Thursday, May 9, 2013

Leadership and PTSD

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.

What 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 responsibility.

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.

Betrayal refers 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 value.

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.

I 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 lay.

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.

Only 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!"

Some 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.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here or see a copy of it found on this blog titled "The Puzzle of PTSD."


  1. Thomas Roesel MD, PhD, FACPMay 9, 2013 at 8:13 PM

    Betrayal certainly would explain the etiology of a lot of the PTSD in the individuals we saw together at the Deployment Health Clinical Center. Thanks for bringing a spotlight on this aspect of leadership. Officers and senior enlisted can both be the source of this misfeasance.

  2. Thanks Tom, and you are certainly right about any level of leadership being capable of betraying their duty.