Soldiers from Iraq, Afghanistan Cope with Combat Stress
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KEME NZEREM, Guardian Newspaper Correspondent: Saturday, May the 19th. It’s late afternoon in Baghdad. Photojournalist Sean Smith captures this image. Inside a Bradley armored car, six U.S. soldiers and their translator are burning to death.
This is Sean’s account of the horrific events of that day and the following two weeks. His footage starts with a rare moment of calm for Apache Company in Amiriyah, western Baghdad. Then, in the distance, an explosion.
This is Fourth Platoon. They rush out to investigate. Sean films the soldiers as they discover the target of the blast, the Bradley upside-down and on fire. It’s been blown up by a roadside bomb.
But Fourth Platoon are too late to help their seven trapped colleagues. Live ammunition explodes inside the Bradley. Seconds later, and nervous, they raid a nearby house looking for the bomb-maker. They detain several men and leave them with interrogators.
SPECIALIST LAKE, U.S. Army: You’ve got grenades going off. You’ve got an IED blowing up your vehicle. And then you’re expected to go back in those four to five hours and relax, to come back out and do another six hours. You just don’t have time to do it. Your body never gets to come down. You’re always on that heightened sense of alertness; you just don’t have that rest.
KEME NZEREM: Forty-eight hours later, and Specialist Lake’s unit are back in the neighborhood. They’re conducting random house checks. They’re jumpy, but this time all they find is a frightened and elderly woman.
The Fourth Platoon finds nothing and leave, but the next morning this is what happened. Apache Company, Second Platoon, are now on patrol. They’re suspicious a car circling their position might be a lookout for nearby snipers. Still nervous after the Bradley attack, they order the car to stop and, when it doesn’t, they open fire.
SOLDIER: Oh, he’s dead.
SOLDIER: No, he’s moving.
SOLDIER: I don’t know.
KEME NZEREM: They drag the driver through the nearest front yard and try to revive him. The soldier’s attempts to keep the man alive fail. A neighbor turns up; she thinks she knows who he is.
SOLDIER: They say they hired that guy. And they say he’s just a taxi driver, that guy who got shot.
KEME NZEREM: The man was killed because he failed to stop. Second Platoon Specialist Vassell was there that day.
SPECIALIST VASSELL, U.S. Army: I challenge anybody in Congress to do my rotation. They don’t have to do anything, just come hang out with me, and go home at the times I go home, and come stay here 15 months with me.
KEME NZEREM: The day starts with Second Platoon called to investigate a blast at an insurgent bomb factory. They pick their way through the rubble. Moments later, there’s a secondary explosion.
Chaos, debris, and flying shrapnel, an Iraqi soldier has taken the brunt of it. Neighbors, both children and adults, are hurt, too. The Americans set up an emergency first aid operation. They try and help the wounded. A young boy has shrapnel wounds in his face and his body.
It’s an ordinary day for the people of Baghdad and Apache Company.
SPECIALIST VASSELL: We’re supposed to be on the way home right now. We were supposed to be flying home in six days. Six days. But because we have people up there in Congress with the brain of a 2-year-old who don’t know what they’re doing, they don’t experience it.
I challenge the president or whoever has us here for 15 months to ride alongside me. I’ll do another 15 months, if he comes out here and rides along with me everyday for 15 months. I’ll do 15 more months. They don’t even have to pay me extra.
Exhaustion of combat units
JIM LEHRER: More now, and to Margaret Warner, who recorded this conversation last week.
MARGARET WARNER: For analysis of what we just saw and what it tells us about the stress U.S. troops are under in Iraq, we turn to two former officers who counsel soldiers exposed to combat trauma. Former Navy Lieutenant Commander Heidi Kraft is a clinical psychologist in San Diego who sees exclusively combat trauma patients. In 2004, she directed a combat stress unit in Iraq and later wrote a book about the experience.
And former Army Major Brian Butler, who served in the first Gulf War, he's now a licensed professional counselor with the Colorado Springs Health Group working with soldiers back from Iraq.
Welcome to you both.
As clinicians in the field -- beginning with you, Heidi Kraft -- what's your reaction to what we just saw? What part of it rings most true to you?
FORMER LT. COMMANDER HEIDI KRAFT, Psychologist: I think the thing, as I watched that clip, that resonated the most with me was overarching exhaustion. I watched these soldiers as they moved through those minutes out there, and we went with them on those missions. And I felt like they just got more and more exhausted as the clip went on.
This is something, unfortunately, that with operational tempo many times we're up against, but of course sleep deprivation and physical and emotional exhaustion all play into a person's ability to cope with stress.
MARGARET WARNER: Brian Butler, what was your overall reaction?
FORMER MAJOR BRIAN BUTLER, Licensed Professional Counselor: My reaction was the multiple levels and dynamics of the trauma, anywhere from seeing a Bradley flipped it upside-down on its top with other Army soldiers dying inside, you have accidentally shooting the wrong person. You're trying to treat civilians who have nothing to do with the combat; they're just simply injured because of a bomb.
So you have all these multiple dynamics of trauma going on at the same time or within a space of a few days and, of course, combined with sleep deprivation and the other stressors that just come with being in a combat environment. It really rang true.
Not knowing who the enemy is
MARGARET WARNER: So, Heidi Kraft, we did see -- a recurrent thing was that they're in and out of these civilian houses, you have bombs going off, you have children bloodied and crying, you have a woman screaming when they just found an old woman looking for an IED planter. What's the overall impact on soldiers with experiences like that?
HEIDI KRAFT: I think that what these guys are seeing in this clip struck me as very, very similar to what my patients who happen to be Marines were telling me about their experiences in 2004. The mission of going door-to-door and working in these environments involves many times not having a clear understanding of who the enemy is and not being able to trust anybody.
There's a real vulnerability of our troops at this time in this conflict, which continues to sort of resonate through everything they do. So of course they're going to be impacted by having civilians be involved in these types of missions, and yet their orders are clear: They can't trust anyone. So it's sort of a double standard that will always be with them and certainly makes this whole process a lot more complicated.
MARGARET WARNER: Brian Butler, of course, the soldier doesn't know whom to trust, but they also see these civilians hurting, physically, emotionally. What kind of impact do you see it in your patients having had?
BRIAN BUTLER: It has a huge impact on them, in terms of the existential anxiety and the confusion they feel in trying to do the mission as well as they can, but at the same time there's no clear-cut boundaries and there's no clear-cut enemy, in terms of trying to distinguish them, the civilians, from the insurgents.
So it does cause a lot of confusion, and it makes them incredibly hostile, because they're in a hostile environment. And when you're in a chronic hostile environment, you tend to begin to see things with a hostile intent, and so you become hostile.
MARGARET WARNER: And the chronic nature of that hostile environment was something that one of the young soldiers talked about. And, Heidi Kraft, I just want to ask you about what he had to say. He said, "Well, you know, we have grenades going off and IEDs, and then we're told to go back and rest for six hours and then come back out again." And he said, "We don't have the time to come down." You're always with that heightened sense of alertness. You don't have time to rest.
Is that actually physically true and psychologically true that they don't get to come down?
HEIDI KRAFT: It is absolutely true, most definitely. The level of arousal in which a person is placed in a situation like that is very, very high. And it is really difficult, both physiologically but especially emotionally, to actually have the recovery process from that level of arousal.
Six hours just isn't going to even start to do it. And yet, as I mentioned, the operational tempo a lot of times doesn't allow them what they really need, which is the time to completely what we call reset, allow their physiology and their emotional cognitive processes to return to normal and heal during that short period of time, and in order to be able to go back.
Time to reset
MARGARET WARNER: And why is that important, to have that resetting time?
HEIDI KRAFT: Well, I think especially in this group that we watched in the clip, they were there for a very extended deployment, which was another thing that they complained about and had a difficult time with, so that we're talking here about two different things, very acute and emergent sort of reaction to what's happening in the moment, which is really the fight-or-flight response, but also a chronic, ongoing and relentless stress that they're up against day after day after day. So the two things layer over each other.
MARGARET WARNER: Brian Butler, what's your sense of what the body and mind need in the way of the intensity of the hostility and the protracted nature of it, to recover from that, to be ready to go back?
BRIAN BUTLER: The concerns I have are the impact on the brain structures and the brain functioning. Long-term chronic exposure to trauma and potential trauma does have an impact on brain function, and there are some recent studies that show that it also has an impact on brain structure.
There's a portion of the brain called the prefrontal cortex. And it is responsible for a lot of executive functions, things that you think about. It kind of is our logic center, if you will, to an extent. Research studies have shown that under prolonged, chronic trauma and stress, the blood flow to the prefrontal cortex is diminished.
There's another portion of the brain called the hippocampus, which other research studies have shown actually could possibly be shrinking in relation to the long-term chronic exposure to trauma, particularly in soldiers. So there's a concern with the impact on brain structure and function that chronic long-term exposure is causing.
And in the short term, absolutely, in World War II and in Vietnam, they frequently would pull whole units out of the front line and give them, oh, easily, a week, sometimes even more, to kind of refit, process what they've gone through, grieve the loss of their friends and their comrades, and then kind of go back in after they've had a chance to calm down and relax.
And those are the things that, if the operational tempo and the mission will allow, need to have happen. And I have no doubt the military is aware of that and are doing what they can to do that.
Processing trauma later
MARGARET WARNER: Heidi Kraft, the other pretty horrible, quite horrible scene, of course, involved the taxi driver mistakenly shot and killed, and then the woman crying and saying he was just coming to pick me up for an appointment. Now, again, what is the impact on soldiers of when something like this happens, when they're involved and responsible? How do they process that?
HEIDI KRAFT: There are many things that people process later in the trauma. A lot of times, these things are not processed in country during the mission, quite simply because you need to keep your blinders on and keep your head in the game and are not allowed -- don't allow yourself to go there, to be able to do the healing work.
But now -- I'm sure Brian would agree -- the people that I see now who have returned from combat and who are struggling with this process, one of the big themes that will emerge again and again is guilt of various types, guilt and shame, many times around the baseline moral and ethical conflicts of combat of any type. This particular conflict, as I had alluded to before, has this element of not knowing who the enemy is and not being able to trust anyone.
And that's what happened with the taxi driver, as well as the old woman. These guys had a very distinct order that they were following, which is, when they tell a car to stop, if it doesn't stop, their orders are clear, because they have to assume that's the enemy.
But I would expect that it's possible some of these guys may suffer from what we call sequelae of that later, and really do -- they struggle with this idea of being a human who values human life and, being in a position like that, having to make that choice, and then having the guilt that they will live with later. It's oftentimes a part of the presentation of post-traumatic stress disorder.
MARGARET WARNER: Thank you so much, Brian Butler and Heidi Kraft. Thanks for being with us.
BRIAN BUTLER: You are welcome. Thank you.
HEIDI KRAFT: Thank you.
JIM LEHRER: And both Heidi Kraft and Brian Butler will be taking questions about combat stress in an online forum. To participate, go to our Web site at PBS.org.