The battle after the war

Coming to grips with PTSD, in culture and in care

Christopher Serra for the Boston Globe

In Roxana Robinson’s beautiful and devastating 2013 novel “Sparta,” a young Marine officer returns from four years of war apparently unharmed. But as the months go by he is gripped by depression, explosive rages, paralyzing headaches, and paranoia. He is angry at his family and girlfriend for not understanding his experience in Iraq, but when they ask him what it was like, he can’t talk about it. Even though this family is highly educated, they are stunned by the magnitude of the psychological damage, its persistence, the suffering it is causing, and the difficulty of reaching the sufferer.

Like Robinson’s fictional Marine, the young veterans profiled in David Finkel’s searing new nonfiction book “Thank You For Your Service” are haunted by their wartime experiences: surviving blasts that killed or maimed a fellow soldier; entering Iraqi houses in the middle of the night to rough up and terrify families, only to learn later that these were the wrong houses; killing people and minding; killing people and not minding. Finkel’s veterans are trying to adjust to life back home, but they struggle with guilt, violent impulses, nightmares, feelings of failure, and thoughts of suicide.

Every war creates a vast number of psychologically wounded veterans. Put bluntly, war causes mental illness.


In addition to the symptoms that define post-traumatic stress disorder — vivid flashbacks or nightmares; emotional numbness; the avoidance of thoughts, memories, people, and places associated with the traumatic experience; and heightened vigilance — PTSD sufferers are also highly prone to alcoholism, drug addiction, anxiety, depression, and suicide. The long-term impact on their health and their lives, and on their families, can be devastating.

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A bulletin board in the lobby of Boston’s VA Hospital is crowded with notices. “Are you a veteran who has experienced stress or trauma?” “Did you experience a blast or explosion?” “Are you a woman veteran who had unwanted sexual experiences during your military service?” “Are you concerned about your alcohol or drug use?” “Are you a veteran coping with both PTSD and pain?” Most of the notices have tear-off tags with phone numbers to call for more info. Most of the tags have been torn off.

Upstairs, Terence Keane, who directs the Behavioral Science Division of the VA’s National Center for PTSD, talked to me about treatment. Therapy begins with detailed retelling of the traumatic events. “What was the terrain? What was the heat like that day? Recounting specific memories helps bring up the feelings,” Keane says. “Often they have shame and humiliation about the event. We can challenge the cognitive distortion, start to show them that the thing they’re feeling guilty about was actually something they had no control over.” Therapy accomplishes more than medication, although researchers are working to identify possible biomarkers of the disorder. “With PTSD, we don’t really know what it is that’s broken,” Keane says.

Despite exponential advances in research and treatment since Keane began working with veterans in the late 1970s, many veterans don’t seek treatment because of the perceived stigma of admitting to psychological wounds. Dr. Matthew Friedman, executive director of the National Center for PTSD, wrote in The New England Journal of Medicine that the fear of stigma is worst among those who are most in need of help: “Those who reported . . . the most severe symptoms were the least likely to seek treatment for fear that it could harm their careers, cause difficulties with their peers and with unit leadership, and become an embarrassment in that they would be seen as weak.”

It has been estimated that 13-to-20 percent of American veterans returning from Afghanistan and Iraq currently have PTSD, or will suffer from it in the future. This means as many as half a million men and women are affected by combat-induced mental illness, just from our most recent wars.


Prevention is hard to quantify or prove. Earlier this fall, the United States was on the brink of going to war with Syria. Many criticized President Obama’s leadership as weak; but by choosing to work through international diplomacy he has, for now at least, kept thousands of US soldiers from undergoing the damaging experience of warfare. They are alive, and they are physically and mentally well — which may in fact be one of Obama’s most significant achievements, not only in terms of diplomacy but in terms of health care.

Joan Wickersham’s column appears regularly in the Globe. Her latest book is “The News From Spain: Seven Variations on a Love Story.’’