[How long have soldiers known about PTSD [Post-Traumatic Stress Disorder]?]

The diagnosis of PTSD, although that's recent -- the phenomenon of reactions of soldiers to combat has been around since the earliest times. It's gone by a number of different names, from Soldier's Heart [to] Traumatic War Neurosis, which was a big one in the early 1900s. Soldier's Heart came back again in the 1950s as Paul Dudley White, who was Dwight Eisenhower's physician, was the one doing a lot of studies about the physiologic effects of combat on the heart, which is part of how Soldier's Heart came back in.

Throughout the years, until recently, it's been thought that PTSD was a reflection of a vulnerability or a weakness in the individual who experienced it, and then the huge numbers of people after Vietnam who had what they originally called Post-Vietnam Syndrome began to make people look a little bit deeper at trauma and its consequences.

By that time, there were a number of studies of civilian disasters. The Cocoanut Grove fire in the middle 20th century, it was a big one; Holocaust survivors [were] being studied more and more in the 1980s and 1990s. And eventually it became fairly clear that all of these different descriptions were describing a specific phenomenon, a clinical phenomenon that has some biological underpinnings as well, and is the response of an individual to overwhelming trauma. In 1980 we finally got the diagnosis of Post-Traumatic Stress Disorder, which legitimatized this as a clear-cut disorder that people can acquire as a result of experience.

Was it specifically related to combat?

The 1980s represented a real shift in opinion away from this being just a specific combat syndrome to one that could occur to anybody under the right conditions. The original diagnostic criteria for PTSD were all about a traumatic experience outside the realm of normal human experience. The sad fact is that as time [went] on, we found [that] more and more awful things happen to people that are within the realm of normal human experience, so that that part of the diagnosis, the criteria, has evolved and was changed in the 1990s to refer to a stressful experience and described in the manner of how it's experienced by the person going through it. And so certainly [it includes] rape, domestic violence, assault, hurricanes, floods, earthquakes, natural disasters of all kinds, things that nature does to us and things we do to each other.

Did World War II vets talk about PTSD?

... The classic story for a World War II veteran is, [he] came home from the war, drank a little bit too much, maybe partied a little too much, got in some fights here and there, had a hard time settling down. Eventually, with a lot of support and perhaps [a] push from the family, he said, "OK, I'm done doing this," and then worked two jobs for the next 30, 40 years, sometimes having an occasional nightmare but basically having the whole experience shut off from the rest of [his] life -- "I put it behind me" -- not talking very much about it with family members or with others, many not associating with other veterans' groups or anything that might bring back some of the remembrance of what they went through.

And then many of those folks, as they reached retirement, as they developed illness, as they went through family stresses or they lost loved ones, suddenly would wake up one night in the middle of a nightmare saying, "Where'd this come from?" And I've seen many of those people from that moment on be plagued by symptoms. ...

It was a different world, it was a different culture that they came back to. It was a culture of a post-Depression era -- "We won the war; we're really great." ... When I ask them one of my standard questions -- "Have you ever talked with your family about what happened?" -- the answer is almost invariably no. Almost to a person, it's always "No, I haven't." "Well, why not?" Well, it's "They don't want to hear it; they wouldn't believe it; I don't want them feeling sorry for me; they haven't asked about it." When you ask their families if it ever gets that far, they say, "Well, we always [knew we] should never ask Dad that question; there were some things we just had to stay away from." ...

Society didn't want to hear it, you know. You don't want to hear that your hero who has just come back from winning the war is troubled by what he did over there and the people he bombed, the people he shot. People didn't want to hear that kind of thing. All anybody wanted to hear at the time was: "Isn't it wonderful? We won. We've saved the world. Thank you." ...

There's a fellow from the other side of the state that I see from time to time, who worked lots of jobs, had positions of authority, was very effective in his work. Within a week after he retired, he was just flooded with symptoms. "Where'd this come from? I have no idea what this is about. I remember these events, I remember how awfully it felt at the time, but I thought I put those behind me years ago. Why are they here now? Why are they back?"

It's a very common response from people who are just now reexperiencing stuff that they thought was long gone, long buried. The mind is a wonderful thing, what it can do. It can protect us from things that are too upsetting. And sometimes we get away with it; sometimes we don't. Sometimes it comes back years later.

What is the ideal window for treatment?

I wish we knew for certain exactly what the best time period is for treatment. We think we know, but we've been wrong before, and I'm hoping that we get it right this time. To the best of anyone's knowledge, giving people [a] little time to readjust after they get back -- I mean, that's a big adjustment, coming back from a war. It's hard enough if you've been over on the front for six months or so and you're an 18-year-old who got drafted and so on, but if, let's say, you're a National Guard person who has got a family, a job, little kids, you come back after a year, everything is different; your family has actually adjusted to being without you. That's a tough blow to people. Spouse is handling the checkbook. Pick up your kid, [he] screams, "Who is this man?" "Well, that's Daddy; he's back." So there are a lot of general adjustment problems that are going to take place when people come home. ...

We don't want to rush in and disrupt the normal process. At the same time, you want to be able to intervene early enough to prevent it from becoming a chronic illness. And it's one of the things that we know about all psychiatric disorders, that the longer they go without treatment, the more difficult they are to treat, and there are probably a lot of very good mechanisms in the brain that account for that. So we don't want to be waiting six months; we don't want to be waiting six years.

The optimum length of time as far as we know -- and some of this is educated guesswork based on a lot of studies -- is probably about 30 days or so. Somebody's 30 days back, been back with the family and is still having trouble sleeping, having nightmares, easily startled, avoiding watching the news, staying away from anything that might remind him of the war or just reexperiencing it in any one of a number of ways, or still seems remarkably different and on edge and irritable with a spouse, then it's probably time to get into treatment. ...

What choices do soldiers have for treatment? Do a lot of them go to the VA [Department of Veterans Affairs] hospitals?

Probably not. We'll probably at least initially see a small number of them. All of the ones who are veterans, who are actually active duty, military, who are then discharged from the military and become veterans, will be eligible for VA health care. Anybody who is part of the Reserves is entitled to treatment in a VA facility for two years for something that is believed to have begun while in Iraq. Those are people who by and large are getting their health care outside of the VA.

I think the VA is not playing the leading role in terms of the number of people that we're going to be seeing. I think most of them are going to be seeing their family physicians. They're going to be out in other sectors. It's important to the VA to get the word out not just internally, but out to other doctors and other care systems of all kinds.

What kinds of treatments do you offer for National Guardsmen?

I can offer you an evaluation to see what kind of help you need, ... [but] I hope not long-term treatment. I think that that's one of the big shifts that we and everybody else have to make in our treatment of these people. [We] made the mistake early on back in the 1980s of trying to provide treatment based on reliving the traumatic experience -- "We're going to fix this; we're going to cure this." We discovered after a while that by the time we were seeing most of these people, it was already a chronic mental illness, and so the emphasis then shifted to maintenance treatment, treatment of the symptoms -- helping with anger management, doing couples therapy to help work out some of the difficulties that couples were experiencing. ... I think that most people [who] have had PTSD for 25 or 30 years are in more of a maintenance and symptom-control mode. We don't want to apply that same model to people whose trauma was three months ago. ...

We should not make the assumption that we're bringing these people into long-term treatment. We have some studies that say these treatments are good in some kinds of trauma. We have medications that help in some kinds of trauma. Combat trauma has always seemed to respond a little bit differently to many of the treatments, whether it's medications or psychotherapy. It seems in many ways to require special handling. But we do need to treat it as an acute problem and not start out with "OK, well, we just have to help you learn how to manage your symptoms."

The hope is that they'll lead normal lives.

Right -- take care of it, take care of the symptoms, try to help get the symptoms under control, get them stopped if we can, and [make] the person able to function as anybody else in society. That's the goal. ...

What are the newest therapies?

Number one, there are the new cognitive therapies. ... Cognitive therapies are psychotherapies that are based on looking at how a person understands an event, how they process it in their own minds at that time. We know that when you're in the middle of a trauma, particularly combat trauma, you're not thinking in the same way that you might be thinking if you're sitting in a chair reading about a trauma. So memories get laid down in a certain way, and they may be in a way that is very negative for the individual. They may prevent his or her recovery. So cognitive therapies tend to be based on re-looking at those events, so all of them require some amount of getting back to what actually happened, most of them by either talking about it or writing about it and then reviewing what you've written with the therapist, who can then help you look at how this might not make as much sense as it did at the time. ...

The older psychotherapies, the exploratory psychotherapies, the insight-oriented psychoanalytic therapy, the stuff from the mid-20th century and early 20th century, those were based on the opposite kind of reasoning: that it starts in here with the feeling, and if you work on that, then the thoughts will change. Cognitive therapy kind of reversed that. And cognitive therapy, for a lot of different things, has shown a lot of value. It actually works, which is a good thing.

The brain is a wonderful organ. I mean, it works miracles. It changes reality; it makes reality; and it develops comfortable pathways, like an old shoe. And memories work the same way. You might have a certain memory, a belief about it, and the longer you have that, the more comfortable and the more part of you it becomes, no matter how dysfunctional it may make you. It is burned in, if you will. We used to use the analogies to software and hardware, that you keep running the same software over and over again, [and] eventually it becomes part of the hardware, and it's very difficult to reassemble it in a different way. It's just now that we're doing some of the studies with cognitive therapy for people who had their trauma 30, 35 years ago. ...

Sometimes people come back to these experiences at the end of their lives.

I think the best piece of work I ever did in treating anybody with PTSD was a Korean War veteran who had been a POW who had helped his fellow POWs escape. Part of the process of that was coming up behind somebody and putting a piece of cord around his neck and strangling him. This man lived with that image for his whole life. It would come to him occasionally while he was working, but not in a big way. When he was dying, I think the best thing that I was able to do for him was help him find a way to talk to his pastor about it. [A] pastor came from the local church and listened to the story and provided the kind of forgiveness that for this man only a pastor could do. Psychiatrists can't do that; we don't have that kind of power.

These people, their spirituality is deeply affected by what they've done. And I've seen many people when they are dying -- and I've done a lot of work with that population -- they start talking about things that happened 50 years ago. Many are looking for forgiveness. Some have given up looking for forgiveness. They just feel this is something that does not fit with how they've lived their lives. Part of the work of dying ... is putting your whole life in context, looking at how it all fits together, and for people like this, this doesn't fit. This is not how they lived. This is not how they were raised as children; it's not how they have functioned as adults. It's an interlude that lasted a year or two, and it does not fit anywhere. And it's very hard work.

What do you see in the future for your program?

I was at a regional meeting a couple of weeks ago, and I was saying to somebody, "Well, when they tell us it's time to reengineer, that's just another way of saying you're going to get screwed." You hear a lot of talking about reengineering mental health services, which tends to fall under the same ballpark as things like "Well, we're going to rightsize; we're going to only do what we have to do with what we need to get the job done," and so on. The sad fact is that there has been a lot of attrition in mental health services, at least in New England, and I think some parts of the country have been hit harder than others. We've been coping with fairly level budgets and staff losses for a number of years now. ... The net result here in White River Junction, [Vt.,] is that we have about the same number of staff now, maybe a little bit less, as we did 10 years ago. And we now have 3,000 patients that we treat in my service, and 10 years ago we had 1,000. ...

Congress did pass a bill within the last year to provide some extra funding for mental health, to help try to rebuild capacity, and I'm hopeful that that will be of help to us. We have a lot of people in my department doing lots of different things. We all do lots of things, and we're constantly shifting what we do based on what's coming in the door. If we're going to start seeing a lot more people with early PTSD, we will learn how to treat early PTSD. Almost all of the therapists in my department have been learning cognitive processing therapy, and when that first soldier went to Iraq in March of '03, I think it was -- it seems like forever -- when that first soldier went to Iraq in March of 2003, we started planning what do we need to know, what do we need to be able to do. And so a lot of people who have been doing other things for a number of years are now shifting back and are ready to provide therapy for PTSD. ...

It's very clear that unfortunately, we're going to have more than enough veterans to keep us in business. The question is whether we'll have enough staff. I'm confident that nobody in my department is going to let people go untreated. What is of concern to me is the number of people who are still there working after I go home at night, the number of people who are coming in on Saturdays, who are not paid to do that. This is a dedicated group of people.

How much funding do you get?

I haven't bothered to look at the numbers because they give me indigestion. I have not looked in a couple of years. We spent a fairly low percentage of our facility dollars on mental health as compared to similar facilities, and by similar facilities, I mean general medical and surgical hospitals, as the VA calls them, that have mental health services, that have training programs. Any time I look at those numbers, we are on the low end.

The funding has changed back and forth a couple of times in the last seven years. ... You know, in 1993 I had three substance abuse counselors; right now I have half a substance abuse counselor. In 2003 I still had one and a half. But because one died, I lost that position. I don't know how $5 million available nationally is going to play out. I think the VA does the best it can with what it gets, but it doesn't get much.

How do the services available now compare with what Vietnam, World War II or Korean War vets got?

I think that the person returning from Iraq is going to see a mental health service that is more sophisticated in its knowledge about what to do to be of help to them. ... They won't necessarily find more resources, but hopefully they will find more effective resources than they did 30 years ago. ... People came home from Vietnam and [were told,] "Well, you're just crazy." They got put into this psych thing; they got treated with major tranquilizers. There were not a lot of specialized programs. So now at least we have specialized programs that not only are specialized but actually have some expertise. ...

One thing we know is that [today's] veteran, more than any other, has a much higher likelihood of actually being in combat. This war is everywhere, in the streets; there's no safe place. In Vietnam there were at least some safe places, relatively safe places that you could be. In Iraq there's no safe place. So people who are coming home will have been on peak alert for 365 days or more, will have had all of their senses tuned to the slightest disturbance, the slightest sound of trouble, so I think it's going to be a very sensitized population. It will have a much higher prevalence of people who have had bad things happen, who have seen combat, who have been in combat, who have lost people close to them, who have had the guy standing next to them blown up, the person in the Humvee sitting next to them blown up. We will see a lot more of that.

They will be coming home to a populace that's heard a lot more about the effects of trauma on people and how combat is not really a good thing for anybody, and a population that has heard a lot more about PTSD. There's a lot of outreach going on in various community groups. ... Communities are very important in protection of individuals from the effects of trauma. Some communities are naturally more supportive and more understanding. This applies to all kinds of trauma, whether it's military trauma, sexual trauma, natural disaster trauma, whatever it is.

Some, for a lot of different reasons, have more natural supports for the traumatized individual; others, not so much. I think it's going to be more difficult for someone to come home to a town, say, dominated by the military than someone coming home to a little town in Vermont where everybody knows them, everybody is supportive of them, [where] the local organizations are waiting for them to come back and people know that something bad has happened. I think that there will be quite a differential depending on the environment that one comes home to. That's going to be very important.

[What about the National Guard versus enlisted soldiers?]

Well, there's two answers to the question about the difference in the experience of National Guard versus regular troops. One answer to that question is [that] everybody is the same over there. And I've heard people who have come back say that, that everybody is treated the same. I've heard other people who have been over there and come back [and] say exactly the opposite, that the National Guard troops are treated as second-class citizens.

I'm not over there; I can't make the judgment. I do know that there is a difference between the National Guard person who is maybe three or four years older, maybe even older than that, who gets called up and leaves the family and comes over there, as opposed to somebody who's 19 years old [and] just signed up to join the Marines because he thought he'd get an education and get to see the world.

Back when we were saying that World War II veterans didn't have so much trouble with PTSD -- or that's what was apparent at the time -- one of the reasons given [was] they were older and more mature. What I've come to understand, from at least the reports that I've been getting from people coming back from Iraq, is that age does not protect you from getting PTSD, that a 19-year-old can get it [and a] 28-year-old can get it just as easily.

Is it hard to come back to the civilian population?

The best book every written about PTSD is Slaughterhouse-Five [by] Kurt Vonnegut. [It's a] wonderful, wonderful description. It was one of the books that I reread to prepare for this wave of people coming back. [I] also reread [Stephen Crane's] The Red Badge of Courage not too long ago so that I could try to get some sense of things. ...

I know people who are bankers, clerks, bus drivers who are over there. They have been going along right here in rural Vermont, driving along the roads, looking at the beautiful foliage, skiing in the winter, raising their children, being with their families, going to church, doing all those things that people do, who are right now walking the streets of Baghdad wondering what's going to explode in front of them or behind them. Many wanted to be soldiers but instead found themselves being policemen, something that they were not trained to do.

They're going to come off the streets of Baghdad and be on the streets of White River Junction, where you can still trust the person walking down the street next to you. They've got to go through a 180-degree shift in everything that has kept them alive for the last year and have to change back to "Everything's fine; everything's peaceful. No one's going to blow you up. You're fine. We've learned to kind of get along without you. We've got our routines; the bills are taken care of. I think your job is still available for you if you want to go back to that. But, you know, we actually did OK without you."

It's not spoken. I mean, families survive; they do OK. But if the person who saw himself as the breadwinner comes back and everything's fine, some will begin to question their own value to the family. We saw a lot of that, actually, in Gulf War I. We saw quite a few people who had trouble with the fact their spouse left them; the family dissolved; things happened while they were gone; maybe their job wasn't there anymore. It's very difficult to make that transition, so I think that's why I say there are going to be a lot of readjustment problems, a lot of very basic readjustment problems that the vast majority of people will make.

Do most soldiers you meet have PTSD or some other kind of psychological effects from combat?

I have yet to meet anyone who has gone through combat who has not been affected by it in a major way. People with PTSD, people without PTSD -- and I think we have to avoid making the assumption that anybody who is a little bit different, is a little bit changed, automatically has PTSD. Most people exposed to trauma are resilient and do recover and do get back to normal. [But] they may have a nightmare from time to time; they may have any number of different ways of remembering what happened.

Actually, Kurt Vonnegut in one of his books said that the only way that combat affected him was that it enabled him to talk with other combat veterans and be able to understand what they were talking about. Given his writings, I suspect that it affected him in a lot of other ways. But does he have PTSD? I don't think so. Maybe the protagonist in Slaughterhouse-Five has PTSD as we would define it, but it's also written in a way that shows that someone like that can get on with life.

… We know that certain groups of people are more susceptible to PTSD. . We also know that some of the defining characteristics of a particular trauma have a lot to do with the development of PTSD. It's quite different to be sitting in a modern bomber pushing buttons and looking at a video screen than it is to be low over the skies watching people running and fleeing from your bombs, and yet again quite different to be actually involved in direct confrontation on the ground with somebody else.

Combat is an experience that changes people. It gives their life a different meaning, a new meaning, but [they] may not have PTSD. We just have to be careful with all of our psychiatric disorders, all of the phenomena that we deal with in mental health, to know when is something pathological and dysfunctional and when is it part of the normal human experience.

Is there a stigma inside the military with regards to receiving mental health treatment?

The stigma to receiving mental health services inside the military and outside the military is huge. Many people simply either fear being exposed as a weakling, which certainly impacts on the military culture of strength, or actually fear retribution and punishment if they express psychological distress and suffering. We don't win wars by people having a hard time killing other people. We don't win wars by people suffering from nightmares and being overwhelmed by the stress of combat. Those don't win us wars. The military's purpose is to win wars. So someone who is suffering is not a big help to the military. And they know that, and you're surrounded by your buddies and "We're all in this together, and we're all going to fight to the bitter end -- who am I to say I don't think I can do this today?" ... That doesn't fit when everybody else is charged up to do what we're supposed to do.

Now there are therapists in the field with combat soldiers. What kinds of things are they dealing with?

One person that I talked with, who was over there providing therapy and is recently back working back in the VA system again, said that the most common thing that he had to deal with as a therapist was people who had just gotten a letter from their spouse saying that they had filed for divorce and were running off with their best friend. ... But he did not see very many coming to him with combat reactions because those were not part of the mentality; they were not part of the culture there. At least that was his estimation of what was going on.

The combat stress units grew out of some of the older studies done in the '80s and '90s, I think primarily by the Israeli military, that kind of brought about this movement to patch them up quick and get them right back into battle; that that was the best way to prevent long-term consequences of PTSD. You at best gave them a little time away from the battle, some soft drinks and a little peace and quiet, a chance to decompress for 24 hours, and then sent them back into battle -- that that was the way to prevent PTSD.

That, I know, was part of the original planning for how they were going to handle combat in Gulf War I. Gulf War I did not last very long, so there wasn't a lot of that. But that's the basic principle, that treatment close to the field with quick return to battle is what's necessary and will help prevent combat reactions of all kinds.

You know, in Vietnam it was the opposite. People were just sent away; they might go days or weeks without anybody talking to them about what had happened to them. They might languish in a hospital with their wounds, and it was thought, well, we're not going to talk about that; we've got to focus on getting your leg patched up and your leg healed. So there wasn't a whole lot of attention given at any point.

Is it a move in the right direction to have therapists in the field?

I wish I knew. I don't know the answer to that question. I've heard conflicting stories. There are conflicting views of this, of course, like anything that we do. ...

In general, how well is the military dealing with mental health?

The military is a large organization, and within that organization there are a lot of individuals in positions of authority, and you may have a general policy set down, but it is still the individual carrying out that policy who gets to demonstrate whether it's a good one or not. And you know, as long as there are different individuals in positions of power and authority, there are going to be different responses. I would like to think that there are some commanders who on hearing somebody who just couldn't do it would say, "Well, let me help you get to our stress consultant; let me help you get the help you need." And that [would] be the end of it. There are others who I could imagine are not going to play it that way. When you come right down to the individual situation, it's still the people, and we all have our own biases. ... We have not removed the stigma of mental illness from society, and I doubt very much that we've removed it from the military. ...

When soldiers come to you, is that meeting confidential? Is it in their records?

I don't know. This is something I'm looking at right now to find out the answer. The first time I saw an active-duty person it was actually just an Army recruiter. This was many years ago, and I was stunned when I got a request from his commanding officer to provide all the details, which of course I declined to do. And then [I] learned from the VA that they had a right to see those records, so I turned them over.

Since then, I'm very careful about what I write in anybody's record, and I think it's something that we all need to get better at. But since the [Health Insurance Portability and Accountability Act] regulations came into effect, I've lost a little bit of the clarity about that. I actually just sent a request to the privacy officer the other day to find out the answer to that question. Interestingly, she hasn't responded. We're still trying to figure out the privacy as we go along.

There's always a question: Who is my duty to? Within the VA, I have no question my primary duty is to the patient in front of me. There's no doubt in my mind about that. If they tell me something that they do not want in their record, it does not go in their record, period. If I was doing a disability exam, a forensic exam or something like that, I have to be very careful and very clear with the person in front of me to say: "I'm working for the VA. You know anything you tell me is going to go in the record." And knowing who you're working for is very important.

Is there more privacy for a vet who is not on active duty?

Probably. Probably, yeah. Medical records can be accessed by a lot of people. Now the VA has all computerized records and a lot of safeguards and a lot of tracking to see who has access to these records. It is as secure as any paper record system that I've ever seen. Information outside of an emergency can only be released to any other agency with the consent of the patient, who can then specify exactly what information is to go out.

What are the barriers in the military to seeking mental health treatment?

I think the biggest barrier that I hear about is being thought of as a wimp, someone who just can't hack it in the midst of a culture of people who can hack it. It's not till many years later that the veterans seem to be able to tell each other the stories of what it was really like for them, even to people that they went through the war with.

The second barrier probably is just the general stigma and the fear of retribution and punishment, that by coming forth with this information I am going to lose my position; I'm never going to get a promotion; I'm not going to be able to make the military my career the way I'd planned to; I'm just better off keeping my mouth shut. I think those are the big two.

And again, they're not specific to the military. It's everywhere. It's out there in the community, some communities more than others, some businesses and occupations more than others. But it's pervasive.

Do the soldiers you've treated have moral clarity about what they did in Iraq?

The few that I have seen and talked with who have come home to this point are very clear that "I needed to be there; I needed to do this; this was my job, and I did it well, and I would go back in a minute." They're very clear about that to a person. [But] I've not seen a lot. The few I have seen have had this clarity of purpose.

What I have seen in other veterans, veterans of other wars, is a gradual fading of that moral clarity that they thought they were seeing. When we had Gulf War I, I was moved by the preponderance of words coming out of the Vietnam veterans: "These are our little brothers. They're going over there; they have a righteous cause. It's very clear they need to be doing this. We hope that they benefit from our experience. We were misunderstood; we were persecuted by society. Hopefully our experience will pave the way for them to have a better one."

I saw the same clarity of purpose and belief among Vietnam and World War II veterans when we started in the current war in Iraq. World War II veterans, a little less so. They're a little more skeptical about what's going on. But certainly the Vietnam veterans were most of the ones that I talked to [and] were very much "We have to be doing this; our purpose is clear; we've got to take care of our friends when they come back." Over the last year, that has dissipated quite a bit. And I see more and more from that generation who feel that we have no business being there, that we've put other soldiers in harm's way, and that we're doing to these soldiers what we did to them. I hear that more and more now.

Will that affect today's soldiers like it did Vietnam vets?

I don't know. I mean, they come home from this war proud. A lot of the Vietnam vets came home not proud, feeling like they had lost. Many were persecuted by society. The antiwar demonstrations unfortunately left the focus of the war and began to demonize the solders. That's not happening. I think that people who are on both sides of the question about whether we should have this war or not are united by a belief that these soldiers are doing what they're supposed to be doing, that the soldiers themselves aren't evil. If you think it's an evil war, fine. Think it's an evil war, but you know that it's not an evil soldier. That's a huge difference.

Does that give you hope for returning vets?

A little bit. Yeah, I'm hopeful. Again, I was talking earlier about the importance of community in recovery from trauma. And if the community of this nation is seeing these people as being soldiers who have done what they are told to do and have done a good job of doing it and have done the best they can, I think they'll be coming back to an environment that is going to be more supportive of healing from the war than the Vietnam veterans came back from. ... I mean, Vermont publicly mourns every one of its victims. Every soldier who has died or met catastrophe over there has been in a newspaper headline, and not just a newspaper headline in his own little town -- in a newspaper headline in the biggest newspapers. The governor, all these people will be there for the funeral. It's a very close, personal state here. Whether it's the same everyplace else, I don't know.

Many soldiers have told us killing the enemy was one of their most haunting memories. Is that usually the case?

I think it's one of the most powerful pieces for most of the people that I've treated who have been in close combat situations. I had one World War II veteran I remember -- to the day he died he could still describe the face of the man he was about to kill. He was that close, that personal, that he felt like he could read the man's entire life just in his eyes, and he was in a situation where he had no choice but to kill him. I hear this frequently.

I think the loss of faith, both in the safety of the world and the loss of faith in one's own humanity, is threatened when people kill other people, which is what we train them to do in war. I mean, it's how you win the war is you kill people, but you take somebody off the street who spent their whole life learning not to kill other people, not to harm other people and put them in a situation where it's his job to kill somebody else. I've not ever met a person who killed others who was not affected by that.

I was hearing a story from a World War II bomber the other day who talked about being able to see the people fleeing and still feeling that today -- you know, "How could I have done such a thing? Where was my sense of reason?" But we know how they did it. There are a lot of military training techniques which are based on dehumanizing the enemy and making people able to kill. I mean, you don't take somebody out of a Sunday school class and try to win a war with that person. You've got to go through some training in between.

What do they tell them in that training?

Very often they will call the enemy by some subhuman name -- you know, "gooks." Who cares about a gook? What's a gook? It's not a person; it's not a human being. Part of the dehumanizing, it's made a lot easier if the person looks different than us, whether it's by names or just firing up "God's on our side; this is our war; we're fighting this, and we should be fighting, and God is proud of us"; a lot of killing is done just with that as the reason. Anything you can do to make a person think this is not the kid next door; this is not the friend that I grew up with that I'm about to blow his brains out; this is some animal; it's not a real person -- simple.

When they get home, they think about it. I had one soldier -- he's long dead now -- who talked about how fearless he was in combat. "I was absolutely without fear," he said, "[and] the day I left, my commander said to me, 'You were a good soldier; you did it like it needed to be done, but you're going to be haunted for the rest of your life.'" Now, this is a World War II commander who is not supposed to know any of that kind of touchy-feely stuff, who's telling this 21-year-old kid that this is going to haunt [him]. And he was indeed haunted by it. He would see faces; he would see people; he would see images. Every night he had nightmares of just killing people. It does not fit. It's a different mentality.

Most veterans that I know have talked about the opening 15 or 20 minutes of Saving Private Ryan as about the only movie that has ever accurately depicted what combat is like, and I've seen that movie, [and] I can't imagine being in the middle of that. Same thing with just reading The Red Badge of Courage. I mean, Stephen Crane was not even a soldier, but somehow [he] had a gift that allowed him to put it into words that people could understand and feel the fear, the chaos and the excitement, all of those things, all in one.

In a different environment, people will do things that they would never think about doing when they're sitting here in Vermont.

How does [the] military deal with the issue of killing?

I don't know. I don't know what the military does with it. I really don't. We were actually one of the first PTSD programs in the country to put a chaplain in our PTSD program. And let me tell you, he was busy. It had a lot to do with "I have killed; I am no longer human. I don't understand; there could not possibly be a God. Everything that I thought was true was not true. Save me from myself. I don't know what to believe in anymore." Those were the kind of things that he would hear from people who had simply lost faith in everything, including in themselves.

What would he tell them?

Well, I remember one phrase he often used: God just looks after the big picture; he doesn't get too involved in the details. The big picture is important. And he used "God" in a very generic sense, kind of referring to just a spirituality that he thought was common to all people. We've worked with a couple of chaplains in that program [who] have had similar approaches. And it takes some time with these people. Many times they're coming to the chaplain looking for somebody who can forgive them for what they've done. But having killed people is a very powerful part of the guilt that a lot of these soldiers feel.

How high are the suicide rates?

[Among current soldiers], I don't know. In Vietnam [soldiers], I was impressed by the number of suicides after the war -- lots of people dying of either suicide or other injurious behavior; dying of drug overdoses, accidental drug overdoses; dying of alcoholism. That's always been very high in the post-Vietnam group.

And do you hear much about the use of antidepressants and sleeping pills on the front lines?

I haven't heard anything about using medications in a frivolous way. I mean, I've heard of antidepressants being used for people with depression. Some of the antidepressants are thought to be effective for PTSD. I don't associate the military with sleeping pills. ...

How can a therapist identify with what these soldiers are going through?

There are a lot of us who have experienced the trauma of combat, come to understand it, only indirectly. There is another dimension of actually being there. There has been a lot of interest in recent years in vicarious traumatization in which hearing trauma stories rekindle traumatic memories [in] the therapist. But beyond that, I can't hope to understand and to really feel what it is actually like to be in combat. And when I'm sitting around with a group of combat veterans, that's very clear to me. I have no question about that. If they start talking about some of the things that have happened, some of the things that they've done, my job is to keep my mouth shut and not try to do anything with that but just let them talk, because I wasn't there.

Even the World War II veterans who won't say anything to their families, have never spoken to their friends, when they get going in a group of them who are all flooded with memories, they have a lot of stories to tell. They won't tell anybody else. And they will say: "It's because Joe understands. Nobody else would understand, and most people wouldn't believe it."

We're beginning to see some of that same trajectory with some of the Vietnam veterans who have been very productive citizens [and] who are now getting into their 50s and 60s. We're seeing more and more and hearing more and more of them coming into treatment saying: "I don't understand what's happening, you know? I've been doing fine all these years, and all of a sudden I'm having trouble. I don't understand." So I expect we will be seeing Vietnam-era people for the next 30 years. And I think we'll be seeing people who are back from Iraq for the next half-century. That's a long time.