The moral dimension of psychological injury remains largely unexplored, at least within mainstream mental health.
—George Loeffler, Lieutenant Commander, U.S. Navy, and Psychiatrist, Naval Medical Center San Diego
That fresh Saturday morning at the end of October promised some relief from the ferocious heat of an Iraqi autumn. But not from the war. It was 2004; Joey Schiano was a junior in high school, dreaming of joining the marines even as the war was accelerating. In Iraq that October, sixty-four Americans were killed in battle. On this day, bombings were leaving broken glass and body parts in the streets of Baghdad and other cities, a Japanese hostage was found decapitated, an American convoy was attacked south of Baghdad, and fourteen civilians were killed in the resulting firefights. Outside Falluja, a city wrecked by house-to-house fighting and now held by insurgents, marines were responding to a mortar-and-rocket attack with a barrage of artillery shells they sent whistling into the city.
A convoy of marines in heavy trucks and Humvee gun trucks, meantime, was moving warily down the main road on the outskirts of the city. An officer later recalled glancing at a black Chevy Suburban creeping along the shoulder, thinking it was odd that the Iraqi driver was sitting with his head down. Moments later, the explosives-packed SUV erupted. A hurricane of fire and jagged red-hot steel shrapnel struck directly at dozens of marines standing unprotected in the bed of a seven-ton truck. Eight were killed immediately, three under the age of twenty-one; another eight fell wounded. Then insurgents struck with small arms and RPG fire. Under constant attack for ten more hours, the surviving marines set up a security perimeter and returned fire as the bodies burned in the wreckage. When the flames died down and the insurgents withdrew, the marines gathered the charred corpses of their buddies from the wreckage to zip into body bags.
Bill Nash rushed to help. As a navy psychiatrist, he had deployed to Iraq with these marines as one of the military’s top experts on psychological trauma. But this was no place for the niceties of research or office-call therapy. His job now was to swallow his own horror and help the shocked marines absorb what had happened and enable them to move on. This was a war, after all, and the marines were assigned to take part in a major assault into the deadly back alleys of Falluja within a few days. As he leaped from his Humvee at the gruesome scene of the attack, Nash recoiled for a moment, feeling a weight of inadequacy before the awful trauma etched on the faces of these young marines.
“I know what it’s like,” Nash wrote home later, “to watch their wracking sobs and feel their anger and fear and grief and see their eyes looking at me like I am supposed to respond with some magical words that will somehow make it better…
“I hate this shit, more than almost anything in my business.”
Nash is a bear of a man whose broad face, booming laugh, and intense manner make him seem larger than his six-foot frame and instantly likable. At home now in a suburban split-level outside Washington, D.C., he wears comfortable sweatpants, running shoes and a loose black shirt, military-short brown hair, a close-cropped beard, and wire-rim glasses. Passion runs close to the Nash surface. He likes to laugh and laughs often, a gleeful, shoulder-shaking heh-heh-heh. Unable to sit still for long, he’d often jump up from his dining room table where we talked and pace to let the words tumble out. Until I learned to rest my tape recorder on a folded napkin, it would register loud detonations whenever he slapped the table for emphasis. His living room is bachelor-neat, slightly crowded with a high-end bicycle trainer wedged between easy chairs, a reminder of his intention, at age sixty-three, to work his way back to the bike-racing trim of his youth. On the fireplace mantel, a reproduction of Vermeer’s Girl with a Pearl Earring, tastefully lit from below.
It’s easy to imagine Bill Nash in body armor and helmet among boisterous marines a decade ago in Falluja, so it’s surprising to find that he’s been painfully shy much of his life. That he grew up one of six kids in a dysfunctional blue-collar family on Chicago’s South Side; that he felt “pretty much motherless” as a kid (“There’s my mother,” he once told me, pointing to the Vermeer); and that his fantasies of a loving family were nurtured by TV sitcoms like Leave It to Beaver. That he was bullied by neighborhood kids until the day in fourth grade he picked up Tommy Gannon and dumped him sprawling on the ground. And that his bedrock belief in cleansing and redemption and forgiveness came from the Catholic Church, where he served as an altar boy. On Saturdays, rather than goofing off, he’d walk the thirteen minutes from home, heading west on Eighty-Seventh Street to the redbrick edifice of Saint Kilian’s for confession, so that on Sundays he could receive communion with a pure heart. “I remember,” he told me with a shy smile, “the feeling of walking home—clean, you know? Renewed. So spirituality and all that was an important part of my coping.”
The marines were still pinned down in firefights around the burning truck near Falluja when Nash arrived, and he threw himself into the initial first aid to the psychologically wounded while absorbing their outpouring of shock and anger and grief. In the following hours and days he met with marines individually and listened to their stories and held more formal debriefing sessions in which he encouraged marines to talk about the experience and to articulate their emotions. He organized and led memorial services for the dead. It was the emotional equivalent of the tourniquets and blood plasma of combat trauma medicine. Whatever succor the marines found, however they managed their emotional and moral wounds, there was little time for healing. Days later, they joined the assault into Falluja in a major two-month battle that would kill 95 American troops and wound 560. Nash went with them, and when their combat tour was complete and they all rotated home to Camp Pendleton, near San Diego, Nash plunged back into clinical work. He carried with him critical new insights into psychological war trauma and a fresh determination to break free of the prevailing doctrine for treating war trauma, a creaky and harmful century-old model used during World War I. That was all he’d had to help the marines of Falluja and it wasn’t enough.
Eventually, Nash would recognize the psychological damage suffered by those marines and so many others in war as moral injury, the term first used by VA psychiatrist Jonathan Shay. Nash’s groundbreaking work, along with that of a handful of others, would begin to form an entirely new basis for helping Iraq and Afghanistan veterans cope with their war experiences.
Until recently, the most common model for treating traumatized combat troops, the one Nash had been taught, was formalized in 1916 during a gathering of German psychiatrists and neuroscientists in Munich. Their concern was not so much the staggering slaughter then under way on the battlefields of Europe. It was the tens of thousands of soldiers returning from the trenches so traumatized that they had been declared unfit to fight and sent home, flooding the hospitals and city streets of the German Empire, supported by generous pensions. The streams of “shell-shocked” troops vividly demonstrated the effects of industrial warfare on human beings, and the hemorrhaging of manpower and treasure was draining the kaiser’s coffers. It couldn’t continue. Something, the graybeards were told, had to be done.
What they devised was a new doctrine stating that if you were traumatized by war, it was because you came to war with a preexisting weakness, what today is termed a personality disorder. This fit nicely with the prevailing understanding that once you grew out of childhood, your personality was fixed; subsequent experiences were fleeting, and whatever pain they caused was temporary. As Freud once wrote, “the primitive mind is, in the fullest meaning of the word, imperishable.” It was a neat solution. War didn’t make you sick, they decided. If the bloody terrors of trench warfare or charging into the machine guns at Ypres or the Marne drove you into an emotional breakdown, it was because you were already sick and war made it worse. But only temporarily.
To the doctors at least, this was heartening. It meant traumatized soldiers no longer had to be sent home (and no longer needed to be paid pensions). They could be treated briefly, near the front—“within the sound of the guns” was a common prescription—and sent back into the trenches. As Freud understood it, at least in the opening months of the First World War, “When the fierce struggle of this war will have reached a decision every victorious warrior will joyfully and without delay return home to his wife and children, undisturbed by thoughts of the enemy he has killed either at close quarters or with weapons operating at a distance.”
The model agreed upon at Munich swept away a century or more of confusion, experimentation, and hand-wringing within the mental health profession about how to deal with wartime trauma. During the Civil War, soldiers suffering psychological damage were ignored and simply deserted or were accused of malingering and sometimes shot. Those who survived long enough to reach medical attention were told they suffered a cardiac condition, “soldier’s heart” or “trotting heart,” although there were discomfiting signs that the trauma went deeper. Peter Reed, a Union infantryman, was confined to the Indiana Hospital for the Insane in Indianapolis in 1862; his doctors noted with some puzzlement that Reed insisted that “he was guilty of great crimes… he thinks he is lost for all eternity.” It became evident, at least to some, that war trauma was not temporary and could continue to do damage if untreated: in 1888, Civil War veteran David Wiltsee was confined at the same Indiana hospital; his chart noted that “his delusion seems to be that he has done something terrible,” a description that today would be recognized as the shame and guilt of moral injury.
Prior to World War I, British surgeons asserted that soldiers suffering from shortness of breath, anxiety, chest pain, palpitations, or other manifestations of trauma were merely suffering from knapsack straps that were drawn too tight; they recommended that soldiers loosen the straps and avoid “stooping.” That proved an insufficient medical remedy as well as bad tactical advice for troops facing murderous German guns after the war broke out. Soldiers found wandering aimlessly in the mud and shell craters of the battlefield were sometimes hauled back, court-martialed, and executed on the spot. German doctors had used electric shock to try to bring traumatized soldiers to their senses, often ordering them first to strip naked, the better to stun them with the current. Ironically, the British military medical establishment seems to have stumbled on what is now known as traumatic brain injury; they called it shell shock and applied the diagnosis to anyone suffering not just the physical effects of brain damage but the emotional ones as well, including nightmares, fatigue, tremors, and confusion. All that was caused, according to Frederick Mott, Britain’s leading neuropathologist at the time, by the blast of exploding artillery shells, which damaged “the delicate colloidal structures of the living tissues of the brain and spinal cord.” British theory also had it that exploding ammunition released carbon monoxide fumes into the air, which caused damage to the central nervous system.
Such debilitating conditions couldn’t be treated casually, the British authorities decided. Rather than risking “lunatics at the loose,” as one Allied psychiatrist put it, shell-shock victims were hurriedly evacuated back to twenty newly built mental hospitals in Britain, a humane response that soon became unsustainable: in the first four months of 1916, 24,000 men were sent home. During that summer’s Battle of the Somme, 40 percent of the casualties, or some 140,000 men, were declared shell-shock patients. Like the Germans, the British began to search for a way out, and in 1917 a British physician and psychologist, who had worked with troops on the front lines and had coined the term “shell shock,” came to the same conclusion the Germans had in Munich the previous year. Given the small international community working on trauma at the time, that was not surprising. Charles Samuel Myers, a handsome English intellectual who had studied experimental psychology, determined that shell shock had emotional as well as physical causes and that emotional trauma could be treated with rest and a respite from battle, close to the front. Implicit in his work was the idea that psychological trauma was an understandable and “normal” response. The promise of a quick return to battle appealed to generals desperate for manpower, and Myers’s approach was quickly adopted. During the fourteen-week Battle of Passchendaele, in 1917, psychological casualties were temporarily withdrawn from the trenches and provided a safe bed, warm food, and a ration of rum. Then they were sent back.
Skip forward a generation to find that this treatment, devised under wartime pressure, survived into World War II and beyond—as Bill Nash experienced at Falluja in 2004. Nearly ninety years after the Munich meeting, Nash was treating troops just as the kaiser’s doctors had treated psychological casualties of the trenches. One custom, though, has been discontinued: punishing traumatized soldiers. Shocked and horrified troops have often deserted; during World War II some twenty-one thousand American GIs were charged with desertion, but only one, Eddie Slovik, was executed for it. General George S. Patton was famously (and temporarily) fired by Eisenhower after he slapped and threatened to shoot two soldiers hospitalized with exhaustion. One of them was Private Paul G. Bennett, an artilleryman who witnessed the severe wounding of a buddy and was carried from the front with fever and dehydration, even though he had pleaded to be allowed to stay with his unit. When Patton came through the hospital ward, Bennett struggled to sit up, explaining that “it’s my nerves.” Patton exploded. “Your nerves, hell—you are just a goddamned coward. Shut up that goddamned crying,” Patton bellowed. He drew his pistol and slapped the man before aides restrained him. Patton later complained that shell shock was “an invention of the Jews.” But for the most part, soldiers were treated with food and rest, a remedy American troops popularized as “three hots and a cot.”
In hindsight, it seems ludicrous to have treated mental health casualties of war under the conviction that war trauma is merely a temporary aggravation of childhood psychological injury, a condition that can be relieved by rest and conversation. As Nash wrote in a letter home from Falluja in 2004, when a person experiences trauma and moral injury, “part of one’s sense of competence and worth as a human being is torn away, sometimes never to return.” Yet the notions that were endorsed in Munich in 1916 are still the basis of much of today’s battlefield treatment of war trauma. In modern U.S. military terms, the technique is codified as PIES, which specifies the principles of treatment: proximity, that treatment should take place close to the battlefield; immediacy, without waiting for lengthy medical evacuation; expectancy, the assumption that the patient will quickly return to normal; and simplicity, without any prolonged or complex psychological treatment. Often the acronym is modified to BICEPS, indicating that intervention should be brief, immediate, performed by a central authority—that is, someone in the patient’s chain of command—and should meet the requirements of expectancy, proximity, and simplicity. PIES and BICEPS are the basis for the most commonly used trauma intervention in the United States, the critical incident stress debriefing. Widely practiced by police, firefighters, and emergency medical technicians, CISD is a group discussion facilitated by a trusted leader immediately after a traumatic event to share perceptions and emotions and to support one another’s coping skills. The technique assumes the participants will return to normal quickly without prolonged treatment.
One reason that critical incident stress debriefing has only limited success, in the view of practitioners like Bill Nash, is it doesn’t allow you time after a traumatic incident to think about what happened and to reach for some perspective. “Time does indeed heal at least some wounds,” University of Virginia psychologist Timothy D. Wilson writes in his book on trauma and memory, Redirect: Changing the Stories We Live By. “Once we are done throwing furniture or sobbing into our pillows, we can take a step back and put as good a spin as we can on what happened.” Corralling people into a group discussion immediately after a traumatic event “can even solidify memories of it, which makes it harder for people to reinterpret the event as time goes by.” But the principle of CISD still underlies the U.S. military’s approach to the treatment of trauma: that trauma is a normal reaction, and if you weren’t psychologically damaged in childhood, you should be able to get over it fairly quickly (three hots and a cot) with a quick stress debriefing. If that doesn’t work, you are just… weak.
“What a massively destructive thing to do to somebody!” Nash snorted. I was thinking of Nik Rudolph, who was neither damaged in childhood nor weak, but he shot a child and came home from Afghanistan with a bruise on his soul. Nash and I were talking across his dining room table one winter morning. He’d made us coffee in a Keurig single-serving pod machine. My tape recorder rested protectively on a folded cup towel.
“If you read the military combat-stress-control doctrines and manuals going back to at least World War One,” Nash was saying, “they all say the same thing, that a combat-stress reaction is entirely normal and it is not to be confused with real mental pathology. No matter how extreme or persistent or protracted, it’s normal!” Wham! Nash’s hand slapped the table. “So somebody could have a full-blown psychotic break on the battlefield, and just because it happened in the stress of something traumatic in combat, we are defining it as ‘normal’?” Nash said with a chuckle. “When I know full well that if that same kid had the same symptoms in any other setting, any other stress that tipped him over the edge, he would get a psychiatric diagnosis, be treated with medication, get a medical board—who knows? But we sure wouldn’t say, Oh, that’s normal. You’re hearing voices and you think the devil’s trying to recruit you for his band? That’s totally normal, that happens to everybody who goes to war, don’t worry about it!”
Nash pushed back his chair, heaved himself to his feet, and began pacing, gesturing as he spoke.
“And it’s all based on PIES and BICEPS, where the key is expectancy. It is, no shit, the power of suggestion! Telling these kids, There’s nothing wrong with you, you will get over this, and you will go back to your job and we’ll hear no more about it.” Here, Nash’s broad shoulders shook with laughter. “Heh-heh-heh… right?” he said, in case I hadn’t appreciated the full absurdity of PIES and BICEPS. “I’m not sure we even totally believe that this is normal, but we need to believe that it is in order to avoid epidemics, which to the leadership was the number one concern. Not what to do with the fifteen or twenty percent who are damaged by the experience.”
But Nash used the PIES and CISD concepts, too, early in his career, because there was no other approved way to treat trauma. As a young navy psychiatrist in 1989, long before he was deployed in Falluja, he was summoned to the scene of a crash on the deck of the USS Lexington, an old aircraft carrier used for practice landings near the naval aviation training station at Pensacola, Florida. One trainee miscalculated and crashed, his jet cartwheeling in flames down the flight deck, killing the pilot and four others and injuring seventeen. Nash gathered small groups of the survivors and had them talk about the event, describing the details of it and sharing their emotional reactions. “Clearing that stuff out of the way,” as Nash described it. “A very attractive procedure for the organization [the navy] because it gave them the impression that we were really preventing mental illness. That if somebody went through this hour and a half debriefing group, they were good to go,” he said. “But there was not the slightest attempt to follow up to see if, for any of them, this was not enough. And we knew that, when you have these command-directed debriefings after an event, not everyone’s gonna go, and the people who don’t even show up are probably the people who are the most badly damaged, and that’s why they don’t want to go, because they know they can’t handle it, they’ll just be retraumatized and be even more ashamed because they’ll break down, they won’t be able to communicate, they’ll dissociate, zone out, it’ll be worse than useless.” He took a deep breath. “Right?” He grinned. “And most of the people who do show up would do fine no matter what you did!”
For the others, he said, rising on tiptoes and spreading his arms, “Might’s well buy ’em a hot dog! Heh-heh-heh. But, yeah… But people didn’t challenge this idea to say, ‘Wait a minute, is that the best sense we can make out of this?’” Deep down, Nash knew PIES and BICEPS weren’t right, that CISD wasn’t enough. “All you gotta do to see how absolutely absurd it is—is talk to a marine and be there with him.” Nevertheless, it was all he had as he was summoned to heal the marines at Falluja. “We were supposed to coerce them into going back to the fight,” he said, adding softly: “No matter what we believed.”
Nash began his military medical career as a naval flight surgeon. The navy paid for undergrad and medical school and he did his residency in orthopedics. But during his first job, providing primary health care to the navy community, he realized his best moments were spent working with mental health cases. He switched and did a three-year residency in psychiatry at the Naval Medical Center San Diego and in 2001 was swiftly hired for the mental health program at the nearby Marine Corps Base Camp Pendleton.
That’s where Nash developed his full-blown panic attacks. One day he was scheduled to give a noontime lecture on depression to family practice residents. They sat with their lunches while he stood at the podium sweating and gasping and unable to speak, and the worst part of it was the shocked look on their faces. Relating the story, Nash took a huge shaky breath. “The part of me that believes in God says, you know, these are experiences I needed to have so that, when the time came for me to go with the marines to Iraq in 2004, I would be prepared.”
Soon after 9/11, marines recently back from Afghanistan began coming to him for help, and it was here that he started to realize that what they had was not PTSD, that it was not terror that had cut deep into their nervous system, that it was something different. Something Nash and his staff had never seen before. Acute war trauma, they called it. They’d had plenty of cases of PTSD, mostly Vietnam veterans. “I knew this was not the same animal,” Nash explained to me. “The prevailing view—an untested belief since World War I—was that if you had war trauma it was because you had a preexisting weakness, a personality disorder. And there were studies correlating personality disorders with PTSD, and so it just allowed us all to sort of write them off.” But with the marines coming back from Afghanistan, Nash said, “I could see what every spouse or mother who knows their kid or husband sees,” that those who return from war “are not the same person anymore. They come back and they’re different. I had a marine wife who brought her husband in. She had no reason to exaggerate, didn’t know about the disability system, but she was saying, ‘This is the way he was before, and this is the way he is now. Help!’ And I was changed by my experiences working with these patients at Pendleton hospital between 2001 and 2003 and feeling like, number one, realizing how wrong I had it, personally in my own understanding, and then making me rethink a whole lot of other things I believed. Like, what is the optimal prevention strategy?”
That question kept Nash up at night. If being traumatized in combat is a “normal” reaction to horror, what is there to prevent? The marines coming to see him at Camp Pendleton were experiencing deep trauma; clearly they needed something beyond PIES and BICEPS. It seemed suddenly obvious to Nash that the kind of war trauma he was seeing was not normal—not a result of childhood psychosis—but a wound. An actual wound. That term, Nash saw, wasn’t just semantics. It suggested that the condition could be treated and healed.
Just before he left for Iraq in 2004, Nash tried out his new ideas at a Marine Corps conference on combat and operational stress control, an umbrella term the corps uses to refer to the identification and treatment of any form of mental difficulty. As the name implies, its central concept is that any adverse psychological reactions to war are normal, temporary, and can be—must be—controlled. The idea that one could be psychologically wounded, as surely as any other combat injury, had never arisen inside military circles. A wound or an injury can be healed, perhaps, but not controlled.
Nash, despite his senior rank as a navy captain, was an outlier in the sessions. The idea of standing up and proclaiming to hardened warfighters that they should see emotional trauma as an actual wound made him worry that he’d get one of his old panic attacks. But his excitement drove him forward. “I was sharing with them some of the stuff I’d learned about trauma being a literal wound, right? A wound! And if you think about it that way, then the wound is the intermediate stage between ‘good to go’ and ‘fucked up for life.’ And most wounds, people get over them. But your chances of getting over it are far better if you acknowledge that you’ve been wounded” and are given appropriate treatment.
Stress injury, Nash called it. The term hung in the air at this Marine Corps conference, then dissipated. Days later, Nash gathered his combat gear and left for Iraq, packing his manuals on PIES and BICEPS because there wasn’t any other approved treatment doctrine. But he came home burning with frustration at what he felt was his inability to heal the shaken, weeping marines of Falluja. He burrowed deeper into the idea of trauma as an injury or a wound. Within two years he had published a book, Combat Stress Injury, with trauma psychologist Charles R. Figley and an introduction by Jonathan Shay, the Boston VA psychiatrist who has written widely on combat trauma.
Nash hit the road to lecture on his ideas, arguing and fighting with his colleagues and seniors. Soon, he’d created such a stir among marine commanders and senior mental health experts that he was summoned to marine headquarters in Washington to explain himself. The tempo of battle was rising in Iraq and Afghanistan, casualties were mounting, and the corps was struggling to meet its manpower commitments. The last thing the generals wanted was another category of injury—especially given the bedrock military tradition of “suck it up,” treating psychological casualties as weenies. What the corps wanted was a way to prevent combat stress from overwhelming its marines, not another injury requiring treatment. Determined to head off this threat, three senior marine combat commanders, those who held the corps’s most revered positions as warfighters and keepers of the corps’s warrior ethos, had written an open letter to the Marine Corps commandant. They didn’t believe in Nash’s “stress injury,” they said. They wanted the term removed from official documents, and they never wanted to hear it mentioned again. Ever.
As Nash packed for Washington, his colleagues in military mental health were ducking for cover. “People thought I was in so much hot water that they were auctioning off my office furniture. They knew I was not coming back,” Nash told me gleefully. At Marine Corps headquarters, a series of stormy meetings ensued that included the three senior commanders and other warfighters, medical and mental health authorities, and a handful of chaplains. It was a curious echo of the 1916 Munich conference but with a dramatically different outcome. They agreed to define psychological health with a simple color-coded “stress continuum” chart. The chart acknowledged that some marines would emerge unscathed from combat, able to rely on their own internal coping skills. On Nash’s scale they occupied the green zone on the far left. Others would experience a temporary stress reaction (yellow). Those with more severe and prolonged symptoms were “injured” (orange), and, on the far right, a red zone for those with major depression, anxiety, or diagnosable PTSD.
The agreement was a significant advance in the acknowledgment and treatment of war trauma. It was the first time the United States Marine Corps recognized that the young men and women it sends into combat could become not just temporarily stunned by combat but actually injured with a psychological wound. Just as significant, it enabled front-line leaders—young sergeants, lieutenants, and captains—to sort out after a combat engagement which of their marines were okay, who needed three hots and a cot, and whose injuries put them at risk of future problems, such as drug and alcohol abuse, risky motorcycle racing, or even suicide, and thus needed psychiatric intervention. “The three generals started this conference to kill the stress injury idea,” Nash said. “And they ended by saying, in effect, that we have solved the problem—stress injury is a terrible idea, it doesn’t fit with our culture, we don’t like it, it’s not true, so instead we want all of our training to be based on the stress continuum model,” Nash said. “It was a way to have their cake and eat it, too.”
Emboldened and a little giddy by this victory, Nash publicly confronted his most severe critic, Lieutenant General Keith J. Stalder, the gruff commander of the Second Marine Expeditionary Force, an air-ground task force of some sixty-two thousand marines and sailors who fought in both Iraq and Afghanistan. At a briefing for hundreds of marines on the new stress continuum, Stalder strode the auditorium stage, imposing in his battle dress uniform, taking questions. Finally he recognized Nash, who was sitting nearby. Nash stood under Stalder’s glare. “I said, ‘General Stalder, sir, do you believe stress injuries are real?’ And he was walking back and forth in front of me, and his eyes were locked on mine. And finally he said, ‘Yes, I do.’”
“Thank you, sir,” said Nash, and sat down with a smile.
It was not long after he returned from Iraq that Nash, working at Marine Corps headquarters in Washington, dialed a phone number at Camp Pendleton, the massive home of some forty-two thousand marines, where he had worked for years. He asked for a therapist named Michael Castellana. A friend had lent him a copy of a treatment model for war trauma that Castellana had written. It incorporated many of the new ideas that had been circulating in Nash’s head. It was a way of helping marines, far beyond the tired notions of PIES and BICEPS. Castellana was unknown to Nash; he wasn’t even a psychologist, Nash noted. But the model he’d written was brilliant. When Nash read it, he was exhilarated. The traumas marines were bringing home were intensifying, and he felt a growing urgency to respond.
“I read your therapy model,” Nash said when Castellana came on the line. In what he intended as a friendly, bantering tone, he said: “Who the hell are you?”