Hundreds of thousands of American veterans of the Iraq and Afghanistan wars are believed to have some form of post-traumatic stress disorder. As many as 40 percent of returning veterans today report symptoms of combat stress in their relationships with friends and family. As the war in Afghanistan draws down, those numbers are expected to rise. When a combat veteran comes home with PTSD or traumatic brain injury, his — or her — condition can affect the entire family. And while resources for veterans are improving, family members are still too often in the dark about what to do. Diane and guests talk about helping families cope with wounded warriors.

Guests

  • Jeff Haugh retired Special Agent for the Air Force Office of Special Investigations and a decorated veteran with combat related disabilities; chairman, Team Racing for Veterans.
  • Marshele Carter Waddell founder of Hope for the Home Front and co-author of "Wounded Warrior, Wounded Home."
  • Dr. Elspeth Cameron Ritchie M.D., chief medical officer at the District of Columbia Department of Mental Health and former chief psychiatrist in the Army. Author of "Battleland" blog at Time.com.

Transcript

  • 11:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. PTSD and traumatic brain injury are sometimes called the invisible wounds of the war on terrorism. Some sufferers say they almost wish they had visible wounds because then their behavior might be better understood.

  • 11:07:18

    MS. DIANE REHMThe toll these conditions take on family members can be devastating. Joining me in the studio to talk about helping families cope with injured vets, Marshele Carter Waddell of Hope for the Home Front, Air Force veteran Jeff Haugh and Dr. Elspeth Cameron Ritchie of the D.C. Department of Mental Health.

  • 11:07:42

    MS. DIANE REHMDo join us with your calls, 800-433-8850. Send us an email to drshow@wamu.org. Follow us on Facebook or Twitter. Good morning to all of you.

  • 11:07:58

    MS. MARSHELE CARTER WADDELLGood morning.

  • 11:07:58

    DR. ELSPETH CAMERON RITCHIEGood morning.

  • 11:07:59

    MR. JEFF HAUGHGood morning.

  • 11:07:59

    REHMGood to have you here. Marshele, if I could start with you. When your husband returned from his last deployment in Iraq, what kind of shape was he in?

  • 11:08:15

    WADDELLWell, I think it's important to point out that when he deployed to Operation Iraqi Freedom in 2003, he had already completed 22 years as a Navy Seal and so as a family, we were already accustomed to all the training and all the real-world deployment.

  • 11:08:31

    WADDELLBut when he returned home in the summer of 2003 with a broken leg, I was very grateful that was the only physical injury we were dealing with. But in the months that followed, I quickly recognized that the broken leg was the least of our concerns.

  • 11:08:49

    WADDELLAnd he began to exhibit behaviors that were not characteristic of his personality leading...

  • 11:08:51

    REHMSuch as?

  • 11:08:51

    WADDELL...to the point. The first thing I noticed in Mark was his inability to sleep through the night. He either wrestled with insomnia or he wrestled with terrifying nightmares. He would awaken in the morning or throughout the night at different times just either shouting or sobbing every time, sweating through so that, you know, for months, we changed the sheets every morning because of the night terrors.

  • 11:09:25

    WADDELLI also noticed extreme mood swings in my husband. He had a very short fuse with us, even on the very best of days. He was sensitive to certain triggers, especially smells and sounds, that had the power to catapult him to another place in time and turn a much-awaited family outing into a day that we would rather forget.

  • 11:09:52

    REHMAnd I guess that would be the issue I'd like to get to here, namely, how was your family as a whole affected?

  • 11:10:10

    WADDELLAny family member that lives with a traumatized service member or veteran is affected by their pain in the aftermath of war and the effect of these invisible wounds of war have a ripple effect through the family. The family members start to exhibit, what I've come to learn and understand as, secondary traumatic stress and also they are dealing with compassion fatigue because over a prolonged period of time of walking on egg shells and caring for the one that they love and the one they want to see heal, it makes an effect on their emotional, spiritual and physical health as well.

  • 11:10:52

    REHMHow old were your children when your husband came home?

  • 11:10:59

    WADDELLThe first time my husband came home from Iraq my children were 12 and 14 and 17.

  • 11:11:07

    REHMAnd so in the midst of teenage years.

  • 11:11:11

    WADDELLRight.

  • 11:11:11

    REHMThat kind of impact must have been pretty strong?

  • 11:11:17

    WADDELLRight, you can imagine a home with three teenagers coming and going and the normal commotion and the normal discipline that has to take place in a home in that season of life. And the normal clutter, the normal commotion, the stresses of life at that season of any marriage is enough, but to add to it the depression and the mood swings and the flashbacks and the triggers, it just pushed our family to the seams.

  • 11:11:47

    REHMMarshele Carter Waddell, she's founder of Hope for the Home Front and co-author of a book titled "Wounded Warrior, Wounded Home." Turning to you, Jeff Haugh, tell us about your experience. How were you wounded in the war both physically and emotionally?

  • 11:12:14

    HAUGHSure, my service took place from 2003 to 2004 and initially I was medically evacuated for what was then thought to be a spinal injury and later I learned I had a traumatic brain injury or TBI.

  • 11:12:35

    HAUGHAt the time, TBI was not a buzz word as it is now. But what I can definitely relate to is initially my wife and I went on this journey together and it certainly has brought us closer, but I can relate to what Marshele was just mentioning, whether it be night sweats and at times, I couldn't have my back to a door.

  • 11:13:02

    HAUGHDriving was very difficult and for several years, my wife even drove. And so I think the invisible wounds are certainly invisible to others, but to family members, they are front and center and this is a new reality of war.

  • 11:13:21

    REHMHow do you think that your behavior changed from what it had been before you went off to war and what it was when you came back?

  • 11:13:37

    HAUGHI do think that we all have a certain change in the way, the manner in which we view the world. And when you return from combat and you return from seeing very difficult things, your entire outlook on the way things work and what's fair and what's not fair is, you know, changed forever.

  • 11:14:02

    REHMSo how does that affect your behavior toward others?

  • 11:14:11

    HAUGHFor several years -- and again, my injury and service was 2003 to 2004, so this is becoming quite dated, but there were several years where I did not want to be around others and I had to be encouraged to be around others. One of the things that I tried to focus on with the not-for-profit that I chair is to encourage people to find -- encourage veterans to find some sort of avenue to be reintegrated again.

  • 11:14:55

    HAUGHAnd it's so easy to remain in a comfortable place whether it's, you know, a house with no one at home and in reality what you need is, you need that encouragement to be out and interact with others.

  • 11:15:07

    REHMJeff Haugh, he is retired Special Agent for the Air Force Office of Special Investigations. He's a decorated veteran with combat related disabilities. He's also chair of the non-profit Team Racing for Veterans. And turning to you, Dr. Ritchie, is what you're hearing fairly typical?

  • 11:15:35

    RITCHIEIt is very typical. And Diane, as you know, but just to remind the listeners, I am an Army veteran myself. I was an Army psychiatrist for 24 years and served in Korea, Somalia and Iraq so I've seen a wide spectrum of the psychological reactions to war to include PTSD or post-traumatic stress disorder.

  • 11:15:59

    RITCHIEOne of the things that Marshele said, I think, is really important to highlight, which is the short fuse and insomnia, the difficulty sleeping and the night sweats and the reactions to smells and sounds that many veterans have. The definition of PTSD, post-traumatic stress disorder is changing as we speak.

  • 11:16:17

    RITCHIEThe new one will officially come out at the American Psychiatric Association in May and the new definition includes insomnia, symptoms of depression, irritability or the short fuse and the visceral reactions, the body reactions to smells and sounds. I think something Jeff said is very, very typical as well, which is not wanting to be around others, especially if they haven't been there.

  • 11:16:44

    RITCHIEAnd that's often the hardest thing about PTSD. It's not just insomnia or nightmares. It's not just a hyper-vigilant, reacting to things in the environment, but the strain on the families of not wanting to be around them. And how can you not want to be around your kids?

  • 11:17:01

    RITCHIEYou've been gone for a year. You're coming back and yet you're hiding out in the basement with a bottle of Jim Beam and that's really tough for families to cope with.

  • 11:17:09

    REHMJeff, how did your family react to you?

  • 11:17:14

    HAUGHWell, I think like many families, they did the best they could with a very foreign, something that no one is used to and no one has experience with. So when I mentioned that my wife Angela and I have been on this journey together what I mean by that is that we were lucky enough to ensure that we viewed the challenges that we were going to have as something we were going to face together. And I think that I was very blessed to have her and I was very lucky to have known to reach out to my loved one, reach to my wife.

  • 11:17:59

    HAUGHI think in many ways I was lucky that I did not have children. I have three young children now, but initially I didn't have kids so I can't imagine what our lives would have been like with three young ones at the time.

  • 11:18:14

    REHMMarshele, you did have young children, did you not?

  • 11:18:17

    WADDELLYes, and it was very common early on for each of them to come to me in their own way and say, is this a good day for daddy? Is this a bad day? So that they could gauge their day, who they were going to invite over to visit or cancel their plans or if they were going to ask for permission to do a certain thing or if it could wait.

  • 11:18:41

    REHMMarshele Carter Waddell, founder of Hope for the Home Front and co-author of "Wounded Warrior, Wounded Home."

  • 11:20:05

    REHMAnd here's our first email. It's from Dwight in Cleveland. He says, "When you send men and women to war, the majority of the negative impact is not left on the battlefield for generations to come. The impact can be traced back to the soldier. The giving of drugs designed to just repress and not address, to remove guilt without absolving of guilt is another issue." Jeff, do you want to comment?

  • 11:20:45

    HAUGHThank you, Dwight, for your question. I can relate to both comments, drugs and guilt. I think for many veterans coming back we will have a sometimes long history and long experience with a variety of medications that we have to try. And essentially learn what works and what doesn't work. And it becomes a very slippery slope because you're in a tough -- it is very difficult to isolate what could be helping you and what could be hurting you. You don't know if it's a specific drug or if it's a behavior or if it's a new outlook. And so that is a -- almost a constant challenge.

  • 11:21:30

    HAUGHRelated to guilt, I think that any veterans that survives that has been in combat can relate to guilt. And it's a painful emotion. We all want to move past some of the experiences that we've had, but ultimately I think that we all feel guilty if we survived and others that we know didn't.

  • 11:21:56

    REHMMarshele, Jeff talked about being able to work through many of the difficulties with his wife. Were you able to help your husband in a way that was good for you or was he shutting you out along the way?

  • 11:22:26

    WADDELLWell, it's important to keep in mind that he was serving as the director of operations for all the east coast SEAL teams between 2003 and 2006. So not only was he deploying four different times, but he was also manning and training and deploying hundreds of other SEALs to two different warfronts. So as a commander at that point he could not show any chinks in his armor.

  • 11:22:50

    WADDELLAnd so when I expressed to him that, you know, I really feel that there are some issues here we need to address as a couple, you know, he gave me the green light to go ahead and seek help for myself. But it was not time for him to do that and he felt no need to do that yet. And so I knew that if I did not seek help for myself that not only would I implode but that my family was going to suffer a longer road. And so I sought help for two years before Mark actually sat down and said, you know, I know there's a problem and I want to address it and I'm going to do that.

  • 11:23:28

    REHMGood for him.

  • 11:23:30

    WADDELLAnd he was diagnosed in 2005 with post-traumatic stress disorder. And I want to point out that most of these veterans returning are also dealing with the physical injury to the brain, which Jeff mentioned as traumatic brain injury. And they can look -- that can look very different from the symptoms that bubble to the surface with post-traumatic stress disorder. So a family that's dealing with what they think is post-traumatic stress disorder, but then they're identifying these other random symptoms that don't fit the definition of PTSD are likely dealing with traumatic brain injury.

  • 11:24:04

    WADDELLAnd in our case Mark had multiple moderate traumatic brain injuries. So my greatest challenge has been learning to distinguish between what is PTSD and what is TBI on the home front and dealing with those circumstances differently once that's determined.

  • 11:24:20

    REHMHelp me to understand the differences, Dr. Ritchie, and how they are actually diagnosed.

  • 11:24:30

    RITCHIETraumatic brain injury is usually secondary to either a blow to the head or another insult, and of course is very common from football players and sports as well. But it really has become one of the biggest injuries of the war and it wasn't recognized early on as is common. The military has done actually a very good job now of screening for TBI. Although similar to PTSD many service members don't want to admit to that because they want to stay in the fight.

  • 11:24:59

    RITCHIEPost-traumatic stress disorder is traditionally secondary to experiencing a horror, seeing something, either a natural disaster, a sexual assault or combat. But there is a great deal of overlap. And I'd like to add that many people also have musculoskeletal injuries. In other words, a bad back or a pulled foot or something that hurts. And you can have the addition of the nagging pain or the disability.

  • 11:25:25

    RITCHIEAnd what might be a minor disability to a civilian, like not being able to quote "hump your ruck," carry your pack, your rucksack for 20 miles and lead your men to an army officer or other service member, if you can't carry your load then that is a real humiliation. So it may be a combination of the TBI, PTSD, pain, disability and humiliation. And unfortunately, as you know, there's a rising suicide rate. It continues to be very high. And I see often in the completed suicides is that you've got these combination of factors there.

  • 11:26:03

    REHMMarshele, you're founder of Hope for the Home Front. Talk about why it's so important for women to help their spouses or their partners to heal.

  • 11:26:21

    WADDELLWell, we at Hope for the Home Front, we are dedicated to reaching out to and to restoring the women who are connected to the combat veterans, whether they're the wife or the mother of the warrior, even sisters and adult daughters. We've had grandmothers come to the conferences as well, and aunts and fiancés and girlfriends as well. As so we aim to educate and inform them. We want them to know that they are not isolated in this journey that they're on, that there is a fellowship, a sisterhood out there of women who understand what they're going through.

  • 11:26:53

    WADDELLThe dangerous place is to think that you are alone in this and that no one else is going through this combination of TBI and PTSD, this dark place. So I found a statistic a couple of years ago that said that about 78 percent of the men that end up -- the veterans, men or women, that end up seeking help for PTSD and TBI do so because a woman in their life cared enough to take care of herself and to get the information and resources in line so that when that veterans recognized, yes I do need some help, as my husband did, they are ready. And they're ready to lead that vet to those resources.

  • 11:27:31

    REHMJeff talked about medications of all kinds. Was your husband ready to acknowledge he needed medication or was he using alcohol? Was he affecting your lives in that way?

  • 11:27:52

    WADDELLRight. It's important for the listeners to know that everything I share about my husband and my family I've said before in his presence and publicly. And we have traveled around the country and he speaks with me at different times and venues. But yes, he did resort to what we call self medicating. He did go through a dark period where he was drinking too much, which only exacerbated the problem for us at home. It made the flashbacks worse. It made the blackouts more frequent. It made that 1,000 yard stare unavoidable. But...

  • 11:28:31

    REHMBut there was nothing you could do?

  • 11:28:36

    WADDELLHe tried the medications. He found some that did help. He would go on and off of them at different times. He was not comfortable being on meds. At different times they made him feel like he was in a fog. It also affected our ability to have a normal -- have normal intimacy at times too, which then would erode his feelings of manly-hood, you know. And so we would just be caught in this downward cycle while he looked for the right combination of meds.

  • 11:29:07

    REHMAnd Jeff, you and meds.

  • 11:29:11

    HAUGHWell, I certainly do not believe that medications aren't useful and they don't have a use. But what -- I think the point that I was trying to make is that for those of us that are having our first experience with any sort of disability, the word itself is still foreign to me.

  • 11:29:35

    REHMPretty tough.

  • 11:29:35

    HAUGHEven considering myself to be a disabled person is -- it's just difficult. So the medications were not only a new phenomenon that I wasn't used to. It was difficult to determine what was working and what wasn't just because of the complexity of some of these injuries. And I think what we're talking about today, post-traumatic stress disorder and traumatic brain injury can have similarities. They can also be different.

  • 11:30:05

    HAUGHAnd so it's difficult to tell what could be creating a certain symptom, whether it be a medication or whether it be a mood that you're in. And so I think that creates a very difficult mystery to figure out. And it's difficult if a doctor asks you, is this helping you. I still at times don't know how to answer the question.

  • 11:30:28

    REHMHow would you describe your current disability?

  • 11:30:37

    HAUGHWell, I -- as I mentioned, I have a hard time even viewing myself as disabled. There is a certain catch 22 to having an invisible injury. On one hand, we are, I think, lucky in that folks can look at men and women like me and not necessarily tell. We can walk around and talk and oftentimes there won't be -- it's difficult to tell that anything is wrong with the person. Other days, you know, the symptoms can be devastating.

  • 11:31:10

    REHMSuch as.

  • 11:31:12

    HAUGHWell, I would say with traumatic brain injury and post-traumatic stress disorder I think that the depression at times can be debilitating.

  • 11:31:22

    REHMAnd that's for you.

  • 11:31:24

    HAUGHWell, I think that I have moved past some of those darker days. I think that I can relate to, you know, some of the comments that were made earlier in terms of the ways that people try to medicate and find ways, you know, to make their pain essentially go away. I have benefitted from having so many loving and such a great support network. I have found that if I'm able to help others, whether it be in a setting of a not-for-profit, whether it be doing, you know, athletic workouts with folks at Walter Reed, that to me is a -- allows me in essence to move past some of my own pain and look at others.

  • 11:32:19

    HAUGHSo I think it is a long road and I think that it is very specific to each person, each veteran. But in my case, I was very lucky to have the family support, especially my wife. I was very lucky to have the medical support as well. So I consider myself to be very lucky.

  • 11:32:43

    REHMAnd you're listening to "The Diane Rehm Show." Marshele, you wanted to say something.

  • 11:32:51

    WADDELLI wanted to echo what Jeff was saying in that in addition to paying attention to the medical advice that my husband was receiving, he also made a conscious effort to get physically fit again. He ran his first half marathon this past Sunday in Dallas.

  • 11:33:04

    REHMHow wonderful.

  • 11:33:05

    WADDELLAnd he also has opened a service disabled veteran-owned small business in the Dallas-Fort Worth area where he and another 100 percent disabled combat vet of the war in Afghanistan, a younger individual, they are engaging and giving back to that very community of veterans. And it's part of their healing.

  • 11:33:25

    REHMNow are you and he living apart at this time?

  • 11:33:31

    WADDELLWe are geographically challenged right now. I'm a master student at the University of North Carolina in Chapel Hill in the school of journalism and mass communication. And he is standing up this business in Dallas-Fort Worth at this time.

  • 11:33:43

    REHMNow is that, would you say, benefitting the two of you?

  • 11:33:48

    WADDELLAt this season in our lives, yeah, it's providing some space and some circumstances where we're communicating in a different way and moving through this thing that we call Passing Through Someplace Dark, PTSD.

  • 11:34:03

    REHMThat's very interesting. What do you think about that, Dr. Ritchie? Does that help a lot of people to get that space after going through such a time of hell?

  • 11:34:18

    RITCHIEFirst of all, that's a lovely phrase, passing through the dark. I really like that. It's going to depend on the people as to whether it's better to stay in the household or separate. And every people have to decide what's right for them. I wanted to come back to the question about medication. One of the things we're seeing now is a lot of people don't like medication or it only partly helps or there's side effects such as with sexual intimacy.

  • 11:34:47

    RITCHIESo where the field is going is towards what used to be called complementary and alternative medicine. Now it's often called integrative medicine. I have a series of articles this spring on integrative medicine. And that's other forms such as virtual reality, which is exposure therapy with a computer or stellate ganglion block which is an anesthetic technique, or art therapy, or acupuncture, or my favorite, which is dog therapy. There's a whole series of other alternative treatments, which usually -- and you mentioned fitness, Jeff, and fitness is very important -- usually by themselves they don't do everything.

  • 11:35:27

    RITCHIEBut they should be part of the therapeutic plan because most people won't respond just to one medication. They need a range of different options and they need to pick what is right for them, what feels good for them. And so in your integrative services often people are exposed to a number of different forms and they pick what's right for them.

  • 11:35:49

    REHMSure. And Marshele, I assume you did not mean to imply that the marriage itself was anything but intact.

  • 11:36:02

    WADDELLRight.

  • 11:36:04

    REHMThat you are simply earning a different kind of degree, you're in separate physical places, but the marriage is still very much ongoing.

  • 11:36:16

    WADDELLI kept the home front fires burning for 11 deployments over the course of a 25-year military career. And when it came time for me to consider fulfilling a dream that I had had, my request of him was, could you look at these four semesters as four short TDYs or four short deployments, where I'm away from home this time pursuing something I feel called to do?

  • 11:36:39

    WADDELLAnd I think it's important to keep in mind that we are, you know, ten years or more into this journey of PTSD and TBI. March 19, 2003 was when these men and women invaded Iraq. So just this week is the tenth anniversary of operation Iraqi freedom beginning. And so it's an important week for all of those individuals and their families. But I certainly would not have considered doing something this unusual year number one or year number five or whatever. But for us, I believe it was time for me and I had that opportunity.

  • 11:37:15

    REHMMarshele Carter Waddell. She's founder of Hope for the Home Front and co-author of "Wounded Warrior, Wounded Home." We'll take a short break here. When we come back, it's your turn to join the conversation. I look forward to speaking with you.

  • 11:40:03

    REHMAnd welcome back. We're talking about the effects of wounds in war, whether they be physical, emotional or mental, some that are seen and some not seen, and their impact on the family. 800-433-8850. First, to Charlie in Ann Arbor, Mich. Good morning. You're on the air.

  • 11:40:33

    CHARLIEGood morning, Mrs. Rehm, national treasure that you are.

  • 11:40:36

    REHMThank you.

  • 11:40:38

    CHARLIEI wanted to thank Jeff for his service. And as someone mentioned, I think himself, a little while ago, realization of how blessed in fact he is. I was a special ed teacher as a career. I had three traumatic brain-injury children over the years, and they were like normally functioning high school kids and then when I come back in the fall they were 9 to 11 years old and seemingly going to be that way for life. And I think there was an insurance advocate, the ones there who described it as a living death. It's sort of an onion. Your peers and friends peel off first because they can't hang around an 11 year old.

  • 11:41:12

    CHARLIEThen your extended family peels off because they're very uncomfortable at a barbeque or whatever. They don't know what to do. And then your immediate family, in two of the three relationships there was a divorce and then the mother was alone. And in all the situations, all of the mothers at every meeting was crying the entire time because of realizing where there child was now and realizing they have to prepare for lifelong care for this child.

  • 11:41:39

    CHARLIESo Jeff was so blessed with support of wife, excellent rehabilitation and the self discipline of being an officer. And I just wish and hope that -- I know he'll run and teach veterans with the same issues and I hope we can do some more research in this terrible area.

  • 11:41:55

    REHMAll right. Thanks for calling. Marshele, I'm sure you can identify with some of what Charlie had to say.

  • 11:42:06

    WADDELLHe mentioned the living death. I attended a retreat this past weekend sponsored by Semper Max and there were about 12 couples. All of the guys, they had TBI. They referred to themselves as TBI guys, and they were all over the spectrum on the severity of the injury. Some it was obvious that they had a brain injury and some you would never know. And we talked about this thing called living grief. The veteran is dealing with the losses that he has experienced and the family member is dealing with losses that he or she has experienced as a result of the war experiences.

  • 11:42:43

    WADDELLAnd the peeling back of the onion, that's a beautiful illustration. People don’t know what to do with the behaviors that they see or the word choices or the withdrawal that TBI veterans exhibit and then also couple that with PTSD. So, yeah, the friends drop off first. The family members that don't live with the combat vet, they either say, you know, no, my vet's fine. You know, what you have described to us is not -- it can't be happening. He looks fine. He's functioning fine. He's still going to work.

  • 11:43:19

    WADDELLHe's still providing for the family. But living with the veteran is another story. And in many cases, yeah, the wives and the spouses peel off that onion, as well.

  • 11:43:29

    REHMJeff, can you relate to any of that?

  • 11:43:33

    HAUGHI can relate. I think that it's a very common military characteristic to take a Spartan approach to any type of challenge. And so one of the things that make military people unique and what makes what I considered to be the greatest generation also, the post 9/11 veterans, some of which have been, you know, deployed for a third of their lives. What's a very common characteristic is that they will find ways to press on and find ways to, at times, mask any type of pain and disability.

  • 11:44:19

    HAUGHI also think that there are many that are optimists and that find a silver lining. I'd like to think that I have tried to find a silver lining in almost everything. And so when it comes to a disability that you have or something that you can't do you find a work around. And this takes time, but over time, with the right support, you can find ways to carry on and at times even excel.

  • 11:44:51

    REHMHere's an email that says, "How much of the military culture is still, suck it up and deal with it, despite the attention being focused on it?" Dr. Ritchie?

  • 11:45:07

    RITCHIEThat is absolutely true. I am on an Institute Of Medicine committee and we look at how the DOD and V.A. deliver care for post-traumatic stress disorder. And what I see consistently is that soldiers and marines and other service members will not go seek treatment until they're already about to get out of the military. They're either about to retire, so raise their hand to get treatment. Or they're what we call ETS-ing, they're getting out of service anyway and then they may get treatment.

  • 11:45:37

    RITCHIEThe other tragedy, coming back to Charlie's point about peeling back the onion, is we're seeing this slide into homelessness and into substance abuse and lack of jobs. And we really have to put the safety net around these veterans. Give you an example, around Camp Lejeune, there's a whole lot of marines that are just living in the woods. And they're okay living in the woods now because they know how to do that, they're young and they're healthy. But 20 years from now they're going to be on the streets, homeless, tremendously expensive to our medical system, and we really have to take care of them now before we get there.

  • 11:46:14

    RITCHIEAnd, unfortunately, in my current job in Washington, D.C., I see too many of the homeless who have slipped through the cracks.

  • 11:46:20

    REHMIndeed. Let's go to Elkhart, Ind. Good morning, Tom.

  • 11:46:26

    TOMGood morning, Diane. And thank you to the families and the veterans for their service.

  • 11:46:30

    REHMIndeed.

  • 11:46:32

    TOMMy question is I was looking and do people of World War II have this problem? As a young man I didn't notice anything. I noticed when men would be shell-shocked, Mom would always say, but was this problem prevalent during World War II?

  • 11:46:51

    REHMOh, I think so. Dr. Ritchie?

  • 11:46:53

    RITCHIEEvery war has had psychological reactions, whether you call it shell-shock after World War I, battle fatigue. One of the differences with both World War I and World War II is that people deployed as a unit, they stayed together for whatever the length of the war and came back home together. So you didn't have the back and forth. You didn't have the email and the Skype that you've got now, which has mixed effects. It's great to be in touch with your family until you find out that there's problems with your family.

  • 11:47:20

    RITCHIEPTSD was not recognized as a diagnosis until after the end of the Vietnam War, but certainly we know that people had it. One point that I don't want to forget, just briefly, is that there's also female service members. We've been talking about the wives of the male service members, but 15 percent of our force is female.

  • 11:47:38

    REHMOf course.

  • 11:47:39

    RITCHIEAnd it's even harder for their husbands or family members to know what to do.

  • 11:47:44

    REHMMarshele?

  • 11:47:44

    WADDELLI also wanted to add to what Dr. Ritchie has pointed out. And that's that, for example, in the Vietnam War for every combat kill there were two warriors that came home and survived their injuries, but for the wars in Iraq and Afghanistan, for every combat kill there are seven who survived their injuries and come home, which is really great news in that we have more surviving, you know, the immediate needs on the battlefields, but the flip side of that is that we have a greater number of survivors who are dealing with the invisible wounds of war.

  • 11:48:19

    WADDELLSo you have a lot of family members and communities rejoicing that the warrior has come home safely, but in the long term the question is, is he living a life worth living. And so you have more surviving, which is great, but you have more invisible wounds in the long term to address.

  • 11:48:40

    REHMAnd here's a question from Kris, who says, "My boyfriend of three years was a combat vet in Iraq. He suffers PTSD and alcoholism. He's doing much better, but we still struggle. Unfortunately, he has found treatment at the V.A. to be ineffective. He found the V.A. hospital to not be sympathetic to his needs or respectful of his views. Where else can we turn to help him deal with these scars of war?" First, Jeff, did you turn to the V.A.?

  • 11:49:29

    HAUGHI did. I was medically retired and my experience with the V.A. was a learning process, also. I have found that my treatment now I would say is satisfactory. But I do think that it is a massive organization and it's an organization, like family members and friends, that are also learning how to interact and deal with post-traumatic stress disorder and traumatic brain injury.

  • 11:50:02

    REHMMarshele, did you and your husband deal with the V.A.?

  • 11:50:07

    WADDELLWe have at different times. I want to honor those who are employed at the V.A. They are very hard-working, compassionate individuals, but corporately, the V.A. is maxed out. I mean it is at max capacity. And the solution to meeting the needs on the home front, on the community level, is going to be a partnership between the private sector and the public sector. They're going to have to merge and we're going to have to lock arms in order to provide the services that are needed.

  • 11:50:42

    REHMJeff?

  • 11:50:44

    HAUGHI wanted to make a comment and to also, you know, piggy back the last point. I think that the V.A. does a phenomenal job with a very deep and complicated problem. I think that it's very important that the V.A. utilize some of the resources available to it. And the comment about the V.A. needing to reach out to private sector couldn't be a stronger point. I have a company and my company is a service-disabled-veteran-owned small business. I'd like to hire more combat veterans. And I'd like to be in a place to deliver services to the V.A.

  • 11:51:29

    HAUGHIt, to me, sounds like a no-brainer, but it's not as easy as using that particular logic. It's difficult...

  • 11:51:39

    REHMBecause?

  • 11:51:40

    HAUGHWell, I think the comment that I made earlier can't be, you know, over emphasized. The fact that there are plenty of veterans that have been deployed for a third of their lives and when they're deployed and when they're volunteering -- because we didn't have a draft. All of us volunteered. Many of us have volunteered continuously, over and over and over again. Our counterparts back here have gone to universities, gotten certifications and created a situation where they are more competitive in the workplace. And so whether it is a service-disabled-veteran-owned small business like I own, which does have the charter, by the way, of hiring other veterans, we are in a place where we are not as competitive as other corporations that have not themselves been deployed.

  • 11:52:38

    REHMBut are you saying that the bureaucracy at the V.A. is such that perhaps there's very little opportunity for a small business like yours to work actively with them to be of help to veterans?

  • 11:52:59

    HAUGHThe V.A. certainly has created initiatives and I do praise their new emphasis. And I agree that employees of the V.A. are also people who serve, in essence, because they help serve us.

  • 11:53:15

    REHMAnd are dedicated.

  • 11:53:16

    HAUGHCorrect. So this is certainly not a criticism towards all of the people who are even my own providers. I think the comment that I was trying to articulate was that there are veteran-owned businesses, service-disabled-veteran-owned businesses. There are veterans that have come back that have amazing skills and value to deliver, but at times it's difficult to get them into the door. And really that's what our job is.

  • 11:53:46

    REHMAnd you're listening to "The Diane Rehm Show." Dr. Ritchie?

  • 11:53:51

    RITCHIETwo points, quickly. One is the idea of public-private partnerships. And you're right, that's absolutely essential. About half of recent veterans go to the V.A. for care, which means they get a lot of care in the private community. There's a lot of resources online to help private practitioners and others know how to treat them. They've got to learn about cultural confidence, how to talk to a service member, as well as treatment. An example of a really nice one is what Massachusetts General Hospital Home Base is doing, where they're working with the V.A. and Mass General together.

  • 11:54:22

    RITCHIEThe other point to piggy back on the question of employment, we all know that the lack of employment is a major issue for recent veterans. Greg Jaffe had a great article on it in last week's Washington Post, but it's so important. The best mental health intervention there is I think is to provide good employment. So I'd just like to echo those two points.

  • 11:54:43

    REHMHere's a tweet which says, "Active duty families are pressured to not talk about their soldiers PTSD or seek help because of risk to their military career." I'm certainly glad we are talking about this today, but I wonder if you felt that kind of pressure, Marshele.

  • 11:55:09

    WADDELLAbsolutely. I felt 100 percent isolated and my husband felt that he could not seek the help that he sensed he needed because of the way it would look. At Hope For The Home Front this is why we have stood up virtual communities online where these women in the lives of combat veterans can come together privately and they can seek emotional and spiritual support from one another in confidence, and to lock arms with each other and to find solutions to practical everyday challenges. And so, yes, absolutely. We felt alone in the beginning and we felt we had to just keep our heads down and keep up the front and be strong for the others that were deploying.

  • 11:55:53

    REHMJeff?

  • 11:55:55

    HAUGHI think that one of the challenges that we have is that when service members want to get help and they have security clearances, it becomes a very difficult catch 22 in itself. On one hand we want all of our veterans to seek the help that they need. On the other hand we have a security clearance process that does look to investigate if you've had mental health treatment. I think that there are solutions here and I think that that would be one of the biggest barriers we could remove and help remove the stigma so folks will go out and get help.

  • 11:56:34

    REHMSo you're saying if that did not have to be revealed or are you saying if that were not held as stigma?

  • 11:56:48

    HAUGHBoth, but I think related to the security clearance, it should not be revealed, as long as it is within the context of an official process, which is a mandatory screening and mandatory treatment that you need to go through.

  • 11:57:04

    REHMWell, I want to thank you all for a fascinating discussion. I hope we can talk more about this. There are clearly so many veterans out there who feel they need the help, both men and women, and who do not have that help available to them. Marshele Carter Waddell, Jeff Haugh, Dr. Elspeth Cameron Ritchie, thank you all so much.

  • 11:57:37

    WADDELLThank you.

  • 11:57:38

    RITCHIEThank you.

  • 11:57:38

    HAUGHThank you, Diane.

  • 11:57:39

    REHMAnd thanks for listening all. I'm Diane Rehm.

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