She ran, terrified and crying, to the bathroom to wipe the blood spurting from her nose. When she stuck her head back into the bedroom, there he was -- punching at the air, muttering how she was coming after him and how he was going to kill her. Kristin started yelling, but Joshua's eyes were closed. He was still asleep.
The next morning Joshua saw the dried blood on his wife. "Oh God," she recalls him saying. "I did that." Peterson doesn't remember the nightmares. He also can't remember punching his wife again a few weeks later, this time driving her front tooth through her lip, all the while murmuring how he'd never go back.
For six months last year, Peterson helped build an oil pipeline across Iraq as a specialist in the Army's 110th Quartermaster Company. On the same highway where Private Jessica Lynch was ambushed, he saw Iraqi soldiers, dead and rotting, dangling out of their tanks. One time, Peterson's truck broke down, and he was surrounded by a group of Iraqi children, some throwing rocks, others toting AK-47s. "I kept thinking, 'God, I can't handle this,'" the 24-year-old says.
Since Peterson came back to Richmond Hill, Ga., in August 2003, these memories have turned him into a man Kristin often doesn't recognize. There are thousands of Operation Iraqi Freedom soldiers across the country like Joshua Peterson. They are coming home with minds twisted by what they've seen and done in Iraq.
A December 2003 Army study -- published in The New England Journal of Medicine -- found that approximately 16 percent of soldiers returning from Iraq were suffering from Post Traumatic Stress Disorder (PTSD), a psychologically debilitating condition causing intense nightmares, paranoia and anxiety. That study is already out of date. Many military and mental health experts predict the rate of PTSD will actually run nearly twice what the Army study found, approximately the same level suffered by Vietnam veterans. Others think it could spike even higher and note that rarely before has such a dramatic rate of PTSD manifested itself so early.
According to the Department of Veterans Affairs (VA), veterans with PTSD are more apt to be jobless, impoverished, homeless, addicted, imprisoned, without a stable family and three times more likely to die before the rest of us.
There is mounting concern over the system designed to help. Numerous reports show that the VA does not have many of the essential services veterans desperately need. "I don't know how many people are going to be seeking treatment or whether the demand is going to be met by available resources," acknowledges Matthew Friedman, executive director of the VA's National Center for PTSD. "What I am confident of is that people who come for treatment will get good treatment."
Yet the VA chronically has underfunded mental health programs and currently projects a $1.65 billion shortfall in those programs by the end of 2007. "If we don't give the VA what it needs immediately, the consequences will be lifelong and devastating," says Steve Robinson, executive director of the National Gulf War Resource Center.
THE EMERGING SCENARIO is that of a generation of new veterans whose psyche is in tatters, their families scarred by the strangers their loved ones have become -- and of an exhausted health care system holding its breath.
On March 25, 2004, Dr. James Scully, medical director of the American Psychiatric Association, testified to the House Appropriations Subcommittee on VA, HUD and Independent Agencies. Scully, a Navy veteran, reported a 42 percent explosion in VA patients with severe PTSD, with only a 22 percent increase in money spent on PTSD services. The discrepancy was particularly "startling," he said, because there were more vets using the VA for psychological help than ever -- nearly half a million. It was the latest blow for an institution that has struggled for decades to fulfill its mission.
A mammoth, federally funded agency, the VA's health care system began treating veterans in 1930, charging a sliding fee based on a variety of factors. But in the wake of the first Gulf War, the system swelled out of control. The soaring cost of civilian health insurance -- combined with aging World War II, Korea and Vietnam vets -- pushed droves of service-people towards the VA where everything was cheaper.
In 1995, the VA began realigning its health care system and opening hundreds of outpatient clinics. Yet by 2001, only half provided mental health services, according to the National Mental Health Association. Again, funding was a factor. By 2003, the previous decade had seen a 134 percent jump in vets seeking care, with only a 44 percent increase in the budget. In April of that year, as U.S. troops pushed toward Baghdad, Dr. Joseph T. English, chairman of psychiatry at St. Vincent's Catholic Medical Centers of New York, told the House Appropriations Subcommittee on VA, HUD and Independent Agencies that veterans were waiting an average of 47 days to get into PTSD in-patient programs and up to a year at some outpatient facilities.
VA secretary Anthony Principi (who resigned as part of the Bush Administration's cabinet shuffle and will leave office when his successor is confirmed by the U.S. Senate) had commanded a Navy gun boat during Vietnam and understood PTSD. He also knew that with combat-dazed vets beginning to trickle home from Iraq, he needed to move. So he commissioned a task force to cobble together the VA's mental health services on short notice.
In a revealing June 2004 memo to VA Undersecretary for Health Dr. Jonathan Perlin, Principi wrote that the task force had discovered four major deficiencies: Mental health services were scattered; substance abuse programs had been reduced; the VA's mental health leadership hadn't been diligent in overseeing the situation; and there was no coherent mental health strategy. Principi ordered VA brass to begin plugging the holes immediately.
While the VA worked on a long-term mental health plan to implement the reforms, the agency's Special Committee on PTSD delivered an October report to Congress, warning that with more soldiers with PTSD arriving home, services needed beefing up. The VA's PTSD patient population is overwhelmingly composed of veterans of wars that ended long ago. "The VA has never been faced with this before, the idea of preventing PTSD while a war is going on," says Madeline Uddo, a clinical psychologist and outpatient program manager of the VA's PTSD Clinic in New Orleans.
During the 1980s, the VA had recommended there be teams of PTSD counselors at all VA medical centers. Two decades later, the report noted, barely half of the 163 facilities had them. The VA plan estimated it would take $1.65 billion by 2008 to fix things.
Similarly, the PTSD Committee conceded that the VA couldn't be expected to treat psychologically troubled vets from Iraq and Afghanistan while still caring for those already in the system. "If the human cost of PTSD and its related disorders is staggering, so are the long-term medical costs to the VA associated with chronic PTSD," the report stated.
SGT. DAVE DURMAN did a tour in the Mekong Delta back in 1969. He was 18 and had joined the Navy the minute he got his draft notice, even though some of his buddies had already gone and died there. "I think it was because I just really loved the water," Durman says.
Durman also loved working on the supply ship where he was stationed and the pulsing adrenaline whenever his unit supported the Marines on missions around the South Vietnamese coast. He loved it all so much that he stayed in the Navy for nine years and, in 1995, joined the Virginia National Guard's 1032nd Transportation Company, 10 miles from his home in Kingsport, Tenn.
In February 2003, Durman's unit was sent to Kuwait. He was 52 years old. Two months later, the 1032nd crossed into Iraq, charged with shipping supplies from the southern city of Talil, 300 miles north to Balad. Other convoys had been attacked on the same route, so Durman and the 19-year-old soldier who rode with him slung their flak jackets protectively over the outside of both truck doors because, Durman says, "you could stab a hole through those doors with a knife."
During one August haul, Durman came upon a group of Iraqi police who had just shot two children for stripping a car on the side of the road. He drove right by their bodies. "We're told not to interfere with domestic affairs," Durman says quietly.
"I didn't want to get personally close to the Iraqis because I knew we might have to shoot them," he continues. "I'd look into their eyes and they all looked like gooks."
In September, Durman's unit shipped back to Virginia. It was then the nightmares started, about Iraq, but also things he'd buried -- his abusive childhood, Vietnam.
His girlfriend, Teresa McKay, noticed that Durman, once confident and kind, now broke into random sweats and angered easily. He drank too much whiskey and bought a .357 pistol. Their sex life, McKay said, went "190 degrees different." To McKay, a former nurse who'd worked with homeless Vietnam veterans, Durman's behavior looked disquietingly familiar.
Indeed, Vietnam provides the clinical and historical framework for PTSD and Iraq. Before Vietnam, treatment of a soldier for the psychological effects of battle was not really treatment at all, even though PTSD had long been acknowledged under a variety of names.
In 1871, a former Union Army medic J.M. Da Costa wrote about a stress disorder caused by heavy fighting. He called it "Irritable Heart," a name changed shortly thereafter to "Soldier's Heart." During World War I, according to VA psychiatrist Jonathan Shay, veterans returning home with Soldier's Heart were told by military doctors they had "shell shock" or "combat neurosis."
After World War II, says Shay, when tens of thousands of soldiers were hospitalized with psychiatric problems, doctors diagnosed the majority with paranoid schizophrenia. "The diagnostic spirit which prevailed was based on Plato's idea that if you had good parentage, good genes, a good education, then no bad things could shake you from the path of virtue," says Shay.
During Vietnam, that Platonic ideal began to shift. In 1970, 20 young vets from the group Vietnam Veterans Against The War (VVAW) called psychiatrist Robert Jay Lifton to speak with them about the war. The vets didn't trust the VA or the military, but knew they needed to calm the devils they'd brought home.
Lifton, who had studied Hiroshima survivors and been an Army psychiatrist, began meeting in New York with the group. He was shocked by the extent of the veterans' traumas. "These men talked about a particular combat situation that had a level of extremity which was new, even to me," Lifton says.
Subsequently, VVAW opened up dozens of "storefront" counseling centers -- places where Vietnam veterans could speak with other vets about their experiences, a crucial part of treating PTSD. Still, despite the growing number of vets clearly suffering, the VA wouldn't accept PTSD as a diagnostic entity. "This was because many of them were talking about atrocities, and that process was associated with a political view of the war," says Lifton.
Finally, in 1979, the VA opened up its own network of storefront "vet centers." A year later, the American Psychiatric Association recognized PTSD as a legitimate medical diagnosis.
When the National Vietnam Veterans Readjustment Study concluded in 1988 that 30 percent of Vietnam vets suffered from PTSD, not many were surprised. By then, Lifton (who never worked for the VA) and individual VA psychiatrists like Matthew Friedman had become leading experts on PTSD and pushed the condition into psychiatric and public consciousness.
Through group and individual therapy, and sometimes medication, the VA was helping veterans heal, though the process could take years. But by the time U.S. soldiers touched Iraqi soil, because of the enormous growth in the number of vets seeking mental health services and the VA's failure to adequately respond, the advancements in PTSD treatment were being compromised.
A new conflict, which bore an uneasy resemblance to Vietnam for the doctors who knew that war's demons, would test those advancements even further. The rate of PTSD occurrence, Lifton says, is inexorably tied to the war itself. "This is a counterinsurgency being fought against an enemy which is hard to identify," he says. "And that leads to extraordinary stress."
AS CRYSTAL LUKER TELLS IT, May 5, 2004, was the day her husband's platoon ran into trouble.
As usual, on that afternoon, Spc. Ron Luker was patrolling a section of Baghdad with his 1st Cavalry Division platoon. "There was a lieutenant in the first Humvee, Ron was in the second, and his platoon sergeant was in the third with a group of privates," Crystal says.
A 19-year-old specialist from Tulsa named James Marshall, whom Ron had been looking after, also rode in the third Humvee. As the convoy snaked through a teeming Baghdad street market, there was an explosion. "The lieutenant was yelling over the radio for all of them to haul ass back to the base because they were coming under fire," Crystal says.
When Luker looked behind him, he was horrified. The third Humvee was gone. He flipped his vehicle around and hurtled back down the street. Crystal says Luker told her that when they found the Humvee, the force of the blast had blown the flesh from two of the privates all over the seats. When Luker looked in the back, he saw Marshall, wrapped around the vehicle's 50-caliber gun. "When Ron tried pulling James' body out, his hands just went right inside of him. He pulled James's flak jacket back, and his chest was gone."
Before that day, Luker called and wrote home religiously. But when he came home to Fort Hood, Texas, for a week in August, things changed dramatically. That first night, at a welcome-home barbecue, Luker cornered his wife in the kitchen. "He asked why I'd been avoiding him and said that I didn't want to be around him," Crystal says. When Luker started cursing, some Army friends pulled him away. "You didn't come all the way home to fight with your wife," they told him.
As the week went on, there was more arguing. Crystal says her husband accused her of cheating while he was gone. He rifled through her purse and bedroom drawers and repeatedly listened to old phone messages, searching for proof.
"I told him, 'You're scaring me! You're not acting right, Ron!'" Crystal says. Luker also seemed bothered around his three daughters, she says. "He said he'd turned into a monster in Iraq. How he couldn't bounce his kids on his knee when he'd shoved guns in women's faces and busted into houses and pushed kids on the floor. He kept saying 'I'm just trying to remember who I was before.'"
Ron Luker's problems fit into those of the growing numbers of PTSD soldiers. They also signal another trend -- soldiers experiencing PTSD early. VA psychologist Scott Murray says many vets won't feel symptoms of PTSD until 15 months from now. "This early on, PTSD is much higher than anything we've seen in previous conflicts," Murray says. "We anticipate the numbers are only going to keep getting higher."
Psychologist Kaye Baron currently treats some 70 active soldiers and their families in a private practice in Colorado Springs, near Fort Carson, Colo. From clinical discussions she's had with soldiers, Baron thinks the PTSD rate could spike as high as 75 percent.
The issue with perhaps the most potential for psychological torment, says Jonathan Shay, is whether soldiers feel they've been led into battle for a noble cause. "If a soldier has experienced a betrayal of what's right by those in charge, their capacity for social trust can be impaired for the rest of their lives," Shay says.
Indeed, Dave Durman says he first began feeling uncomfortable in Iraq when it became clear there were no weapons of mass destruction. He says his unit was furious when Gen. Tommy Franks retired mid-war, while the rest of National Guard and Reservists were subject to the Army's "stop-loss" policy, which extends soldiers' deployments.
Many of the soldiers Baron treats tell her they only want to get far away from their lives at home. "They just want to go off in the mountains," she says. "And be by themselves."
So far, more than 10,000 veterans from Iraq and Afghanistan have sought psychological help from the VA, and there's every indication the numbers will jump significantly.
Despite the challenges these numbers predict, Harold Kudler, co-chair of the VA's PTSD Committee, says, "We've never been so prepared," and points to unprecedented cooperation with the Department of Defense, intensified PTSD outreach and the 206 vet centers.
But some say that preparation is not enough. "You can only provide the services for which you have the resources," says VA psychologist Scott Murray. "There has to be significant improvement in an allocation of funds to make that occur."
Government minimization of PTSD cases coming out of Afghanistan and Iraq is part of the problem, says New Orleans attorney William Detweiler, a former national commander of the American Legion, a veterans' service organization. "You don't hear anything about it," he says. "All you hear from the government is the deaths and people being physically injured."
On Nov. 20, Congress added $1 billion to the Bush Administration's $27.1 billion VA health care budget for 2005. The amount fell $1.5 billion short of what was recommended by the House Veterans Affairs Committee. And while Congress earmarked an additional $15 million for PTSD, few think that money will make much difference.
"The heads of the VA health care networks are all trying to figure out how the hell they're going to manage," says Rick Weidman, director of government relations for Vietnam Veterans of America.
As for the VA's mental health plan, which estimated an extra $1.65 billion was needed to fix things fully, VA spokesperson Laurie Tranter says, "We cannot comment on this now. The plan is still being finalized."
Still, all the money and services in the world will not necessarily solve the pain of PTSD. In 1968, a young soldier named Lewis Puller came back from Vietnam without his legs and parts of his hands, blown off by a Viet Cong land mine. Puller, the son of the most decorated Marine in American history, soon became a veterans' rights advocate and later a Pentagon lawyer. He married a politician, had two children and, in 1991, wrote a Pulitzer Prize winning book titled, Fortunate Son: The Healing of a Vietnam Vet. Popular on Capitol Hill and among veterans, Puller had seemingly risen from the physical wounds and the depression and alcoholism which haunted him for years to live a remarkable life. On May 11, 1994, 26 years after returning home, Puller shot himself.
Amidst an outpouring of grief, one Vietnam vet wrote an email to Jonathan Shay. "I get real tired of hidin' and runnin' from the demons," the vet wrote. "Am I the only one? Has it crossed anyone else's mind? You think maybe Lew was right? Is it the only real escape? I got questions. I'm out of answers."
Thirty years from now, many veterans from this war may echo those words.