Post-traumatic stress: The battle after the battle

KIRKUK, Iraq -- Sgt. Seth "Doc" Musikant could be a recruiting poster for the Army's new approach to PTSD, post-traumatic stress disorder.

Last April, Musikant and his team were driving around a traffic circle in the city of Tuz. It was their second time through the roundabout that day, and between trips somebody had planted a homemade bomb. It blew up their Humvee.

One of his comrades was killed, and three were wounded. In the frenzy that followed, Musikant handed his M-4 rifle to the Iraqi interpreter, screaming, "Pull security!" Then Doc, a medic, scrambled to treat the wounded.

Musikant, with the 3rd Battalion, 6th Field Artillery of the 10th Mountain Division's 1st Combat Brigade, was on his second tour in Iraq. Although he felt that he'd proved he had guts during his first tour, in Baghdad in 2005, the incident in Tuz bothered him. "It's like there's an invisible wall," Musikant said about the anxiety that temporarily troubled him.

He went to see the brigade's main mental health officer, Maj. Kyle Bourque.

"I told him it was bothering me," the 23-year-old former art student recalled. "I literally walked away with scratches. He said not to keep it inside, gave me some Ambien (a sleep aid). I still don't talk about it with anybody I don't know."

Never has the U.S. military been forced to confront so much of "the battle behind the battle" -- the psychic and emotional wounds of war. What's more, grunts no longer bear the brunt of such attacks; thanks to suicide bombers and homemade bombs, drivers, cooks and other rear-echelon troops have also been killed and wounded.

A recent Rand Corp. study (criticized by the military for relying on too small a sample), calculated that some 300,000 out of 1.6 million veterans of these two wars have suffered some sort of PTSD or TBI, traumatic brain injury, which used to be called a concussion.

Nor has the military ever faced such sharp criticism for its handling, or mishandling, of the mental well-being of its troops, but never before have commanders and their troops dealt with the problems and the stigma of PTSD more directly than they've begun doing in Iraq and Afghanistan.

For one thing, it's cheaper to treat PTSD than it is to train a new recruit. For another, said Bourque: "The healthier their personnel, the better off the Army is."

Now the Army identifies a condition called Acute Stress Reaction (ASR) -- the immediate aftermath of a traumatic incident in a combat zone. Since PTSD takes months, sometimes years, to manifest itself, military doctors and counselors prefer the new term to describe what they regard as normal reactions among troops confronted by abnormal situations. Last year, the Army launched a mandatory training program to identify and treat the causes and symptoms of PTSD. The Pentagon no longer treats visits to a counselor as an adverse factor in giving security clearances.

What the 10th Mountain's 1st Brigade Combat Team has been doing for the past 11 months in Kirkuk province offers an inside look at how a gung-ho gun-slinging outfit is dealing with the toll its troops cannot see.

Because its commander, Col. David Paschal, one month into this tour, had to deal with the deaths of four of his personal security detail, the 3,500-strong 1st Brigade is probably more proactive about the problems posed by PTSD than many of its Army counterparts are.

Its troops generally agree that during this tour, much more is being done for soldiers gripped by nightmares, flashbacks, survivor's guilt, apprehension and thoughts of suicide.

"The command has zero tolerance for blowing off a soldier's concerns," said Sgt. 1st Class Keven Duncan, himself wounded in Baghdad during his unit's 2005 tour. (It was Musikant who pulled him out of a burning Humvee.)

The Army's term for what happens when a soldier sees what Col. Paschal calls "things so horrific that no human should ever have to see" is called a CID, a Critical Incident Debrief. That mandatory session takes place 24 to 72 hours after an event that may be sapping a soldier's will to fight.

All the soldiers involved in the incident gather, and Bourque and one of the unit's chaplains join them at the medical clinic or the company command post. The meeting persuades soldiers to re-experience what happened so there's a common view of the facts. Sometimes, participants write accounts of what happened; they're asked to include not just the facts, but also their feelings -- even smells -- of what went down.

That first meeting is supposed to show the soldiers several things:

The Army isn't looking for fault or blame.

The Army isn't looking to send them home.

Other soldiers feel the same ways they do. "We help them take an abnormal event and normalize it as much as possible," says Capt. Miller Eichelberger, a brigade chaplain.

More help is available than was in the past. Capt. Lindsay Tepelsky and her unit, the 528th Combat Stress Center at the brigade's main base, said they help dozens of soldiers a month with problems ranging from acute stress reaction to marital problems to sleeplessness.

After the first talk among soldiers directly affected by an event, treatment begins for those who say they need it and those singled out by their immediate leaders.

One common approach is regular one-on-ones with a psychiatrist or social worker in the unit. The combat stress detachment sends its counselors out to the solders' "workplace" -- a remote hilltop communications outpost or a base inside an Iraqi village. Seeing traumatized troops in surroundings familiar to them helps them open up more, Tepelsky said.

In theater, commanders administer a Unit Needs Assessment, which anonymously asks soldiers questions about their health, behavior, family and other issues.

Mental health pros such as Tepelsky give feedback from the survey to leaders. "The Army says, 'Let's address things before they spiral out of control,'" she explained.

If the anxiety persists or worsens, the soldier is sent to a "fitness" program at two big nearby U.S. bases, where there are classes, consultation with a therapist and an exercise regime. Counselors and chaplains continue to meet the soldier regularly to gauge progress, or a lack of it. Some are given temporary limited duty or even some in-country time off.

Only a few return to the unit's home base, Fort Drum, N.Y., or elsewhere for further treatment. Fort Drum recently opened an off-base clinic and other facilities for long-term care of its troops.

Although brigade officers insist that any stigma once attached to seeking psychological counseling has disappeared, some enlisted soldiers disagree.

"There sure as hell is" a stigma, said one female noncommissioned officer. "I wouldn't want it on my record." Added another enlisted man, "Everybody wants to be hooah (enthusiastic), and nobody wants to be thought of as a (wuss)." Neither would be quoted by name as they weren't authorized to speak to the media.

Some soldiers have found ways to cope with PTSD and other stressors. Sgt. Andrew Bennett, 22, a tall, taciturn infantryman from Seattle nicknamed "Robot" for doing square roots in his head while talking over his Humvee's internal radio, was wounded in the neck and shoulder during his unit's 2005 deployment in Baghdad.

When Bennett was being treated at Fort Drum, he didn't go near a counselor, and he was glad to redeploy to Iraq last year. "I didn't feel I needed it," he said. "I didn't have any of the PTSD symptoms. I sleep fine and don't have nightmares."

The 1st Brigade has been aggressive in pinpointing and dealing with its troopers' mental health in part because of what its commander, Col. Paschal, went through. He sat in a Critical Incident Debrief after an IED shredded a Humvee in their convoy a month into their deployment. Four of his own bodyguards were killed.

Nearly a year later, as he talked about what his brigade was doing about PTSD, Paschal recalled that event. Sitting in his small office, insisting that his soldiers will immediately pick up "fear or doubt in your eyes or voice," he suddenly stopped talking.

He looked at his boots, then at his big hands, rubbing them together, swallowing and blinking. Finally, he completed his thought -- that he and his sergeant major had put the remains of the four dead soldiers into black rubber body bags.

The colonel looked up: "There's not a day goes by that I don't think about 'em."