Tribe: On Homecoming and Belonging(19)

The discrepancy might be due to the fact that intensive training and danger create what is known as unit cohesion—strong emotional bonds within the company or the platoon—and high unit cohesion is correlated with lower rates of psychiatric breakdown. During World War II, American airborne units had some of the lowest psychiatric casualty rates of the entire US military, relative to their number of wounded. The same is true for armies in other countries: Sri Lankan special forces experience far more combat than line troops, and yet in 2010 they were found to suffer from significantly lower rates of both physical and mental health issues. (The one mental health issue they led everyone else in was “hazardous drinking.”) And Israeli commanders suffered four times the mortality rate of their men during the Yom Kippur War, yet had one-fifth the rate of psychological breakdown on the battlefield.

All this is a new way to think about battlefield trauma, however. For most of America’s history, psychological breakdown on the battlefield, as well as impairment afterward, has been written off to neuroses, shell shock, or simple cowardice. When men have failed to obey orders due to trauma, they have been beaten, imprisoned, “treated” with electrocution, or simply shot as a warning to others. It was not until after the Vietnam War that the American Psychiatric Association (APA) listed combat trauma as an official diagnosis. Tens of thousands of vets were struggling with “post-Vietnam syndrome”—nightmares, insomnia, addiction, paranoia—and their struggle could no longer be written off to weakness or personal failings. Obviously, these problems could also affect war reporters, cops, firemen, or anyone else subjected to trauma. In 1980, the APA finally included post-traumatic stress disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders.

Thirty-five years after finally acknowledging the problem, the US military now has the highest reported PTSD rate in its history—and probably in the world. American soldiers appear to suffer PTSD at around twice the rate of British soldiers who were in combat with them. The United States currently spends more than $4 billion annually in disability compensation for PTSD, most of which will continue for the entire lifetime of these veterans. Horrific experiences are unfortunately a human universal, but long-term impairment from them is not, and despite billions of dollars spent on treatment, roughly half of Iraq and Afghanistan veterans have applied for permanent PTSD disability. Since only 10 percent of our armed forces experience actual combat, the majority of vets claiming to suffer from PTSD seem to have been affected by something other than direct exposure to danger.

This is not a new phenomenon: decade after decade and war after war, American combat deaths have generally dropped while disability claims have risen. Most disability claims are for medical issues and should decline with casualty rates and combat intensity, but they don’t. They are in an almost inverse relationship with one another. Soldiers in Vietnam suffered one-quarter the mortality rate of troops in World War II, for example, but filed for both physical and psychological disability compensation at a rate that was 50 percent higher. It’s tempting to attribute that to the toxic reception they had at home, but that doesn’t seem to be the case. Today’s vets claim three times the number of disabilities that Vietnam vets did, despite a generally warm reception back home and a casualty rate that, thank God, is roughly one-third what it was in Vietnam. Today, most disability claims are for hearing loss, tinnitus, and PTSD—the latter two of which can be imagined, exaggerated, or even faked.

Part of the problem is bureaucratic: in an effort to speed up access to benefits, in 2010 the Veterans Administration declared that soldiers no longer have to cite a specific incident—a firefight, a roadside bomb—in order to be eligible for disability compensation. They simply had to claim “a credible fear of being attacked” during deployment. As with welfare and other so-called “entitlement” programs, a less rigorous definition of need—though well-intentioned—may have produced a system that is vulnerable to error or fraud. Self-reporting of PTSD by veterans has been found to lead to a misdiagnosis rate as high as 50 percent. A recent investigation by the VA Office of Inspector General found that the higher a veteran’s PTSD disability rating, the more treatment he or she tends to seek until achieving a rating of 100 percent, at which point treatment visits plummet and many vets quit completely. (A 100 percent disability rating entitles a veteran to a tax-free income of around $3,000 a month.) In theory, the most traumatized people should be seeking more help, not less. Investigators reluctantly came to the conclusion that some vets were getting treatment simply to raise their disability rating and claim more compensation.

In addition to being an enormous waste of taxpayer money, misdiagnosis does real harm to vets who truly need help. One Veterans Administration counselor I spoke with, who asked to remain anonymous, described having to physically protect someone in a PTSD support group because other vets wanted to beat him up for seeming to fake his trauma. This counselor said that many combat veterans actively avoid the VA because they worry about losing their temper around patients who they think are milking the system. “It’s the real deals—the guys who have seen the most—that this tends to bother,” he told me.

The vast majority of traumatized vets are not faking their symptoms, however. They return from wars that are safer than those their fathers and grandfathers fought, and yet far greater numbers of them wind up alienated and depressed. This is true even for people who didn’t experience combat. In other words, the problem doesn’t seem to be trauma on the battlefield so much as reentry into society. And vets are not alone in this. It’s common knowledge in the Peace Corps that as stressful as life in a developing country can be, returning to a modern country can be far harder. One study found that one in four Peace Corps volunteers reported experiencing significant depression after their return home, and that figure more than doubled for people who had been evacuated from their host country during wartime or some other kind of emergency.