HAVERHILLL, Mass. -- Before her life fell apart, before suicide began to sound like sweet release, Natasha Young was a tough and spirited and proud Marine.
Straight off the hardscrabble streets of Lawrence, Mass., a ruined mill town ravaged by poverty and drugs, she loved the Marine Corps' discipline, the hard work, the camaraderie, the honor of service to her country.
She went to war twice, the last time five years ago in western Iraq with a close-knit team of Marines who disabled IEDs, roadside bombs. It was nonstop work, dangerous, highly stressful and exhausting. Six of the Marines were killed in bomb blasts, each death a staggering gut-punch to the others. After they returned home the commander took his own life. Staff Sgt. Young broke down, too, spent physically, emotionally and mentally. Eventually, she was diagnosed with post traumatic stress disorder (PTSD) and, last October, was medically discharged from the Corps.
Having been a strong warrior, now she simply couldn't function. "I was ashamed of myself," she says in a whisper at her home in Haverhill, Mass.
Young is one of a generation of 2.4 million Americans who fought in Iraq or Afghanistan, many of whom are coming back profoundly changed by what combat veteran and author Karl Marlantes described as the "soul-battering experience" of war.
The shock of war, of course, is hardly new. But now the cascade of combat veterans from the Iraq and Afghanistan wars is forcing mental health practitioners to a new recognition: the effects of combat trauma extend far beyond the traditional and narrow clinical diagnoses of PTSD and traumatic brain injury (TBI). The current crop of veterans is at risk of a "downward spiral" that leads to depression, substance abuse and sometimes suicide, as Eric Shinseki, secretary of the Department of Veterans Affairs, said in a recent speech.
Almost a quarter million Iraq or Afghanistan vets have been diagnosed with mental health injuries from combat service. Many more are not diagnosed, yet go on with their lives while experiencing short-term memory loss, headaches, insomnia, anger or numbness -- conditions that can range from merely annoying to highly disruptive on the job and within the family. For some of them, hard work can temporarily mask these symptoms. But only temporarily.
"You can work through it [with therapy], or become a workaholic," says Tom Berger, who still suffers nightmares from his time as a medical corpsman with the 3rd Marine Division during bloody Vietnam fighting in the late 1960s. "Left untreated, you reinforce the trauma, so it makes sense to keep that loaded .357 [revolver] next to you on the car seat," adds Berger, who is a senior adviser on veterans health at Vietnam Veterans of America.
Those who go to war, it turns out, carry the traumatic after-effects longer and deeper than previously recognized — perhaps for a lifetime.
At the Army medical center at Fort Gordon, Ga., Dr. John L. Rigg, director of the Traumatic Brain Injury Program, is treating active-duty soldiers complaining of headaches, mood swings, anger, insomnia, and memory loss as many as five years after they experienced concussive blasts in combat. They're still functioning, but they're struggling. "They're not getting better," says Rigg. "In fact, they may be getting worse."
With treatment, says Rigg, some can learn to manage.
"No one gets out unscathed," says Col. Katherine Platoni, a senior Army combat trauma psychologist with two battlefield tours in Iraq and Afghanistan who has seen and felt the deepening effects of combat trauma.
Large-scale U.S. military action is finished in Iraq and scheduled to wind down in Afghanistan. In those places, as President Obama has noted, "the tide of war is receding."
But at home, the tide of war is not receding for millions of veterans returning to a long, difficult and often dangerous transition back into civilian life, struggling to reconcile their searing combat experiences with a civilian society that largely disconnected itself from military service and now, according to polls, tired of war.
Like others leaving the ranks, Natasha Young's struggles with her psychological and emotional storms were compounded by the sudden decompression from the intensity of combat service. No one back home in the civilian world understood what she had gone through, or what she was going through.
"Out here," she says, "you realize how different you are from people who haven't served."
STRUGGLING WITH PTSD
Other veterans are encountering the same void that envelops Young.
How to explain to a civilian the fierce pride a warrior feels in having mustered the stamina, the professional skill and the courage to complete a second or third combat tour, in a war that seems to have no point and no end, where the enemy is frustratingly elusive but the blood and death are real and immediate?
How to explain why a combat veteran feels anxious in crowds, startles at the pop of a toy balloon, wrenches awake with night terrors?
How to express the rage and sorrow of survivor's guilt — that a medical corpsman couldn't save a wounded buddy, that a squad leader didn't bring all his guys home safe?
How to share the agony of a Marine platoon leader who is severely injured and medevaced after an IED blast kills two of his men and abruptly removes him from the men he had vowed to protect?
Outside the Marine Corps, severed from others with the same experiences, Young unravelled. She was 31, a single mom, and sick. Her Harley gathered dust in the garage. She stopped writing poetry. "I couldn't cope," she says. "I felt so scared.
"I think my son kept me from clicking off ‘safe' more times than I'd care to admit," she confides, referring to the temptation to turn off her weapon's safety mechanism and end her life.
Such combat trauma wounds are largely invisible -- but the numbers are arresting. Roughly 2,413,000 young Americans have served in the Iraq or Afghanistan war, so far.
More than 600,000 of them may be struggling with PTSD and major depression. The Department of Veterans Affairs (VA) has formally diagnosed 207,161 Iraq and Afghanistan war veterans with PTSD. But experts believe many more are affected because of shortcomings and defects in screening and diagnosis.
A recent study by the RAND Corp., a Pentagon-funded think tank, suggested how many undiagnosed veterans there might be. It estimated that some 14 percent -- or about 337,820 -- of post-9/11 veterans suffer from the headaches, sleeplessness, irritability, depression, rage and other symptoms of PTSD, whether or not they are formally diagnosed. An additional 14 percent suffer from major depression. The VA's National Center for PTSD confirmed the numbers as accurate.
In addition, some 40,000 veterans of Iraq and Afghanistan have been diagnosed with traumatic brain injury they received in combat. The condition involves a bruising of the brain caused by concussion or other head injury, according to the Defense and Veterans Brain Injury Center. Many more veterans may be suffering without diagnosis or treatment, experts say. (Overall, the Defense Department has diagnosed 233,000 individual cases of TBI since 2000, the vast majority caused by training injuries or vehicle accidents, not combat.)
Head wounds were considered fatal until the 20th century and the arrival of better and faster medical care. As with PTSD, the diagnosis and treatment of TBI have improved significantly during the past decade.
Still, in a chilling reminder of war's long-term effects, the VA reported that last year it treated 476,515 veterans for PTSD -- most of them veterans of the Vietnam war almost 50 years ago. Tragically, the Vietnam generation of vets didn't have access to the kinds of services now available through the VA.
While the Greek historian Herodotus mentioned the trauma of war 25 centuries ago in his account of the battle of Marathon, it wasn't until 1980 that American psychiatry formally recognized and named the condition, describing PTSD as an injury caused by an outside stimulus rather than by an internal human weakness. More effective forms of treatment followed slowly.
Today, with rising veterans' demands for mental health services, the VA is making a determined and costly effort to reach those who live in remote areas or who may be unaware of VA services. It has launched 70 mobile outreach vans to cruise the streets of cities and towns across the country. It's also expanding its secure teleconferencing facilities and expects this year to provide 200,000 mental health consultations with veterans who lack easy access to its outpatient clinics or outreach vans. Since 2009, the VA's mental health budget has increased 39 percent to almost $6 billion this year, and its mental health staff has grown by 41 percent.
Diagnosed or not, all veterans are eligible for mental health services. But the VA cannot require them to come in, as VA officials are quick to point out.
The pernicious effects of combat trauma are not confined to mental health issues, though. New research findings indicate that veterans who have PTSD are more vulnerable in their later years to diabetes, cardiovascular disease. One study of VA patients found that those with PTSD were twice as likely to develop dementia as veterans without PTSD.
"It's a lifetime sentence," said Rick Weidman, a combat medic with the Americal Division in Vietnam who still struggles with post-traumatic stress.
Some cut that lifetime short. More than 2,500 active-duty military personnel have committed suicide since 2001, according to Defense Department reports. So far this year, active-duty troops have taken their own lives at a rate of almost one per day.
Many more make the attempt. In its most recent analysis, the Pentagon reported that in 2010, 863 active-duty service men and women had attempted suicide; most, 60 percent, were under the age of 25. National Guard soldiers and reservists have an equally high suicide rate. Last year, 118 Army soldiers killed themselves while not on active duty, a number almost certainly under-reported.
Among veterans -- those who have left military service entirely -- the lure of suicide appears even stronger. The national veterans suicide crisis line (800-273-8255), operated by the VA, gets an average of 17,000 calls a day. The VA believes the suicide rate for all U.S. veterans is more than 500 per month.
Most of those who committed suicide had struggled alone and never got help. The VA's Shinseki said recently that perhaps two out of three veterans who commit suicide were not enrolled in the VA's health care system. Nor had they ever been diagnosed. "The majority," the Pentagon reported, "did not have a known history of a behavioral health disorder" or treatment.
"We have underestimated the human costs of war, not just for the victims but for the warriors as well," said Dr. David Spiegel, a neuropsychiatrist and director of Stanford University's Center on Stress and Health. "War is an unnatural experience. It doesn't surprise me that a substantial number of people are impaired."
"I BELIEVE IN YOU"
The striking fact about today's epidemic of war trauma is that it affects a self-selected population of Americans who have already demonstrated courage, grit and resolve by volunteering to serve in wartime.
Take Natasha Young. She grew up in a bleak neighborhood with a wandering, crack-addict father and a single mom on welfare who struggled with drugs. Natasha was a good student but got into her fair share of trouble.
When she was 17, she met a Marine Corps recruiter and her life changed.
"He represented everything I wanted for my life," she says. "He said we expect you to work hard, show up on time, be a good human being, service to others, pay your bills, don't drink and drive, don't do drugs -- all the things I would want for my child."
What had been a dead-end future for her suddenly opened up with a steady paycheck, honorable work, perhaps even college.
"It was the first time in my young adult life someone said, ‘I think you can do this, I believe in you,'" she recalls. "For the first time in my life, someone said to me, ‘I see more in you than you ever saw in yourself.' That really resonated with me because I wanted to make somebody proud, I wanted to be better than the opportunities I had at the time. I wanted to be great … I knew I was capable of it."
She excelled in boot camp, won promotion after promotion. She was deployed to Okinawa when a call came from home: her mother was unable to care for her 6-year-old son and was giving Natasha custody. Natasha was 19 years old. She scraped together money for a plane ticket and flew home on emergency leave to complete the paperwork.
Just before she was scheduled to fly back to Okinawa, her father was beaten to death in a bar fight. Natasha was next of kin. The Marines extended her emergency leave so she could arrange the funeral. The Marine Corps League and the American Legion chipped in to replace her non-refundable plane ticket back to Okinawa. Family and friends looked after her brother until her overseas tour was over.
By the time she was assigned to the 2nd Explosive Ordnance Disposal (EOD) Company, at Camp LeJeune, N.C., the Marines had become her real family. In the year before she flew to Iraq, she got to know the EOD guys, their wives, their children. Facing the terrible risks of unstable explosives, they trained exhaustively and partied hard and grew emotionally close and tight -- no secrets.
They arrived in western Iraq in 2007 to find a bloody terror of fighting, with an escalation of booby-trapped IEDs detonated by cellphones and garage-door openers. The blasts were erupting beneath soldiers and Marines, causing horrific injuries and death. That year, 764 Americans were killed in Iraq, mostly by IEDs.
Frantic calls to the bomb disposal teams, spread out over al-Anbar Province, came in every hour of every day of every week. Natasha was on the road making sure each team had the gear and supplies it needed. In a single day, April 27, the team lost two Marines, Sgt. Bill Callahan, 28, who left a wife and a 3-week-old son, and Sgt. Peter Woodall, 25, who was married with a 3-year-old son.
Amid the carnage, Natasha went numb. It was her job to gather the dead Marines' personal effects, make sure letters got written home to the families and that nothing got sent home with blood on it "because of the biohazard."
What was that like for her? Tears welled in her eyes as she felt again the shock and grief that she had stuffed deep inside five years ago. "At the time … I just … functioned," she says. "I'd make a pot of coffee because I knew we'd be up for two or three days."
Such enormous stress is the heart of war trauma -- including PTSD and TBI -- that causes physiological or neuro-chemical changes in the functioning of the brain, according to Rigg, the TBI director at Fort Gordon.
Many of the symptoms of post-traumatic stress -- nervousness, insomnia, anxiety in crowds, jumping at a sudden loud noise -- are primitive, involuntary instincts necessary to survival in a combat zone.
"I don't use the term ‘post-traumatic stress disorder' because I don't consider it a disorder," Rigg says. "I mean, you're in a situation where people are trying to kill you!"
When the instinctive, unthinking part of the brain, the amygdala, senses danger, it reacts instantly with a flood of stress hormones that raise blood pressure and heart rate, dilate the eyes to sharpen sight, and squirt adrenalin into the bloodstream -- the hyper-arousal that prepares the body for "fight or flight."
That's appropriate in combat. But back home, the brain may misinterpret danger signals: all strangers are not the enemy; trash along the Interstate probably doesn't contain an IED; an explosion may be harmless fireworks, a bad dream may be just that.
Doesn't matter: the amygdala still pumps out a flood of stress hormones that make the veteran uncomfortable and jittery, wide awake at night, anxious and prone to flashes of anger. This is a neuro-chemical mechanism, Rigg explains. And it's involuntary: "People don't decide -- ‘Hey! I want to be stressed today.' No -- it's the way we are wired."
Traumatic brain injuries usually involve a concussion that bruises the frontal lobes of the brain and can cause confusion, temporary amnesia, and a range of other symptoms similar to PTSD -- insomnia, irritability, anxiety or depression, headaches, memory loss -- in large part because many TBI patients also have PTSD.
"Basically, the brain's not working right," says Dr. James Kelly, a neurologist and director of the Defense Department's National Intrepid Center of Excellence for traumatic brain injury and psychological health.
"You can help people compensate and get better in some ways," Kelly says. But in severe cases, in which sophisticated computerized tomography (CT) scans or magnetic resonance imaging (MRI) may detect damage to the frontal lobe or to tissue deep inside the brain, patients don't recover fully, "typically not back to where they were before, ever, with that kind of injury."
How common are such deep-brain injuries? "We don't know," Kelly says. Not every combat soldier receives a CT or MRI scan. "And the problem is if you don't scan everybody, you don't have a good way of knowing that."
Recent experience has shown that even CT scans in military emergency rooms in Afghanistan may not detect microscopic damage to brain tissue, he said.
Detected or not, both forms of combat trauma can cause sexual dysfunction, adding to emotional distress and marital tensions, veterans say.
"The levels of shame and embarrassment are pretty stark for us," said Ben Tupper, an Army major who came back from Afghanistan with "a raging case" of PTSD -- and erectile dysfunction. "I eventually mustered up the courage to deal with it," he said, and wrote about it for the online magazine Slate.
ANGRY WITH GOD
Current treatment for PTSD and TBI consists in part of teaching patients to manage stress.
At Fort Gordon, Rigg puts soldiers with mild traumatic brain injury through an intensive, three-week "functional recovery" program focused on coping strategies that include deep breathing, yoga, massage, meditation and mind-body relaxation exercises using bio-feedback. Deep breathing actually slows the cascade of stress hormones that trigger the "fight or flight" reflex. Massage eases tense muscles that cause headaches.
Rigg doesn't prescribe drugs, which are often used elsewhere to dull the reactions of PTSD patients. "Medication doesn't fix this stuff," Rigg says. "It only relieves some of the symptoms."
For patients with TBI, treatment is similar: "Our job is to help people find coping strategies, tolerate their limitations," says Kelly. "The idea of getting better, in the sense of recovering back to who you were, is not commonly a reality for them."
For a lot of veterans, he adds, "simply pointing out how they survived this long, with all the things that have happened to them -- they have internal resilience they weren't even aware of." In many cases, he says, veterans "go on to really succeed in ways they hadn't anticipated."
Talking individually or in groups with a trained therapist can help a patient recall traumatic events with less emotion. Advanced techniques, such as cognitive behavioral therapy and exposure therapy, can help patients understand and cope with the sounds, smells, sights or memories that trigger stress reactions.
Through exposure to virtual reality programs, troops relive combat, a technique that has been shown to significantly desensitize them to the trauma they experienced and to minimize the hyper-arousal caused by the release of stress hormones.
But many therapists find such cookie-cutter approaches unworkable, says Platoni, the Army combat trauma psychologist and co-editor of a forthcoming book, "War Trauma and Its Wake." Her book explores the broader impact of combat experience, which she believes includes issues of self-identity, alienation, disillusionment with the U.S. government and its leaders, and damage to religious and spiritual beliefs, or "moral injury."
That term is a hot button for many Vietnam vets.
"A lot of guys come back angry with God -- how could the God we understood and were raised to believe in let this war stuff go on?" says Weidman, who served with the Americal Division. "We witnessed and participated in so much horror, that was in such violence with the value structure in which we were raised. It's a miracle people come back as together as they are. The whole concept of spiritual or moral pain goes beyond traditional psychotherapy."
What worked for Natasha Young was talk, work, medication and a dog. She found a sympathetic counselor at the VA outpatient clinic in Lowell, Mass. "They believed in me," says Young, "and they remind me that I'm human, that it's okay to have bad days and good days, that there are things I can't control."
Through a veterans service organization, The Mission Continues, she was awarded a 26-week fellowship that pays her to work with veterans at the Northeast Outreach Center, which offers food, shelter, counseling and other services to New England veterans. "I like being around other veterans; a lot of them don't have anybody else, and I get that," she says.
Another non-profit organization, Patriot Rovers, provided her with a service dog, a yellow lab named Josh, who helps remind her to take her medication and guards her own personal space in crowds. She takes medication to help her sleep.
As she began to heal, Natasha enrolled in full-time coursework at Northern Essex Community College for an associates degree in counseling and social work; a four-year college is next.
"My dream job is to work for the VA, with women suffering from military sexual trauma," she said.
In September 2011, she married Robert Alicea, a young man she's known since childhood and who has remained a close friend through all her trials.
"He's persistent, I'll say that for him," she says. And Natasha's mom has fought off her addictions and accepted her son back into her legal custody.
The trauma still lurks, however, and Young, like so many veterans, keeps on the path with a frenetic work schedule: her full-time classes, her work at the veterans center, and caring for her son, who is now six. "I don't know how to relax any more,'' she admits.
Yet Young has no regrets about the trajectory of her life.
"Knowing my mistakes … I wouldn't change anything," she says. "My deployments, my failures, I wouldn't change any of it."
When a visitor remarks that her future looks pretty good, she pauses to reflect.
"I'm hoping. I have had a couple of bad patches but I'm back on track. Failure is not an option for me."
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