When trying to understand who exhibits PTSD and who doesn't, we mostly consider just two variables: the degree of "the trauma" and any preexisting vulnerability. But when considering the effects of combat, I suggest a third factor: failure of leadership.
does it take to get a normally self-preserving person to face deadly
fire in combat? To willfully approach an enemy intent on killing
him/her? An answer I came across but can't relocate said three things:
A belief in the justice of the cause, faith in the integrity of the
officers, and trust in the fidelity of your fellow soldiers. Of these,
the second is the most important.
Officers make the
strategic, operational, and tactical decisions that determine soldiers'
destiny. The decisions that put them in harms way, require enduring
unendurable hardship, demand effort exceeding capability, and result in
losses beyond bearing. With such power comes commensurate
I believe Eisenhower captured the full
import of this responsibility in a single sentence: "I believe the
American soldier can endure almost anything as long as he knows his
officers are looking out for him." By "looking out for him" Ike doesn't
mean tucking them in bed at night. Nor does he mean just ensuring they
have food, weapons, and training, although those are all a part of it.
What he means is that in every decision the officers make they are
"looking out for," caring about, the lives of their soldiers. And, most
vitally, they decide how to conduct combat operations with a sole focus
on doing what is necessary to achieve victory and doing it only because it is necessary, not for any
other reason. It is necessity that steels a soldier's will. If any
part of the officer's motivation is self preservation, self-promotion, a
failure to exercise due diligence, or any other concern, the troops
will know and morale will suffer. In truth, soldiers have a huge
tolerance for such failures; we all know we are all human. But it is
also true that every person also has their limits and when that limit is
exceeded, a seismic shift occurs.
to "the breaking or violation of a presumptive contract." A soldier
signs a blank check. S/he enters an opaque contract, putting his/her life in the hands of unknown,
anonymous others. Whenever any officer in the chain of command,
commissioned or non-commissioned, up to and including the Commander in
Chief, issues any order or command not based on military necessity he or
she violates that contract and the soldier has the lived experience of
betrayal: someone's failure to faithfully execute the duty to care
(about my life.) The person may feel treated as if their life has no
Almost without exception, every Service member I treated while at
Walter Reed expressed some sense of betrayal. He or she stated, not
always explicitly but more or less clearly "I did what I was told to do
and they didn't take care of me." Who the "they" was and how
specifically identified he/she was varied but their was always a someone
who they felt had betrayed them. Often, my task was to help them know
and verbalize the exact injury done. What, exactly, had happened. Who
had precisely what responsibility for what? Who failed in their
responsibilities and exactly how? Frequently many of the charges were
against themselves and overstated while their characterization of the
betrayal was most often understated. A common line I came to use was
"You're charging X with a misdemeanor but the behavior you've described
is a major felony."
Such a betrayal is an intolerable
diminishment. It is unacceptable to anyone with any degree of pride and
can be crushing to those with a less solid sense of self worth.
Ordinarily it stirs anger that demands action, some fight-back. But in
the military, the huge difference in power across the ranks may make
this all but impossible. A corporal has virtually no way to hold a
colonel accountable. "Having PTSD" offers a way. The dysfunction of
PTSD can be understood as a communication, a statement that says "See
what their incompetent leadership did to me. See the effects of their
cowardice (or incompetence, uncaring, etc.) This is what I suffered
because of them."
I offer one story to illustrate.
had already been treating veterans at Walter Reed for many years when
this story begins. A new group included two men from the same unit who
immediately told of the poor leadership of their unit and its
consequences. But I experienced one of the two as unusually aware, and
conscious of the subtleties and circumstances surrounding the story he
was telling. He seemed quite self-aware and told the story of his
betrayal with a lighter touch, even a hint of irony that was uncommon.
Based on my assessment of his strength I made a mistake with him: I
invited his attention to his contribution to his present difficulties
well before I should have. He said nothing, but the next day the two
returned to the group and announced their plans to become professional
hitmen after they were released from active duty. Hearing me as blaming
them, they came back placing the blame firmly where they believed it
I realized this indicated I had made a mistake but
was not clear what to do about it. Everything I tried to find some way
to connect with them, understand them, confront them, yielded nothing.
They masterfully deflected my every move. At some point I decided I
had no choice but to abandoned them and try to limit the damage done to
the rest of the group. Undoubtedly they left the program feeling
betrayed again and they were right. Here, I was the "officer" who
failed in my duty to understand and effectively engage them.
after the program was over and they had returned to their duty stations
did I finally recognize the accurate emotional logic of their
statement. By going to the extreme, they were helping me see what I had
missed earlier. To this day I wish I had had the wisdom to say,
sincerely, " Brilliant! You've found the perfect way to speak the truth
that can't be spoken. To show how the criminal incompetence of your
unit's leadership created a situation so horrible that it turned two
decent country boys like you guys into soulless killers. I can only
hope the country hears you."
Betrayal is a bitter bill, toxic if swallowed but
so hard to spit up. The desire for revenge is as human as the desire
for justice. In addition to having to struggle with all the horrors of
war, the killing, mayhem, and losses; in addition to having to struggle
with one's own history and specific vulnerabilities to having old wounds
reopened, in addition to all that, the combat veteran must also often
struggle with his/her desire, and inability, to say to some other "Look
what you did! Take responsibility for the god-awful mess you made!"
will say I diminish the soldier by saying these things of those who are
struggling with the effects of combat. But I say I honor him/her,
offering a vision of what they are doing that respects the meaning of
what they have been through and are trying to do. That acknowledges the
need to express that which can't be said. That this is their desperate
attempt to speak truth to power. And hopefully, by recognizing this,
they may be able to find a less personally costly way of doing so.
For the background and context for these remarks, please read my article
on PTSD published in the Psychotherapy Networker which can be found
here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."