Cry havoc, and let slip the dogs of war.
—William Shakespeare, Julius Caesar
Darren Doss had just come back from a morning patrol on the outskirts of Marjah, Afghanistan, when his best friend, Kruger, got shot. It was a blazing-hot day, June 1, 2010, and Americans and Taliban fighters were locked in a desperate fight along Marjah’s narrow, shadowed streets and back alleys and across its outlying poppy fields and irrigation canals. The White House and the Pentagon had vowed to wrest Marjah from Taliban control and create a prosperous, safe, democratically run city as a model for the new Afghanistan. Doss and Marine Corporal Zachary Kruger and the marines of One-Six, along with thousands of other American troops, had been struggling since January to make this happen. The Taliban were dug in and determined to stay. The fighting was continuous and deadly.
Darren Doss is a slender man with dense black hair, a prominent nose, and soulful brown eyes that often reflect unvoiced pain and sorrow. Like the combat marines I know, Doss is outwardly tough; he’s endured extremes of discomfort, deprivation, and grueling physical and emotional stress that most of us will never know. During his two combat tours as an infantryman in Afghanistan he was an aggressive fighter, not one to hang back. And yet Doss seems the most sensitive among the marines of One-Six, more vulnerable to emotional bruising. To this group of men hardened by the violence of war, it felt as if Doss was the youngest, everyone’s little brother. In Marjah, he was about to turn twenty-two.
That morning, Doss was the last man in a line of marines heading back to their outpost after a routine patrol. Climbing a low wall, he heard AK-47 rounds impacting around him and realized that someone was trying to shoot him in the back. He scrambled quickly over the wall, cursing loudly, and made it back okay, but he barely had time to catch his breath before guys came running, yelling “Marine down! Marine down!” and grabbing their body armor and helmets and weapons. Doss raced out with them, and as they sprinted across an open field he could hear on another marine’s radio that there was a firefight under way, it was bad, and the casualty was Kruger.
“I was tight with Kruger,” Doss said. “My heart just sank.” With reason: death was a constant in their lives. Two marines had been killed within days of their arrival in January. Others followed, including Corporal Jonathan Porto, who drowned when his armored vehicle tipped over into an irrigation canal and he was trapped inside. That May, the marines of One-Six had been shaken by the death of a popular leader, First Lieutenant Brandon Barrett, who was shot by a sniper. In the following three weeks, Joshua DesForges, Nicolas Parada-Rodriguez, and Philip Clark were killed. On Monday, May 31, Anthony Dilisio was killed. Now, on Tuesday, Kruger was down.
The marines leaped into the gully where Kruger’s squad was hunkered down in a firefight so intense that the barrel of one marine’s SAW was glowing red. Doss fell to his knees beside Kruger, who had been shot in the thigh and was bleeding heavily. They got a tourniquet on; a medevac helicopter had been called. Doss grabbed Kruger’s hand and squeezed, making jokes, trying to keep Kruger conscious. An army chopper landed a distance away, and a crewman came sprinting through gunfire across an open field and flung himself down. He hadn’t brought a stretcher. As the marines returned fire to cover him, the medic ran back to the chopper and returned with a stretcher. Doss and another marine grabbed Kruger’s arms and dragged him up and out of the gully and got him on the stretcher. Then they ran. The field they had to cross had recently been plowed, leaving foot-high ridges, making it difficult to run without turning an ankle. The larger danger was the Taliban gunfire raking the field. All hell was breaking loose, Doss thought. He could hear rounds impacting the dirt. By chance a New York Times photographer was riding on the chopper; one of his images shows Doss, his right hand gripping the stretcher handle, helping to shove Kruger into the chopper. Doss waited as it lifted off in a blizzard of pebbles and grit and tilted away. Then he ran back through sporadic gunfire. Within a few minutes the firefight died away, leaving an enormous emptiness, and the marines trudged home. Kruger survived. The army medic received a medal for bravery. No medals were awarded to the marines, who resumed their work without pause.
The shock and grief of seeing his best buddy grievously wounded, in pain, and at risk of dying clearly were an emotional blow to Darren Doss. But in the continuing maelstrom of Marjah, there was no opportunity to quietly absorb what would be a shattering experience for any human being. Here, it became just another emotional injury to a young man already wounded by loss.
“Over there, you don’t really talk about it,” Doss once told me. “You don’t have time to sit there and cry about shit. You got shit to do, go on patrol. You don’t dwell on it.”
Darren Doss told me the story about Kruger over lunch recently at the Blue Ribbon Diner in Schenectady, New York. I had picked him up that morning at the VA medical center in nearby Albany, where Doss was an outpatient in the mental health clinic. He is diagnosed with PTSD, but his moral injuries have cut more broadly and deeper. He carries wounds of the soul that are eating away at him. Five years after Marjah, Doss was able to name six separate prescription drugs he is currently taking for anxiety, depression, pain, and insomnia. All for his experiences at war. At lunch his head drooped, his eyelids sagged, and occasionally he appeared to doze off. When we were done, he stepped outside to smoke a Newport. He stood alone in the parking lot, gazing out into the distance.
The politicians and policy makers and generals who rushed the United States into war in 2001 and again two years later never thought to prepare for the length and intensity of those conflicts and the psychological wounds the troops would bring home. Thousands of military professionals and intelligence analysts work briskly in offices along the Pentagon’s seventeen miles of fluorescent-lit corridors, but when the United States went to war in Afghanistan in the autumn of 2001, few of them foresaw that cleaning out the ragtag bands of Taliban would last much beyond the spring of 2002. Attention had quickly turned to Iraq, which the Pentagon and the White House gave assurances would be a short campaign. After all, the most recent war in the experience of many officers, Operation Desert Storm in 1991, took only three weeks of air strikes and a four-day ground war to achieve victory over Iraq’s military, and psychological injuries seemed to be minimal. By the time American troops poured over the border into Iraq in March 2003, the invincibility of the U.S. war machine was a bedrock conviction within military and political circles. On May 1, six weeks after U.S. troops invaded in the spring of 2003, President George W. Bush declared that “major combat operations have ended.” That was something of a surprise to the grunts of the Second Armored Cavalry Regiment with whom I was embedded as they conducted patrols and weapons searches that summer in East Baghdad. The small-scale skirmishes and bombings then breaking out were modest compared with what was coming. But Washington held to its belief that the war in Iraq was winding down. By October, despite the battle losses of 225 Americans dead, the Pentagon was making plans to recall 30,000 troops from Iraq as not needed.
GIs were assumed to be bedrock strong as well. A report prepared for VA clinicians in 2004 acknowledged “insufficient” understanding of the impact of severe war-zone stress. But judging from how quickly people seemed to recover from car crashes, the report said, “it is safe to assume that although acute stress reactions are very common after exposure to severe trauma in war, the majority of soldiers who initially display distress will naturally adapt and recover normal functioning during the coming months.”
There had been early signs that Afghanistan and Iraq would be different, more challenging for the troops, and at a higher human cost. In July 2003, the army surgeon general, Lieutenant General James B. Peake, sent a team of mental health specialists to Iraq. It was an act of courage and foresight not appreciated within Washington’s ruling circles at the time. But Peake knew combat stress and its effects on troops. As a young enlisted soldier, he’d been selected for West Point, was commissioned an officer, and won a Silver Star for combat valor in Vietnam before becoming a physician. He was aware of the lingering physical and mental health problems that followed the troops’ return from previous wars. When the invasion of Iraq was launched, he told me recently, “we recognized that the quicker we got on this, the quicker we would understand what the realities were of the current war, the better prepared we’d be to deal with it.”
Peake’s team found what he suspected. That December the army’s Mental Health Advisory Team (MHAT) reported that 15 percent of the troops then serving in Iraq, or roughly 20,000 soldiers, screened positive for “traumatic stress.” A larger group was tagged with depression, anxiety, or traumatic stress. But fewer than one in four of them had gotten any help, because they were afraid of the stigma of seeking help or because no help was available. The military’s overriding culture, by necessity, was one of stoic acceptance of pain and discomfort. Not complaining. But the cost was becoming evident: the surgeon general’s report noted the rising suicide rate among troops in Iraq—15.6 suicides per 100,000—was already dramatically higher than the army’s peacetime average rate of 11.6. The numbers might be an aberration, the mental health team concluded, adding somewhat hopefully that the data “did not signify an escalating rate of suicide.” But the flood of military mental health injuries was under way. In 2005, the VA began frantically hiring some seventy-five hundred additional mental health professionals to care for the rising tide of returning troops in need of psychological care. It wouldn’t be enough.
By 2006, the year Stephen Canty was itching to join the marines, fighting in Iraq had increased in intensity and savagery. Eight hundred twenty-three Americans were killed in combat there that year; 6,412 were wounded. Fifteen hundred miles away, the war in Afghanistan was bogging down in its fourth year of bloody slogging; American combat deaths had doubled since 2002. And back home, a majority of Americans for the first time agreed that the war in Iraq was a mistake and that President Bush had no plan to end it. John Murtha, a retired marine and a conservative senior congressman, declared that the war was “flawed policy wrapped in illusion.” Regardless, voters kept returning to office politicians who were determined to press ahead with the wars.
The army surgeon general’s Mental Health Advisory Team returned to Iraq that summer of 2006, where it again conducted surveys and focus groups among soldiers and marines and found significant psychological trauma. Two-thirds of marines then serving in Iraq had seen the severe wounding or death of a buddy. In individual interviews, one soldier told the army researchers he had witnessed “my sergeant’s leg getting blown off.” Another had seen “friends burned to death.” Others reported, “I had to police up my friends off the ground because they got blown up,” “A friend was liquified [sic] in the driver’s position on a tank, and I saw everything,” and “A huge fucking bomb blew my friend’s head off like 50m from me.”
Like Darren Doss, most of the Americans we sent to war seemed capable of toughing their way through even this level of emotional stress, at least temporarily. But the survey team documented high levels of anxiety and depression: 20 percent of soldiers, just over twenty-eight thousand, screened positive for depression or anxiety, and some were diagnosed with PTSD. More significant, the detailed surveys also turned up strong evidence of damaging moral injury: the personal and military moral codes that young Americans took with them to war were being corroded by their experiences in battle. Despite what they’d been taught about honor and dignity, for instance, almost two-thirds of the marines surveyed told the MHAT researchers they would not report a buddy for injuring or killing an innocent noncombatant. Fewer than half of soldiers and marines believed that Iraqi civilians should be treated with dignity and respect, the MHAT found.
Equally distressing, the military suicide rate kept rising, by the end of 2006 reaching 16.1 per 100,000. Over the next six years the rate for active-duty soldiers would double, rising to a shocking 29.6 suicides per 100,000. The survey team, reporting back to Washington, strongly urged that the Defense Department develop “battlefield ethics training so soldiers and marines know exactly what is expected of them.”
In other words, train soldiers to recognize the key to preventing moral injury: helping them see and act on “what is right.” But it was already too late.
For the physically wounded, astonishing advances in military trauma medicine meant that almost everyone in these new wars who fell wounded in battle was being saved. In World War II, seven of ten wounded GIs survived; the others died of their wounds. In Afghanistan, nine of ten wounded troops were being saved, a rate of 93.3 percent. The surviving wounded were carried home grateful to be alive but often weighed down with the trauma of losing limbs or genitals, guilt for having survived buddies who died, angry at themselves for getting hurt, shame at having to leave buddies behind. The battle wounded were beginning to attract attention as they recuperated. At Walter Reed Army Medical Center in Washington, D.C., I watched cheerleaders, politicians, rock stars, and baseball players arrive to visit, and occasionally the president would quietly slip inside. The wounded were feted at regular off-campus steak dinners held in their honor and at annual July 4 extravaganzas on the Mall in Washington.
But larger numbers of patients were quietly evacuated from the war zones with invisible mental health injuries, a testament both to the ferocity of the wars and to the psychological damage they were causing. By 2011, the army’s medical community had acknowledged an “epidemic” of psychological trauma, with a half-million troops diagnosed with symptoms common to PTSD and moral injury. Some of the damage was severe. Across the military forces, the rate at which troops were hospitalized for mental illness had risen 87 percent since 2000. Roughly a quarter-million army soldiers were receiving outpatient mental health therapy a year; ten thousand a year were hospitalized for mental health treatment. At least seventy-six thousand army soldiers had been prescribed opiate drugs; other pills, for anxiety and insomnia, were handed out informally to troops in combat. A study by the Institute of Medicine (IOM), the health arm of the independent, nonprofit, and nongovernmental National Academy of Sciences, concluded that the rapid rate of multiple deployments was having a cumulative effect. Thirty-three thousand soldiers who had deployed three or four times had received a diagnosis of depression, anxiety, or acute stress, according to the IOM report. Many were being returned to battle nonetheless, but by 2010, the army was holding back thirteen thousand active-duty army soldiers, physically and mentally battered, who had been declared unfit to deploy.
The repercussions of these psychological injuries didn’t just impact individuals; they resulted in a deterioration of the military itself, a faint echo of the demoralized, crime-ridden post-Vietnam army of the 1970s. An alarmed army report published in 2012 found that violent crime in the ranks shot up 31 percent between 2006 and 2011; that year the army recorded 122 homicides among its soldiers. On active duty at the time were 42,698 convicted criminal offenders and 11,257 convicted drug and alcohol offenders. The roster of criminal offenders included 4,877 soldiers convicted of multiple felonies; 438 active-duty soldiers had been convicted of multiple violent sex crimes. Some families were breaking under the stress: domestic violence cases across the army rose 50 percent between 2008 and 2011, while incidents of child abuse climbed 62 percent. By 2010 almost 4,000 military personnel from all services were hospitalized for attempting or threatening suicide. That year, 280 active-duty, reserve, and Army National Guard soldiers died by suicide, along with 15 military family members. Suicides among women veterans rose 40 percent between 2000 and 2010; suicides among comparable nonveteran women rose only 13 percent during that period. By 2010, suicides per 100,000 had risen to 35.9 for veterans, nearly three times the civilian suicide rate of 12.4.
But it wasn’t until June 2013 that the full extent of the psychological damage became evident, in a detailed analysis by the Armed Forces Health Surveillance Center. It found that the most frequent diagnosis for patients medically evacuated from Afghanistan for treatment between 2001 and 2012 was not traumatic amputation or blast injury but “adjustment reaction,” a medical diagnostic code that includes anxiety, depression, and acute stress. Also high on the medevac list: patients with episodic mood disorders and dissociative, somatoform disorders.
In short, the military was experiencing moral injury on a scale that was both massive and unrecognized outside a small circle of researchers.
America had been to war before. Why was this psychological wounding of troops so widespread? It was the new kind of warfare U.S. troops were facing, forms of conflict that began to surface when I was with marines in Somalia in 1993. It was evident in Chechnya in 1994 and Liberia in the late 1990s: chaotic, extremely violent conflicts fought by ruthless, often-suicidal extremists who violated every Western concept of warfare. Three-fourths of U.S. battle casualties in Iraq and Afghanistan were caused not by direct action—gunshots in a firefight—but indirectly, by blast injuries from the tens of thousands of land mines left over from decades of war in Afghanistan, then from booby traps or IEDs. These “improvised” devices were made from bombs and artillery shells looted from Saddam Hussein’s arsenals in the lawlessness unleashed by the U.S. invasion. Later on in Afghanistan, IEDs were constructed of simple fertilizer and fuel oil packed in a bucket with stones or nails and scrap metal and a detonator and buried with a simple trigger made of two sticks, a discarded double-A battery, and a piece of wire. Such devices exploded anonymously, leaving the survivors no one to fight back against. And because they exploded almost anywhere and without warning, the troops learned that each footstep in Afghanistan could ignite a fireball and shatter limbs. I attended an early mine-awareness class in Afghanistan in January 2002, given by an army explosives expert. He had just finished clearing mines from a dirt path that led from the runway at Bagram, which would become a major U.S. base. Days later he walked the same path, and a land mine that had worked its way up through the mud detonated and severed his leg.
Danger in these wars was like that, random and often deadly, leaving troops constantly in dread of, or resigned to, the sudden blast that would shear off arms and legs, rip through soft bodies, crush organs and bone, and drive dirt, rocks, and filth deep into torn flesh, often leaving the genitals shredded or missing. Several soldiers and marines told me they’d rather be dead than live without their genitals and sex. Often it was the first question the wounded would ask as they awoke from surgery: Do I still have my nuts? But by 2012 several hundred soldiers and marines were listed with these “genitourinary” wounds.
These new wars also threw young troops into legal and moral swamps that GIs of past wars could hardly imagine. Certainly men have caused atrocities in every war: World War II saw war crimes of unimaginable horror; atrocities in Vietnam were rare, but they happened and for the most part were prosecuted. Generally speaking, though, soldiers on all sides of twentieth-century conflicts fought under common understandings that prisoners were not shot, for instance, and civilians were not considered targets. But in the alien world of combat in Iraq and Afghanistan, the enemy used the tactics of atrocity at will. The last-century signposts of behavior, the Geneva Conventions and the laws of war, seemed to disappear in the fiery blasts of IEDs and suicide vests worn by women and teens that killed and maimed indiscriminately in places like civilian markets and mosques. At ground level in these wars, the insistence of Higher headquarters that American troops play by those old rules seemed quaint and irrelevant, even dangerous. A young infantryman, for instance, might watch an idle Afghan villager scope a crowd with binoculars, then dial his cell phone seconds before an IED exploded in a crowded market. But the infantryman might hesitate to take a shot as the spotter fled: appearances to the contrary, he could be an innocent civilian noncombatant, protected under international law. Or he could be part of an IED gang and kill again.
Complicating these choices were the increasingly strict rules of engagement (ROE). Issued on plastic-laminated cards to every military service member in Iraq and Afghanistan by U.S. Central Command, the regional military headquarters, the rules governed the circumstances in which deadly force could be used. The ROE, backed up by the threat of court-martial if they were violated, demanded that every armed serviceman and -woman make a tangled legal calculation—while trying to stay alive and kill the enemy. That calculation generally required a PID, positive identification of a potentially threatening person as an actual and legal enemy. That meant making a determination that someone “is engaging in a hostile act or demonstrating hostile intent,” according to the ROE. In Iraq, families were allowed by U.S. occupation authorities to keep an AK-47 at home. (The rule was changed during the summer of 2003 to allow three weapons.) That sometimes put soldiers in the dangerous position of trying to determine if some guy down the alley at dusk was holding a weapon in a threatening manner or just carrying it home, whether his intent was “hostile,” whether he was about to open fire. For an American soldier, guessing wrong could mean court-martial. Or death.
In Afghanistan, the ROE were tightened further under the counterinsurgency strategy of Generals David Petraeus and Stanley McChrystal, to provide greater protection for civilians. The practical effect was to transfer some portion of risk from Afghan civilians onto guys like Darren Doss and Stephen Canty. Marines told me that when Taliban fighters realized that the Americans couldn’t shoot back unless they were holding a weapon (demonstrating “hostile intent”), the Taliban sometimes would shoot and then throw down the weapon, knowing the marines probably wouldn’t fire back.
And if a military police soldier serving as a turret gunner in a gun truck felt her position was under attack by a car speeding toward her, for instance, she was supposed to employ a process of “escalation of force.” That required shouting, waving a flag, or blowing a whistle and, if that didn’t work, then brandishing a weapon, then firing a warning shot, then shooting for the tires, and only then shooting to kill. All that was supposed to happen in seconds. The enemy, of course, had no such rules, giving rise to the burning conviction of many grunts that they were fighting with a huge disadvantage imposed by Higher sitting in far-off, immaculate air-conditioned offices. Justified or not, the ROE caused frustration and bitterness among the working-class military. It’s understandable that the surgeon general’s 2006 report found that 10 percent of soldiers and marines acknowledged to military researchers that they “modified” their ROE in order “to accomplish the mission.”
But even attempting to follow the rules could lead to sickening self-recrimination. Lieutenant Colonel Rob Campbell, a tall officer with sandy hair and freckles, commanded a cavalry squadron in eastern Afghanistan when we talked during a foot patrol outside the city of Gardez in 2009. We were picking our way through ankle-high weeds, keeping one eye on the horizon for snipers while also scanning the ground for telltale detonation wires or the fresh dirt of a newly buried IED. One night, Campbell said, overhead surveillance that was beamed into his command center showed what looked like a team of insurgents planting IEDs beside a road. He and his staff watched until they were certain that the ROE and international law had been satisfied and then called in a strike. The dead men turned out to be local farmers engaged in midnight planting. “It was horrible, something I’ll have to live with,” Campbell said with anguish on his angular face.
In Garmsir, Afghanistan, on the sweltering afternoon in 2008 when a rocket-propelled grenade (RPG) suddenly whooshed overhead and detonated, none of the marines of One-Six was hurt. But they boiled up like angry wasps, taking positions behind a wall and peering at a distant ridgeline where two Afghan teens were riding a motorbike back and forth, watching us. The marines were certain the two either had shot at us or were signaling to a hidden shooter. But unless the marines could see a weapon, they had to hold fire. Staring intently through their rifle scopes, they could see no weapon. “We got PID?” someone demanded. “C’mon, c’mon pick it up,” another marine kept urging, convinced the RPG launcher lay just out of sight at the youths’ feet. Eventually the two moved off on the motorbike, and the disgruntled marines returned to pick at their MREs.
The rules seemed most difficult to interpret and follow at vehicle checkpoints, where often the most-junior soldier or marine was given the job of turret gunner, responsible for spotting and halting suspected suicide bombers. That’s the situation Jake Sexton found himself in during his first combat deployment to Iraq in 2007. Jake had grown up in the crossroads hamlet of Farmland, in the corn-and-soybean belt of eastern Indiana. Now he was a twenty-year-old soldier with the Indiana National Guard, sitting atop a Humvee gun truck behind a .50-cal machine gun.
Jake’s dad, Jeff Sexton, told me the rest of the story, as he came to understand it. Jeff is an army veteran and a short-haul truck driver; he runs air-conditioner parts every day from Muncie down to the Honda plant outside Columbus. Late one April afternoon after work, he sat on his back porch in Farmland and talked. His son Jake had spent eight months in Iraq. “When he came home, I knew he was different, but it wasn’t really that much different. But then as things went on, he started opening up about Iraq a little more,” he said in his slow, quiet voice. “He, ah, told me about this situation where he was manning the turret where they had this roadblock, and a car came up and didn’t stop, and so he had to open fire on the car, and when they went to investigate, it ended up being a family of four. No weapons. Just a miscommunication. And that really tore into him. He was the only one who fired, so there was no doubt he was the one that caused… you know, caused it. I said, ‘What did they do?’ And he said, Well, they had the investigation and said it was a clear-cut case of he had no choice. He said he didn’t want to be back in the turret after that, and they took him off it. He was home almost a year and a half before I knew that happened.”
Had Jake Sexton served in World War II, he would have had time to decompress with his buddies on the long trip home by troopship. Soldiers coming home from Iraq and Afghanistan returned in a disorienting two or three days (as did Vietnam veterans). I have convoyed out of a combat forward operating base in Iraq, caught a ride to the Baghdad airport, flown to Kuwait and on into the peaceful summer twilight of Washington, D.C.—all in the same day. Active-duty troops returned to Fort Hood, Texas, or Camp Lejeune with their buddies and stayed with their unit more or less intact. But National Guard soldiers like Jake Sexton returned abruptly to civilian life, civilian friends, and civilian jobs, often with no one around who understood what they’d just gone through. And that added to Jake’s problems.
Come to find out, Jeff said, his son was having trouble sleeping and was drinking heavily and never was offered or sought the help of mental health experts. But he volunteered for another deployment, serving this time in Afghanistan on a quick-reaction force, racing out every time someone hit an IED to secure the site and brace for the inevitable second attack. Mostly, Jeff understood, it was Afghan civilians getting blown up. “He had all kinds of pictures on his computer of the devastation and all that; it really bothered him,” Jeff told me. “He loved kids. And seeing all these kids getting blown up…”
Jake came home on leave, and one afternoon he and his dad talked some in the garage. With the little bit Jeff could get out of him, he could sense his son’s anguish and frustration. As Jeff remembered it later, what was eating away at Jake was “the senseless killing of innocent people and then not knowing who you are fighting when it did happen.” Like most soldiers, Jeff said, “he’d get a little alcohol in him, and he’d open up a little bit, but any other time he kind of kept it all inside.”
A few days later, Jake and his brothers and other friends went to the movies at the Muncie Mall to see the horror-comedy film Zombieland and settled in. After twenty minutes or so, Jake took a handgun and shot himself in the temple and died instantly. He was twenty-one years old.
Shattered, Jeff Sexton went to see the master sergeant in his son’s unit and found out the sergeant knew Jake had PTSD. “And I’m sittin’ there going, ‘Well, why didn’t somebody say something?’ And it was, ‘Well, we can’t interfere unless they step up,’” Jeff told me. And of course the military code of honor is you don’t admit to weakness and you don’t ask for help. And Jake didn’t. That wasn’t okay, Jeff thought. So even before the funeral, he went back to Jake’s National Guard unit and spoke to the assembled soldiers, urging them to see a mental health specialist if they felt they needed to, not to put it off. “I went and told them flat out, ‘If you’ve got a problem, to hell with Suck it up, soldier.’ I said, ‘Jake’s buddies in Afghanistan had to do that because they still had a mission to do, but you guys are home now, and if you got a problem it’s time to take care of it, so step up.’” A couple of days later Jeff got a call from the first sergeant. “He thanked me for coming by, and he said he already had three guys step up and say they’re having problems. And I told him, ‘Well, that’s three less we gotta worry about.’”
It wasn’t as if the military brass and the Pentagon’s vast civilian workforce in Washington didn’t care about the psychological health of the men and women they were sending to war. True, they were primarily concerned with warfighting and with the daily drudgery of defense budgets, acquisition programs, and congressional appropriations and the ceaseless politicking that went along with all of that. What made it difficult to find a way to tackle the issue of war trauma was the deep disagreements inside the mental health community about the very nature of trauma: what exactly was it?
Most people thought any kind of war trauma was simply post-traumatic stress disorder. By the time of the terrorist attacks on 9/11, it had been two decades since PTSD had been officially recognized. The American Psychiatric Association, after studying psychologically damaged Vietnam veterans for over a decade, finally in 1980 certified post-traumatic stress as an official disorder in its Diagnostic and Statistical Manual of Mental Disorders, used by physicians, insurance companies, and the government as the final word on illness. A diagnosis of PTSD, it said in the third edition of the DSM published that year, must be based on the patient’s experience of “intense fear, terror and/or helplessness,” must be reexperienced in “recurrent, intrusive” dreams, flashbacks, or memories that provoke intense distress, and must cause the patient to react with emotional numbness or avoidance—staying away from fireworks, for instance, or isolating yourself from your family. You could get help from military and VA therapists if you met those criteria. If not, good luck.
While the public accepted PTSD as the explanation for all war trauma, inside the mental health profession the view was far from unanimous. “The views of what PTSD was were very confusing. At least fifty blind men and an elephant,” said Dr. Harold Kudler, a psychiatrist and chief mental health consultant at the VA. Nobody, for instance, agreed on exactly what constituted “intense fear,” since its intensity depended on the ability of the patient to articulate precisely how fearful he or she had been. And some rejected entirely the idea that war trauma had to be fear based. “A lot of my friends who are major authorities got excited about fear, but I don’t believe there is a great scientific basis to say that trauma is a fear phenomenon,” Kudler said. “When you boil PTSD down to fear, you’re saying, ‘Oh, you were afraid, that’s your problem,’ and I don’t think that’s the case.” Under fire, the APA retreated. In its fifth edition of the DSM, published in 2013, it added that you could have PTSD if you were exposed to possible death directly or indirectly (through the death of a relative, for instance). “It turned out,” Kudler told me, “that even though fear and a feeling of helplessness made sense, it did not predict who would develop PTSD. And that put us back at square one.” In a stunning acknowledgment, coming as it did after more than a decade of continual war, Kudler concluded: “We do not know what trauma is.”
Very gradually, it has become clear that the disturbing psychological effects that troops were experiencing in Iraq and Afghanistan were broader than any of the specific diagnostic specifications for PTSD laid down by the APA. As early as 1994, psychiatrist Jonathan Shay published his groundbreaking book Achilles in Vietnam, which described the modern U.S. military as a moral construct: not because its actions are always moral, but because it is “defined by shared expectations and values,” Shay wrote.
Even then, Shay could see that the moral codes that grunts really lived by did not rely solely on the military’s own values and ethics that it demanded be memorized by recruits. Instead, he wrote, they combined some formal regulations, some shared traditions, and some generally accepted truths among warfighters about what is okay and what is not. All together, Shay wrote, “these form a moral world that most of the participants most of the time regard as legitimate, ‘natural,’ and personally binding.” Moral injury, as Shay saw it in his decades of work with Vietnam veterans, was a violation of this collective and deeply personal sense of “what’s right.” Not fear-based trauma. “I do not believe the official PTSD criteria capture the devastation of mental life after severe combat trauma,” he wrote. In Shay’s subsequent book, Odysseus in America (2002), about veterans’ homecoming, he writes of “the moral dimension of trauma” and complains with evident irritation that the APA’s diagnostic manual “has saddled us with the jargon ‘Post-Traumatic Stress Disorder’ (PTSD)—which sounds like an ailment—even though it is evident from the definition that what we are dealing with is an injury.”
For instance, the moral injury of the soldier who saw his buddy “liquified.”
The accumulating evidence of war trauma made it more and more difficult to cling to the notion that most veterans experiencing psychological problems simply had PTSD. Researchers studying psychological autopsy data following military suicides, for instance, found that the majority of completed suicides did not meet criteria for a DSM-IV disorder, or PTSD, at the time of suicide. Shira Maguen, the research and clinical psychologist at the VA in San Francisco, had published much peer-reviewed clinical research on the effects of combat, especially of killing. In her work she found PTSD to be an important but minor part of war trauma. “While the predominant view is that the majority of war zone traumas involve a fear-based reaction to life-threatening situations, there is accumulating evidence that trauma types are far more diverse, involving a much wider range of emotions at the time of the trauma, and varying post-trauma reactions in the aftermath,” she wrote in 2013. The powerful emotions Darren Doss was feeling, for instance, when Kruger was shot.
While the mental health community was struggling to simply define “war trauma,” the Pentagon and the VA were scrambling to find practical ways to respond to the psychological problems evident among the thousands of troops rotating home from war. In 2005 the Defense Department instituted mandatory physical and mental health screenings for soldiers back from deployment. The mental health portion of the four-page checklist had items to check if you’d had a frightening experience, were having trouble sleeping, or were easily startled. The Defense Department hired health-care contractors to ask additional questions, including “Have you ever felt you’d be better off dead?” This Post-Deployment Health Reassessment was a start. But there was no system to track whether individuals who were flagged with serious mental health concerns ever got help. Many did not. There was a serious shortage of mental health specialists in the military services and at the overwhelmed VA, where the suicide hotline was drawing 170,000 calls a month. When the military could hire outside contractors to help, they often had no familiarity with the military and no insight into soldiers’ lives.
The experience of Mike McMichael, a North Carolina National Guard officer, was typical of those whom the military mental health system had failed. Mike is a stocky, well-muscled man whose commanding presence, friendly backwoods demeanor, and liquid Carolina diction camouflage a world of hurt and struggle. He came home damaged, with an undiagnosed traumatic brain injury from an IED blast. And suffering nightmares, shame, and guilt over his experiences. In an incident in 2004, a convoy he was commanding was trapped and ambushed north of Baghdad, and one of his fuel tankers was shot up and leaked fuel, which caught fire, engulfing Iraqi civilian bystanders. In his nightmares: the frantic bellowing of his soldiers, his own desperate struggle to get the convoy moving. And as he pushes his trucks through the wreckage, the screams of the Iraqi civilians, shaking their fists at him as they burn.
On his return home, a military nurse gave Mike the checklist of PTSD symptoms. He filled it out and handed a copy back. He never heard from the army. Years later he looked at the copy he’d kept and realized he’d checked every indicator of severe traumatic stress on the sheet: Were you ever in fear of your life? Check. Felt hopeless? Check. Ever see bodies, check; ever see civilian injuries, check. Anxious and sleepless? Oh yeah, check. And so on. But Mike was never examined for his psychological wounds and never got effective treatment. Over the ensuing years, he fought his memory lapses, tremors, fits of rage, blackouts, and anxiety attacks that left him gasping on the floor. Occasional screaming nightmares. He lost his job at the local power company and had to resign his commission as a National Guard officer. The unwritten warrior’s code kept him from admitting his problems. “I had guys that lost legs; what’s wrong with me that I can’t handle this, there isn’t anything really wrong with me. I didn’t want to show weakness,” he told me. He narrowly resisted the lure of suicide and eventually found a sympathetic psychologist at the VA; intensive therapy helped. Now Mike runs a program to train and certify veterans to become peer counselors for the VA. But life is a continuing struggle, and his marriage has fallen apart.
Such realities belied the feel-good rhetoric that had been coming from defense officials and generals. During a congressional hearing in the summer of 2006, I heard Jack Keane, a gruff retired army four-star general, angrily reject the idea that the military was breaking under the stress of repeated combat deployments. “This is a war, and we should expect stress and strain on our soldiers and marines,” he said dismissively. Despite that, he said, “They are performing magnificently.” True enough, perhaps, but that was a testament to their grit and determination, not to the troops’ mental health. Amber Robinson, a sergeant with the Tenth Mountain Division, told me later that summer about a friend who was killed in combat in Afghanistan. She had collected her friend’s bloody clothes and personal gear and carried them all back to base. “A lot of soldiers are depressed, angry, having drinking problems,” she said. “But you get desensitized. I don’t cry anymore.” After a few moments she added in a soft voice, “Sometimes I wake up and cry for no reason.”
As the wars ground on, the accumulating evidence of their psychological costs was causing concern among politicians on Capitol Hill, who began hearing demands for help from constituents with sons and daughters returning from Iraq and Afghanistan. Defense Secretary Donald Rumsfeld and other Pentagon officials were regularly lambasted in congressional hearing rooms for having rushed to war without providing proper armor protection against IEDs and for fumbling the response to the increasing mental health demands of troops at war. (“You go to war with the army you have… not the army you might want” was Rumsfeld’s shrugging response.) That October 2006, Congress passed legislation requiring the Pentagon to expand the testing of troops before and after their deployment to the war zones and to tighten its tracking procedures to ensure that troops flagged with mental health conditions, like Mike McMichael, be seen by mental health practitioners. The conclusions of a Defense Department task force on mental health, published a year later in June 2007, confirmed what many soldiers, marines, and their families already knew: that the Pentagon’s mental health services were “woefully inadequate” to meet the demand. Unprepared—six years after we went to war.
“Our involvement in the Global War on Terrorism has created unforeseen demands not only on individual military service members and their families, but also on the Department of Defense itself, which must expand its capabilities to support the psychological health of its service members and their families,” the task force reported. “New demands have exposed shortfalls in a health care system that in previous decades had been oriented away from a wartime focus. Staffing levels were poorly matched to the high operational tempo even prior to the current conflict, and the system has become even more strained by the increased deployment of active duty providers with mental health expertise… the system of care for psychological health that has evolved over recent decades is insufficient to meet the needs of today’s forces and their beneficiaries, and will not be sufficient to meet their needs in the future.”
Things weren’t much better over at the sprawling VA, where its 280,000 employees were struggling unsuccessfully to keep up with the unanticipated demand by Iraq and Afghanistan War veterans for mental health services despite its $140 billion budget. Senior VA officials assured me things were fine, but in 2009, a coalition of veterans groups sued the VA, and the U.S. Court of Appeals for the Ninth Circuit agreed that the VA, because of inadequate mental health care and other medical lapses, had violated veterans’ constitutional rights. It found the “influx of injured troops returning from deployment in Iraq and Afghanistan has placed an unprecedented strain on the VA and has overwhelmed the system.” As a consequence, the court determined, veterans were forced to endure lengthy delays for treatment, especially for mental health care. Some, it found, had committed suicide. “The VA’s unchecked incompetence has gone on long enough,” the court declared. “No more veterans should be compelled to agonize or perish while the government fails to perform its obligations.”
Few veterans disputed the court’s findings, but its decision eventually was overturned on constitutional grounds. The VA continued to sink. Its employees worked fast, but new benefits claims came in even faster: between 2009 and 2013, the VA’s clerks processed 4.1 million claims for benefits; but during that period 4.6 million new claims came in the door. Eventually, VA officials were discovered lying to cover up their inability to handle the workload, and in 2014, Secretary of Veterans Affairs Eric Shinseki, a decorated combat veteran himself, was forced to resign to make way for a promised bureaucratic housecleaning.
The army, meantime, decided it better get serious about preventing battlefield trauma, even if the experts couldn’t agree on what exactly trauma was. In 2008 General George Casey, the army’s chief of staff, began working with the Positive Psychology Center at the University of Pennsylvania, whose director, psychologist Martin Seligman, had written such popular self-help books as Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment. Together, Seligman and the army came up with a program they called Comprehensive Soldier Fitness, later expanded to Comprehensive Soldier and Family Fitness, or, as the army refers to it, CSF2. The army hired Seligman and his center, on a no-bid $125 million contract, to develop a way to build “resilience” in soldiers. The goal was to increase their psychological strength and positive performance and “reduce the incidence of maladaptive responses of the entire U.S. Army,” according to Rhonda Cornum, the retired army brigadier general who oversaw CSF2. Cornum, a biochemist and board-certified surgeon, had been a POW during Desert Storm, when she was sexually assaulted by Iraqi soldiers.
CSF2 requires every soldier to complete an annual self-assessment test and, based on that score, to master one or more online training programs to strengthen their resilience. Master “resilience trainers” are scattered throughout army units to provide further encouragement and training. The idea is to enable soldiers to “bounce back from adversity and to grow and thrive,” Sergeant First Class Eric Tobin, a master resilience trainer, told me in 2014. “Not to eliminate adversity, we all know bad stuff happens, but to work through those situations… change your thoughts to be more productive in the moment.”
Say a buddy is killed in combat, Tobin said. “My thoughts in that moment could be, Shit, that guy’s dead, which is gonna make me feel terrible. I may freeze. Or my thought may be that we’re all gonna die, and that leads to freezing. If my thoughts are, That guy’s dead, but I have to save the rest of us, that’s gonna drive a different reaction. Lean on my [CSF2] training, do that battle drill, and keep everyone else alive. In that moment,” Tobin said, “I can still function.”
Sharyn Saunders, the director of army resilience programs, told me the training modules “don’t really talk about how to emotionally handle” morally tough issues that might arise on the battlefield, such as seeing a buddy killed or killing a civilian. Although the mental resiliency program is six years old, she said, “We have not yet addressed the mental perspective or the psychological perspective or the emotional perspective of that particular moment.” What is addressed, she said, is “how do I support my own optimism at that moment.” As the army builds more programming, she said, “It will be interesting to see how that connects to future PTSD.” How could it not? I asked, and she shot back, “That’s my thinking! We are really pushing forward in this particular area to robust that,” she said. “The good stuff is yet to come.”
The army’s CSF2 and similar programs by the other military services were studied in 2014 by the IOM’s sober graybeards, who cast a bleak eye on all of them, observing the lack of evidence that any of them actually work. “A majority of DOD [Department of Defense] resilience, prevention and reintegration programs are not consistently based on evidence,” the IOM said. “There has been no systematic use of national performance measures to assess current DOD screening programs.” In short, these outside experts said, the army had no way of telling whether its resiliency programs were effective or a total waste of time and money.
Veterans and families frustrated by all this have found some leverage in Congress, which has been hounding the Pentagon and VA for failing to care for the troops. Congress has forced the VA to adopt such reforms as adding new mental health caregivers and increasing research into war trauma.
Some individuals have taken direct action. In the years after his son’s suicide, Jeff Sexton worked tirelessly to try to find ways to improve the military’s mental health services. He wrote letters. Heard nothing back from the Indiana National Guard, received polite form letters from army and Defense Department officials—We’re sorry for your loss, we’re working on the problem. “But as far as anyone doing anything,” Jeff said. “Nobody. Ever.” Then one day he heard his new senator, Indiana Democrat Joe Donnelly, talking about the need to do something about military suicides. Jeff sat down and wrote an e-mail.
Dear Senator Donnelly,
Me and my wife know all too well the pain of military suicide. Our son Jacob took his life Oct 12, 2009. I’m glad to see you talking about the suicide rate among our service members. For too long I felt like the military has tried to hide the facts from everyone and not let the true cost of 10 years of war be told.
I’m willing to help you in any way I can. All you need do is ask and I will be there by your side to tell anyone who is willing to hear how a young man takes his own life and leaves the ones he loved behind. And how his PTSD did not go to the grave with him but passed on to his father.
The next day in Farmland, Jeff’s phone rang. The number indicated the call originated from a Senate office in Washington. This is Joe, a deep voice said. I want you to come to Washington.
In late 2014, the Jacob Sexton Military Suicide Prevention Act, sponsored by Senator Joe Donnelly and Senator Roger Wicker, Republican of Mississippi, passed Congress and was signed into law by President Obama. It required the military to give annual mental health assessments to all service members, strengthened privacy provisions for those seeking psychological help, and directed the Pentagon to experiment with giving training and responsibility to sergeants to monitor the mental health of their troops. All were measures that might have kept Jake Sexton alive and helped veterans like Darren Doss manage their own demons.
As I dug into stories of people like Darren Doss and Jake and Jeff Sexton, I began to realize the breadth and depth of the moral blows that American troops were absorbing. I felt angry that we were sending them to war without any emotional protection, spiritual armor. Apart from the threadbare homilies about punishing the terrorists of 9/11, or fighting them over there so we didn’t have to fight them here at home, there seemed to be no grand purpose that might justify the damage being done to them. Years ago I had written some about the doctrine of just war. I never heard any grunts mention it, but I thought it might apply to the two wars. I went back and reread, and what I found was surprising.