pumping in a life-or-death situation simply cannot be matched.
And here’s the catch: this sense of aliveness and power from the past has no connection with now, back home, the present moment.
These contrasts don’t become clear immediately, but often become so only after a prolonged time of reflection. This could take years. Meanwhile the state of hyper-vigilance persists, as does an outrageously vivid sense of justice.
These youngsters—19, 20, 21—have touched the "third rail" of life, surviving the voltage and current usually fatal for us. That core experience from the past is still immediate—and here right now. Compared to it, daily life pales, doesn’t engage. Daily life’s lack of "juice" craves additions you have to provide.
Back then, there was no time for grief, for apology, for forgiveness. Not only was it not possible, it could have been fatal to try to take time for it. There may appear to be time now to "catch up," but the deeply instilled habits crucial for survival still leave no room for anything else.
Most of those who have known acute combat stress will never admit it, never ask for help. Instead, a combat veteran may come to you through another person—a loved one, the relative of a colleague, a family member of a casual acquaintance. The first healing step is with that contact person; the messenger needs and deserves help.
Further, it’s virtually impossible to overstate the strength of bonds formed among comrades facing combat together. We all know that peak experiences, when shared, last a long time. You have trusted your life to another. Risking your life for a comrade and his doing so for you forges ties that are often stronger than those with family. It’s not unusual for a wounded veteran, just returned to the family he loves, to decide abruptly to leave for a time to go see and help a buddy with whom he faced death and who now calls for help.
Recognition of these invisible wounds has helped provoke a rethinking of the meaning of stress itself. It is now assessed on a continuum of severity of stimulus, recognizing that everyone faces stress, and measurement by degrees opens the way not only to recovery but to the hope that makes it possible.
Stress injuries are literal injuries that involve a loss of centeredness and a loss of function. Repeated samples, tests, and reports show that 20 percent of those deployed will show its effect. Stress injuries do provoke a protective healing response, but the injuries cannot be undone. They include moral injuries composed of remorse, guilt, shame, disorientation, and alienation from the remainder of the moral community.
It is important not to confuse combat stress injury with traumatic brain injury (TBI)—commonly known as concussion: the injury resulting from a powerful blow to the skull that moves and shocks the brain enclosed. Their symptoms often partially overlap. Combat stress injury symptoms of acute combat stress, however, are distinguished from TBI (although both might have occurred) by avoidance, emotional numbing, and hyper-emotional-arousal symptoms.
What are the injuries caused by combat stress? It shatters assumptions and beliefs about safety, fairness, and identity. It endangers one’s sense of control. Life is over or can’t last much longer. The future isn’t years, it’s days or hours— even less. We and our world become strangers for those with acute combat stress as the trauma threatens the very essentials that make up the self.
Acute combat stress makes a victim vulnerable to the events of daily life that can trigger recall of the trauma. A taste, a fragrance, the first few notes of a popular song can quickly transport any of us back to a previous time. In this manner, a shape, a configuration, a smell, a sound can send the combat stress victim back to the warfare setting he thought he’d left behind.
Further, the healing capacities of the body stimulate the repeated recalls and reliving of the event as an atavistic attempt to "fix" or "repair" something from the past, something that remains broken.
Injury may take the form of guilt, which could have many sources: responsibility for accidental U.S. or civilian casualties, driving on without stopping after a pedestrian stepped in front of a military vehicle, ignoring and leaving behind—as a mission required—an accidentally wounded civilian, violation of a personal pact or agreement to cover the back of another, being the sole survivor of an explosion that killed your superiors and your friends.
The experience that emerges from those who share with each other their tales of combat is that healing may require not weeks or months, but years. In this complex and persistent mix, fear and anxiety can combine with anger, rage, guilt, shame, sadness, and loss resulting in a deep sense of betrayal, shattering of beliefs, extreme disconnectedness, and acute moral injury. Character that we may have thought well established faces threats to assumptions about right and wrong, decision-making, and acting out. The very sense of connectedness to anyone other than one’s unit is under assault.
The injuries don’t go away. Forty years after the Vietnam War, a third of those who knew combat still have combat stress injury. The Veterans Administration reports that the average interval between exposure and seeking treatment is ten years. (That’s not a misprint: ten years.)
A summary of the American Psychiatric Association’s Diagnostic Symptomatic Manual’s (DSM-IV) criteria for PTSD (which we’re all trying, instead, to call combat stress injury) reveals these essential features:
- Exposureto an event or threatened death or serious injury with a response of intense fear, helplessness, or horror
- Persistent re-experiencing of the event, avoidance of stimuli associated with the trauma, and a numbingof general responsiveness
- Continuing symptoms of increased emotional arousal not present before the trauma
In a military culture compounded of honor, courage, and duty, the stigma associated with admission of such symptoms or seeking treatment for them has overwhelming power. The label PTSD, especially the D for disorder and its implication of permanent weakness, occasions widespread fear among wounded soldiers and Marines—that they will never gain the useful civilian employment they will seek after discharge if PTSD ever appears in their personnel records. The armed services work hard to remove this stigma, but it remains alive and vital in the grapevines that so often guide decisions.
Toward Recovery: Our Role
There are not enough professionals to respond to the number of patients. The rest of us will find ourselves in positions of potential response. The strongest element we can provide outside military circles to aid recovery is social support. That is the case if we can be nonjudgmental—if we’re willing to listen, perhaps we can establish a trusting and caring rapport that makes it safe for a combat veteran to talk. Nevertheless, we will not be comfortable with what we hear. We may wish we had never offered to listen. We will be sorely tempted to make the session far shorter than what the speaker craves. But there is a connectedness that arises from nonjudgmental intimacy. Putting words to stress can make it more manageable, making it possible for us to learn to manage it.
Indeed, if we can recognize the spiritual presence of witnesses in our own lives, we can work to summon this forth in others as a healing presence. We know there are persons and historical figures whose guidance and affirmation have made us who we are. These 20-something valiant young bundles of courage may not have had occasion to review the enormous power of those others who have shaped them.
For years we have built habits about feeling helpless and hopeless in regard to this war. Such habits are terribly hard to change. If you feel helpless to care for those who have "borne the battle," remember that helpless is precisely the hole you have to climb out of to start.
Helplessness has three great allies. One is sloth, right out of the lineup of the seven deadly sins. Its motto: tomorrow trumps today. The next is communalization. Just about everyone we know feels just as helpless as we do. The herd instinct abides. Number three is that pervasive conviction framed as the question, what difference can one person make?
Here are three obstacles I have found that we have to avoid. First, we have to stop thinking about ourselves. Second, we have to stop thinking about what we cannot do. Third, we have to hold at bay the fear we naturally feel about stepping into the unknown.
Stop doing these and you will be disoriented, weak, and afraid, but— believe it or not—you will be there, ready to begin. This is a great starting point from which you are less inclined to judge or blame. Reach deeply into what feeds your compassion and use the five Cs of COSFA, the acronym for military-approved Combat Operational Stress First Aid, as your road map. Provide cover—make sure the veteran feels safe with you. Encourage calm—reduce anxiety or high arousal, or numbing emotions. Enlarge capacity—for belief in one’s own capabilities and regulating one’s own thoughts, emotions, and behavior. Kindle confidence—by showing and stimulating positive expectancies about life and oneself. And strengthen connectedness—by trying to establish relationships that strengthen problem-solving and help reduce guilt and shame. Just remember that you may have to listen longer than you want to, and you will probably be offended by what you hear.
These five Cs further form the basis of a language that can be mutually helpful among military, medical, and civilian caregivers who struggle to find common ground to talk with each other.
What Not to Do
As for language, here are some things not to say: Talking about "support of our troops"; "Did you kill anybody?"; "Time to move on"; "Let’s try to get back to normal" (Life is forever changed, forget any return to "normal"); "I don’t think we have time to keep going on this, let’s take it up another time"; "Win some, lose some"; "I know what you mean"; "How could you possibly have done something like that?"; "Everything’s going to be okay"; "How many times do I have to tell you? You shouldn’t have gone."
All of us add meaning to our lives by organizing our experiences into narratives. We all need to do this about our life trajectories. Those injured by combat stress injury weave narratives that often reveal a loss of faith. Over half of interviewed combat veterans returning from Iraq and Afghanistan report this loss. Over half feel God is punishing them for sins or lack of spirituality. Half wonder if God has abandoned them. Lack of forgiveness is overwhelming. Research shows that over three-fourths have not forgiven themselves or others. Rage and anger from combat stress injury is often directed not at others, but at God.
David W. Foy, the respected director of a 60-day residential PTSD treatment program, reports that major spiritual issues needing to be handled include these:
Suffering: Why does God allow the innocent to suffer?
Forgiveness: How can we forgive, that is, manage to give up the right to resentment when we or others have been harmed?
Meaning: What can I do to strengthen perception and interpretation to shape my story and make meaning of my life?
The combat isn’t over. The numbers injured are greater than we know. Those returning are going to be closer to us than we realize, through friends, associates, even family. The injuries are deep, sinister, and lasting. The wounds fester, bleed, and infect. They’re invisible but have drastic power. If you are called to "strive on to finish the work we are in," remember that it’s our war, not their war. Those who have gone into battle have done so to faithfully carry out orders from officials we have put in office and kept there. Whatever your rage about the waste and carnage of this war, those who have borne the battle don’t deserve the blame for what they did in the service of their country—our country.
Finishing the work we are in will probably take at least the next two generations. Nothing you or I do will achieve anything quickly. Reminders of the decision to undertake this war and the triumphs of advanced medical practice will be among us for the next 50 years.
My fear is that we are pitifully unprepared to face the existence for a couple of generations of many walking monuments to the folly of this war among us, so that the war and its consequences will retreat to the background of our collective consciousness. I fear that the presence of apparently able-bodied men and women unable to perform basic hygiene, schedule-keeping, memory-recording, and chore obligation tasks at work or at home will make them the target of resentment, disdain, and blame.
The unpalatable truth that I didn’t dare write about in my earlier essay ("Unpalatable Truths," FJ Sept. 2007) was facing the admission that in the middle of the night, after a dreadfully tiring day of providing care and with no prospects of any kind of improvement by the impaired patient who "survived" the war, the question arises about one’s dearest loved one: Wouldn’t it have been better that he had died than that he came home as crippled, helpless, and unrecognizable as he is? Rage is going to be tapped as this question gathers strength.
We can say "What a shame!" We can shake our heads in despair. We can try to close our eyes and ignore the several hundred thousand who will affect the lives of all those around them. Or we can let these circumstances ask us with the prodding and provocative power prompted by Quaker-inspired queries:
- How can we seize opportunities to offer to provide time, attention, and support to strengthen the quiet caregivers who provide heroic care for their injured loved ones?
- How can we gain the courage to urge family and friends to be aware of the signs of combat stress among those we encounter among veterans, or caregivers at work, or while traveling, or hear about in a beauty parlor, bar, or coffee shop?
- What can we do to be more vigilant and alert to ways we can become part of the resources that will help us bind up the wounds?
- How can we help one another to free ourselves from thoughts about only ourselves, about what we cannotdo, about our fear of stepping into the unknown, that shackle any urging to offer help to the invisibly wounded?
- What will help us trade head-shaking for hand-shaking, and helplessness for helpfulness?
- How can we respond to George Fox’s epitaph, Let your Lives Speak, when faced with, "What can only one person do?"
- What prevents us from seeing that binding up these invisible wounds is not simply a task for professionals but is indeed the work we all are in?
Nearly a century and a half later, Lincoln’s words call to us once more.