Summary:

Paragraph 17 reads:  "Haynes had a hard time relating to the problems the other patients in the therapy sessions described, so he stopped going. He took the antidepressant and drank a lot of bourbon in an attempt to quiet his mind. Neither method worked particularly well, so he tried to shoot himself with a handgun. His wife stopped him, and over time the intensity of the nightmare seemed to fade. “You know, it comes and goes,” he says. Several years after the battle, he sometimes takes over-the-counter painkillers before going to bed so he will not be haunted by the dream."
SSRI Stories Note:  The Physicians Desk Reference states that antidepressants can cause a craving for alcohol and alcohol abuse.  Also, the liver cannot metabolize the antidepressant and the alcohol simultaneously,  thus leading to higher levels of both alcohol and the antidepressant in the human body.  

http://bostonreview.net/BR34.6/mckelvey.php


God, the Army, and PTSD

Is religion an obstacle to treatment? Tara McKelvey

When Roger Benimoff arrived at the psychiatric building of the Coatesville, Pennsylvania veterans’ hospital, he was greeted by a message carved into a nearby tree stump: “Welcome Home.” It was a reminder that things had not turned out as he had expected.

In Faith Under Fire, a memoir about Benimoff’s life as an Army chaplain in Iraq, Benimoff and co-author Eve Conant describe his return from Iraq to his family in Colorado and subsequent assignment to Walter Reed Army Medical Center. He retreated deep into himself, spending hours on the computer and racking up ten thousand dollars in debt on eBay. Above all, he was angry and jittery, scared even of his young sons, and barely able to make it through the day. He was eventually admitted to Coatesville’s “Psych Ward.” For a while the lock-down facility was his home. He wondered where God was in all of this, and was not alone in that bewilderment and pain.

In a 2004 study of approximately 1,400 Vietnam veterans, almost 90 percent Christian, researchers at Yale found that nearly one-third said the war had shaken their faith in God and that their religion no longer provided comfort for them. The Yale study found that these soldiers were more likely than others to seek mental health treatment through the Department of Veterans Affairs (VA) when they came home. It was not that these veterans had unusually high confidence in government or especially good information about services at VA hospitals. Instead, they had fallen into a spiritual abyss and were desperate to find a way out. The trauma of war seems to be especially acute for men and women whose faith in a benevolent God is challenged by the carnage they have witnessed.

Of course, not all veterans with mental health concerns are led to VA hospitals by a loss of faith: many simply want to get a night’s sleep without being terrorized by nightmares. Whatever kind of assistance they are seeking, it has been in increasingly short supply. The decline in resources for veterans’ mental health services started in the 1980s, as part of a nationwide effort to move psychiatric patients into outpatient treatment. The number of inpatient psychiatric beds fell from 9,000 in the late ’80s to 3,000 by 2008.

During the Iraq war, however, the great difficulty veterans experienced in getting psychiatric care­greater than before­was not a product of cost-cutting, but of conviction: many Bush administration officials believed that soldiers who supported the war would not face psychological problems, and if they did, they would find comfort in faith. In a resigned tone, one prominent researcher who worked for the VA, and asked that he not be identified because he was not authorized to speak to the press, explained that high-ranking officials believed that “Jesus fixes everything.” Benimoff and the others who returned with devastating psychological injuries found a faith-based bureau within the VA. At veterans’ hospitals, chaplains were conducting spirituality assessments of patients.

The story of the mistreatment of returning veterans from Iraq is well known and shocking. But the role of religious ideology in that mistreatment­how, inside the government, it was a potent tool in the betrayal of an overwhelmingly Christian Army­is much less known.

“I couldn’t stand to hear that phrase any longer­‘God was watching over me,’” Benimoff wrote.
He wasn’t watching over the good men I knew in Iraq. Faith was the center of my life yet it failed to explain why I came home and those soldiers did not. The phrase was a Christian nicety, a cliché that when put to the test didn’t fit reality.

• • •

Things had already begun to change dramatically at the VA by early 2005, shortly after Roger Benimoff left for his second deployment to Iraq. Many appointees at the agency were disturbed that so many Iraq veterans showed symptoms of post-traumatic stress disorder (PTSD). In part the concern grew from skepticism about the diagnosis itself, which some believed to be a legacy of the Vietnam-era anti-war movement. Whatever the merits of the diagnosis, it was clearly widespread and, moreover, staggeringly expensive to treat. In 2008 the RAND Corporation put a number on the problem, reporting that one in five veterans of the wars in Iraq and Afghanistan has suffered some form of mental illness, mostly PTSD and depression.

“God doesn’t like ugly,” one political appointee told Paul Sullivan, an analyst in the VA’s Veterans Benefits Administration, in a clumsy attempt to reduce the cost of caring for psychologically traumatized veterans. “You need to make the numbers lower.” Sullivan left the VA in 2006 and became head of Veterans for Common Sense, a group that filed a class-action lawsuit against the secretary of the VA for the shoddy treatment of veterans. It was dismissed in 2008 and is now being appealed.

PTSD, along with its diagnosis and treatment, has been a charged subject in the United States since the term was introduced nearly three decades ago. Studying returning veterans and working with a group of psychiatrists and others in the 1970s, former Air Force psychiatrist Robert Jay Lifton pushed to create an entry for “post-traumatic stress disorder” in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the official manual of the American Psychiatric Association. Lifton and his colleagues believed that the kind of horror induced by the experience of war and other comparably catastrophic shocks needed a special category that would distinguish it from lesser kinds of trauma. A definition appeared in the DSM-III in 1980. The DSM-IV, published in 1994, included revised diagnostic criteria that reduced the severity of the external shock required to induce PTSD. From the start, conservatives charged that the disorder was created by anti-war activists with a political agenda. The debate about it has been marked by passion, rhetoric, politics, and religion, all of which have only made things worse for the individuals who have suffered from the disorder.

Tens of thousands of soldiers, including Benimoff, have been diagnosed with PTSD, which occurs when an individual responds to a traumatic event with “intense fear” and feelings of helplessness. For PTSD sufferers, that experience is followed by horrifying nightmares, hyper-vigilance, sleeplessness, and other potentially debilitating symptoms. Some of those diagnosed with the disorder never recover, and for this reason skeptics say that the DSM definition has turned ordinary men and women into chronic sufferers, dependent on government assistance and relieved of responsibility for their own lives. It is true that some Iraq veterans with full-blown PTSD diagnoses have been granted government benefits­usually between $200 and $2,600 per month­even though they might be able to support themselves. (I have met several of them while traveling across the country.) Nonetheless, far more suffer either with poor care or no care at all.

• • •

One soldier I spoke with, Army Specialist Bill Haynes, had grown up attending Highland Baptist Church in Paducah, Kentucky, and was awarded a Bronze Star for his courage during a March 2005 battle in Iraq. When he came home, he was plagued with a recurring nightmare. “At first, it was the same thing over and over and over,” he told me. “It was the March 20 attack. Then one time in my dream, we didn’t have any guns at all, and I knew we were all going to get captured and tortured and killed. This dream was so damn real.”

Haynes saw a therapist at the VA and, like so many veterans who sought help, was given a prescription for trazodone, an antidepressant. He was also sent to group therapy, but the sessions were filled with civilians. “They’re like, ‘I was working in a warehouse, and a piling fell on my head,’” as he recalls. His nightmares centered around the bloodshed he had witnessed on a highway near Salman Pak, an Iraqi city near Baghdad.

Haynes had a hard time relating to the problems the other patients in the therapy sessions described, so he stopped going. He took the antidepressant and drank a lot of bourbon in an attempt to quiet his mind. Neither method worked particularly well, so he tried to shoot himself with a handgun. His wife stopped him, and over time the intensity of the nightmare seemed to fade. “You know, it comes and goes,” he says. Several years after the battle, he sometimes takes over-the-counter painkillers before going to bed so he will not be haunted by the dream.

The treatment for PTSD varies widely; there is little agreement on the best method. However, most experts believe that treatment should be determined by a careful case-by-case analysis, and will most likely include a combination of therapy and medication and, in some cases, a spiritual dimension. Some veterans do well when they receive only counseling, in either group or individual sessions.

Medication alone rarely works, as the family of Derek Henderson, another Iraq veteran, discovered after he returned from the war in 2003. Henderson suffered from psychotic episodes and terrorized the people around him. He carried a knife and other weapons and once tried to run over his mother with a car. She tried repeatedly to get him admitted to the VA hospital in Kentucky for proper care, but nobody was willing to take responsibility for him. Instead, he was admitted for short stints and given prescriptions for a variety of antipsychotic medications. Finally, in June 2007, he jumped off a bridge over the Ohio River and drowned. In this and in other cases, the veterans were not getting a course of treatment tailored for them. All too often they were given a handful of prescriptions and sent on their way. Bruce S. McEwen, a neuroscientist at The Rockefeller University who has spent decades studying post-traumatic stress, told me, “The simple pharmaceutical solutions are just that­oversimplified.” Veterans’ advocates say the pared-down treatment and the over-reliance on drugs is a result of government skepticism about PTSD, and the desire to cut costs.

• • •

Sullivan was working as an analyst at the Veterans Benefits Administration in Washington in early 2005 when he was called to a meeting with a top political appointee at the VA, Deputy Assistant Secretary for Policy Michael McLendon. McLendon, an intensely focused man in a neatly pressed suit, kept a Bible on his desk at the office. Sullivan explained to McLendon and the other attendees that the rise in benefits claims the VA was noticing was caused partly by Iraq and Afghanistan veterans who were suffering from PTSD. “That’s too many,” McLendon said, then hit his hand on the table. “They are too young” to be filing claims, and they are doing it “too soon.” He hit the table again. The claims, he said, are “costing us too much money,” and if the veterans “believed in God and country . . . they would not come home with PTSD.” At that point, he slammed his palm against the table a final time, making a loud smack. Everyone in the room fell silent.

“I was a little bit surprised,” Sullivan said, recalling the incident. “In that one comment, he appeared to be a religious fundamentalist.” For Sullivan, McLendon’s remarks reflected the views of many political appointees in the VA and revealed what was behind their efforts to reduce costs by restricting claims. The backlog of claims was immense, and veterans, often suffering extreme psychological stress, had to wait an average of five months for decisions on their requests.

When I asked him years later about the meeting, McLendon laughed. Then his face darkened in anger. “Anybody who knows me knows I wouldn’t talk that way.”

Nevertheless, McLendon was open about the skepticism he felt toward the diagnosis of PTSD, calling it “a made-up term,” which has “taken on a life of its own.” As he spoke about the diagnosis, he pounded the table with the side of his hand more than ten times, hitting it so hard that the wooden surface shook. “Do I think they have a mental illness and should be stigmatized for the rest of their life?” he asked. “What gives a psychiatrist the right to do that?”

Later, in an email about our conversation, he wrote:
[PTSD] is not a diagnosis based on empirical evidence, but rather . . . it is an artificial construct erected by a vote of selected psychiatrists. This does not mean that there are not problems that certain individuals do have [and] issues that need to be addressed. But rather, it means that we have created policies and programs that have not served veterans well.

He recommended several books on the subject, including The Selling of DSM, whose authors, Stuart Kirk and Herb Kutchins, show a deep mistrust about the disorder and the scientific rhetoric surrounding the diagnosis. McLendon’s outlook seems to have had a significant impact on the way veterans are treated upon their return from war.

McLendon and many of the other high-level officials at the VA shared political convictions that, along with doubts about the science of PTSD, made them less likely to push for additional psychiatric services for veterans. They believed in streamlined government and free markets, and they supported a prominent role for faith-based organizations. The secretary of the Department of Veterans Affairs, R. James Nicholson, had previously served as chairman of the Republican National Committee and as ambassador to the Vatican. McLendon’s politics closely mirror his boss’s, and under Nicholson’s watch, veterans had increasing difficulty in obtaining adequate psychological care.

When a 2006 Government Accountability Office report raised questions about whether soldiers were getting the psychiatric help they needed, an assistant secretary of defense disputed the report’s findings, pointing to the fact that soldiers were being referred to chaplains. During this time contracts for veterans’ services were increasingly parceled out to leaders of faith-based organizations rather than to secular ones, even though veterans’ advocates opposed any bias toward faith-based treatment and argued that replacing empirically proven, nonsectarian programs with faith-based ones was a mistake.

The religious programs grew, despite concerns. At the VA Healthcare Network in upstate New York, chaplains compiled spirituality assessments of patients within twenty-four hours of their arrival. The VA Greater Los Angeles Healthcare System gave patients a questionnaire that stated one of the System’s goals as helping veterans “Maintain Optimal Spiritual Health.” In Coatesville, patients in the psychiatric ward had a daily, thirty-minute block of time scheduled for “SPIRITUAL UPLIFTING.” Meanwhile Benimoff wondered, “what kind of God would allow people to sink to the depths we here in this ward had sunk?”

• • •

For spiritual uplift, many soldiers and veterans depend heavily on pop-Christian books, especially Rick Warren’s The Purpose Driven Life, and themes of divine purpose and devotion to God. As a chaplain in Iraq, Benimoff himself used the book to cope with the mayhem. He also relied on it to help the troubled soldiers he knew, and he appreciated that the book emphasized helping other people, while other spiritual self-help books tended to promote selfishness. But even a book like The Purpose Driven Life could not solve the problems he faced. Over time, he began to wonder about his own purpose in Iraq and about the government’s, and he felt uncertain and scared.
We had gone to Iraq because there were weapons of mass destruction stockpiled across the country, yet those weapons were never found and may never have existed. I had gone to Iraq thinking that was the cause. But if the cause had been wrong, what did that say about our role there, and mine?

As Benimoff and other soldiers eventually discovered, The Purpose Driven Life was not helpful, especially as the war’s own purpose grew less clear. Since Vietnam we have learned that PTSD tends to hit people especially hard when they fight in wars of choice. Bobby Muller, the head of Veterans for America, told me it was difficult for soldiers to talk about the war in Vietnam after they came home; years later, though:
I would get in touch with some of these guys, and they all had to come to the realization, ‘This is bullshit.’ It’s not just the horror of killing, but its context. . . . If you’re fighting a necessary war, it’s awful. But it’s kind of what you got to do. Let’s take a war that turns out to have been unnecessary. And in fact your leadership betrayed you. That willingness to serve was betrayed by a leadership that lied and squandered that trust. The very moral fabric of your life gets ripped apart.

Despite its limitations, The Purpose Driven Life is still used in the military to inspire soldiers and ease doubts about their mission. Nobody forces soldiers or veterans to read The Purpose Driven Life, of course, but it is extremely popular. Paperback copies are passed around among soldiers, and one edition of the book was published with a camouflage cover, a savvy move by the publisher that helped tap into the military market.

In May Harper’s magazine reported that at a mandatory 2008 suicide-prevention assembly of 1,000 aviators at a U.S. Air Force base in Lakenheath, England, a chaplain relied on the book for his presentation. Warren’s inspirational messages did not always take hold, though, and one soldier, LaVena Johnson, who ended up killing herself in Iraq, according to military documents, had a copy of The Purpose Driven Life.

Many soldiers turned to the book for solace once they came home. One Kentucky veteran who had been wounded in a 2005 battle in Iraq kept the book in his basement apartment, but nevertheless tried to shoot himself and was admitted to a lock-down psychiatric ward in a VA hospital. Nobody believes that the book itself drove him and others to suicide or attempts to end their own lives, but its popularity is yet another indication of the existential despair that many soldiers and veterans feel after serving in combat and the desperation with which they seek help. Military culture places high value on self-reliance, so a spiritual self-help book made sense for Johnson and fellow fighters. But their stories show that, when faced with the immense task of coming to terms with the horror of war, an inspirational book such as The Purpose Driven Life, or a prescription for antidepressants, or any other simplistic approach to the problem, is inadequate.

• • •

The 2010 budget proposed by President Obama includes the largest funding increase for veterans in the past thirty years, and much of it is devoted to treatment of PTSD. The new secretary of the Department of Veterans Affairs, Eric Shinseki, a retired general who was injured in Vietnam (and fought with Rumsfeld over the size of the force needed in Iraq), has shown a strong commitment to the care of veterans. Unfortunately, bureaucracies are slow to respond. After years of neglect during the Bush administration, veterans now have nearly one million claims pending, a record high for the agency. VA officials say that, technically, it is not a backlog, because thousands of claims are resolved each month, and thousands more are added. But none can deny that the situation is enormously frustrating for suffering veterans.

The political fallout from the Iraq war and the government’s failure to care for its veterans has been far-reaching. Shortly before Benimoff resumed his chaplaincy­now at Walter Reed­stories describing inadequate treatment at the hospital appeared in The Washington Post, appalling the public. “I was walking into an institutional crisis,” he wrote. “I’ll speak for myself when I say it felt like everything was broken. If the system was broken, so was I­a broken healer for broken soldiers in a broken system. God save us all.