When Johnny and Jane Come Marching Home: How All of Us Can Help Veteransby Paula J. Caplan
Traumatized veterans returning from our wars in Iraq and Afghanistan are often diagnosed as suffering from a psychological disorder and prescribed a regimen of psychotherapy and psychiatric drugs. But why, asks psychologist Paula J. Caplan in this impassioned book, is it a mental illness to be devastated by war? What is a mentally healthy response to death,
Traumatized veterans returning from our wars in Iraq and Afghanistan are often diagnosed as suffering from a psychological disorder and prescribed a regimen of psychotherapy and psychiatric drugs. But why, asks psychologist Paula J. Caplan in this impassioned book, is it a mental illness to be devastated by war? What is a mentally healthy response to death, destruction, and moral horror? In When Johnny and Jane Come Marching Home, Caplan argues that the standard treatment of therapy and drugs is often actually harmful. It adds to veterans' burdens by making them believe wrongly that they should have "gotten over it"; it isolates them behind the closed doors of the therapist's office; and it makes them rely on often harmful drugs. The numbers of traumatized veterans from past and present wars who continue to suffer demonstrate the ineffectiveness of this approach.
Sending anguished veterans off to talk to therapists, writes Caplan, conveys the message that the rest of us don't want to listen or that we don't feel qualified to listen. As a result, the truth about war is kept under wraps. Most of us remain ignorant about what war is really like and continue to allow our governments to go to war without much protest. Caplan proposes an alternative: that we welcome veterans back into our communities and listen to their stories, one-on-one. (She provides guidelines for conducting these conversations.) This would begin a long overdue national discussion about the realities of war, and it would start the healing process for our returning veterans.
"This book goes a long way toward shaking us out of our "comforting illusions" about war and its effects. Perhaps now the fields of psychiatry and psychology can join with religion, ethics, and aesthetics to create true hope and community for all of our veterans." Journal of Trauma and Dissociation
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When Johnny and Jane Come Marching HomeHow All of Us Can Help Veterans
By Paula J. Caplan
The MIT PressCopyright © 2011 Paula J. Caplan
All right reserved.
Chapter OneWhen Johnny and Jane Come Marching Home: The Problem
An abnormal reaction to an abnormal situation is normal behavior. —Viktor Frankl, Man's Search for Meaning
I had read every word in the book of poems by the handsome, physically strong David E. Jones about his time at war in Vietnam before I met him at a Starbucks on January 19, 2010, so I should have thought of this, but it never crossed my mind. We met, and I got my drink first and went to a corner table that had one side against the wall and three chairs placed around it, one on each of the other sides. As I stepped between the seat on the far left and the one facing a wall, I was vaguely aware that Dave had come over and had somehow shifted his weight to one side. Only partly consciously, I sensed that I was about to take the wrong seat, assuming it was because we had just met, so it could be awkward for us to sit at right angles from each other. So I moved toward the seat on my left. "Fine," I thought. "Now he can sit across from me rather than next to me." But Dave shifted again, and once again, I sensed that I had gone to the wrong place, so I moved toward the seat on the right. Dave swept swiftly into the seat on the far left and sat down. Ah, yes! It struck me then: He needed his back against the wall, and he needed to face the door. I have seen this before in people who have lived in danger. Dave ' s war had ended three and one-half decades ago, but the psychological wounds of war can last as long as the physical ones, which Dave also has. To sit with someone whose sense of danger is immediate and palpable, who needs to be on guard even in an American coffeeshop all these years later, is to experience something most of us are graced never to have to feel originate in us. I do not believe that I can fully understand what Dave was feeling as he tried to be polite and gracious while finding a safe seat that day, but I know that if you are feeling calm while sitting quietly in a room with another person, and you suddenly feel anxious, you can be sure that it is because the other person suddenly became anxious. Anxiety is communicated instantaneously and wordlessly to anyone in its presence. How much more true that is for hypervigilance—and for fear.
That day with Dave E. Jones came years after the beginning of my concern about what would become of the veterans of the United States' wars in Iraq and Afghanistan. I had already been alarmed by the building tragedy of massive proportions for the veterans, their loved ones, and many others. I had already been worried in principle that we knew too little about what would help the vets, given the appalling current statistics about homelessness, suicide, violence against others, relationship breakdowns, drug and alcohol abuse, fear, and despair in veterans of wars from decades past. But beginning with that stunning recognition of the intensity of Dave's need to take a particular seat, I felt completely overcome by the magnitude of what war does to one person's life, for the rest of that life, and when I tried to imagine it multiplied by the millions of veterans in this country and in others, I felt the kind of nausea that arises when one feels helpless in the face of unnecessary suffering. Like many vets' actions, what Dave did just after I met him wordlessly showed me at least part of how it feels to have been in physical, mortal danger. And like many vets, when he speaks, as he did for three straight hours that day, he makes it possible for us to learn about the emotional, moral, and spiritual wounds of war.
By far the most common way Americans describe the emotional suffering of war veterans these days is to say they have Posttraumatic Stress Disorder (PTSD), a label that is listed in fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, sometimes called the psychiatrist's Bible of diagnoses of mental disorders. But to call the psychological effects of war mental illness is to sanitize the effects of war, to make them seem to constitute clinical entities or diseases, and to set apart those to whom we give clinical labels as different and thus separate from the rest of us. In 2005, Dr. Terence Keane, the director of the behavioral science division of the VA's National Center for Posttraumatic Stress Disorder, actually said, "the most powerful predictor of mental health problems is the intensity of the war, and this is a very intense war." Consider: If "mental health problems" result from war's intensity, should we really be calling them "mental health problems," as though they were medically caused or brain-based disorders, rather than calling them "pain," "suffering," and "devastation"? Similarly, military psychiatrist Colonel Elspeth Ritchie and her colleagues have said that experiencing combat, seeing dead and mutilated bodies, and feeling helpless to stop a violent situation lead to normal reactions of emotional upset. A user posting an email under the name "Cory" in response to a National Public Radio (NPR) broadcast wrote, "The human mind is not meant to bear this sort of burden." Culture analyst Elaine Showalter has written that, according to "most military psychologists and medical personnel, if not generals," the emotional suffering of war is caused by the "warfare itself, by chronic conditions of fear, tension, horror, disgust, and grief." Finally, Barry Romo, National Coordinator of Vietnam Veterans Against the War, notes that war trauma is a normal reaction to an abnormal situation. It does little or no good sweepingly to label the wracking emotions caused by war "PTSD" or other labels for mental illnesses, and it does veterans considerable harm, often increasing their isolation and always adding to their burdens by conveying the message that their reactions to war are somehow overreactions, that they should have been "over it" by now, and that the problems arose from within them. (Are feelings of terror and a need for constant vigilance after a powerful hurricane or an automobile accident illnesses?) As a result, veterans are often unthinkingly classified as Other, as different from the rest of us rather than (in some way, paradoxically) as people like us who have been through kinds of hell that we have not. This makes it harder for us to understand and empathize with them and therefore makes it harder to hear what they really need. In chapter 2 I discuss this extensively, including some of what the veterans feel and where it comes from other than mental illness, but first it is important to look at what the sheer numbers at this stage show us so far about the magnitude of the suffering of Iraq and Afghanistan vets.
As we begin our journey, it is important to keep in mind this context: As a nation, we have failed to learn from previous wars what soldiers and veterans need to help them grapple with the emotional devastation that so many suffer. The sight of the poor and deeply troubled veterans who haunt our cities, sleeping on sidewalks and in doorways or holding pieces of ripped cardboard with signs saying "Homeless Vietnam Vet" and asking drivers at stop signs for a dollar, makes us want to look away—or give them a dollar, look away, and drive on. What drives us to avert our gaze is partly our feeling that we are powerless to help them. But we are not powerless. Let us remember that as we look at some indications of what needs to be done, realizing that all of us can help. Let us also remember that, because fewer than 1 percent of Americans currently serve in the armed forces, it has been too easy for most citizens to remain innocent of the effects of war, and something similar is true in Canada and many other countries.
As waves of veterans come home from war, an emergency of massive scale is building fast. Early on, people who work with first responders such as police officers and ambulance drivers sounded the alarm. They warned that soldiers from Iraq and Afghanistan would come home traumatized by actual combat or by the terror of knowing that anyone may turn out to be the enemy, and that an improvised explosive device (IED) could blow them up anywhere, at any moment; they foresaw that the rates of suicide, homicide, domestic violence, poverty, drug abuse, and homelessness would skyrocket. So did advocacy groups, such as the National Gulf War Resource Center, whose executive director, a twenty-year Army veteran, Stephen Robinson, warned in 2004 that "There's a train coming that's packed with people who are going to need help for the next 35 years." As noted above, the Association for Women in Psychology decided just before the Iraq War began to issue a warning in an official white paper. For a long time, these voices were ignored. Then the evidence of the gathering storm began to be harder to ignore. Because of the George W. Bush administration's decision to extend soldiers' tours of service and then President Barack Obama's expansion of the war in Afghanistan, only a small proportion of those soldiers who will ultimately return home have done so, yet the troubles of many are already known. We face a building disaster of enormous magnitude. To help forestall this disaster, we must look immediately and head-on at the psychological carnage inflicted on Americans involved in the wars in Iraq and Afghanistan and tell the truth about the causes and nature of that carnage, as well as the truth about what will—and will not—help.
Neither the military nor the VA has learned the lessons it should have from Vietnam and the first Gulf War, and the last thing we want is still more veterans who struggle with broken families, homelessness, drug and alcohol abuse, rage, violence, and despair. As just one example, as Vietnam vets enter their sixties, the number seeking treatment for emotional trauma from the war is actually increasing. As another, as of 2008, the VA still had nearly one million veterans from the Vietnam War, more than 200,000 from the Gulf War, more than a third of a million from World War II, and more than 160,000 from the Korean War on disability pay. If the alarm is not sounded, and sounded soon, we will be overwhelmed by the problems of the veterans of both sexes from current wars, as well by the problems of their families. As the vets return, and as their numbers increase and the effects of their war experiences spread through society in waves, almost no one will remain untouched by the pain, anguish, and terror that these vets bring home. But we can create an "army" of Americans who can help, and later in this chapter, I will begin to look at how we can.
The realm of reactions to physical injuries warrants an entire book on its own, but it is important to keep in mind that many of the veterans described here as struggling with the emotional consequences of war are also dealing with the physical ones. My focus in this book is on the emotional ones because so little work has been done to uncover the limitations of the treatment of emotional trauma from war and because that realm involves so much jargon, mystification, and pseudoscience.
What Is Happening to the Veterans?
Many years ago, a woman who had for decades been a close friend (and had certainly never been to war) confessed to me that she had had a dream that made her feel ashamed, and she said that she could never tell anyone what it was about. It was just a dream. From the way she referred to it, I had the sense that it was something sexual. I told her I could not imagine judging people harshly because of a dream they had, as opposed to something terrible they had actually done, but that made no difference to her. She has never told me the content of her dream. To her, it is unspeakable. For veterans, who have confronted mortal danger and the lowest depths of what people, perhaps themselves and perhaps others, can do—purposefully or not, knowingly or unknowingly—how much more fear and shame can weigh them down, make them believe that what they experienced must never be told? They will tell you that they feel it is unspeakable partly in the sense that the stories are so harrowing that they do not want to burden friends and family even by alluding to what happened, and they feel it is unspeakable partly because they believe it reveals terrible things about them, such as that they were unable to save another soldier's life, or they discovered that the "enemy" they had killed without seeing them turned out to be infants, children, and the very old. Imagine a vet who is utterly devastated from having seen a best buddy blown to bits by an IED or from having unintentionally killed an Iraqi or Afghani child. Is utter devastation not a profoundly, movingly human response? Are nightmares and terror and guilt not understandable ways to feel? And is it not completely comprehensible for those feelings to plague the vet for weeks or months or years, even for decades? What do we gain if we call these reactions mental illnesses and send the sufferers into the increased isolation of therapists ' consulting rooms? This is not to say that some therapists will not be helpful by listening with compassion and understanding and by offering insight, but one must be aware of the risks of sending vets into therapy, both the risk of calling their reactions to war pathological and the risk of treating them as Other by implicitly or explicitly encouraging them to save their talk of war for the therapist's office. If their reactions to war are to be called mental illnesses, then what exactly would we call a healthy emotional response to war's shattering events? In Man's Search for Meaning, Viktor Frankl describes what he calls the mortification of normal reactions, the extinction of normal responses through punishment of them; examples related to war would be the suppression of feelings such as fear and of certain moral considerations in the service of training soldiers. Harvard University psychiatrist and anthropologist Arthur Kleinman asks how, in the face of horrific events, one could not be devastated, and in this connection he suggests that many veterans' reactions are more usefully and accurately called moral disorders than mental ones. To the extent that the vets' troubled feelings reflect spiritual or existential crises, what are the consequences of throwing emotion-numbing and mind-numbing psychiatric drugs at them, suppressing their capacity to grapple with and work through those crises? As we will see in this book, it is not that the military, the VA, and the mental health community do not wish to help. It is that far too much of their efforts, time, and money are going into initiatives that fit within the traditional box of classifying reactions to war as mental illnesses.
Because so many veterans feel such pressure not to speak of what they have been through, the following statistics should not surprise us. A 2006 article in the Journal of the American Medical Association reveals that the percentage of vets from Iraq and Afghanistan experiencing serious emotional difficulties was by then already far higher than the percentages from any previous wars. A 2007 Army report showed suicides to be at their highest point in twenty-six years and revealed a significant correlation between suicide risk and the number of days deployed. July 2008 brought the announcement from the VA that 22,000 vets called its suicide hotline during the previous year. According to Department of Defense press releases, eighty-two active duty Army personnel had committed suicide in the first five months of 2009, and by June 2009, soldiers were "taking their own lives in record numbers, and Army leaders [were] struggling to understand why," though the DOD cited "failed marriages, financial problems, military disciplinary actions and upcoming deployments" as possible contributing factors. According to Aaron Glantz, no one really knows the numbers of former soldiers who kill themselves, because the VA refuses to track these people, even though those with military experience have been shown to be twice as likely to kill themselves as those with no military experience, and this is true for veterans from World War II, the Korean War, the Vietnam War, and the Gulf War. The Department of Veterans Affairs estimates that 107,000 veterans are homeless on any given night and that 260,000 are homeless at some time during the year, and the National Coalition for Homeless Veterans reports that veterans account for about 23 percent of all homeless people. About 5 percent of homeless vets are women, and roughly 56 percent are African-American or Hispanic, although these two groups account for only 12.8 percent and 15.4 percent of the U.S. population, respectively. Although most homeless vets are from wars that preceded the current ones, estimates in early 2010 were that during that year, there would be 419,000 homeless vets from Iraq and Afghanistan. 27 In addition, there is some evidence that Iraq War veterans are becoming homeless sooner after their military discharge, even immediately, than those from Vietnam.
According to a 2010 New England Journal of Medicine article, warfare in Iraq and Afghanistan differs greatly from that of, for instance, the 1991 Gulf War, which ended quickly. The current wars have involved intensive combat on the ground, attacks by insurgents, and many deaths and injuries to American troops. This has increased the burden on families of soldiers and Marines, and the authors of the article say that these burdens are not as well understood as those of previous wars. For longer periods of time, spouses back at home have to maintain the household, function as a single parent, and try to cope with strains on the marriage because of the physical separation, and the duration of separation is often unpredictable. These problems have led to increased marital dissatisfaction, divorce, unemployment, and decline in emotional health. And, the authors note, the strains occur before, during, and after deployment. (The Bush administration's use of "stop-loss," or cancelation of scheduled dates to return home from deployments when soldiers' enlistment times were due to end, increased those strains.) In spite of this, they say, associations between these intense pressures and emotional problems of various kinds have not been studied well in military families. In their own large and sweeping study, the authors note that the majority of active duty servicemen are married, and they report that wives of servicemen who had prolonged deployments were more likely than others to receive psychiatric diagnoses. Putting aside for now any discussion of the unscientific and potentially harmful nature of such diagnoses, I wish to emphasize here that these women sought professional help because they were suffering. The nature of their suffering included troubling moods, anxiety, and sleep problems.
Excerpted from When Johnny and Jane Come Marching Home by Paula J. Caplan Copyright © 2011 by Paula J. Caplan. Excerpted by permission of The MIT Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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What People are Saying About This
Veterans' own stories put a human face on this book's careful research and thoughtful analysis. This book is a must-read not just for those who care about our veterans but for anyone who has benefited from their sacrifices, which is to say all of us." Kenneth S. Pope , psychologist, ABPP, and co-author,Ethics in Psychotherapy and Counseling
"Finally we have an all-encompassing, meticulously researched,brilliantly thought-out, and marvelously written book about the effects of war on humans and how all of us can help our veterans heal. Dr. Caplan cuts through the smoke of the institutional lies to the true nature of the emotional injuries sustained by these poor souls and offers a detailed and sensible path to healing.
This brave and astonishing book stands as the classic, and the standard, for understanding the atrocities of war." Samuel Shem , author of The Spirit of the Place and The House of God
"I am truly amazed by Caplan's grasp of not only the psyche of the combat veteran but of the human heart and soul as a whole. There is no prosthesis for the amputated spirit, but Caplan certainly comes close to discovering just that through her extraordinary insight. Brilliant!" Michelle Wilmot ,Women's Outreach Coordinator for Vets4Vets
"If we, as citizens, want to do right by the young men and women who serve in our military and fight our wars, we can start by reading this profound and moving book. By the book's end, you will be certain of one 'therapeutic' truth: A society that sends its young off to war needs to be ready to hear their stories when they return and know that 'there is healing power in not only listening, but also in remembering what the speaker says.'" Robert Whitaker , author of Anatomy of an Epidemic and Mad in America
"Paula Caplan's book is powerfully informative and creates an image of the importance of listening to our war veterans and the stories they have to share.
This book provides an opportunity for their message to support life-enhancing and healing experiences." David Collier , licensed psychologist/team leader, Salem (OR) Vet Center
"Paula Caplan's important book is profoundly empathetic to the psychological needs of our soldiers. She is especially attuned to those needs in a political culture that shifts the burden of its pathology onto its soldiers. Dr.
Caplan teaches that the most salutary treatment for both the culture and the soldiers is the necessary exposure of the truth of their experience. Continued denial deepens the trauma and enables its repetition." Robert Shetterly , artist and author of Americans Who Tell the Truth
"Rather than dealing with soldiers' post war pain through denial or the distancing, detachment, diagnosis, drugs, and dis-ease of professionals, Caplan advocates that we all contribute by listening when soldiers tell their stories, and she presents a clear and convincing case that we should not recoil from or deny the horrors of war. Refusing to recognize the experiences of soldiers contributes to the continuation of both war and the debilitating impact of war on returning warriors.
Caplan employs prose, poetry, literature, logic, and empirical data to convince us of our power to contribute to a community that connects with and socially supports returning veterans. It is important for all of us, laypersons and professionals, to hear what Caplan has to say and to listen to the stories that veterans have to tell." Maureen C. McHugh , Professor of Psychology, Indiana University of Pennsylvania
"Some of the most tragic and lasting consequences of the U.S. military invasions of Afghanistan and Iraq only begin after our troops return home to resume their lives. They bring back with them deeply-disturbing experiences and memories largely unknown and often unrecognized by family and community turning these soldiers into outcasts even when greeted as heroes. Paula Caplan's timely new book illuminates the inadequacies of current societal and mental health system responses,and explores promising alternatives for confronting the stigma and isolation experienced by so many of our combat veterans." Roy J. Eidelson , Past President, Psychologists for Social Responsibility; President,Eidelson Consulting
"The suffering of returning Iraq and Afghanistan war veterans, their families, and those whose lives they affect is likely to be the greatest mental health tragedy of at least the next decade. Dr. Caplan's passionate, eminently readable book makes a compelling case that this is about human pain, not mental illness. Dr. Caplan's critically reasoned review of the multiple dimensions of this crisis is both a call to action and a guidebook for how we can all do our part (still to be done for Vietnam vets) to welcome our American heroes home." Paul Block , Director, Psychological Centers, Providence,RI
"This is a work of profound and astonishing humanity. A distinguished champion of public health, Paula Caplan shows that emotional trauma is often the normal and healthy response of soldiers to the brutalities of warfare. So what we need is not a narrow redefinition of the soldier's experience as a medical 'syndrome' but rather an honest social healing process that treats the soldier with dignity and respect and as a harbinger of hope for all of society." Jamin Raskin , Professor of Law, American University, and Maryland State Senator
Meet the Author
Paula J. Caplan, a clinical and research psychologist, is an Affiliate at Harvard University's DuBois Institute and a Fellow at theWomen and Public Policy Program in Harvard's Kennedy School of Government. She is the author of The Myth of Women's Masochism, They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal, and eight other books. Her articles, essays, and op-eds have appeared in both scholarly and popular publications.
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