A Q&A with Richard North Patterson on PTSD
Post-traumatic stress disorder (PTSD) is central to In the Name of Honor, which depicts the searing combat experiences that generate PTSD, its effect on veterans of the Iraq war, and its use as a defense to murder charges in a military tribunal.
Why are you qualified to discuss PTSD?
I first wrote about PTSD twenty-five years ago in my novel Private Screening, which dealt with the impact of combat on veterans of Vietnam. At that point, this subject was little understood, and the Veterans Administration (VA) did not even address PTSD. Nonetheless, I interviewed numerous veterans of the war, along with their psychiatrists and their lawyers, and used what I learned in portraying a Vietnam veteran charged with murder and a lawyer who invokes PTSD as a defense. Ever since, I've had a deep interest in the impact of war on combat veterans, and the way in which our society deals with them.
Before I revisited this subject in In the Name of Honor, I interviewed veterans of the Iraq war, the professionals who treat them, and the lawyers who represent them. Thus I have a perspective on what has changed since Vietnam, the similarities and differences in traumatic experiences, and deficiencies in how the military and the VA deal with vets. And, as a former trial lawyer, I understand the potential uses of PTSD as a defense in capital cases.
Finally, a novel like In the Name of Honor can dramatize PTSD in a more powerful and accessible way than merely reciting facts. The fact that the vivid anecdotes in the book are based on actual events only adds to its authenticity.
What is the scale of PTSD among victims?
Here, statistics do tell a compelling story. Take three examples. Out of roughly two million veterans of Iraq and Afghanistan, experts estimate that more than 750,000 suffer from PTSD and/or traumatic brain injury (TBI). More than 100,000 of these veterans are homeless. And though the VA doesn't track suicides, the several thousand suicides estimated exceeds the number of veterans killed in these two wars.
What causes PTSD, and how do you compare the trauma of Vietnam vets with the trauma of veterans of Afghanistan and Iraq?
A central aspect of PTSD among Vietnam vets is that so many saw the war as both meaningless and murderous—a brutal conflict in which they kept taking and giving up the same territory, were despised by the Vietnamese, and couldn't find a compelling rationale for their mission. That so many Americans loathed the war and villainized the warriors only exacerbated their problems. Thus one similarity between Vietnam and Iraq is the widespread doubts about the justification for these wars and a persistent suspicion that the government misled Americans to secure our involvement.
Another is that in Iraq and Afghanistan, as in Vietnam, it was often difficult to distinguish friend from enemy and civilians from combatants. Our relationship with the Iraqis was frequently schizoid—trying to make friends by day, then storming homes by night to uncover militiamen or weapons. Soldiers never knew if the can of Pepsi that a cute Iraqi kid held was a soft drink or an improvised explosive device (IED). They couldn't be sure if the Iraqi woman driving through a checkpoint was an enemy or was pregnant and desperate to get to the hospital. They couldn't anticipate when searching for weapons if they were interrupting a family at dinner or about to encounter armed Iraqis prepared to kill them.
The threat of death was unrelenting—it came not just from soldiers, snipers, and enemies disguised as civilians but from devices that could be hidden in ditches by the road, in potholes, or under a pile of garbage. Yet another threat was rocket-propelled grenades (RPGs) that could strike in seconds from a great distance. The result could be terrible carnage—not just the dead but dead friends in pieces.
These conditions created the central component of PTSD: a scarifying combat experience under difficult conditions. In Iraq and Afghanistan, this involved constant exposure to IEDs and RPGs; the involvement of civilians in combat situations; the inability to reliably identify combatants; the death of close friends and comrades; being forced to handle the bodies of fellow soldiers mutilated by explosive devices; and lethal house-to-house fighting. These problems were severely exacerbated by multiple tours of duty. The more violence one sees, and the more threats one experiences, the worse the trauma becomes.
What is the impact of PTSD on returning veterans?
The impact is pervasive. Returning vets experience multiple problems in much higher rates than the population as a whole. These include violence; domestic violence; divorce; substance abuse; suicide; homelessness; depression; sleeplessness; alienation from family and friends; hypervigilance and a recurrent fear of danger; dissociation; sudden bursts of anger; road rage and other traffic incidents; difficulty retaining employment; and educational deficits caused by the inability to concentrate or retain information.
One story typifies this tragedy. A veteran in his early twenties was nearly killed by an RPG that hit a cement wall beside his head. The result was PTSD and TBI—a common occurrence caused by random explosions. The vet was discharged from the service, but given only 20 percent disability, despite a serious diminution in intellectual capacity. Frustrated by delays in receiving treatment at the VA, he became angry and was labeled disruptive on the VA's computerized record system, resulting in denials of care. Because of his inability to hold a job, his home was foreclosed on and he went bankrupt. He now lives on the streets, a statistic in the epidemic of homelessness among vets.
What is the cause of higher rates of violence among veterans suffering from PTSD?
In war, a soldier lives with the prospect of dying in an instant. He no longer feels safe and may have a fierce adrenaline flow in response to startling sounds or movements. If the experience is intense enough, the veteran may not be able to turn it off simply by coming home.
In cases of PTSD, veterans who become violent often experienced a combat trauma that triggers an instinctive reaction. What looks like anger is actually a reflexive fear and the ingrained need to defend oneself. So what may lie beneath a bar fight is an instinctive response to a perceived or real threat.
How does PTSD affect marriage?
The war is ruining families. Again and again, spouses report that the returning veteran isn't the same person who left for war.
Often, the experience that partners have with people who suffer PTSD may seem bipolar. At certain moments, the veteran may become detached, shut off, and extremely quiet. Then, quite suddenly, he may erupt in sudden and seemingly inexplicable anger.
Bottled-up anxiety and rage may cause vets to overreact to the normal stresses of parenting. A particularly tragic impact is dramatically increased rates of domestic violence among vets who can no longer handle their anxiety or emotions.
Why the higher rates of suicide?
This results from feelings of depression, isolation, and alienation from loved ones. If the isolation becomes severe, suicide may follow. One fairly typical story involves a sergeant too traumatized to maintain his marriage. When his commanding officer sent him to the VA for a psychiatric evaluation, he was put on a six-month waiting list. Shortly thereafter, he hanged himself in his former wife's garage.
One irony is that a number of veterans commit suicide after being recalled to duty. The VA does not consider these as suicides by military personnel because they are committed by "civilians."
What role does guilt and shame play in exacerbating PTSD?
Guilt among traumatized vets is common. It can stem from some act committed in war, perhaps involving harm to civilians; or the feeling that one failed to help comrades; or guilt over surviving when friends have died.
Very often soldiers compare themselves to the myth of an ideal soldier and believe that they failed when confronted with the violence and chaos of war. As a result, they feel vulnerable, mortal, and frightened. Obviously this can lead to deep depression and, ultimately, the desire to take one's own life.
Why are there increased rates of substance abuse?
Nightmares and flashbacks tied to traumatic experiences are as common as they are unpredictable. A way to seek refuge is to numb oneself— with either alcohol or drugs.
What role does the difference between the wars in Afghanistan and Iraq play in PTSD?
We know from Vietnam and Iraq that if the cause is complex, controversial, and murky; it can increase the likelihood of PTSD. By contrast, the war in Afghanistan is tied to al-Qaeda and the Taliban, the authors of 9/11. Thus there is more sentiment among the troops that the cause is justified. This, some experts believe, will result in a lesser incidence of PTSD among veterans of the Afghan conflict.
Who is "blame" for PTSD?
An essential point is that PTSD is not the fault of the military nor of individual soldiers. It stems from the nature of war itself, and what war demands that human beings do in combat.
Of necessity, military training is meant to reduce fear and allow people to defend themselves or, if required, to kill. Again, the problem is not the military but what we ask soldiers to do—often while remaining ignorant of the nature of their experience.
This lack of understanding stems from the nature of our society. Unlike the Israelis, as one example, we separate civilian from military life. And because relatively few of us serve, many Americans have no understanding of the problems of veterans affected by war.
Moreover, America is filled with armchair warriors, who "support the troops" by sending them to fight but who are ignorant or indifferent to the impact of war. As for the veterans themselves, they may be handicapped by a warrior ethic that suggests that to admit stress or anxiety is a weakness. Thus some may be too ashamed, or too fearful, to seek help.
To what degree have we succeeded or failed in helping vets, and how does this differ from the situation after Vietnam?
After Vietnam, we had virtually no resources for treating veterans with PTSD. This tragedy has condemned countless veterans to a life defined by a thirty-year-old combat experience.
By contrast, we were much more prepared to treat PTSD at the start of the Iraq war. We have 235 or so veterans centers that offer treatment for vets. Nonetheless, the system is overwhelmed. The VA is an enormous bureaucracy of 250,000 employees. And yet there is a mismatch between the location of VA facilities and the distribution of veterans, many of whom come from small towns and rural areas where the nearest VA center is more than 200 miles away.
Compared to the immensity of the problem, the VA centers are insufficiently staffed. The single best treatment for PTSD is one-on-one therapy, in which the professional gradually builds trust with the veteran he or she is treating. But a single therapist can't see more than thirty people a week, and treating PTSD requires at least six months of intensive work. Therefore, in any given year, an individual therapist can see roughly sixty veterans. In a nation where well over one million soldiers suffer from PTSD, treating them individually would require an army of more than sixteen thousand psychiatrists, psychologists, therapists, counselors, or social workers. At most, the VA employs roughly one-quarter of this number. Moreover, relatively few private therapists treat PTSD.
This results not only in harmful waiting periods but in funneling veterans to therapies that are far less effective—group treatment, drugs, or cognitive therapy. Although there is ongoing research to find more efficient ways to treat PTSD, they have yielded little results. Indeed, group therapy is often counterproductive: not only are veterans ashamed to tell their stories to fellow vets but listening to other terrible experiences can reinforce their own trauma.
In short, while there is greater awareness of the problems of PTSD, this public-health tsunami overwhelms our current resources. Overwhelmingly, the vets who suffer the worst effects of PTSD are those who have not received adequate treatment—or any treatment at all.
Is there a predisposition to PTSD?
Several studies yield little evidence that there is a predictable profile for who will suffer PTSD. However, there is one exception—exposure to family violence. The incidence of abuse within families is a very good predictor of future PTSD.
How does In the Name of Honor link to PTSD?
I have placed PTSD at the heart of this novel. The troops led by Lieutenant Brian McCarran suffer all the potential flashpoints for PTSD—the death of comrades; dealing with the bodies of murdered friends; the constant threat of IEDs and RPGs; the inability to distinguish combatants from civilians; repeated exposure to frightening and sometimes horrific experiences; and a dubious rationale for their mission and for the war itself.
Moreover, the fatal conflict between the shooter, Lieutenant McCarran, and his victim, Captain Joe D'Abruzzo, stems directly from combat circumstances that cause McCarran to perceive D'Abruzzo as a threat—even when they are stationed in Virginia.
Finally, PTSD is central to Captain Paul Terry's defense of Lieutenant McCarran in his military court-martial for murder. In a very real sense, the trial presents a microcosm of the Iraq war and its effect on those who fought it.
Why does In the Name of Honor put PTSD on the legal cutting edge?
As of now, no military court—anywhere—has allowed PTSD to reduce murder to manslaughter. Thus the trial I portray would be a landmark in military law.
However, PTSD fits very well under the definition of insanity used in military courts. That test is whether the defendant has a "mental disease or defect" that prevented him or her from knowing that an action was wrong. As suggested in In the Name of Honor, PTSD can lead to the shooter's mistaken but honest belief that a fatal shooting was justified by self-defense. In such a case, the defendant would not believe that his actions were "wrong." Logically, proof that PTSD was central to an act of violence could lead to a finding of not guilty by reason of insanity.