As the U.S. military wrestles with President Barack Obama's plan to expand the war in Afghanistan while reducing its presence in Iraq, there's a mounting cost on the home front for the 1.9 million soldiers who have been deployed to those conflicts and are now beginning the often difficult transition back to civilian life.
Inadequate stateside mental health and other veterans' services has been serious problem for years (see "Soldier's heart, 12/22/04). A report in January 2008 by the RAND Corp. titled "Invisible Wounds of War" found that nearly 20 percent of Iraq and Afghanistan veterans report symptoms of posttraumatic stress disorder (PTSD) or major depression, and that an additional 19 percent experienced a possible traumatic brain injury while deployed. But only slightly more than half of these returning veterans seek treatment that RAND called "minimally adequate."
The report estimated that PTSD and depression will cost the nation $6.2 billion in the two years following deployment, but also estimated that investing in more high-quality treatment and thus lowering the rates of suicide and lost productivity among veterans could reduce those costs by $2 billion within two years. Modern life-saving and protective technologies and repeated deployments appear to be making the problem worse now than in previous wars.
"Early evidence suggests the psychological toll of the deployments may be disproportionately high compared with physical injuries," the report stated, concluding that a national effort is needed to expand and improve the capacity of the health care system and to encourage veterans to seek this care.
That national picture is reflected in San Francisco. Judi Cheary of San Francisco's Department of Veteran Affairs medical clinic said that 25 percent of the service members they see returning from Afghanistan and Iraq receive a mental health diagnosis.
Keith Armstrong, the clinic's PTSD counselor and a professor of psychiatry at University of California-San Francisco, noted that veterans often have a diagnosis that includes depression and PTSD, or substance abuse and PTSD. "So they may be struggling with many problems," said Armstrong, who wrote Courage After Fire: Coping Strategies for Troops Returning from Iraq and Afghanistan and Their Families (Ulysses Press, 2005). "Others simply have adjustment challenges from being in combat."
For instance, traffic can be difficult for returning service members who drove in combat conditions, where explosives were a constant concern. "They are scanning the environment because that's what kept them safe in combat, or pushing the steering wheel when a friend is driving, trying to move from one lane to another," he explained.
According to V.A. data, California has the third-highest number of veterans in the nation. In Northern California, most live in the Central Valley, leaving some San Francisco vets feeling isolated. "There's a lot of talk about supporting the troops, which is nice, but it's intellectual," Armstrong said. "Here people may not disclose that a family member is in war, not because they're afraid people will spit on him, but because they are afraid that people will say dumb things."
His clinic has seen an increase in these veterans in the past year. Armstrong typically sees three clusters of PTSD symptoms: intrusive symptoms (vets can't get particular images and experiences out of their head); avoidance symptoms (vets believe they don't have a great future ahead; they feel numb, it's hard to get close to them); and arousal symptoms (vets are often irritable and angry).
Anger often causes the most problems. "We see more self-destructive and reckless behavior in younger folks," he added. "They have anger, revenge-based fantasies. They know what it's like to blow someone's head off or to see it being blown off, so when they get angry, that crosses their mind." But he said that couples and families often talk more about "the numbing" and "the inability to connect."
Armstrong also pointed out that many vets worry about the effect on their career of getting help, and how it looks to others if they do. "That's due to both their training and age group," he said, noting that 50 percent of soldiers are 17-to-24-year-olds, and 89 percent are male.
"So it's not just about war, but about the developmental stage of the troops," he said. "It's an appropriate age to be independent and not get any help. But that, combined with the stigma of asking for help and if they have PTSD avoidance symptoms can keep them from going in."
As a result of recent studies showing that PTSD can develop up to five years after discharge, the V.A. extended what was previously a two-year limit in which veterans could get help to a five-year window. They also now have a suicide prevention hotline number for vets: 1-800-273-8255.
"The V.A. overall has made some mistakes, but it has really taken suicide prevention seriously," Armstrong said.
There are nonprofit options as well. Founded in 1974, Swords to Plowshares provides counseling and case management, employment, training, housing, and legal assistance to homeless and low-income veterans.
Equally important, it's staffed by veterans like Walter Williams, who served in Iraq and Afghanistan and has combat-related PTSD, and Tia Christopher, a survivor of military sexual trauma. "The experience of being in a war zone as well, or being sexually assaulted by some one in your own unit, that's profound," Armstrong said.
As Christopher explained, she and Williams have similar symptoms and attend weekly V.A. appointments to deal with their own mental health issues, between providing services to other veterans at the group's Howard Street office.
"Pretty much everyone coming back has combat stress and everyone I know has been buying rifles," Christopher said, noting that cleaning guns can be a meditative therapeutic activity for veterans. "Combat stress becomes clinical PTSD when those symptoms don't go away."
Christopher said women who were in combat and survived military sexual trauma face "a double whammy." Out of the military for more than seven years, Christopher observed that "things get better, but the memories don't go away."
In 2007 there were more than 2,000 reported military sexual assaults, but only 181 were court-martialed, she said. "So basically survivors are dealing with injustice of nothing happening.
"I used to wish that PTSD gave you purple spots," she added. "That way people would know you had it. Instead, you are left dealing with getting panic attacks all of a sudden and being on edge."
"I call it a flare-up," Williams said. "It's different each time. Sometimes, when I have to focus and get my mind around something, I'm blank. I feel like I want to cry, but I can't."
Unlike past generations who openly identified as vets, "this new wave of vets is "more intent on blending in," Williams said. "They're trying to suppress their symptoms. They don't want to be seen as weirdos."
Deployed to Iraq and then Afghanistan as a communications specialist in 2004, Williams recalled having to give up his weapon twice and being put on suicide watch. "For a week, they watched me, then they gave me my weapon back."
He's convinced that the best solutions to the challenges facing this latest wave of PTSD-afflicted vets lie in "listening to stories from the mouths of people with it," he said.
Bobbi Rosenthal, regional coordinator for V.A.'s homeless program, said that an estimated 20 percent of the 6,514 people recorded in San Francisco's 2009 homeless count are veterans.
Anita Yoskowitz, administrative site manager for the V.A.'s homeless services center on Third Street, said 90 percent of the vets who use the clinic' showers, laundry facilities, and computer lab have PTSD.
And while many of the center's clients are still from the Vietnam and Desert Storm era, the average age is starting to come down, she said, as veterans from Iraq and Afghanistan begin to trickle in.
Veterans can come to the clinic every day, but those who are not clean and sober are limited to three times a week. When folks come for medical care, Yoskowitz said, "the clinic is on the look out for mental health problems."
Jacob Hoff, who volunteers at the center's computer lab, said that from conversations he overhears, it's clear that coming back is hard. "There's a lot of survivor's guilt. I can really tell the young kids who are coming in and learning how to be homeless. The older guys tell them where to go for food."
Donald Fontenot, who enlisted in 1980, was on the computer looking for housing when he shared his story. He enlisted when he was 18 and then messed up his knees jumping out of a C-141 jet, so he understands the stress of no longer being able to perform.
"You are young and strong and then all of a sudden, you can't do these things," said Fontenot, who was living in his car behind the clinic until it got towed by the police. "So I wound up more homeless."
Currently staying with a friend, Fontenot recalled meeting a Vietnam vet who likes to walk around Golden Gate Park at night with a pistol. "It gives him the feeling of walking around in the jungle," said Fontenot, who is searching for suitable Section 8 housing another unique challenge for PTSD-afflicted veterans in San Francisco.
For some, the road to recovery leads them from the streets of San Francisco back into the arms of their family. One such local family shared their story with the Guardian and we decided to shield their identities for privacy. Mike recalled the dramatic change he saw in his brother, Joe, who joined the Marines directly after 9/11, after he tore up his shoulder in Iraq.
"His whole mentality, even if he didn't support the war in Iraq, was of a to-die-for-it Marine," said Mike, recalling the hurt and disappointment in Joe's voice after he had two surgeries, and couldn't return with his unit to combat.
Mike said his brother's state of mind worsen after he had been out of active duty for three years, and that the first signs that his brother might have PTSD were night sweats and an inability to pay attention.
"But how can you expect soldiers to pay attention to isolated thoughts, words, and action, when they are or have been immersed in culture that teaches you to 'walk, talk, shoot, shit'?" Mike asked.
Joe was homeless in San Francisco for stints in 2007, but never longer than a week. Mike recalled how things came to a head when the two brothers got into a fight one night after Mike closed the bar where he worked.
"Here we are, I'm 30 and he is 28, in a fist fight, and I told [Joe], 'I think you're losing your mind.' And he said, 'then save me,' lying on my kitchen floor at four in the morning. But then that was it, no more conversation."
Joe soon checked himself into a couple of private facilities where he berated psychiatrists for not knowing about military combat zones and could always check himself out. "Then he went over to the East Bay, went into a 24-hour Fitness Center to use the shower, got into it with a security guard for trespassing and disorderly conduct, got arrested, and was brought to the V.A.'s PTSD center in Palo Alto," Mike said.
It was at this state-of-the art facility that Joe began to get help, and this year he returned to Chicago, where he is living with family until he returns to school to pursue his master's degree. Joe's mother, Betty, said dealing with all this has been minor compared to the prospect of losing her middle son permanently. But she resisted labeling behavior she believes was connected to his imploding marriage and financial problems when he moved to California, as well as to fallout from his injuries in Iraq.
She recalls getting an e-mail from their now former daughter-in law saying, "Joe has been living in the park, camping." Betty said the first year after Joe came back was pretty tough. "We knew the marriage was over. And a couple of times I called two of his real close friends who are Marines, to tough-talk to him. For a period of time, he was acting out, a different person. You could tell something wasn't right, and yeah, some blamed it on the service."
Asked what she thought of giving vets with PTSD a Purple Heart, an idea the military floated earlier this year, Betty said, "I don't know. They all have to go through it in some respects. My feelings about why he ended up totally collapsing is that he was trying to do too much on too little. They are over there, building cities and lives for people. Then they get back and find they can't support their families or themselves. But at least it's not like when folks came back from Vietnam and were labeled as bums."
Guardian staff writer Sarah Phelan's son deployed to Iraq in 2007 and returned in April 2008.