The invisible wounds of war can take a heavy toll. Researchers are working to better understand – and treat – post traumatic stress disorder (PTSD). We explore the moral and ethical aspects of combat-related PTSD, as well as new efforts to push back against the stigmatization of the condition.


  • Nancy Sherman Professor of Philosophy and Fellow at Georgetown University's Kennedy Institute of Ethics; public policy scholar, Wilson Center; author, "The Untold War: Inside the Hearts, Minds, and Souls of Our Soldiers"(W. W. Norton & Company) and "Stoic Warriors: The Ancient Philosophy Behind the Military Mind (Oxford Univ. Press)
  • Jonathan Shay, MD, PhD Former Staff Psychiatrist, Boston VA Outpatient Clinic; author of Odysseus in America: Combat, Trauma, and the Trials of Homecoming” (Scribner)
  • Col. Charles Engel Director, Deployment Health Clinical Center; Associate Professor of Psychiatry, Uniformed Services University of the Health Sciences


  • 13:06:42

    MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Soldiers' heart, shellshock, post traumatic stress, whatever you call the fallout, serving in combat can fundamentally change people. Over 300,000 veterans and active duty troops have been diagnosed with post traumatic stress disorder or PTSD. And that may be just the tip of the iceberg. As military members return from Iraq and Afghanistan, the struggle to make peace with what happened on the battlefield often follows them back home.

  • 13:07:28

    MR. KOJO NNAMDIResearch on PTSD is constantly evolving with diagnosis and treatment taking place everywhere from in theater to the local Wal-Mart. And there's renewed interest in the moral aspects of the injury. As therapist work to help soldiers rebuild their trust in others and reintegrate into society after experiences the trauma of war. Joining us to discuss the military and PTSD, in studio, is Nancy Sherman. She's a professor of philosophy and Fellow at Georgetown University's Kennedy Institute of Ethics and a public policy scholar at the Wilson Center. Her latest book is called "The Untold War: Inside the Hearts, Minds and Souls of Our Soldiers." Nancy Sherman, thank you for joining us.

  • 13:08:14

    DR. NANCY SHERMANThank you so much, Kojo.

  • 13:08:16

    NNAMDIAlso with us in studio is Col. Charles Engel. He is the director of the Deployment Health Clinical Center and a professor of psychiatry at the Uniform Services University of the Health Sciences. Chuck Engel, thank you for joining us.

  • 13:08:31

    COL. CHARLES ENGELHi, Kojo, thanks for having me.

  • 13:08:33

    NNAMDIAnd joining us from studios at the Christian Science Center in Boston is Jonathan Shay. He is an independent scholar and retired Department of Veterans Affairs staff psychiatrist. His books include "Odysseus in America: Combat, Trauma and the Trials of Homecoming" and "Achilles in Vietnam: Combat Trauma and the Undoing of Character." Jonathan Shay, thank you for joining us.

  • 13:08:57

    DR. JONATHAN SHAYIt's a great pleasure being here again, Kojo. First time I've seen your face.

  • 13:09:02

    NNAMDIThis is true because now we have Skype and we're actually using it. If you'd like to join this conversation, call us at 800-433-8850. If you or a loved one has been diagnosed with PTSD after serving in the military, we'd like to hear from you about the experience, 800-433-8850. Charles Engel, some have called Post Traumatic Stress Disorder the signature wound of the wars in Iraq and Afghanistan. Just how common is it among our troops?

  • 13:09:33

    ENGELWell, the estimates vary depending on study. But it's safe to say, on the order of about 15 to 20 percent of our soldiers that deploy and face combat will return with some severity of Post Traumatic Stress Disorder.

  • 13:09:51

    NNAMDIAnother injury that has been a hallmark of these wars in Iraq and Afghanistan is Traumatic Brain Injury. How does TBI overlap with PTSD?

  • 13:10:02

    ENGELThere seems to be a fairly extensive overlap and there's various ways of understanding how they overlap from my psychiatric perspective, sort of, the easiest way to think of this is that if one has a serious head injury and is about to lose consciousness, it's probably the closest moment that one could ever imagine feeling to death. And that just the trauma aspect of that experience, I'm sure, is likely to produce the psychiatric effects of Post Traumatic Stress Disorder.

  • 13:10:41

    NNAMDIIt takes Americans an average of 12 years, it's my understanding anyway, to seek treatment for PTSD. Why do you think it takes people so long to come forward and once they do, how are they diagnosed and treated? First you, Chuck Engel, and then Jonathan Shay.

  • 13:10:56

    ENGELWell, I think it's a complicated mix of factors. And that's exactly right, that in the United States, our best estimate is about the median time is 12 years. I think one part of it is self recognition on the part of the individual. And particularly in the military, when folks come back from the deployment experience, they have been keyed up for a long time and that's been a very adaptive thing. When they come home and now they're with family and friends, that keyed up part of themselves has to transition to a lower key civilian way of living.

  • 13:11:32

    ENGELAnd when you first get back, you may not recognize at all that this an unusual set of symptoms that you're experiencing and overtime it dawns on you. So that piece of personal recognition is one part of it. Having a system that reaches out to you and gives you a chance to raise your hand and say that you're struggling is another aspect of it. And knowing that the people that might respond to you, when you raise your hand, having trust in confidence that they'll do the right thing. You know, those are all pieces of the puzzle in terms of trying to reach a larger and larger proportion of these folks in a shorter period of time.

  • 13:12:10

    NNAMDIJonathan Shay?

  • 13:12:12

    SHAYWell, for years, I've been agitating to eliminate the word disorder in this label.

  • 13:12:20

    NNAMDIA conversation we'll also expand on, later.

  • 13:12:23

    SHAYOkay. I'll just finish the sentence at the moment. And that is that in that culture, in the military culture, to have an illness or injury, a sickness or disorder is not dishonorable, but it sure is unlucky. And no soldier wants to share a fighting hole with an unlucky soldier. It's stigmatizing in that culture. And that stigma seems to carry over. It's entirely honorable to be injured in the service of your country. And I notice that nobody says that Secretary of Veterans Affairs, former Army chief of staff, General Eric Shinseki doesn't suffer from Missing Foot Disorder.

  • 13:13:16

    NNAMDISo Nancy Sherman, you point out that the ethical and the moral conflicts that soldiers cope with don't just manifest as PTSD. Yesterday, it was reported that a U.S. soldier opened fire on Afghan civilians, killing at least 16 people. How does an incident like that fit into this issue as we understand it?

  • 13:13:38

    SHERMANWell, we don’t yet know all the answers. We know very few answers to the questions we're asking about this. But the questions that get raised in my mind, about this kind of you know, was a rampage, we think at this point alone or with others, is what were the psychological burdens this individual was carrying that may be were recognized by buddies but no one came forth. Maybe were recognized by the unit commanders but not sufficient red flags were raised.

  • 13:14:19

    SHERMANYou know, Post Traumatic Stress can leak out into enormous amounts of aggressive behavior and in this case, if that was one of the symptoms, the combat rage, you know, went ballistic. So I don't know. But we certainly know that these have been long wars with multiple deployments. This individual probably had back to back, two or three deployments. And I think it's amazing we haven't had more of these kinds of incidents. But this is a real tragedy for international relations and for the war.

  • 13:14:54

    NNAMDIAllow me to go to the telephones, here is Josh in Washington, D.C. Josh, you're on the air. Go ahead, please.

  • 13:15:01

    JOSHKojo, thank you for having me today. I am a civilian who has deployed to multiple war zones, multiple times over the past 10 years. And just wanted to kind of ask the panel kind of what they think about, you know, the (unintelligible) between how the military deals with PTSD and how a lot of these civilian agencies that have been increasingly called upon to serve in dangerous and post conflict environments, you know, chose to deal with it?

  • 13:15:29

    JOSHYou know, I've watched a lot of my colleagues struggle with this because a lot of my colleagues also hold security clearances which are not supposed to be in danger by (word?) seeking counseling or seeking therapy or treatment for things such as PTSD. But in reality, a lot of times that does endanger those security clearances, which then endangers their ability to kind of work at all. And I think it's a real problem that's kind of gone unaddressed because, you know, things like the security clearance process are often times still kind of shrouded in mystery and secrecy. Just want to hear kind of what the panel has to say about the civilian side of the PTSD conversation.

  • 13:16:13

    NNAMDIFirst you, Chuck Engel.

  • 13:16:15

    ENGELYeah, I think one thing we have to acknowledge is that we know very little about the occurrence of PTSD and other mental disorders and behavioral problems in the DOD civilians and the other civilian workers that are in theater that work with us. I think that, you know, the point that the caller is making around the, you know, stigma and bringing this up, the very direct stigma and that it may impact their work is a real one. It's real in the military as well. You know, it's probably, you know, the principal dilemma for many of these folks.

  • 13:16:59

    ENGELOne, you know, one study done by the Army out at Walter Reed Army Institute of Research showed that of those people with Post Traumatic Stress Disorder, that about half of them said that they feared for their career should they go to get assistance. In another study, it was very interesting to me that even the spouses of these folks, about a 1/3 of spouses said that they felt concerned about going to get assistance for mental health problems because it may affect their loved ones career.

  • 13:17:31

    ENGELAnd, you know, I think that while there's a pretty rational basis to be made, that the mental health status of the service member could very well affect their career, that the spouse rarely factors into this sort of thing. And just the sense that that could be a factor should tell us a lot about just sort of the, you know, the complicated dynamic of trying to help people to trust the system to do the right thing for them.

  • 13:18:00

    NNAMDIWell, one of the things that tells us, Jonathan Shay and Nancy Sherman, is that we're not simply talking about members of the military here, we're also talking about spouses and we're also talking about civilians. Surveys have found that up to half of all service members fear that seeking mental health care would harm their career. Now, we're hearing about civilians feeling the same thing. The American Psychiatric Association is considering a proposal to remove the D from PTSD which is what you were talking about earlier, Jonathan Shay, a move many people hope would lessen the stigma of a diagnosis. Why do you think it would?

  • 13:18:38

    SHAYWell, if nothing else, Vice Chief of Staff Chiarelli has reported, as of what spokesman for his culture, that it would. I'm sure it would not solve every problem. It maybe wouldn’t prevent a single case of psychological injury, but would make it better for a few people, a bit better. And it's worth doing because what's at stake? What's the cost?

  • 13:19:08

    NNAMDINancy Sherman?

  • 13:19:09

    SHERMANI can't speak to the full complexities here of what's involved in the reordering of the diagnosis and the DSM, the manual. But I will say, having gone to a number of meetings of late with General Chiarelli's staff and his replacement now, General Austin as Vice Chief of the Army. There is a very slow but noticeable shift afoot to try to de-stigmatize mental injury, whether it concerns suicides, service members suicides and the failure to seek help before that or the spouses that have been in great psychological distress and been fearing, as Col. Engel said, to come forth.

  • 13:19:59

    SHERMANSo and it's not -- and I think the caller, Josh, makes a very good point. The stigma attached with mental illness is not just a military problem. It's a general public problem. DOD civilians but in the public sphere as well. And I think the military is part of that larger problem that we have to fight.

  • 13:20:20

    NNAMDICharles Engel, can a diagnosis hurt a military career?

  • 13:20:25

    ENGELWell, I think there's no question that it can hurt a military career. That if one has a medical diagnosis, there's, you know, public domain regulations on the specific diagnoses and how they're rated and so on. And it's not just a mental health disorder, it's every kind of medical illness that these, depending on the severity and the amount that it disables the service member and what their job is, it very definitely can threaten their career.

  • 13:20:57

    NNAMDIAnd, Jonathan, you have been talking about this subject for many years now. You say that the word disorder is stigmatizing in the military world. But as you just underscored in the case of General Shinseki, wound or injury is not.

  • 13:21:14

    SHAYThat's right. In that culture, that's entirely if you're -- if you can recover well enough to be fit for duty, there is no limit to where you can go. Look at General Shinseki's career. He lost his foot in Vietnam.

  • 13:21:30

    NNAMDIGot to take a short break. When we come back, we will continue our conversation on PTSD or post traumatic stress disorder and the move to have the word disorder removed from it. We'll also be looking at what treatments are available and the kind of effects it can have, 800-433-8850 is the number to call if you'd like to join the conversations. What questions do you have about post traumatic stress and how it's being diagnosed and treated within the U.S. military.

  • 13:21:57

    NNAMDIYou can also send us email to Send us a tweet @kojoshow or go to our website, Join the conversation there. I'm Kojo Nnamdi.

  • 13:23:52

    NNAMDIWelcome back to our conversation on post traumatic stress and the military. We're talking with Nancy Sherman. She's a professor of philosophy and a fellow at Georgetown University's Kennedy Institute of Ethics. She's a public policy scholar at the Wilson Center. She joins us in studio along with Colonel Charles Engel. He is the director of the Deployment Health Clinical Center and a professor of psychiatry at the Uniformed Services University of the Health Sciences.

  • 13:24:19

    NNAMDIJoining us from studios in Boston is Jonathan Shay. He's an independent scholar and retired Department of Veterans Affairs staff psychiatrist. You can call us at 800-433-8850. Send us a tweet @kojoshow. We got a tweet from Randy who asks: Are there early records of post traumatic stress disorder from World War I, World War II, Civil War, Revolutionary War? Do you know, Chuck Engel?

  • 13:24:44

    ENGELYeah, there is a group in the U.K. actually who has done the most work in this area, headed by Professor Simon Leslie at King's College and they've done fairly extensive work looking at pension records. And identifying, you know, what post-war syndromes have looked like over time and how they've changed or stayed the same and how society has responded to.

  • 13:25:12

    NNAMDIBack to the telephones. Here is Pablo in Leesburg, VA. Pablo, your turn.

  • 13:25:19

    PABLOYes. I've been listening to the show and find it really interesting. It's really interesting how the panel is mentioning that PTSD can hurt a career when I can honestly say that it does hurt a career. I'm retiring from the Navy. And when I voluntarily went to seek help after a deployment to Iraq, it definitely hurt my career. It automatically throws the stigma on you of being crazy. It truly hurts because automatically they have the obligation in a sense that we'll have to say that it's a good thing to have the obligation to let you go to your appointments to do the things that you need to do to take care of yourself.

  • 13:26:09

    PABLOBut automatically that has repercussions in terms of what management you're going to have and what options you have within the military, because automatically you are set up to be unreliable in your work. I would like to hear what your panel has to say about that and I'll take my answer off the air. Thank you.

  • 13:26:34

    NNAMDIAnd, Jonathan Shay, I'll start with you. What do you think can be done outside of removing the word disorder to remove that kind of stigma?

  • 13:26:41

    SHAYWell, first of all, the caller emphasizes career. And I think that's an important thing for everybody to register. If you are a junior enlisted person who does not aspire to make a career in your service, things have never been better in terms of being able to get help if you ask for it. That's not to say that there aren't junior enlisted who very rightly feel that their sergeants resent their asking for release to go to the mental health clinic and so forth.

  • 13:27:27

    SHAYThe problem is with the staff or career NCOs, depending on what service you're talking about, and officers. And they perceive, and I think it's probably with a good foundation, that it's basically career ending to ask for help for combat trauma.

  • 13:27:51

    NNAMDIChuck Engel, it's been estimated that as much as 60 percent of mental health care is delivered by primary care physicians. How does the military work with and train those doctors to help veterans? And is there anything that they can do to help avoid the stigma that obviously is associated with it?

  • 13:28:10

    ENGELYeah. I think one of the things that primary care docs can do is to take the steps, the appropriate steps to recognize and manage these things early. I run a very large program, have since 2007 called RESPECT-Mil. We're now in 87 Army clinics around the system. And we're integrating with the new patient center medical home approach that is being put in place. Go back to the 12 years that it takes for the average person in the civilian sector to get care.

  • 13:28:47

    ENGELOne of the principal problems that we have is there is a large group of folks out there with unrecognized challenges. These folks don't come to see the mental health professional on average that maybe only about a fourth of them will come to see a mental health professional. But they're seeing their regular doctors up to, you know, large numbers of times. But on average, about three and a half times a year.

  • 13:29:13

    ENGELSo, if we can create a system that will not only train the clinicians but I think even more importantly put the support mechanisms in place for those primary care clinicians who have to do their work in a very different environment than psychiatrist or a psychologist might have to do it, put the system in place to support them in the care of folks and to help clinics make sure that they ask the right questions of each person coming through about whether they're having these kinds of symptoms, we can do a better job of recognizing it and manage it. And we have data to suggest that we can do just that.

  • 13:29:48

    NNAMDINancy Sherman?

  • 13:29:49

    SHERMANYeah, I think the program is amazing. I think that sort of thing is also needed in the civilian world as well to catch mental illness. I just want to return to Pablo's remarks about career killing and Jonathan's response. I think it is significant that the sort of Sergeant Major Chandler in the vice chief's office in the Army has come forward with the discussion of his own PTSD. And that's a signal that it's okay or there are some recognition within the enlisted ranks of this problem and that it's not just top brass that can talk about it with some impunity, but that the enlisted can.

  • 13:30:33

    SHERMANAnd I continue to have some hope that the more those that are in leadership positions in, you know, in units can protect soldiers in some way from the stigma and shame that attaches to this illness the better off we'll be. But it is a command culture phenomenon that has to come from the top down as well, sometimes from the bottom up.

  • 13:31:00

    NNAMDIWe're talking about post traumatic stress in the military.

  • 13:31:02

    SHAYI want to jump in on this matter.

  • 13:31:04

    NNAMDIHere's Jonathan Shay. Please come on.

  • 13:31:06

    SHAYYes. Of the general medical officers, the primary care doctors and the VA primary care doctors in the civilian sector, my pipe dream is that every single person in that role really feels empowered and competent to do basic sleep medicine, because it turns out that the loss of sleep caused by combat trauma is one of the main engines of the bad stuff that comes out, people lose their ethical self-restraint, they lose their emotional self-restraint, they lose their social judgment and they tumble downhill.

  • 13:31:53

    SHAYAnd a whole lot of it is because they can't sleep and sleep is fuel for the frontal lobes of the brain. It's -- the physiology there is really clear.

  • 13:32:05

    NNAMDIBack to the telephones. Katie in Wood Vine, MD. Katie, you're on the air. Go ahead, please.

  • 13:32:12

    KATIEHi, Kojo. Thanks for taking my call. First, I'd like to just start off by saying that I'm a grad student at McDaniel College. I'm in the counselor education program. I hope to become a licensed clinical professional counselor. So I am quite familiar with the implications as well as the stigma of suffering (unintelligible) diagnosed with mental health disorders in general.

  • 13:32:32

    KATIEAs for the prevalent PTSD and mental illness regarding our veterans, my question for the panel is, why do you think considering the mass amount of DOD spending that's given yearly to various programs it's taken so long for the DOD to put proper amount of funds into properly treating our soldiers suffering from PTSD and other mental illnesses? And I'll take the answer off the air. Thanks, guys.

  • 13:33:00

    NNAMDIJonathan Shay, I'll start with you.

  • 13:33:05

    SHAYI don't know that I have a sharp pencil answer for that question. It clearly causes many barriers to be raised. It involves saying we've got this problem and it involves the people who have the problem being willing to say, yeah, I got it.

  • 13:33:34

    NNAMDICare to add anything to that, Nancy Sherman?

  • 13:33:36

    SHERMANI'll add just one thing and that is, we know that there is, in general, a shortage of behavioral care specialists. This is no defense for the military. And I actually think that the military, perhaps the DOD, I've heard this as much, we're taken aback a bit, by surprised in the first two years of this war, realizing how many people they were able to save physically because of the armor and the general nature of frontline medicine. And yet, we're not able to help psychologically in that they tried very hard to bring in forward...

  • 13:34:14

    NNAMDIWell, let's talk about...

  • 13:34:14

    SHERMAN...forward deployed psychiatric care.

  • 13:34:16

    NNAMDILet's talk about that. Oh, I'm sorry. Chuck Engel, I didn't give you the opportunity to answer.

  • 13:34:19

    ENGELThat's all right. I mean, my response really is that -- and I thank the caller for asking the question because I think it's an important one, is all the things that we've talking about here is that, you know, the proper response really calls for a wide variety of things. We're talking about cultural and organizational change. We're talking about health service systems and their response and the emphasis on primary care is a relatively new kind of generational thing in all of health care.

  • 13:34:51

    ENGELThe reconsideration of the diagnostic label, the education of clinicians, the education of patients, the education of service members and, you know, the hiring of health care providers, the ramping up of the hiring, realizing, you know, what the actual need. And anytime that you put 2.2 million people in theater over the course of 10 years and bring those folks back, there's going to be a lot of change that has to take place over, you know, a very short period of time.

  • 13:35:25

    ENGELAnd some of that is, you know, problem solving as we go. And I think, you know, we've done the best that we can. I think it hasn't always been pretty, but, you know, we've done the best that we can under the circumstances and continue to work hard at it. And, you know, I feel like as someone who deployed to the 1991 Gulf War, I look at, you know, the cultural change within the military that's just occurred over that period of time.

  • 13:35:54

    ENGELAnd the systems in place to screen soldiers before they leave, when they return and to try to identify these things, you know, there's been dramatic changes just in the last 20 years. Are we there yet? No way, shape or form, we're not there. We got a long ways to go. But certainly there's a lot of hard work and a lot of attention that's been put on this.

  • 13:36:16

    NNAMDIAnd, Katie, if you're looking for some budgetary numbers, we're talking in the final analysis about hundreds of thousands of soldiers. And the Congressional Budget Office estimates that the cost per soldier treatment is $8,300 in the first year, $4,300 in the second. And there's been a call from Secretary of Defense Leon Panetta to reexamine the way PTSD is diagnosed after it was alleged that some soldiers were stripped of the diagnosis and denied benefits. Nancy Sherman, you were going to say?

  • 13:36:46

    SHERMANYeah, I wanted to just say that there is also, you know, with the cultural shifts that Colonel Engel mentioned, responsibilities I think a lot of us have in our communities, at the university where I am at Georgetown, you know, we have returning veterans. They often are unrecognized as such until there's a forum in which to gain recognition. And it's critical for us as civilians to really begin to dismount some of the barriers between civilians and military and understand what's going on in their minds, what they went through and what they think of us and what think of them.

  • 13:37:29

    NNAMDII'd like to go to the moral and ethical issues, but I'll have Hal in Silver Spring be the first to raise them. Hal, you're on the air. Go ahead, please.

  • 13:37:39

    HALHello, gentlemen and ladies. My question is this. I'm a Marine Corps training officer. And I'm wondering about your views of pre-deployment resiliency training, specifically ethics training and physical and mental toughness training. The question I have is, what format do you feel is most effective, if any of them are effective, whether it's classroom, small discussions or even role-playing exercises?

  • 13:38:02

    NNAMDIAnd, Hal, by way of getting some historical context here, moral and ethical quandaries can be a big part of the anguish that accompanies post traumatic stress, behavioral guidelines the soldiers rely on in combat are very different from one that shape our every day conduct. In responding to Hal, can you talk about how military ethics have evolved from, say, the Vietnam era to the current period? Nancy?

  • 13:38:27

    SHERMANWell, it's a large subject. There's always traditionally in philosophy at least, military ethics sometimes thought of rather formally and abstractly. Is the war just? Is the way you're fighting it just? So, just cause and just conduct. Can you separate them? Can you ever really fight justly if the cause for which you're fighting is not ultimately justified or just? So those are philosophical issues. War post bellum, is the community you're setting up afterwards going to be just?

  • 13:38:59

    SHERMANAnd how do you establish that, especially with the people that you are involved with and that you leave behind who may be at risk? But I've been interested, and I know Jonathan has as well, in the soldiers' inner wars. And specifically, I've been thinking about and soldiers tell me about the guilt that comes with luck, with moral luck. It doesn't always require -- it doesn't always justify actual guilt.

  • 13:39:30

    SHERMANIndividuals aren't culpable necessarily for accidents. They're not culpable when they survive and their buddies. They're often not culpable for collateral incidents. And yet they bear this terrible burden of luck and sometimes shame that they couldn't be as good as a soldier as they hoped they would be. Those are moral burdens that need to be addressed and often aren't. And they could be thought about a bit in advance in these kinds of trainings that Hal talked about.

  • 13:39:58

    SHERMANSome of those trainings are in part meant to reduce the sense in which you unfairly beat up on yourself. So some of it is positive psychology training. The army's been involved in this comprehensive soldier fitness in particular. So I think resilience training advance is critical. We need strong minds in advance, not only strong bodies, but understanding that the guilt and shame soldiers bring back and sense of betrayal often isn't just irrational.

  • 13:40:27

    SHERMANJust don't -- to say get over it quickly isn't, I think, the reasonable response. We need to understand it and we need to empathize, and the individuals need to empathize with themselves as well.

  • 13:40:38

    NNAMDIJonathan Shay, and then Chuck Engel.

  • 13:40:41

    SHAYIt appears that I coined the phrase moral luck which surprises because they're two common words. But my definition and other psychology people definition is not exactly the same. Mine has to do essentially with leadership malpractice, that when there's a betrayal of what's right by someone who holds legitimate authority in a high-stake situation, moral injury is present.

  • 13:41:18

    SHAYOther folks are saying when there is a betrayal of what's right by the self, one does something in war that is abhorrent to one's own ethics or commitments, even though it's within the rules of engagement and isn't a violation of the law of land warfare, it still leaves people with a wound on their soul in a high-stakes situation. These are both important. They both exist. My game has been, for years, to improve everything we can improve in policy and practice and culture that will reduce the frequency and severity of injuries.

  • 13:42:09

    NNAMDIChuck Engel?

  • 13:42:10

    ENGELYeah. First, you know, Hal, thanks for your question. I really appreciate it. Thanks for your service. I think that preventive efforts are incredibly important. I'm gonna come at it from a slightly different angle, though, and ask the question, you know, what does mental health and mental health providers have to contribute to it? This is something that we don't have any vaccines for. We just simply don't have easy answers for how to prevent PTSD that we can say that we have science in support of it. And I think that, in many ways, it's sort of an arrogance of the mental health community that we can step up and improve on what, you know, what the military, the war-fighter community has for thousands of years perfected, and that is how to make troops, you know, maximally resilient in the face of very violent situations.

  • 13:43:13

    ENGELI think that, you know, our services do a great job through the course of the training that they do in terms of fostering resilience. And the other follow-on point to all this I would make is that from a, you know, from a mental health service system perspective, I think really that what we have to prepare ourselves for anytime that we go to war is that this is gonna be something that happens. And if we're not willing to acknowledge that, if we're not willing to put forward, in a societally ethical way, the effort to take care of folks who are casualties of this, then we ought not enter into the conflict up front. And let me just make the point of why I think that, you know, resilience from the mental health side may be, you know, a bit of a challenge.

  • 13:44:03

    ENGELFirst, I think the major contributor to PTSD is trauma itself, and the, you know, when you look at preventive things, the analogy I would use is sun block for skin cancer. We know that when people put sun block on and they go out to the beach, the more sun block they use, the longer they spend in the sun. And I think, to some extent, we have to recognize that our goals in the military are going to be to make our service members more resilient in battle. That means the more resilient they are, the longer they're gonna be there, and the more likely they're gonna experience trauma, and I think, at best, probably what we're looking at is wash.

  • 13:44:47

    ENGELThat doesn't mean a wash meaning that, you know, our efforts are not going to do a whole lot better in the end than what people would have done otherwise. But nonetheless, I think, you know, it's important that we do everything that we can, but I think we shouldn't put false hope on the idea that early on, you know, mental health providers are gonna be able to work some sort of resilience magic that will make this problem go away. It will be there. We have to have a service system that will respond to it.

  • 13:45:22

    NNAMDIHal, thank you for your call. We've got to take a short break.

  • 13:45:24

    SHAYI would like to jump in, Kojo, if I may.

  • 13:45:27

    NNAMDIWell, both Jonathan and Nancy, could you hold for a second, because we do have to take this short break. When we come back, we'll pick up where the conversation left off. Hal, thank you for your call. We're talking about PTSD in the military. I'm Kojo Nnamdi.

  • 13:47:27

    NNAMDIWelcome back. We're talking about the military and post-traumatic stress disorder. We're talking with Jonathan Shay. He's an independent scholar and retired Department of Veteran's Affair staff psychiatrist. His books include "Odysseus in America: Combat Trauma and the Trials of Homecoming," and "Achilles in Vietnam: Combat Trauma and the Undoing of Character." Colonel Charles Engel is the director of the Deployment Health Clinical Center and a professor of psychiatry at the Uniform Services University of the Health Sciences, and Nancy Sherman is a professor of philosophy and fellow at Georgetown University's Kennedy Institute of Ethics, and a public policy scholar at the Wilson Center.

  • 13:48:05

    NNAMDIHer latest book is the "Untold War: In die the Hearts, Minds, and Souls of Our Soldiers, " and Nancy Sherman, Chuck Engel seemed to have brought a responsive spark when he talked about if we increase our expectations for resiliency in the face of combat, then we have to have, I guess, expectations that post-traumatic stress is also likely to be with us.

  • 13:48:32

    SHERMANWell, that's right. I think one worry some have, and I think it's a legitimate worry is that this inoculation so to speak won't fully -- or fool proof inoculate. That's obviously got to be the case, and that those who still manifest and present symptoms of post-traumatic stress will not be further stigmatized or somehow not screened for -- as a result of that kind of preventive training. And I just want to say, too, the whole topic of moral luck has been out there in the philosophical literature for decades, and it begins in some ways with something I write about in "Stoic Warriors," trying to have -- be invulnerable to luck by being tough and being stoic, and toughing it out.

  • 13:49:21

    SHERMANAnd being stoic has some resonance with the military, but it can be dangerous and the moral fog of war brings all sorts of luck that you just couldn't do as well as you wanted to do or that what happened could have gone differently. And that the could-haves somehow entail should-haves for you, and those are heavy, heavy burdens that we need to try to relieve people of.

  • 13:49:46

    NNAMDIJonathan Shay, on this inoculation, however well prepared a soldier might think he or she is for combat, the reality is really difficult to anticipate, isn't it?

  • 13:49:55

    SHAYWell, there is certainly that, but my main objection to both these ideas of inoculation and resiliency is that they are somehow individual characteristics of the soldier or marine or sailor or airman. These are primarily social and institutional characteristics. Are the units stable and cohesive? Is the leadership expert, ethical, and properly supported? Is the training sufficiently prolonged, detailed, and realistic?

  • 13:50:33

    SHAYThese are institutional properties and they're all protective factors that have great impact on the individual, but they are not, in themselves, individual characteristics. It's a mistaken focus.

  • 13:50:51

    NNAMDIThis is an injury, Jonathan, as old as war itself. In your books, you connect the struggles of recent veterans to those of Odysseus and Achilles. How are older generations of veterans helping Iraq and Afghanistan vets cope?

  • 13:51:07

    SHAYWell, I got a touching email from a current theater veteran asking me to thank the Vietnam veterans, and saying that in this veteran's view, the Vietnam generation had fought a lot of battles that the current generation doesn't have to fight as a result. He was very grateful.

  • 13:51:30

    SHERMANI think just on that subject, Kojo...

  • 13:51:33


  • 13:51:33 know, the Vietnam memorial wall is a place not just where Vietnam veterans go, but, of late, where soldiers of the current wars go and often talk to those that are docents or those that are the Vietnam era men about their wars and that the healing intergenerationally is a critical part of returning to war and of returning from war and reentering society.

  • 13:51:59

    NNAMDIHere is Barbara in Bethesda, Md. Barbara, you're on the air. Go ahead, please.

  • 13:52:05

    BARBARAThank you, Kojo. Thank you very panel for addressing this very urgent topic. I'm the mother of a 17-year-old son who is planning a career in the military. In fact, we have just been through the DODMERB process and are still trying to clear a treatment which has been a cutting-edge treatment for a concussion which my son has suffered. And I'd like to know, to the panel, what is the embracement of an advancement in non-traditional medicine, such as hyperbaric oxygen therapy in treating post-traumatic stress disorder?

  • 13:52:45

    NNAMDIAre you familiar with that at all, Chuck Engel?

  • 13:52:49

    ENGELWell, I think...

  • 13:52:50

    NNAMDIHyperbaric oxygen therapy as an alternative treatment for PTSD?

  • 13:52:55

    ENGELRight. I am certainly not an expert in the use of hyperbaric oxygen for the treatment of post-traumatic -- or I'm sorry, traumatic brain injury. But I am aware that it is a experimental treatment. It's one that I believe that there is study underway within DOD to look at this. There are anecdotal reports that it can help from both clinicians and people who've undergone the treatment, so we're trying to look at it scientifically.

  • 13:53:27

    ENGELIt's, you know, it's not necessarily a harmless treatment, so like any medical treatment, we have to look at it carefully and make sure that it does more good than harm, and I think that's the major question around it.

  • 13:53:44

    NNAMDIBarbara, thank you for your call. I'd like to hear from Neal in Tyson's Corner, Va. Neal, you're on the air. Go ahead, please.

  • 13:53:52

    NEALHi. It's really serendipitous to be hearing this show. I'm a civilian, but I have been diagnosed with PTSD in the past, and also had a traumatic brain injury, TBI, so I just wanted to comment. It's really good to hear that we're touching on the physical component of this because there often can be a physical component behind it. For instance, an injury that causes a concussion, the lingering concussion, and how that interacts with PTSD, or in my case, the cumulative effect of several previous concussions resulting in something like post-concussion syndrome, PCS, which in some cases can just be a lingering concussion sort of lingering symptom.

  • 13:54:37

    NEALSo it's very difficult to articulate to anyone that hasn't experience this what it's like to feel sleepy from a concussion, yet unable to sleep from the tension that comes from PTSD, or hyperaware because of PTSD, yet still very cloudy because of this physical injury that's still lingering. So I just really appreciate that I heard that. I know that there's a lot of different ways that soldiers can experience a concussion, so I just really want to say thank you for the show.

  • 13:55:07

    NNAMDIOkay. Thank you very much for your call. We got Alexis on Facebook who said, "Could the guests comment on higher rates of PTSD and suicide among National Guard and reservists versus members of the rest of the military? Do Guard and reserve members have access to appropriate mental health care?"

  • 13:55:25

    ENGELWell, on the first question, I think it's hard to necessarily really compare the National Guard and reserve components to the active components in terms of the rates of suicide because these rates have been kind of going back and forth in terms of which is higher, which is lower. One thing we can say is that there has been a considerable trend upward in suicide rates over the decade of war altogether, you know, in particularly the army. And the second question again?

  • 13:56:06

    NNAMDII forgot what the second question was.

  • 13:56:07

    ENGELYeah. Sorry about that.

  • 13:56:10

    NNAMDIOh, adequate access to care. Do the members of the reserve and National Guard have appropriate access to mental health care?

  • 13:56:16

    ENGELYeah. That's a crucial question. I think that there are many unique aspects of serving in the military when you're in the guard and in the reserves. One unique aspect is your access to health services, and I think that, you know, once you demobilize, you come back and you demobilize, and you're no longer in an active duty status, then, you know, you're reliant on any private insurance that you might have and so on for care.

  • 13:56:46

    ENGELNow, since, you know, again, this is change since the 1991 Gulf War where we realized that this was going on, now service members when they come back, have access to VA services. Last I was aware it was for five years after they deploy, no questions asked. It doesn't have to be service connected in order to get it. That's an effort to try to shore up the care of those folks. But I think, you know, again, in the VA, they're also practicing a similar model in a lot of places to respect mental -- this primary care program I was referred to earlier where we've screen about two million visits over the last several years in these primary care settings.

  • 13:57:30

    ENGELYou know, the VA has similar programs around the system to help identify folks and get them the care that they need. Again, it's a situation where if you're a long ways from a VA hospital, or you're a long ways from a military hospital, you know, the access is gonna be less. It's...

  • 13:57:47

    NNAMDIAnd I'm afraid that's all the time we have. Colonel Charles Engel is the director of the Deployment Health Clinical Center and a professor of psychiatry at the Uniform Services University of the Health Sciences. Thank you for joining us.

  • 13:58:00

    ENGELThank you, Kojo.

  • 13:58:00

    NNAMDINancy Sherman is a professor of philosophy and fellow at Georgetown University's Kennedy Institute of Ethics, and a public policy scholar at the Wilson Center. Her latest book is "The Untold War: Inside the Hearts, Minds, and Souls of our Soldiers." Nancy Sherman, thank you for joining us.

  • 13:58:14

    SHERMANThank you, Kojo.

  • 13:58:15

    NNAMDIAnd Jonathan Shay is an independent scholar and retired Department of Veteran's Affair staff psychiatrist. His books include "Odysseus in America: Combat Trauma and the Trials of Homecoming," and "Achilles in Vietnam: Combat Trauma and the Undoing of Character." Jonathan Shay, thank you for joining us. I'm Kojo Nnamdi.

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