Over the course of a year in Iraq, the 3rd Brigade of the U.S. Army's 3rd Infantry Division saw action in some of the country's most violent places, insurgent strongholds such as Ramadi in the west and Baqubah in the north. By the time the brigade's 4,000 members returned home in January, as many as 800 had been flagged as potentially "at risk" in a psychological screening process conducted in Iraq, according to commanders and medical personnel.
Yet four months after their return, fewer than 80 are still in treatment. Psychologists here attribute what they call a relatively small number of persistent psychological issues to an unprecedented program of battlefield therapy and follow-up care, including having mental health experts assigned to most brigades and combat stress experts deployed for the first time to frontline bases throughout Iraq.
Composed of soldiers who are also trained therapists, the combat stress teams are often sent immediately to debrief soldiers in the hours after a patrol, firefight or bomb attack. They seek to identify those who may need treatment months before they return home, pulling some out of their units for two to seven days of group therapy sessions, video games and sitting by the pool at a cushy compound in Baghdad's fortified Green Zone.
"The point is to get at some of these issues before they start to fester back here," said Capt. Christopher Hansen, 33, of Jamestown, N.D., a psychologist assigned to the 3rd Brigade. "In Vietnam, nobody did much about this stuff until it was too late."
The most comprehensive psychological study of Iraq war veterans -- completed in 2004 as the insurgency was still gaining strength -- found that about 18 percent suffered from post-traumatic stress disorder (PTSD), a constellation of physical and psychological symptoms first diagnosed among soldiers who served in Vietnam.
Partly in response to the troubled generation of Vietnam veterans still under treatment in government hospitals, there has been an unprecedented commitment of resources for helping soldiers of the Iraq conflict cope with psychological conditions, both on the battlefield and upon their return.
But high rates of stress-related disorders remain a major concern of military commanders and doctors treating soldiers. Combat stress was mentioned last week as one possible explanation for the alleged killing by U.S. Marines of 24 unarmed Iraqi civilians in the town of Haditha last year. The slayings reportedly followed a roadside bomb attack that killed a Marine.
"It's stress, fear, isolation, and in some cases, they're just upset," said Brig. Gen. Donald M. Campbell Jr., a spokesman for U.S. forces in Iraq, when asked why such killings take place. "They see their buddies getting blown up on occasion, and they could snap."
Irritability and insomnia
Among the symptoms of PTSD, Hansen said, are irritability, insomnia, occasional flashbacks to traumatic incidents, anxiety and depression. But violence, including battlefield retaliations, rarely result from stress, he and other experts on the condition said.
"People don't kill other people because they are stressed," Hansen said. "Can it make them cranky or impulsive? Sure. But pinning these things on PTSD is simply not scientific. This condition does not cause otherwise normal people to commit crimes."
"Combat stress is not an excuse," said Col. Dan Kessler, 45, of Latrobe, Pa., the 3rd Brigade's deputy commander. "Discipline and leadership are the bedrock of any organization, and that should overcome whatever these guys go through."
The Veterans Affairs Department's National Center for PTSD, in White River Junction, Vt., lists dozens of potential "effects of traumatic experiences," from drug and alcohol abuse to gastrointestinal problems. Violence is not mentioned.
"In point of fact, violence or aggressive behavior is simply not a part of PTSD," said Matthew J. Friedman, a psychiatrist who is executive director of the center.
Triggered by prolonged or instantaneous exposure to traumatic incidents such as a car accident, assault or other violent act, PTSD causes neurological changes, particularly in sections of the brain such as the hippocampus and amygdala, which are involved in processing memory, mental health professionals say. The disorder also causes the body to produce higher than normal levels of hormones tied to stress.
"One way of understanding PTSD is that it is about responses to danger and safety. People with the disorder . . . would be worried, hypervigilant, with lots of locks on their doors, or they get a Rottweiler," Friedman said. "The preoccupation with danger drives a lot of this."
The result can be changes in behavior that make it harder for the afflicted to function in society. The most far-reaching research on the disorder has been conducted on war veterans, particularly those of the Vietnam era. A landmark 1988 study found that 13 years after the United States evacuated Saigon, about 15 percent of Vietnam veterans still had symptoms of PTSD and about 30 percent had experienced symptoms at some point since their return.
Because the Iraq war poses similar challenges to soldiers -- from booby traps and attacks by an unseen enemy to fighters who blend seamlessly into the civilian population -- combat stress experts expect similar levels of stress disorders among the current generation of veterans. For National Guard and reserve soldiers, who have played a major role in Iraq, finding treatment can be harder because they often live far from a major military base.
Army Lt. Col. Kathy Platoni, 54, a clinical psychologist who led combat stress programs in Iraq before returning to the United States in January, said she hoped her efforts and those of other therapists would help expedite the recovery process for those suffering from PTSD.
Platoni, a reservist and 27-year military veteran, spent four months in the insurgent stronghold of Ramadi, working with the 2nd Battalion, 69th Armor Regiment of the 3rd Infantry Division's 3rd Brigade. Once, after seven soldiers were killed over two days in a pair of roadside bomb attacks in October, she was taken directly to the scene to debrief troops still in shock.
"The highest compliment a soldier ever paid me was when I got back to Georgia and one of them said, 'Ma'am, last time I saw you, you were face down in the dirt,' " she said in a recent telephone interview. "We were out there living with them, going through what they were going through and trying to help them get through it."
Weekly meetings
When the unit, which suffered more casualties than any in the brigade, redeployed to Fort Benning, commanders established a program dubbed CARE, which brought together social workers, family counselors, psychologists and doctors to track at-risk soldiers during the readjustment period. The group met weekly, compiling detailed files on hundreds of soldiers.
"When the unit first deployed to Iraq, during the invasion [in 2003], they came back and not much was done," Kessler said. "With the work people like Kathy did in-theater, and the continuing care back here, we have seen about one-third the number of psychological issues this redeployment."
Maj. Robert Ashe, executive officer of the 2-69, said soldiers in the battalion had occasionally misbehaved or were unable to perform duties because of the effects of stress, but he said he was never aware of anyone under his command reacting violently. Like other officers here, he described the Haditha attacks as a failure of leadership.
"Our battalion commander uses this catchy phrase every day -- 'the slippery slope of morality.' He warned about what happens when you lose track of values," Ashe said.
He described two incidents from his time in Ramadi -- the capital of Anbar province, where Haditha is located -- that he said could have easily led to violent retaliations. Once, a popular staff sergeant was killed by a sniper, who was tracked down and detained without a shot being fired. Later, after five soldiers were killed by a roadside bomb, a raid led to the capture of the alleged triggerman, who was also detained without incident.
"You're not going to get any more traumatic than the loss of a beloved [noncommissioned officer] or a whole crew like that," Ashe said. "Haditha was a tragic incident, and you won't get anyone telling you anything different. But if there was ever going to be a time for them to slip down that slope, that would have been it. And they didn't."