As Hilbert Caesar told his harrowing war story one night recently in the living room of his apartment, he patted the artificial limb sticking from a leg of his business suit. "This, right here," he said, "this is a minor setback."
Eighteen months after Caesar's right leg was mangled by a roadside bomb near Baghdad, and after weeks of coming to terms with what he thought was the end of his life, the former Army staff sergeant believes he has emerged a richer person -- wiser, more compassionate and more appreciative of life.
Asked whether he would endure it all again, he replied: "The guys I served with were awesome guys. . . . I would go through it again -- for the guys that I served with. Yes. Absolutely. I wouldn't change it for the world."
Although the shattering psychological impact of war is well known, experts have become increasingly interested in those who emerge from combat feeling enhanced. Some psychiatrists and psychologists believe that those soldiers have experienced a phenomenon known as "post-traumatic growth," or "adversarial" growth .
Although war left him with a leg of plastic and steel, Caesar, 28, of Silver Spring, appears to be among those who return home with psyche intact and a sense that they are in some mysterious way improved.
"I'm the same person," he said, "but I'm a different person now."
Ability to exhilarate
Combat's potential to inflict psychic wounds has been recognized as far back as the ancient Greeks, but so has its ability to exhilarate, intoxicate and instruct those who experience it, experts say.
"If you think about all of the heroes and heroines in cultures across the world . . . all of them, in one sense or another, faced some sort of a dragon," said Matthew J. Friedman, director of the National Center for Post-Traumatic Stress Disorder and a professor of psychiatry at Dartmouth Medical School. "The transformation from that encounter has been celebrated from antiquity."
University of North Carolina psychologists Lawrence G. Calhoun and Richard G. Tedeschi, who have studied post-traumatic growth for 20 years, said they are careful in describing what occurs.
"We're talking about a positive change that comes about as a result of the struggle with something very difficult," Calhoun said. "It's not just some automatic outcome of a bad thing."
Calhoun said their studies suggest that for growth to occur the trauma must be severe. "We tend to use the metaphor of an earthquake."
He said the person first ponders the details of what happened. "And then there's a much more abstract process of finding some higher meaning . . . in what has transpired," he said.
Tedeschi said there can be feelings of spiritual development, improved relationships, a sense of personal strength, a better appreciation of life and new interests and priorities.
Both men stressed that growth is not necessarily a goal, nor is trauma "good." Calhoun said: "Post-traumatic growth occurs in the context of . . . suffering. We hope everybody who goes to Iraq comes back safe and sound and doesn't have any traumas to grow from."
Mental health problems rarer than assumed
Although scientists continue to worry about war's impact on mental health, experts say research now shows that most people exposed to combat and other traumatic events do not develop chronic mental health problems.
"It used to be thought that virtually everybody who experienced these kinds of catastrophic events would go on to develop" PTSD symptoms, said Lt. Col. Charles C. Engel Jr., a psychiatrist at Walter Reed Army Medical Center in Washington. "That was kind of a post-Vietnam War assumption. What we've learned over time is that probably, on average, really about two-thirds to three-fourths don't develop PTSD."
Friedman, of Dartmouth, said that research on the issue has not been that extensive and that the "deleterious" effects of trauma have received the most attention.
But that is changing. "The whole field, in the last four years, has shifted to a certain extent [to focus on] resilience, on human potential," he said.
Friedman said studies of World War II veterans often showed that they valued the experience, even though they had serious post-combat stress: "Yes, I've suffered," he said men would report, "but I wouldn't have given up this experience for anything in the world. . . . The things I experienced have made me a better man today."
Studies of Vietnam War POWs have shown similar sentiments. One study, in 1980, found that 61 percent of American POWS in North Vietnam believed their experience was ultimately beneficial.
Tom McNish, a former Air Force pilot who was a prisoner in North Vietnam for six years, said: "There is no question in my mind that the experience I had in Vietnam has had an overall very positive effect on my life. But I don't recommend it for anybody else. And I don't want to have to do it again."
Wounded veterans of the Iraq war say similar things. Adam Replogle, 25, of Wellington, Colo., a former Army sergeant and tank gunner who lost his left hand and the vision in his left eye in a battle in Karbala in 2004, said that he still has ups and downs but that after his experience in Iraq, not much worries him.
"Sometimes it takes people a lifetime to realize what it's all about and what's important and what's not," he said. "And you go through something like this and it grows you up a little bit and makes you realize that stuff a lot earlier in life."
Caesar, a native of Guyana who grew up in New York City, was a six-year Army veteran and a section chief in a field artillery unit in Iraq. He was in charge of a long-range, self-propelled 155mm howitzer -- a huge vehicle with treads that resembles a tank.
He was out on patrol in the self-propelled gun when the explosion occurred April 18, 2004. When the black smoke cleared, he looked down at his leg. It was flipped backward and "just dangling by the skin," he said. "It was severed at three different places in the knee. . . . The bone was splintered in different places. I knew there was no way they could put that back together."
He tried to hand his machine gun to a comrade but realized it was bent. He could hear gunfire and yelled for the hatches to be closed. He thought: "Oh, man. This is it. My life is over."
But it wasn't. The insurgents who staged the ambush melted away. He was medevaced to safety, and six days after the attack, he arrived at Walter Reed.
There, he was all right, except when he was alone. Then he would worry about the pain -- and the future. He was an athlete but realized that he might never run again. He wondered how women would react to a man with an amputated leg. It was depressing. Again, he said he would think, "My life is over."
A few days after he reached Walter Reed, he got more bad news: Eight men from his platoon had been killed by a car bomb in Baghdad. They were men he knew. One, in particular, had been a role model. "I was really devastated," he said.
Not all mental health experts believe in post-traumatic growth. Some think such positive attitudes simply stem from individual resilience or a natural course of psychological recovery.
George Bonnano, a psychologist at Teachers College, Columbia University, is skeptical of the growth theory. He said such reactions to trauma are better explained by personal resilience.
"I'm saying most people are able to maintain equilibrium pretty well after a traumatic event," he said. In addition, "it's fine to just recover," he said. "Bad things happen, and we get over them. We get better, and we put it behind us, and we move on."
In the weeks after his arrival at Walter Reed, Caesar met other severely injured soldiers and heard stories about their recoveries. "You start to build your confidence up," he said. "You start to shift focus.
"I'm a positive person," he said. "I try to look for the best. It could be worse. I lost a few friends out there. I made it back with just one missing limb, and I'm grateful for that. I'm thankful for just being here. Period."
At the same time, he said, he believes that he has changed. "It makes me appreciate life a whole lot more. . . . I'm looking forward to settling down, having a family."
Caesar said he has a friend who lost both arms in the war. Caesar said his friend once told him: "I would give anything to lose a leg. I would give both of my legs to have one of my arms" to be able to hold a child someday, should he ever become a father.
"Things like that make you think," Caesar said. "I can't complain. I haven't lost enough to complain."
Since being wounded, Caesar became a U.S. citizen last year, participated in three marathons using a racing wheelchair that he pedals with his hands, left the Army in January and landed a job with the U.S. Department of Veterans Affairs.
His leg still bothers him, and he walks with a pronounced limp.
At times, the opaque plastic socket of his artificial limb, which fits over his stump, lacerates his skin. The stump hurts when the thigh bone pokes against the skin. And he still gets down when he thinks about his dead buddies.
"It was a long journey back," he said. "I'm still not fully there. I'm still not 100 percent. I'm never going to be 100 percent. But at the same time, I can get as close to it as possible."