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Drawing on his 20 years counseling veterans as mental health counselor for the VA in Vermont as well as his service in the Vietnam war into which he was drafted at 19, Jim Dooley offers a clear-eyed overview of soldiers' experience in war, the psychological impact, and the great problems many have in adjusting to being back home. "What we're saying is 'You have no idea what the other part of the world is like, and I do. And you should know it. If I have to know it, you should know it. ' And I think that's where the anger is -- it's that their value systems have been fundamentally changed by that experience. And they keep that value system the rest of their life." This interview was conducted on Oct. 5, 2004. [View video of Dooley talking about the impact of his Vietnam combat experience.]

When you're finally back here, and you finally make connection with your safety, which is your family, that's when you begin to vibrate with the fact of where you were.

Tell me the type of person that comes to you.

It really is quite a range. I think the youngest is 21; the oldest is 86. The population is from people that have been in wars from World War II -- Battle of the Bulge, Guadalcanal -- POWs, Korean combat vets, all the different services from all of the combat services. The vast majority of my practice is probably with Vietnam-era [vets], and Vietnam combat vets particularly. With the Iraq [and] Afghan activity, the last 18 months have been an explosion of veterans that are struggling with their own memories and are very anxious about other young men being hurt like they were.

So they're watching the news or hearing what's going on?

Constantly.

What are the things they're telling you? Would you say they're mostly Vietnam guys you are talking about?

Well, the interesting part for me is that it goes absolutely across every era of veteran in that there is a universal concern of young men being hurt again and again and again. And every day they're watching the death rate climb. That gets enunciated by every single era, and they're all concerned with it. They're not sleeping as well; they're checking the perimeter of their house constantly, checking windows, doors; staying up at night, most of the night; not eating as well; irritable, angry. So it's been an increasing crescendo of problems directly from the activity of the war for people that haven't been in war in 60 years.

Is the current war triggering relapses of PTSD in veterans?

I think it just triggers such vivid memories and such vivid flashbacks that usually the spouses encourage the veteran to come in to talk. People that I haven't seen in three years will be suddenly appearing again. And it gets to be very difficult because of the scheduling. You don't have the available time, and yet you have to make the available time. So part of my struggle is not just to meet with the veteran and to deal with that, but how do you integrate quality services in a time when it just seems to be expanding exponentially?

It's so surprising. It's a little bit counterintuitive to me, because what I would have expected you to say [is] that your practice was expanding because all these guys were coming home. But what you're actually saying is that already, veterans from World War II, Korea, Vietnam, they're basically having some similar PTSD kind of reactions to just watching the news and thinking about these guys over there?

Yes. I think the video watching has a significant effect on them, and I strongly urge them and I argue with them not to watch the news, not to read the newspapers, to pull themselves out of [the] media stream, and they're quite resistant to it.

I think there's an attraction to watching war if you're a veteran. I talk with [them] about it, and they giggle, because I say, "Really, what you're trying to do is seeing if these guys are doing it right." And they know that that's really what they're doing, because they already know what combat is about. They know how to protect themselves, and they're anxious to see if these guys are doing it right. But it also triggers older memories of themselves being at risk and their friends dying and being wounded. So it serves no good purpose other than to make them very anxious, and that's not really what they need at all.

Would you say veterans across all wars experience this reaction to Iraq right now?

Yeah. I do think that the current activities of uncertainty, of unending war, [trigger] a lot of anxiety and anger in veterans throughout all of the different wars, from World War II and Korea and Vietnam and Haiti and Somalia and all of them.

Tell me about the anger. What's the anger about?

I think the anger is that the men that I'm working with have experienced abandonment in a very profound way. That's difficult to really talk about, because they were all raised with the values that if the country needed you, that you would step forward and volunteer, or go if you were drafted. And when they did that, they experienced that the military and the country really didn't fulfill what they said they were going to do. They trained them in one job, but when they got to the war, they were not allowed to do that job. They were put in as an infantryman, as a rifleman, and they were totally unprepared for that in training. And after the war, they were basically discharged without a lot of assessment of what happened to them, without a lot of talking, without a lot of support. So from their perspective, they're witnessing another generation being victimized the same way, and that really angers them.

Would you say that this mostly surrounds Vietnam vets?

I think the culture of Vietnam vets is such that I think we are more outspoken. We name it as best we can. I think the language is different with the different generations, but the feelings are the same. And I think that if you peel back the language, it really is the feeling of abandonment that really rings true to me.

One the most emotional scenes that I've actually witnessed on this film is being in New York City during the Republican National Convention, and there was a group of Vietnam vets who were speaking out and saying that they would never abandon the guys coming home from Iraq the way they were abandoned by "the greatest generation," the World War II guys. Will you talk about this in relation to how the Vietnam vets are feeling right now about really reaching out to Iraq veterans, guys coming home from Iraq?

Well, I think that the lesson that Vietnam vets have learned about the next war -- and there will probably always be war, unless we can really profoundly change our brains -- is that the commitment to the next generation is to be supportive and to be nonjudgmental and to be available. I think that if you look at the activities of veterans -- doing fund raising, soliciting [donations], selling magnets on the side of the road in order to fund-raise for comfort of bug spray and toilet paper and things that are not easily gotten -- I think those kind of things really say by behavior that they're not going to be abandoned. And that is something that you don't really understand until you're there.

When you guys came home, did you feel like you got support from the World War II guys? Did you feel any support from them?

I felt personally that I received no support when I returned home from any of the veteran organizations. I approached one veteran organization to ask about my injuries and whether I had gotten fair compensation, and they [said], "Oh, it's closing time at our storefront in New York City." And the two men that were moving towards the door, they said, "Well, you're lucky you got what you got, and we need to go home now, so see ya." And I don't think I came back to that organization for 20 years based on that one, I would say, 30-second interaction. They couldn't be bothered with me -- then why could I be bothered with them? I could [do] it better by myself.

Tell me about what you expect to be different for the Iraq veterans starting to come home.

I would hope that we would learn that we can be a society supportive of the veteran without supporting the war. I think that's very important.

You think it's possible?

Yeah.

Realistic?

We need to understand that when you put somebody at risk, they risk everything. We're sitting here in a comfort, and they're doing the work.

What can the VA actually offer them? When you look at the budget cuts, you look at what's really truly given to them when they come home, what do you think about that?

I think the VA is attempting to respond to the needs. I think that there will be a need [for] outreach that's very active, that is not waiting for people to knock on our door. I think that we need to be present in the community more, and I think we need to interact with families more. I think that the vast majority of the veterans will be men [who] don't express easily how they feel. They demonstrate it through their anger, and the families are the recipients usually of that anger. I think we need to be able to have an educational process that explains to the families how we can be of support to them. I think it's critical.

Let's just talk about you and the fact that you're already overwhelmed. ... How do you expect to deal [with] the folks who really are going to start to come home, hopefully in the next few years?

It will certainly be a challenge. You know, I think that the realistic answer is that you look at the need of the person, and you look at how you can best serve that need, and you prioritize the intensity of the services, the scope of the services. You look at auxiliary services. You look at who else would be able to support this person.

[Iraq] is the most damaging type of war psychiatrically. You have no protection anywhere at all times.

We're doing some training of the community mental health agencies to help the clinicians all over the state of Vermont to able to understand Post-Traumatic Stress Disorder better. I think it's a wonderful educational process, and from my experience, it's very much needed, even without the civilian population, to have clinicians be aware of how to deal with it better.

I think it will be a challenge, though, how to deal with the numbers that are coming home. I'm already beginning to deal with Iraq vets, and they will receive services from me. It's really that simple. That's what has to happen.

What are you seeing different in their experience than all the other vets that you've dealt with? Are there particular things that are different?

I think the intensity of the experience is so new that they're, in effect, still there. And I think that having a warm receiving place -- to be able to be safe, to be able to talk about it -- is very important. You don't begin to talk about it early; you encapsulate it in a safe, protective area that you never want to go to.

Yesterday I met a family -- a husband and wife, and he was a Vietnam vet -- and he clearly said to me: "I have these problems, and I have Vietnam experience. I will not talk about Vietnam. Don't ask me to." And that was the line. And I'll respect that line, but it also means that there's an enormous amount of difficulty that will not be attended to.

I think that's a real mistake. And I think that if we can learn anything from war, if you look back on the experiences of war from World War II and World War I and the Civil War -- Soldier's Heart and combat neurosis and all the other euphemisms of what it means to be exposed to that type of experience -- I think that you have to be able to support the veteran in a way that is respectful of their experience, which is absolutely unique.

I describe war as a unique war for every individual that was involved. Even if you and I were this close, your experience will be different than mine, and your reaction will be different than mine. And that makes it much more complicated. ...

When civilians try to understand experiences like this, there's just a huge gap. What is it that civilian culture, people who haven't been into combat, what is it that we can't understand?

I think it's the feeling of [being] trapped. If you don't like what we're talking about, you can turn to another channel. If you don't like what you're witnessing, you can go to a different location. In war you can't. It is all around you. ...

Civilians, can they understand? If they can stretch their mind to being trapped, then they'll understand. And if they can understand the commitment that it means to go to war, then they'll understand that, too.

When I look at Vietnam, I look at the draft. A lot of you guys were just sent over without any choice. And look at the guys going over now to Iraq: They're enlisted. Is there a difference there? Do you think [that] when they come home, there will be a difference in their psychological reactions [to] the combat that they were in?

I think for some there is a commitment to being a soldier and to making it a career, and to be in five different combat zones over a 20-year period may not necessarily be that unusual. I'm working with some veterans that way right now. For the vast majority of people that are in the war currently, they were not necessarily planning [on] these things, [but] they stepped forward and honored their commitment. But I don't think they necessarily expected it to happen.

When you join the National Guard, the recruit[er] doesn't really mention that you might go and lose two years of your life. They['d] rather say, "Well, it's a weekend drill [once] a month, and you get paid for it, and you can get college tuition paid." There is an attractive quality about that, but they also don't talk about the other side.

... Vermont has a huge number of National Guardsmen coming back right now. What would you say about those guys in particular and their experience?

In any war, you're really never prepared. [They're] coming from northern Vermont, and they're going into 110-degree temperatures with sand and dirt and disease and a culture that's absolutely different. The cultural changes are usually really dramatic. I witnessed that with Vietnam. They [are] wonderful people in Vietnam, but their values were very different, and sometimes it became jarring to really understand that you and they think so totally differently. And I think that the returning soldiers from Vermont will have to readjust some of their expectations of how things are done again here.

One of the most common stories that I've heard is when they're coming back, a lot of them are coming through the main airports. And some of their first sort of stress reactions are being in line with other Americans and watching how spoiled Americans are, and how they complain about the smallest things, just to the point where a lot of these guys have told us they wanted to smoke out the guy who's complaining [about] the flight being late. Can you describe this coming-home experience?

Well, again, being in Vietnam, it was not of this world. So when the people talk[ed] about rotating back, completing their commitment and being allowed to go back, they call[ed] it "going back to the world." And that was not just something that was laughingly said, but they really meant it, that they were in an absolutely strange place, and that when they were allowed to leave, they escaped back to the world. And the vet two days ago talked about it as "the Nam." It becomes a place that is not necessarily geographic in nature, but rather cultural, and I think that they will also be talking about being in Baghdad and returning back here, and it will be a totally different world.

One of the things that we've noticed is that upon their return, a lot of these guys have not been wounded, the ones that we're speaking to -- not all of them, but most of them. And I've actually done that intentionally, because I'm really curious about the psychological experience separate from being wounded. And what we found is that they're just so relieved to get home that they're not thinking about anything when they're coming home except for seeing their family. And then basically it all hits the fan.

Right.

What's that about? What's that delay about? Can you describe it for me?

My experience talking with other vets ... [is] that when you're finally back here and you finally make connection with your safety, which is your family, and you actually begin to relax, that's when you begin to vibrate with the fact of where you were, because now you finally don't have to suck it up. You can actually acknowledge how scared you were. And it sounds silly, but you cannot lose focus when you're there. You cannot allow yourself the luxury of saying, "I don't want this," you know.

[When I was in Vietnam,] in the morning we would say: "Saddle up. Let's rock 'n roll." Did we really mean that? No, but it was what was necessary in order to step forward.

One of the things that feels a little counter[intuitive] to me is that soldiers coming home, often they have this very wonderful reunion with their family, but slowly, and sometimes not so slowly -- sometimes it's quickly -- they start to distance themselves. And so this sort of feeds upon itself. I'm trying to understand [why] the people who are closest to them in this safe environment are the people that they feel the least able to talk to.

It's a very interesting area. I think what happens when soldiers return is they're really beginning to struggle internally with what they experienced, what they did and what they didn't do. And they initially want to be reunited with the family, but what develops is usually a couple of things sort of [happen] simultaneous[ly]. They begin to have nightmares. Now that they're safe, they actually begin to acknowledge, in an unconscious way, exactly what happened. Sometimes they'll have flashbacks, which are videos in real time during the daytime that do not come announced. They just -- (snaps fingers) -- happen.

And it scares them, and they don't want to talk to their families about it, because they don't want the images of what they're feeling to be transmitted to the people that they love; they don't want to contaminate [them]. And they especially don't want to talk with females. They don't want that horror. So they look around at either relatives that have been in the service to try to talk with them or friends that have been in the service.

The other thing that happens almost simultaneously is a significant increase in substance use. Men have talked about being drunk for the first year, drunk constantly, because it's a way of not thinking; it's a way of turning your brain off chemically. And they go for the effect because they just want to put it away. But it doesn't stay away, and that's part of the problem. It's that ultimately they have to deal with it in some way. Either they compartmentalize it, which men tend to do -- women are much more sophisticated; they look at everything as holistic, and men tend to sort of put things in little boxes and think that it's going to stay there. And it doesn't. It contaminates.

One of the soldiers who just came home from Iraq not long ago said that alcohol is really his only friend. Can you tell me about that? What is the substance abuse link?

There's a serious problem with the culture of the military and substance use. With the younger people, it's poly-substance use: It's both drugs and alcohol. [It] is the way to stop the thinking, to relax, to not have that internal tension that you're vibrating inside. And [though] it stops that, it creates a whole host of other problems that ultimately lead to enormous problems. But in the short term, as a chemical, it does work, and they use it. And they're not stupid, and it's easily gotten, and it's almost instantaneous, and nobody has to give a prescription for it.

The problem is that it creates ... other problems. That's the real problem with it. They lose their jobs. They lose relationships; their children distance [themselves], because they're inappropriate and angry. Their anger comes out. They isolate more. They have more accidents. They have more fights. Life just is not good.

In a support group, we found pretty much every guy in the room talked about alcohol in that way. This big thing: "Nobody understands." "You just can't understand." Is that barrier something that can be overcome?

I think it can be overcome, but I think when a person is struggling with that, it's very difficult to put into words what goes on inside your head. What I find is that there are two major issues that are very, very difficult to really talk about. And one is guilt, and one is shame; one is doing things, and one is not doing things. And those things become the major problems, and the only place that I can see myself serving people is that I do understand, having been there. That is a leg up, so to speak. That is an advantage, I think. I'm glad that not everybody has that advantage, however.

It must be frustrating to have people that said good-bye a few years ago coming back now.

Yeah, it's hard, because they were doing better, but now they're not. But now they're learning that there's somebody that would be willing to talk with them about it, where before they really didn't think that that would happen. I call it skidmarks to the door. [Usually] the vet is pushed here by their wife, who says, "You either do it, or you're gone." And that is a repeated statement time after time after time after time. ...

So you're saying one of the biggest issues is ... [the need for these vets to feel that sense of heightened awareness, the adrenaline rush, that they felt when they were in combat]. A couple of the guys in Chicago were describing that for me. And what were your thoughts on that?

Well, I think that if you look at it as the ultimate threat, you need to react with that, and that if you look at risk-taking for veterans, it increases substantially. They begin, a significant portion of them, to carry weapons. They do riskier things [than] the general population would be doing. After World War II, veterans came back, and they started motorcycling. Before that, it was a gentlemen's thing. Now they were going cross-country. There's just an increase in risk that way, I find.

Jail times, drugs, fighting -- I think that they really understand that there are no limits. I describe wars as organized insanity. But if you look at the rules of war, there are no rules. And as soon as you understand that, then you're really challenging the basic assumption of your society. If there are no rules during war, then why would I want to do it? And therefore, I can do anything I want, and they have to catch me at it. And if you look at the population of veterans in jails, it substantially went up, fueled a lot with alcohol. But I think [they] also thought that there are no rules, and I can pretty much do what I want. Who's to stop me? And if they try, I'm going to resist. At some point, that becomes a very lethal arena. ...

Is that part of the frustration that soldiers have coming home with Americans [complaining] about being late on a plane or losing their luggage?

I think so. I think they don't understand. I think American society is insulated from the rest of the world that way. When you go to almost any other place in the world, you'll see populations struggling to put food on the table and to have something that they can call a home. And we are unaware of the rest of the world. When you go to a war, you are integrated into that society to a certain extent. You are part of that experience, and you take back how little do we really appreciate what we have.

Is that where the anger comes in, when these guys come home and are exposed to American culture again? I mean, the level of anger that I've heard from some of these soldiers is shocking -- mad at the college students, mad at the guy in the Starbucks line, wanting to chop off someone's head for cutting them off at the supermarket.

There are no rules. If you look at that as really what they're operating with, then the anger just comes roaring out of them. I think it's displaced anger. It's not the Starbucks guy. What we're saying is that you have no idea what the other part of the world is like, and I do. And you should know it. If I have to know it, you should know it.

And I think that's where the anger is. It's that their value systems have been fundamentally changed by that experience, and they keep that value system the rest of their life.

Everyone has told us that every soldier who goes into war comes home changed. What does that mean to you?

I think the experience of war is absolutely unique. I think that people -- men, women -- go into war with their own histories, and some of their history is good, and some of it isn't good. And I think that their experiences will forever color the rest of their life. Culturally, it's difficult for people who have not been in war to understand that.

The closest that I can describe it is two different ways: One is that it's a rape of the soul; it's a rape of innocence. You are exposed and see things and do things and [don't do] things that really challenge a lot of your values. The other description that I have is a car accident: Bad things happen, and people get hurt, and it's an instant in time that stays inside your head the rest of your life and affects you, and you are forever changed by that experience. That's as close as I can describe what it means to be in war, to be with your friends and watch them day by day by day die and be wounded.

And the question turns back to, for what? For what reason? And there isn't a really good way of saying there was really a good reason. It's a difficult area that we need to continue to be not enthused with going to war.

You had mentioned that there are two feelings: There's guilt, and there's shame. Can you elaborate on that? What did you mean by that?

When I talk with combat vets about their difficulties, there are memories, there are videos, there are stills, there are smells that are hardwired into their brain. They will not forget those, ever. Part of what happens is they interpret what they did and they interpret what they didn't do from the view of their age that they are currently. And they look backward on their experiences, and they said, "I should have ..." or "Why did I ...?" They convict themselves, and they're angry with themselves for a moment in time and a decision.

I have a lot of arguments about this issue, because I think it borders on spiritual issues, moral issues, and that none of us are judges except ourselves. And yet when we judge ourselves, are we putting the judgment in the hands of a 19-year-old? Or are we judging ourselves as a 57-year-old, as I am today? And that's what I argue about, that they still are judging themselves in the mind-set of a 19-year-old. When you look around -- from my experience, anyway -- at a 19-year-old, they're not quite adults; they're just extremely large teenagers. And you give them toys, and they make decisions that aren't necessarily the best decisions.

I went through a village [in Vietnam] one time, and I spotted coconuts up in a tree, in a palm tree. [I had] a rifle, an M-16, and I put it on automatic and let a burst out on the tree, and down came the coconut. And out of the hut screamed a mother, yelling at me in Vietnamese, that I had shot down her milk supply. And I didn't know that at the time. I felt bad. It was like, I was only playing. That's what it means to be in war at 19.

These soldiers, a lot of them will be coming back middle-aged soldiers from the Reserve and National Guards. I think that that will be an advantage. I think that as we age, we are able to define ourselves better, and I think that will be hopefully a help to them readjusting back to their families and their life after the war. ...

Talk to me about killing and what it means.

I've talked with people recently about the individual act of killing someone else. ... I've talked with individuals as well as several groups. A group discussion is very interesting, because men began to talk about how they felt about killing others. And the consensus was that it had to be done, because [if they didn't do it, they would be killed]. But there was also a sadness about it. They experienced it as a profound experience, each and every one of them. As we get distance from people, it becomes less and less.

... The people that we've spoken to, if they have killed someone, those images in particular are the most haunting, which I thought was a little bit counterintuitive to me. [I thought that] seeing your buddy die or seeing other horrible things that you could imagine happening [would be the most traumatic image], [but it] is really the act of actually taking another person's life that in the long run had the most emotional strain on them. Have you found this?

I think it is a very important thing [to understand] that when your friends are wounded or dead, it's a real loss. It's a loss of your friend that you trusted and you loved in a very intense way. When you personally take another life and you go up to that lifeless body with a hole in it and you look down on it, and you say, "I did that," I think it is a loss of yourself at the same time, and I think that [once] they understand that, they can't go back again. They can't say that it didn't happen, or [that] maybe somebody else did it.

The enormous firepower that were are currently expending in our modern wars, from Vietnam onward, blurs the line considerably, because if there's a massive fire and 2,000 rounds are going out at one time, who knows who shot who[m]? But all we know is there's a lot of people in front of us that are dead. That absolves you of the responsibility of looking at that lifeless body and [seeing that] some mother, some son, some father, some uncle, is now dead. And that's different than not knowing. Knowing, I think, is the Rubicon. And they talk about it with sadness. It's not something that they're prideful of; it's a profound sadness.

But its seems the military doesn't even address it, doesn't even ask about it. [On the post-deployment questionnaires] they ask questions like, "Did you see dead bodies? Did you see combat? Did you see anyone die?" They don't actually ask about a soldier doing the act of killing and the kind of emotional impact that would have. What would you say about the military's edict on that? ...

Well, I think that the military avoids it. I think the cursory questions that they're asking -- let's call them hallmark questions -- [are like] "Are you developing Post-Traumatic Stress Disorder?," but the questions are so vague that if you had images in your head that you didn't want to think about and you didn't want to talk about, it would be very easy to blow past those questions.

A questionnaire is a very impersonal way of doing it. The entire effort of assessment post-deployment is at best cursory. There are a lot of Web sites; there's a lot of literature; there are questionnaires. But there's no live human being sitting in front of you asking the questions, and that really makes the difference, because who would want to report something that you don't want to have? But if someone asks you directly in front of you -- a live human being -- it's a big difference. I don't think the military is doing that. I think they're avoiding that. It's expensive. It's expensive to have me and tens of thousands of me, and that's what's needed.

At some point, if we're going to go to war, and we value our young people, what better way to help them to be reintegrated into society, to have a positive life? ... I say that as a person that came back from war, and that didn't happen to me. And I had to struggle with my own memories and sort it out by myself. It wasn't easy, and I don't think it was fair.

[So basically the military just ignores it ... the actual subject of killing?]

The issue [of] the aftereffects of killing, personal killing, I believe isn't understood. I don't think the military understands how to deal with it. It is the effects of personal responsibility for taking another life. How do people react to that? How do they look at the spiritual issues? How do they look at the societal issues? How do they look at their family values?

We have been always taught not to hurt others. I know when we go to war, we're taught to kill directly. The current war in particular will have a profound effect on people, because of the very nature of the directness of the killing. We're not talking about distance killing. We're not talking about an atomic bomb or a firestorm, [like the one] in Dresden that killed 200,000 in a night. We're talking about disintegrating someone in front of you. That needs to be addressed by acknowledging that it does have an effect on people. That is what it means to go to war, but that person will [need] some support in understanding themselves better and not to have a silence about it.

The silence is really the damaging part, and I would strongly encourage people to talk to people that they trust about it. And if that isn't possible, then they need to figure out who they can begin to trust with [it], because they shouldn't just sit on it. They shouldn't just try to make it go away. It won't go away.

... The Army now does offer combat stress control [to] people who are actually in combat: trained therapists, counselors, psychologists, even psychiatrists. [But the anecdotal evidence] is that [for] soldiers who actually seek help, the stigma is so huge, most won't seek help in the field, in combat, in theater. And if they do seek help, the stigma that happens to them and their careers afterwards is so detrimental that it just sets an example for all the other folks who might use [the resources].

The military career is based upon being powerful and being in command at all times. I have a picture of John Wayne on my wall, because we as men are taught to be John Wayne from about 2 years old onward by our mothers. I think that's really cool, and yet the problem with attempting to be John Wayne is that you can't be yourself. You can't be expressive; you can't have weaknesses; you can't have reactions; you can't have sadness; you can't be grieving; you can't be confused, lost.

When you look at soldiers in the command structure, how people make advancement is on their fitness for duty, their readiness, their ability, their successes. If a person is struggling, that's not necessarily good for their career. I've had soldiers come in quietly, not wanting the military to know, asking me directly, "Does the military have access to my records here?" So there is a significant concern that they will not be made for the next promotion. They will not get that next job based upon the perception that we have a weak link.

Is it a realistic fear that if they do turn to mental health professionals, ... their careers [may] be affected detrimentally?

I think that it's a very gray area, because the soldier is not necessarily an employee that can say to their employer: "I have a right to privacy. You can't see my records." A soldier is part owned by the military. If you hurt yourself in the military, they can charge you with destruction of government property. I love that one. So at some point, the military can require that you provide those records, if they know about them. And that becomes a dual-edged sword. So I think there's a real disincentive for coming in for counseling and to admit that you have a mental health issue to begin with. Even in American society in general, it is the most discriminated[-against] disability that there is.

A soldier comes to see you. You're part of the VA. Are his records confidential?

His records are confidential as long as he's not required to sign a release of information for the military to access it. If the military says to him, "We require to see your records at the VA," then the soldier has a problem.

Can the military do that to any soldier they want to?

You betcha. The military, I believe, can request fitness-for-duty reports. If they have questions about a soldier's ability to function, they have a right and a responsibility to make sure about that. So there is a conflict of interest, let's say, between fitness for duty and the right for privacy. And in the scheme of things, the government says, "Our right supersedes your right for privacy, and if you're not willing to allow us to see those records, then we're going to make decisions based upon that."

[It seems pretty obvious, then, why soldiers don't seek out help for their mental health issues.]

The issue of talking to somebody when you're having problems I think really is a major problem. I think we don't do any kind of real assessment of after-action. We don't do debriefing. The best case is that if the unit is pulled off the line for resting time, alcohol will be available, and you and your squad of eight men can all get drunk and be stupid and sloppy and talk to each other and reveal. And that's probably as close to what will be expected, permitted, structured as the military will provide. I think that to do otherwise would be to really invest heavily in this area. They have MASH units that are fully equipped to deal with blood; the military, I think, avoids emotional blood. I don't think they see it as real problems. And I think that's the problem.

[But why don't they invest more in person-to-person mental health treatment?]

Money. Web sites are all low-cost issues. That can be set up and deployed worldwide at very low cost. To be able to assess for trauma, you have to have live human beings doing it. You cannot do it through systems, and that costs money that the military does not necessarily [want to] invest in. They would rather invest in hardware. They underestimate the destructive nature of war, and I think that's a major policy mistake.

What do you mean when you say they underestimate the emotional impact of war?

They think it goes away; it just goes underground. It doesn't go away. And 50 years later, it can reemerge. What have we done in those 50 years to that family? How has that person benefited from serving his country? I don't believe that that's the price that veterans should have to pay. I think it's the price that we should have to pay first.

You were saying that the military believes emotional trauma goes away. They don't deal with the "emotional blood," as you were calling it.

Right. I think what the military doesn't invest in is the responsibility to assist with the adjustment of the veterans to the emotional reactions to war. I think they're investing in the wrong product. They should be investing in their most valuable resource, which is their people.

And how you protect that is by allowing at-the-minute help. You don't postpone it. You don't say, "It isn't there." You don't say, "You'll get it when you become a civilian again." You say: "We really care about you, and here's somebody that we want you to talk with. We [don't want you to have] this 'emotional blood.' We want you to function in a way that you can function better. We're really interested in helping you with that, and ... we're not going to punish you if you seek that."

I think that in American society in general, there is a real difficulty with acknowledging that [in addition to] medical illnesses, we also have mental illnesses. ... Then, if we can look at the military as just an extension of the society bias, then we really ought to take a look at how we prepare soldiers for war and how we prepare soldiers to become civilians again. And I don't think we do justice to the middle all that way. ...

Something that Andrew Pomerantz has talked to me about is that there is a real treatment window: There's a window of time where if vets could come in -- returning soldiers who are here just on a year leave or whatever it is -- if they would actually talk about it sooner, that would be better.

What happens with the returning vet is that they have these feelings, these images, these smells, these nightmares occurring frequently, and they're quite disturbed by it. They're spooked by it. Their readjustment time is much more difficult because of it. Let's call it the golden hour of being able to have someone surface or reach out to someone and say, "Gee, how you doin' with that experience?" They're more likely to be able to say, "These are the things that are happening to me, and I don't know what to do with them, and I'm feeling bad about myself." I think if soldiers are allowed to distance themselves from that, they encapsulate it. They put it in a box. They lock the box, and they stuff it under their bed. They don't ever want to go there again.

I began to talk with a blind World War II Navy man who was running on a board ship at the battle of Okinawa, and his small ship was directed to go near the shore just so that the enemy could shoot it out so that the bigger ships could shoot at the enemy. In effect, he was bait. He had never talked about it in 55 years. You need to be able to have the [same] type of timely services as you would if a person is bleeding. It's the same kind of effect, but we don't acknowledge that.

A counterargument could be made: What's the big deal if he doesn't deal with it for 55 years? What does it do to that man's life?

I think it does two things. One, the avoidance of dealing with it provides no help to the veteran. The life quality is significantly shortchanged. The interaction with family is very distant. ... You have frequent job changes, frequent divorces. The men last week at the group therapy session had five divorces. So these kinds of things really do impact the quality of the veterans' life over their lifetime. And as [with] most preventive things, if you enter early, you'll have a much greater effect in improving the quality of the life. ...

Again, it comes down to the confusion that for each individual, they have their own war and their unique reaction to that war. And for that man to say "I cannot do this" was a statement of truth. And it was not seen as a statement of truth.

When I was in Vietnam, there was a man walking point before me by the name of Schwartz, and Schwartz lasted three days walking in minefields. And on the fourth day we said, "Saddle up," and he just started crying. He said, "I can't do this anymore." The commanders made him into a cook at base camp. I thought that was a humane treatment of a man that really, really tried.

We have to look around at what ... it means to have a reaction to trauma, to seeing a dismembered body and internalizing that: It could be me, I could be next, or maybe I'll do that to somebody. At some point, we can't make those kind of judgments for somebody else's view. And I think that we need to be open to allowing the soldiers to be human and not to be a machine, because when they become a machine, they're not human anymore. That's part of the problem.

Your command made the guy a cook, but that's not what I'm hearing happens in most cases. Tell me what really happens.

What really happens is that the command looks around and says, "If we let this guy loose, we're going to have a herd going in the same direction, and therefore we're going to have to set real limits." And they set limits that are really not respectful. It's a trap. Once you're in, you're in, and no amount of whining will get you out. Yet that doesn't really address the issue of real people struggling and emotionally bleeding and not being able to function. ...

What I'm seeing is they actually do have these guys in the field --

They don't.

They have some of these [counseling] guys out there --

If you look carefully -- you've got to get past the PR stuff -- they have privates; they have corporals; they have ordinary soldiers walking around different units saying: "How ya doin'? What's news?" And that's what they have. If you really look around at the company that [is] doing the assessment, there is [one] psychologist. There is not a company of psychologists. That's a different price tag. That's a different level of professionalism of real understanding of assessment. They don't have transportation proper. They don't have communication.

At some point, it's a PR piece, in my opinion. If they wanted to provide a company of psychologists to do the assessment and to do the triage and to do the PTSD assessments, that would really help them to retain more people and to recover people that are troubled back into active-duty service again. But at some point they see it as a threat, a very clear threat to them, and they don't --

What's the threat?

The threat is that they'll lose control of who goes and who stays, that the psychologists will then become the ultimate decider. And I don't think that they like that, because there's a disregard for psychological babble talk. It's easy to quantify a bullet wound or a blast and an amputation into money. It's much more difficult to say, "I have these problems, and I can't function because of these problems that are in my head." That's a harder place for the military to trust that it would be fair. ...

While in the military or in the VA, have you seen evidence that if people were to ask for psychological counseling, it is, in effect, the end of their career?

I've seen that people seeking counseling have been reassigned, and their job has been taken away from them because of that. It can be because of the command decision to reduce the stress, or it can be the command decision that the person is in a job that needs to have somebody fully functioning. And I'm not making a judgment of how they do that, but [it does] have an impact on their career[s]. ...

A lot of us are in therapy. We're highly functional people. We have jobs, but we seek help. What I hear in the military is even if you seek help, your career could just come to a halt, even by the simple motion of saying, "I need help."

The issue of the military having a reaction to a person's seeking help really comes down to the perception that seeking help means that they have a weakness of character and that can they [n]ever be trusted again not to break. Therefore, [the military] opts not to take the risk, as opposed to invest[ing] in the person. There's a real difference if you consider the resource of the person or [if] you consider the person a unit. And if that unit has a history of seeking counseling, what will happen in the future? The [answer] is, we pass on that person. It's the avoidance of risk with no justification for why they're doing it.

So the second that you have an issue or a problem or have an adverse reaction to something horrible that you just saw, you're just sort of kicked out? What's that about?

It has to do with the unrealistic expectation that you can take anything -- anything -- and not break. We are deluding ourselves on that issue. We all have breaking points. All you need to do is be presented with it, and you'll break. Will you break in the future? Not necessarily. But then again, maybe yes.

That's really what it's about. We assume that the military is omnipotent and ever strong and made of steel. [But] it's struggling human beings. That's what it's about. If we can acknowledge that we're all human, that we all struggle, that we all have our breaking points, then [it's a matter of] having national security or functional issues. But don't base it upon maybe sometime in the future. That's not good enough. It betrays the trust that the veteran has provided to the military. ...

Can you just address how once you've been through [combat], everything else you'll do in your life for the most part pales in comparison? How [does] that start to formulate your sort of mental makeup for the rest of your life?

The issue of adrenaline and combat is one that I find interesting in that there's an intensity that you don't easily have as a civilian prior to the military. There's an attraction to it. There's a high, a chemical high, an adrenaline high that makes every pore alive, every sound, every movement, every color becomes more vivid. I must have seen 30 colors of green in Vietnam. It was just that alive. And when you return back to the civilian world, there's an attraction back to it. ...

And there's the issue of fear. When you've looked at how combat produces fear and yet you can control the fear most of the time, there's not a fear of losing control then. So it's easier to approach the adrenaline high because you know that you have that control of yourself. There's almost a recreational use of it. To return back to that level of instantaneousness and focus, you don't get that in the civilian world of polishing the car.

Something people have told me about is this feeling of being sort of dead or empty when you come home.

Right. It's hard to explain because it's almost suicidal in nature. [It's] that you don't care. I came back [from Vietnam] and I started quoting Chief Joseph, one of the great Indian chiefs of all time. He said: "Today is a great day to die. And if you're prepared to die today, as I am prepared to die today, then you've lived your life." But if you're saying, "Well, gee, I really want to do this sometime in the future, but I'll get to it soon," you'll have regret. So there's a real immediacy to this. You can attend to yourself today, because tomorrow you may not be here. That's the difference. We tend to postpone life up until the end, and then we want more. But there is no more. ... In combat, three minutes is a lifetime. So you don't come back saying "I'm going postpone." You come back saying, "This is what I'm going to do."

I got out of the hospital process, and the next day I started college. I knew that immediacy was there. Being in the moment is what I talk about constantly. If you can be in the moment, then you're fully living your life. If you're living in the past, you're not in the present. If you're worrying about tomorrow or next year, you're not right now. Now is now. That's the only part that I truly control, is right now in the present with you here.

So you really believe that these therapies work, that these soldiers can recover from PTSD?

I long ago decided that if I wanted to be a raving lunatic, I am fully capable of being that. I can be lethal. And at one point in my life, I was -- after Vietnam. It scared me, and I said [to myself], you really ought to take care of business, Jim; you ought to get your own head straight about your own experiences. And I did that. I don't want go back to being in that dark place again, so I try to be realistic, and yet I also look at human nature as being a positive thing, a hopeful thing. I really am. Without that, I don't think that I could do the work that I do.

And when I work with people, it's my assumption that things will get better. My joy is that, when they come in and tell me: "Gee, Jim, I'm doing OK. I don't need to see you anymore. I'll call you if I need you." They do that on a regular basis, and that's what rewards me. That's really the high of the work, is to see people reunited with their families and being stable and enjoying themselves again and moving forward. That's a very big part of the addiction of doing my work. To see that kind of joy, happiness.

So to sort of advertise, I think if people are struggling with these adjustment issues and these memories, the best thing that they could do, both for themselves and for their families, is to talk to somebody that they can learn to trust, that they can talk about important things with, and sort out their own self, because sometimes it's really hard to do that in a cave. You just can't get out of the circle of thinking. Somebody else may have a better idea of how it really works.

I look at the other VA centers around, and I'm not seeing the same level of just giving that I hear from you. ... The system is already so overburdened. So I'm looking to the future; all of these guys coming home over the next three or four or five years, and I'm wondering how an already overburdened system can even begin to reach out to these folks.

The reality is that the VA is committing resources to be able to help. Do they have the funding from Congress? No. Has Congress approved the mandatory funding of the VA? No. And it should; it's desperately needed. That would end the chronic underfunding. I think that if people can reach out and seek help, they'll get it. There are a lot of people, actually, like me in the VA that do care. I found as a patient of a VA ... that most people do care.

... There will need to be decisions made by individual people on how they're going to handle the increase. For some it will be a system shift. They will rearrange whole teams of people. For others, for myself, for example, in an isolated outpatient clinic, I'll need to reprioritize how I divide my work, who do I prioritize and what time goes to who[m]. It's already happening now. But I need to be able to serve those that are in most need. To do otherwise is to betray them. I won't do that. ...

To ask someone to do something that they can no longer do condemns them. At some point, we have to really look around at why we can't have a humane command. Is it all or nothing? Why? I think it sends the clear message to other soldiers in that unit that you have no option, and we'll let you know when you're done. Otherwise, there may be encouragement of malingering: "I don't feel well. I have a headache. I don't want to go on patrol today. It's a rainy day. It's cold." This is not the way the military operates. They say "go," you go. They tell you to jump, you ask, "How high?" It's raining? You sit in the mud. What's the problem?

I think this thing will challenge some of those authority issues on humane issues. It may actually encourage some of the restructuring that needs to happen as far as the counseling, to be on site within the theater in the division, and not just window dressing.

Tell me about the range of care that's offered for mental health.

The question of quality of counseling services and triage is a really interesting one. Walter Reed has been in the news a lot. Actually, I got a call about a month and a half ago, two months ago, from Walter Reed, looking for a Vermont vet. They were looking to see if we had satellite transmission uplink capability, and I needed to let them know that we didn't have it; [rather,] we had it, but we didn't have it currently, and the nearest one that we had for the VA would be an hour and a half away for the soldier.

They had a psychiatrist that wanted to do telemedicine talking via television to the veteran to continue the therapy. I also offered services at the clinic, which is about three miles away from him. The VA is beginning to understand the need to focus on this.

I think there [are] PTSD specialty teams at each of the medical centers. I think that's a help. The long-range planning of increasing the medical team with counseling in the more remote areas such as my outpatient clinic is very helpful.

So those things are moving forward. There's going to be, in the next five years, a real effort to put the telemedicine technology in the smaller clinics. That will broaden expertise; that will allow an increase in timely services.

But ultimately, it really comes back to the issue of funding; that if there was money, the VA would spend it to help veterans. I truly believe that. But I think until Congress sees that as a national policy shift, the VA will continue to try to do what they can do with what they have. And that may not be good enough. That's the real problem with them. The VA becomes looked at in negative light, when in effect, if you look at the reasons why, it's pretty apparent why.

 

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posted march 1, 2005

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