http://bostonreview.net/BR34.6/mckelvey.php
Is religion an obstacle to treatment?
Tara McKelvey
NOVEMBER/DECEMBER 2009
When Roger Benimoff arrived at the psychiatric building of the
Coatesville, Pennsylvania veterans' hospital, he was greeted by a
message carved into a nearby tree stump: "Welcome Home." It was a
reminder that things had not turned out as he had expected.
In Faith Under Fire, a memoir about Benimoff's life as an Army
chaplain in Iraq, Benimoff and co-author Eve Conant describe his
return from Iraq to his family in Colorado and subsequent assignment
to Walter Reed Army Medical Center. He retreated deep into himself,
spending hours on the computer and racking up ten thousand dollars in
debt on eBay. Above all, he was angry and jittery, scared even of his
young sons, and barely able to make it through the day. He was
eventually admitted to Coatesville's "Psych Ward." For a while the
lock-down facility was his home. He wondered where God was in all of
this, and was not alone in that bewilderment and pain.
In a 2004 study of approximately 1,400 Vietnam veterans, almost 90
percent Christian, researchers at Yale found that nearly one-third
said the war had shaken their faith in God and that their religion no
longer provided comfort for them. The Yale study found that these
soldiers were more likely than others to seek mental health treatment
through the Department of Veterans Affairs (VA) when they came home.
It was not that these veterans had unusually high confidence in
government or especially good information about services at VA
hospitals. Instead, they had fallen into a spiritual abyss and were
desperate to find a way out. The trauma of war seems to be especially
acute for men and women whose faith in a benevolent God is challenged
by the carnage they have witnessed.
Of course, not all veterans with mental health concerns are led to VA
hospitals by a loss of faith: many simply want to get a night's sleep
without being terrorized by nightmares. Whatever kind of assistance
they are seeking, it has been in increasingly short supply. The
decline in resources for veterans' mental health services started in
the 1980s, as part of a nationwide effort to move psychiatric
patients into outpatient treatment. The number of inpatient
psychiatric beds fell from 9,000 in the late '80s to 3,000 by 2008.
During the Iraq war, however, the great difficulty veterans
experienced in getting psychiatric caregreater than beforewas not a
product of cost-cutting, but of conviction: many Bush administration
officials believed that soldiers who supported the war would not face
psychological problems, and if they did, they would find comfort in
faith. In a resigned tone, one prominent researcher who worked for
the VA, and asked that he not be identified because he was not
authorized to speak to the press, explained that high-ranking
officials believed that "Jesus fixes everything." Benimoff and the
others who returned with devastating psychological injuries found a
faith-based bureau within the VA. At veterans' hospitals, chaplains
were conducting spirituality assessments of patients.
The story of the mistreatment of returning veterans from Iraq is well
known and shocking. But the role of religious ideology in that
mistreatmenthow, inside the government, it was a potent tool in the
betrayal of an overwhelmingly Christian Armyis much less known.
"I couldn't stand to hear that phrase any longer'God was watching
over me,'" Benimoff wrote.
He wasn't watching over the good men I knew in Iraq. Faith was the
center of my life yet it failed to explain why I came home and those
soldiers did not. The phrase was a Christian nicety, a cliché that
when put to the test didn't fit reality.
• • •
Things had already begun to change dramatically at the VA by early
2005, shortly after Roger Benimoff left for his second deployment to
Iraq. Many appointees at the agency were disturbed that so many Iraq
veterans showed symptoms of post-traumatic stress disorder (PTSD). In
part the concern grew from skepticism about the diagnosis itself,
which some believed to be a legacy of the Vietnam-era anti-war
movement. Whatever the merits of the diagnosis, it was clearly
widespread and, moreover, staggeringly expensive to treat. In 2008
the RAND Corporation put a number on the problem, reporting that one
in five veterans of the wars in Iraq and Afghanistan has suffered
some form of mental illness, mostly PTSD and depression.
"God doesn't like ugly," one political appointee told Paul Sullivan,
an analyst in the VA's Veterans Benefits Administration, in a clumsy
attempt to reduce the cost of caring for psychologically traumatized
veterans. "You need to make the numbers lower." Sullivan left the VA
in 2006 and became head of Veterans for Common Sense, a group that
filed a class-action lawsuit against the secretary of the VA for the
shoddy treatment of veterans. It was dismissed in 2008 and is now
being appealed.
PTSD, along with its diagnosis and treatment, has been a charged
subject in the United States since the term was introduced nearly
three decades ago. Studying returning veterans and working with a
group of psychiatrists and others in the 1970s, former Air Force
psychiatrist Robert Jay Lifton pushed to create an entry for
"post-traumatic stress disorder" in the Diagnostic and Statistical
Manual of Mental Disorders (DSM), the official manual of the American
Psychiatric Association. Lifton and his colleagues believed that the
kind of horror induced by the experience of war and other comparably
catastrophic shocks needed a special category that would distinguish
it from lesser kinds of trauma. A definition appeared in the DSM-III
in 1980. The DSM-IV, published in 1994, included revised diagnostic
criteria that reduced the severity of the external shock required to
induce PTSD. From the start, conservatives charged that the disorder
was created by anti-war activists with a political agenda. The debate
about it has been marked by passion, rhetoric, politics, and
religion, all of which have only made things worse for the
individuals who have suffered from the disorder.
Tens of thousands of soldiers, including Benimoff, have been
diagnosed with PTSD, which occurs when an individual responds to a
traumatic event with "intense fear" and feelings of helplessness. For
PTSD sufferers, that experience is followed by horrifying nightmares,
hyper-vigilance, sleeplessness, and other potentially debilitating
symptoms. Some of those diagnosed with the disorder never recover,
and for this reason skeptics say that the DSM definition has turned
ordinary men and women into chronic sufferers, dependent on
government assistance and relieved of responsibility for their own
lives. It is true that some Iraq veterans with full-blown PTSD
diagnoses have been granted government benefitsusually between $200
and $2,600 per montheven though they might be able to support
themselves. (I have met several of them while traveling across the
country.) Nonetheless, far more suffer either with poor care or no
care at all.
• • •
One soldier I spoke with, Army Specialist Bill Haynes, had grown up
attending Highland Baptist Church in Paducah, Kentucky, and was
awarded a Bronze Star for his courage during a March 2005 battle in
Iraq. When he came home, he was plagued with a recurring nightmare.
"At first, it was the same thing over and over and over," he told me.
"It was the March 20 attack. Then one time in my dream, we didn't
have any guns at all, and I knew we were all going to get captured
and tortured and killed. This dream was so damn real."
Haynes saw a therapist at the VA and, like so many veterans who
sought help, was given a prescription for trazodone, an
antidepressant. He was also sent to group therapy, but the sessions
were filled with civilians. "They're like, 'I was working in a
warehouse, and a piling fell on my head,'" as he recalls. His
nightmares centered around the bloodshed he had witnessed on a
highway near Salman Pak, an Iraqi city near Baghdad.
Haynes had a hard time relating to the problems the other patients in
the therapy sessions described, so he stopped going. He took the
antidepressant and drank a lot of bourbon in an attempt to quiet his
mind. Neither method worked particularly well, so he tried to shoot
himself with a handgun. His wife stopped him, and over time the
intensity of the nightmare seemed to fade. "You know, it comes and
goes," he says. Several years after the battle, he sometimes takes
over-the-counter painkillers before going to bed so he will not be
haunted by the dream.
The treatment for PTSD varies widely; there is little agreement on
the best method. However, most experts believe that treatment should
be determined by a careful case-by-case analysis, and will most
likely include a combination of therapy and medication and, in some
cases, a spiritual dimension. Some veterans do well when they receive
only counseling, in either group or individual sessions.
Medication alone rarely works, as the family of Derek Henderson,
another Iraq veteran, discovered after he returned from the war in
2003. Henderson suffered from psychotic episodes and terrorized the
people around him. He carried a knife and other weapons and once
tried to run over his mother with a car. She tried repeatedly to get
him admitted to the VA hospital in Kentucky for proper care, but
nobody was willing to take responsibility for him. Instead, he was
admitted for short stints and given prescriptions for a variety of
antipsychotic medications. Finally, in June 2007, he jumped off a
bridge over the Ohio River and drowned. In this and in other cases,
the veterans were not getting a course of treatment tailored for
them. All too often they were given a handful of prescriptions and
sent on their way. Bruce S. McEwen, a neuroscientist at The
Rockefeller University who has spent decades studying post-traumatic
stress, told me, "The simple pharmaceutical solutions are just
thatoversimplified." Veterans' advocates say the pared-down
treatment and the over-reliance on drugs is a result of government
skepticism about PTSD, and the desire to cut costs.
• • •
Sullivan was working as an analyst at the Veterans Benefits
Administration in Washington in early 2005 when he was called to a
meeting with a top political appointee at the VA, Deputy Assistant
Secretary for Policy Michael McLendon. McLendon, an intensely focused
man in a neatly pressed suit, kept a Bible on his desk at the office.
Sullivan explained to McLendon and the other attendees that the rise
in benefits claims the VA was noticing was caused partly by Iraq and
Afghanistan veterans who were suffering from PTSD. "That's too many,"
McLendon said, then hit his hand on the table. "They are too young"
to be filing claims, and they are doing it "too soon." He hit the
table again. The claims, he said, are "costing us too much money,"
and if the veterans "believed in God and country . . . they would not
come home with PTSD." At that point, he slammed his palm against the
table a final time, making a loud smack. Everyone in the room fell silent.
"I was a little bit surprised," Sullivan said, recalling the
incident. "In that one comment, he appeared to be a religious
fundamentalist." For Sullivan, McLendon's remarks reflected the views
of many political appointees in the VA and revealed what was behind
their efforts to reduce costs by restricting claims. The backlog of
claims was immense, and veterans, often suffering extreme
psychological stress, had to wait an average of five months for
decisions on their requests.
When I asked him years later about the meeting, McLendon laughed.
Then his face darkened in anger. "Anybody who knows me knows I
wouldn't talk that way."
Nevertheless, McLendon was open about the skepticism he felt toward
the diagnosis of PTSD, calling it "a made-up term," which has "taken
on a life of its own." As he spoke about the diagnosis, he pounded
the table with the side of his hand more than ten times, hitting it
so hard that the wooden surface shook. "Do I think they have a mental
illness and should be stigmatized for the rest of their life?" he
asked. "What gives a psychiatrist the right to do that?"
Later, in an email about our conversation, he wrote:
[PTSD] is not a diagnosis based on empirical evidence, but rather .
. . it is an artificial construct erected by a vote of selected
psychiatrists. This does not mean that there are not problems that
certain individuals do have [and] issues that need to be addressed.
But rather, it means that we have created policies and programs that
have not served veterans well.
He recommended several books on the subject, including The Selling of
DSM, whose authors, Stuart Kirk and Herb Kutchins, show a deep
mistrust about the disorder and the scientific rhetoric surrounding
the diagnosis. McLendon's outlook seems to have had a significant
impact on the way veterans are treated upon their return from war.
McLendon and many of the other high-level officials at the VA shared
political convictions that, along with doubts about the science of
PTSD, made them less likely to push for additional psychiatric
services for veterans. They believed in streamlined government and
free markets, and they supported a prominent role for faith-based
organizations. The secretary of the Department of Veterans Affairs,
R. James Nicholson, had previously served as chairman of the
Republican National Committee and as ambassador to the Vatican.
McLendon's politics closely mirror his boss's, and under Nicholson's
watch, veterans had increasing difficulty in obtaining adequate
psychological care.
When a 2006 Government Accountability Office report raised questions
about whether soldiers were getting the psychiatric help they needed,
an assistant secretary of defense disputed the report's findings,
pointing to the fact that soldiers were being referred to chaplains.
During this time contracts for veterans' services were increasingly
parceled out to leaders of faith-based organizations rather than to
secular ones, even though veterans' advocates opposed any bias toward
faith-based treatment and argued that replacing empirically proven,
nonsectarian programs with faith-based ones was a mistake.
The religious programs grew, despite concerns. At the VA Healthcare
Network in upstate New York, chaplains compiled spirituality
assessments of patients within twenty-four hours of their arrival.
The VA Greater Los Angeles Healthcare System gave patients a
questionnaire that stated one of the System's goals as helping
veterans "Maintain Optimal Spiritual Health." In Coatesville,
patients in the psychiatric ward had a daily, thirty-minute block of
time scheduled for "SPIRITUAL UPLIFTING." Meanwhile Benimoff
wondered, "what kind of God would allow people to sink to the depths
we here in this ward had sunk?"
• • •
For spiritual uplift, many soldiers and veterans depend heavily on
pop-Christian books, especially Rick Warren's The Purpose Driven
Life, and themes of divine purpose and devotion to God. As a chaplain
in Iraq, Benimoff himself used the book to cope with the mayhem. He
also relied on it to help the troubled soldiers he knew, and he
appreciated that the book emphasized helping other people, while
other spiritual self-help books tended to promote selfishness. But
even a book like The Purpose Driven Life could not solve the problems
he faced. Over time, he began to wonder about his own purpose in Iraq
and about the government's, and he felt uncertain and scared.
We had gone to Iraq because there were weapons of mass destruction
stockpiled across the country, yet those weapons were never found and
may never have existed. I had gone to Iraq thinking that was the
cause. But if the cause had been wrong, what did that say about our
role there, and mine?
As Benimoff and other soldiers eventually discovered, The Purpose
Driven Life was not helpful, especially as the war's own purpose grew
less clear. Since Vietnam we have learned that PTSD tends to hit
people especially hard when they fight in wars of choice. Bobby
Muller, the head of Veterans for America, told me it was difficult
for soldiers to talk about the war in Vietnam after they came home;
years later, though:
I would get in touch with some of these guys, and they all had to
come to the realization, 'This is bullshit.' It's not just the horror
of killing, but its context. . . . If you're fighting a necessary
war, it's awful. But it's kind of what you got to do. Let's take a
war that turns out to have been unnecessary. And in fact your
leadership betrayed you. That willingness to serve was betrayed by a
leadership that lied and squandered that trust. The very moral fabric
of your life gets ripped apart.
Despite its limitations, The Purpose Driven Life is still used in the
military to inspire soldiers and ease doubts about their mission.
Nobody forces soldiers or veterans to read The Purpose Driven Life,
of course, but it is extremely popular. Paperback copies are passed
around among soldiers, and one edition of the book was published with
a camouflage cover, a savvy move by the publisher that helped tap
into the military market.
In May Harper's magazine reported that at a mandatory 2008
suicide-prevention assembly of 1,000 aviators at a U.S. Air Force
base in Lakenheath, England, a chaplain relied on the book for his
presentation. Warren's inspirational messages did not always take
hold, though, and one soldier, LaVena Johnson, who ended up killing
herself in Iraq, according to military documents, had a copy of The
Purpose Driven Life.
Many soldiers turned to the book for solace once they came home. One
Kentucky veteran who had been wounded in a 2005 battle in Iraq kept
the book in his basement apartment, but nevertheless tried to shoot
himself and was admitted to a lock-down psychiatric ward in a VA
hospital. Nobody believes that the book itself drove him and others
to suicide or attempts to end their own lives, but its popularity is
yet another indication of the existential despair that many soldiers
and veterans feel after serving in combat and the desperation with
which they seek help. Military culture places high value on
self-reliance, so a spiritual self-help book made sense for Johnson
and fellow fighters. But their stories show that, when faced with the
immense task of coming to terms with the horror of war, an
inspirational book such as The Purpose Driven Life, or a prescription
for antidepressants, or any other simplistic approach to the problem,
is inadequate.
• • •
The 2010 budget proposed by President Obama includes the largest
funding increase for veterans in the past thirty years, and much of
it is devoted to treatment of PTSD. The new secretary of the
Department of Veterans Affairs, Eric Shinseki, a retired general who
was injured in Vietnam (and fought with Rumsfeld over the size of the
force needed in Iraq), has shown a strong commitment to the care of
veterans. Unfortunately, bureaucracies are slow to respond. After
years of neglect during the Bush administration, veterans now have
nearly one million claims pending, a record high for the agency. VA
officials say that, technically, it is not a backlog, because
thousands of claims are resolved each month, and thousands more are
added. But none can deny that the situation is enormously frustrating
for suffering veterans.
The political fallout from the Iraq war and the government's failure
to care for its veterans has been far-reaching. Shortly before
Benimoff resumed his chaplaincynow at Walter Reedstories describing
inadequate treatment at the hospital appeared in The Washington Post,
appalling the public. "I was walking into an institutional crisis,"
he wrote. "I'll speak for myself when I say it felt like everything
was broken. If the system was broken, so was Ia broken healer for
broken soldiers in a broken system. God save us all.
.