As reports emerge that as many veterans have taken their lives this year as have been killed in the 13 years of the war in Afghanistan, a new narrative is emerging around post-traumatic stress disorder. By Martin McKenzie-Murray.

PTSD and the rehabilitation of returned soldiers

His reckoning came on the Kokoda Track, among the mud and mosquitoes, but it wasn’t the physical toil that awoke him. It was the stories. Adrian Talbot had taken this pilgrimage as part of Families of the Fallen, a group of veterans and families who had lost serving children. They bonded negotiating hellish inclines, but were more deeply joined by the stories they shared at day’s end. “There were guys talking about transitioning to civilian life,” Talbot tells me. “And families would tell us how their sons died. It resonated. I broke down on that mountain.” 

It was 2013 and Talbot was suffering. He was withdrawn, volatile, distressingly numbed. At the funeral of a friend’s daughter – she had died agonisingly young, taken by muscular dystrophy – he watched the father carry the tiny coffin. Then he scanned the room. Everyone was swollen with grief. “I knew I should be feeling sad,” Talbot says, “but I didn’t. I had suppressed so much.”  

He had left the defence force after six operations on a shattered hip forced a medical discharge, and he drifted. Before the discharge he had been first on the scene when a colleague killed himself with a single shot to the head. He had watched as the body bag of a dead soldier was moved and recognised the attached service number as a friend’s. He had patrolled Afghanistan during a counterinsurgency where it was often impossible to immediately determine the enemy. Here, hyper-vigilance and paranoia were adaptive virtues. Now, though, they were expressions of an illness. In civilian life, he was working in security, like many vets. He was also abusing prescription pills and drinking heavily. 

Adrian Talbot had post-traumatic stress disorder, even if he didn’t realise it yet. He tells me he was fortunate enough to have a wife who “stayed with me when I was an awful individual. Something inside her told her I’d come back.” 

On the Kokoda Track, years of suppressed emotion finally revealed itself. The stories he heard struck a chord. He realised he wasn’t alone. Realised he had been defying assistance. When he got home, he asked work for time off and barely left the couch for two weeks. He was exhausted. But he was going to get help. 

More than a decade earlier, in 2001, Talbot was in his early 20s and coaching young tennis players in New South Wales. One day, at home, he watched the twin towers collapse live on television. Something stirred. He tells me this inner agitation was partially naive, confused. But it was insistent. He wasn’t sure how he was meant to go back to work the next day; how he could pretend nothing had changed. His daily routine – his purpose – suddenly seemed less vital. “A seed was planted,” he told me. 

Four years later, while travelling in Europe, he joined Britain’s Royal Marines Commandos. He later deployed to Afghanistan. 

1 . Controversial diagnosis

Post-traumatic stress disorder did not appear in the Diagnostic and Statistical Manual of Mental Disorders until 1980, when it was added largely as a result of the dismal flood of United States Vietnam vets who were experiencing the disorder. An estimated 700,000 veterans required some psychological help. But even then, PTSD remained controversial among clinicians – it required the pioneering work of psychiatrists such as Chaim Shatan to champion its inclusion in the DSM. 

The US military had launched Operation Salmon during the Vietnam War, embedding therapists in every battalion, and had seen reduced numbers of infantry demonstrating psychological distress compared with the Korean War. It was initially thought a success. But in the years following the war it became clear there was a generation who, in the words of famed war correspondent Michael Herr, “had their lives cracked open for them”.  

For centuries the symptoms of PTSD were recognised, but their cause was found in moral dissolution. In Shakespeare’s Henry IV, the titular king returns from war and his wife mournfully asks him: “What is’t that takes from thee thy stomach, pleasure and thy golden sleep?” Centuries later, 300 British soldiers were executed for “cowardice” during World War I. 

What might be clinically recognised as PTSD today, was variously referred to as “shell shock”, “battle fatigue” or “war neurosis” throughout the 20th century’s major wars. These conditions were considered at the time to carry implications of individual fault or lack of moral fibre. 

What was crucial about the PTSD as it was described in 1980 was that it formally shifted the etiology – or causation – of battle-induced trauma. Where previously it was attributed to an individual’s weakness, it was now recognised as the result of an external, catastrophic event. Today, it is a household phrase. 

“Over 30 years ago,” Professor Mark Creamer tells me, “when I started, I had to try very hard to convince people that it was real – that it wasn’t the result of weakness or cowardice. Thirty years later and it’s almost the opposite – I’m trying to convince people that people are resilient and that the majority of veterans aren’t significantly affected.”

Creamer is a professorial fellow at Melbourne University’s psychiatric department, and an expert in PTSD. He tells me there are four core elements of PTSD. “One, that the person is haunted by this past horror. Two, the person avoids any reminders of it. Three, there’s a more general psychological distress that overlaps with depression or anxiety, say, and finally a hyper-arousal. You will see fluctuations between each of these.” 

It was reported by the Herald Sun last week that 41 veterans had taken their lives this year – the same number of troops who had lost their lives on deployment to Afghanistan in the past 13 years. It is a shocking number, and those duelling statistics suggest a war more fatal for those who have left it. But because we don’t adequately record veteran suicides, the numbers we have vary. Regardless, the report compelled Senator Jacqui Lambie to call for a senate inquiry this week. “Successive Australian governments have betrayed our veterans and have not been prepared to properly look after them when they return home injured,” she said. 

Days earlier, the prime minister had announced a review of mental health services for veterans. “The best way we honour the diggers of 1916 in this centenary year,” he said, “is by caring for the veterans of 2016 and their families.” 

2 . ‘Holes in the system’

Geoff Evans enlisted in the Australian Army in 1994. By 2008, after having served in Timor-Leste, he was a team leader in Afghanistan. Evans suffers PTSD and acquired a traumatic brain injury while on tour. “There are glaring holes in the system,” he says, adding: “In reality it’s an adversarial system [for veteran compensation]. It’s hard to process in a timely fashion. But once you’re processed, it’s world class.” 

Creamer tells me he thinks the system is quite good, and that psychological treatment is automatic for veterans. “They don’t need forms. It’s free. Claims, though, for compensation can be nasty. It’s adversarial. But I have to stress my first point: the barriers to that treatment are quite small.” 

Most people I speak with politely express frustration with how veteran trauma is reported in the media. Each expresses gratitude that there is greater public awareness of the issue, and accepts that it usefully diminished stigma in the military community. But an abundance of goodwill is distorting public sentiment. 

“We typecast soldiers as either heroes or PTSD-riddled wrecks,” John Bale tells me. Bale is the chief executive officer of veteran support group Soldier On. He is a former Australian Army officer who served in Afghanistan and founded Soldier On after a close friend was killed by an improvised explosive device (IED) while on tour in Uruzgan province. “We need to change the narrative of veterans as victims and find empowering employment for them. We need to see veterans as a resource for this country, even after they’ve taken the uniform off. Veterans have unique skills. They don’t want to be seen as victims.” 

Take Geoff Evans. He is uninterested in discussing his past with me – “I’m sick of reading about myself” – preferring to discuss policy issues and his charity work. A former firefighter, international relations graduate, and founder of Australia’s only dedicated homeless shelter for veterans, Homes for Heroes, Evans isn’t a victim – he’s a high-functioning, articulate community leader. 

Before I speak with Mark Creamer, he emails me to express his hope that my story will be balanced – that it include “positive stories” also. “I don’t want to minimise PTSD,” Creamer says. “But there are myths surrounding it. One myth is that PTSD is a life sentence. It definitely is not, and we have been able to treat it much better over the past 10 or 15 years. We see about one-third of people will respond almost completely to treatment, about one-third who will show substantial improvements, and one-third that do not respond well to treatment. There’s a very pessimistic idea out there about PTSD, but the real challenge is people being able to access evidence-based care.”

A balance must be struck between recognising the needs of our modern soldiers, and condemning veterans to condescension or cultural fetish. That requires a delicacy that’s anathema to most reporting. “The media need a victim and a villain,” a former soldier tells me. “It’s more complicated than that. Most return okay, but in need of help changing their lives.”

The distortions of goodwill aren’t limited to media reporting. “There’s approximately 3500 organisations for veteran affairs out there,” Evans says. It is a point made repeatedly to me – that small veteran aid groups were flourishing, but floated ineffectually among their prevalence. Or, worse, were collectively chewing up limited resources. “There’s amazing public support out there,” John Bale says. “But there’s duplication. These groups have absolutely exploded in number and it’s untenable in the long term. There’s passion, but that passion can be divergent. We’d like to see it come together more.” 

Creamer echoes the point: “There’s new organisations springing up every day and it dilutes resources.” 

A smart consolidation of veteran bureaucracies – both public and private – is required, but that’s not sufficiently dramatic to bear front pages. 

3 . Looking for deeper meaning

In 2007, David J. Morris was a reporter embedded with the First Infantry Division in Baghdad. It was his third trip to Iraq. On previous tours he had been shot at, lost friends, and witnessed extraordinary bloodshed in the Battle of Fallujah. “Spooky is just a word in your mouth until you have heard the sunset call to prayer in a half-rubbled city surrounded by al-Qaeda fighters,” he wrote later. 

On October 10, 2007, he was riding with members of the division in a military humvee. They were inspecting a street in the suburb of Saydia, where Shiite residents were torching their Sunni neighbours’ homes. The street was black with smoke – “like entering a cave” – and they realised they were in a cul-de-sac. Suspecting an ambush, their vehicle reversed and struck an IED. They all survived. 

Morris later experienced PTSD. While watching an action film, a scene of a car explosion brought the Saydia incident back. Nightmares followed. Morris began thinking about apophenia – the perception of patterns between random incidents. “I think this is sort of a common theme among survivors, of trying to look for a deeper meaning, some sort of meaning in the near-death experiences that they’ve been through,” Morris told NPR radio. 

A related aspect of trauma is what clinicians refer to as global cognitions, a grand and inescapable extrapolation from the traumatic incident: Because this happened, the world is dangerous. Perception is polluted, the universe darkened. Trauma experts have told me how useful it is for the traumatised to appreciate randomness, to bracket their experience with that acknowledgment. 

4 . Counterinsurgency issues

“Afghanistan reminded me of those old western films,” Adrian Talbot tells me. “That lawlessness element. It’s incredibly volatile, and you’re not essentially sure who’s friend or foe. You’re trying to fulfil some kind of mission but you don’t know who’s going to kill you. I think this helps embed PTSD and hyper-vigilance.” 

There are obvious comparisons with the Vietnam War. “The Iraq War is actually quite similar to Vietnam, Somalia, East Timor and Afghanistan in that it was largely a counterinsurgency,” Morris says. “The intermixing of insurgents among the local civilian populace can make postwar readjustment very challenging for veterans. I know one Marine veteran of Somalia who lived in a neighbourhood of San Diego where many East African immigrants were moving in. This was upsetting to the veteran because these immigrants were fairly new to America, didn’t speak English and wore their traditional garb. For this and other reasons, he found their presence triggering and after some deliberation he chose to move to a different neighbourhood.” 

The cruelty here is that hyper-vigilance is necessary on the battlefield, but once you’re home it’s a disorder. Professor Mark Creamer tells me that “a whole lot of behaviours that were very adaptive on the battlefield become maladaptive back home”.

Differences of warfare may affect trauma, and so too differences of public reaction. Veterans of World War II were feted without qualification, they were “the Greatest Generation”; Vietnam vets were spat on in the streets and labelled murderers. “I think it makes a huge difference,” Creamer says. “We can probably tolerate higher level of trauma if we think it’s for a good cause. When you’re in a position where you’re condemned – Vietnam is a powerful example – people find it more difficult to adapt.” 

Adrian Talbot’s work brings him close to veterans of all ages, and he tells me there’s a sad distinction to the Vietnam vets. “The World War II vets are still living fruitful lives, but the Vietnam guys are going into homes earlier. I saw one guy with early onset dementia which came from substance abuse – that was a result of the treatment he received when he got back.”

Each veteran I speak to stresses the importance of helping returned servicemen and women into civilian life. There can be a loss of personal definition, camaraderie, self-esteem. 

“We need to give hope, not dread, to those transitioning out of defence,” Talbot says. “And for those with PTSD, it’s not factually correct for people to say it’s a lifetime sentence. It doesn’t mean we can’t function.”

John Bale tells me that when people are discharged they can feel lonely.

“You’ve lost your tribe,” he says. “I was in for 12 years, and you do get institutionalised. The military is different to the community, obviously. Veterans need that support. But as I say: it’s a very important time not to create stereotypes. We plug huge amounts of money into [commemorative] infrastructure, but most people have absolutely no idea about modern warfare. The modern vet is seen almost as a caricature – the larrikin soldier. I really don’t think the community understands.”

Morris says Australia is in some ways better than the US in its treatment of vets. “PTSD awareness is a big thing in the US, but access to medical care and utilisation of that medical care is poor in the US, which doesn’t have socialised medicine like Australia,” he says. 

“The US is also a more atomised and, in some ways, less cohesive society than Australia, and veterans returning to small-town Oregon or Ohio can feel alienated, alone and unemployable. 

“But healing and homecoming isn’t really a medical problem. Proper homecoming involves healthcare but also finding ways to reincorporate veterans into society by helping them find work, get back to school and get socially reconnected.”

 Adrian Talbot has reconnected – in 2015 he was appointed head of the Homes for Heroes program. He’s proud, he’s functioning, but he still carries the war with him. Spending so much time with injured vets – some of whom have hit rock bottom – can be distressing. But, he tells me, “I want veterans elevated and their skills respected.”

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This article was first published in the print edition of The Saturday Paper on August 20, 2016 as "Pressed out of service".

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Martin McKenzie-Murray is The Saturday Paper’s associate editor.

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