Are We Failing to Honor Psychological Injuries?

This past week, a grievously wounded Special Operations soldier shared a picture on social media of himself lying in a hospital bed, wires connected to unseen medical devices cascading down his body, both legs missing from the knee down, a confident look on his face, and arms raised in triumph.

It’s accompanied by a powerful caption about the day of his injury in combat, his desire to die post-injury, his newfound desire to live, and his will to thrive. He ends by encouraging those who “hurt[s], the one who thinks death will end the pain. I see you. Stay with us a little longer. And be alive." And hashtags, #mentalhealth.

Its poignancy and bold celebration of the ability of the human spirit to triumph in the face of tremendous adversity caused it to go viral on many veteran social media pages. Nearly overnight, he gained roughly 15,000 followers who were inspired by him, his resilience, and candor.

I am hopeful his remarkable journey and vivid sharing of the dark and light sides of his own recovery post-catastrophic injury will help some seek healing and contribute to the destigmatization of receiving treatment for physical and psychological wounds.

And I would be remiss if I didn’t also share my worry that moments like these unintentionally shame others into silence about their own struggles.

For those of us who work with military members and veterans, helping them heal from the wounds of war, we all too often hear variations on the following themes:

Undeserving

“Some I served with have it way worse than me. I don’t want to take their or someone else’s spot.”

Unqualified: “I haven’t earned it. I wasn’t physically wounded.” Or, "I didn't see much (or any) combat."

Unworthy: “I can’t accept this, I didn’t do enough.”

Unsubstantial: “My buddy lost his arm, and he’s doing great. I haven’t lost anything, and I can’t get it together. It’s my fault, I must be fragile. I’m weak.”

We consecrate and honor physical loss and injury of our service members with the Purple Heart. It is the oldest military award still given in the U.S. military.

It's unique in many ways, but it differs from the rest of the military’s awards in that an individual is not recommended for it, they are entitled to it—if they meet the criteria.

For generations, the criteria remained a wound inflicted by the enemy during direct or indirect combat operations (or friendly-fire if the intent was to destroy the enemy or enemy equipment) that required medical treatment and is officially recorded.

In 2011, the following revisions were made:

“Award may be made of wounds treated by a medical professional other than a medical officer provided a medical officer issues a statement in the service member’s medical record that the extent of the wounds were such that the wounds would have required treatment from a medical officer if one had one been available to treat the wounds."

And,

"For concussive events caused by enemy action that occur on or after the start of GWOT (11 SEP 2001), award of the PH is authorized when... 1. there is loss of consciousness (LOC) of any duration as a result of a diagnosed mTBI/concussion, or 2. when the persistent signs, symptoms, or findings of functional impairment from a diagnosed mTBI/concussion result in a medical officer disposition of 'Not Fit for Duty' for a period greater than 48 hours."

Clearly, the intent of this inclusion was to partly address one of the hallmarks of warfare—mild traumatic brain injury.

To date, the Department of Defense (DoD) regards and recognizes some TBIs as eligible for the Purple Heart, largely because those injuries can be diagnosed using brain scans and other objective medical tests.

Yet, there is substantial evidence to suggest that PTSD can develop following mTBI (see references below). There is some evidence to suggest that PTSD and postconcussive symptoms are interdependent and mutually influence one another, and while brain scans can't necessarily diagnosis PTSD, there is abundant evidence of changes in the structure and function of the hippocampus and increased activation in the amygdala.

Post-Traumatic Stress Disorder Essential Reads

Can Art Be Data?

Undoing Emotional Numbing May Be Key to Trauma Recovery

In spite of this, there is a contentious debate on the inclusion of psychological wounds, like PTSD, as appropriate for receipt of the Purple Heart.

The loudest arguments against its inclusion do not come from the scientific community but from the military's own, citing ambiguity about the intentions of the enemy in inflicting psychology injury, bringing dishonor to those who have received it for physical wounds and worse, “medals aren’t awarded for illness or disease, but for achievement and valor.”

To those points, one might argue that psychological warfare is perhaps the oldest form of warfare. Degrading the will of the enemy to fight, demoralizing, intimidating, and influencing the thinking and behavior of the opposing force is a tactic as old as hand-to-hand combat. Moreover, we know that ISIS and Al-Qaeda delineated specific lines of effort to wage psychological warfare on American troops.

Perhaps, it's time we acknowledge that suffering is not a zero-sum game and that the perpetuation of suffering as a predominantly physical and binary variable is not grounded in science or good practice.

Finally, with suicides on the rise and significant distress manifesting on both active duty and for veterans, perhaps it's time to utilize all avenues of approach for destigmatizing and normalizing all wounds of war. Moreover, there are many who place themselves in harm's way time and again knowing they are suffering psychologically and emotionally. Is that not its own brand of courage?

Regardless of which side of the argument you fall, we might all agree that our system is fragmented and illogical.

You can be 100 percent disabled for service-connected PTSD through the VA and told by the very institution that qualifies you for that treatment, the DoD, that your injury, while unequivocally service-connected, is definitively not the result of enemy action or worthy of that distinction.

Then you receive a monetary award every month as recompense for opportunities lost as a result of your non-enemy, combat-related injury.

I can't help but read between the lines: We’ll give you money, but we won't give you honor.

I don't imagine I'm the only one.