Combat: When Do You Go Back?

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Army photo / Staff Sgt. Michael L. Casteel

When soldiers like these in Afghanistan confront mental issues, an Army psychiatrist's bottom line boils down to a seemingly simple question: is the soldier better off on the front lines, or back home?

The military psychiatrist serves both the service member and the military. The classic decision for a military psychiatrist in the theater of war is how to balance the needs of the individual against those of the organization when deciding when to evacuate for psychiatric reasons.

Lessons from World War I, World War II, and the Korean War taught us that those we evacuated for “shell shock” or “battle fatigue” did not do well after evacuation.

If a Soldier were sent home for psychiatric reasons, the shame and stigma persisted. They usually would be discharged from the military. However, if they could be maintained on the front line, they maintained their ties with their unit, and had the satisfaction of having served honorably.

Beyond that, those sent home were lost to the fight. Replacements were slow in coming. The Army Medical Department motto is “Retain the fighting strength.”

Thus, both Soldier and the Army seemed to do better when the Soldier stayed on the battlefield. (Or so goes the conventional wisdom goes. We do not actually really know the mortality rate of those who stayed in theater.)

This practice became part of the Army’s Combat Stress Control doctrine. The mnemonic was “PIES” — Proximity, Immediacy, Expectancy and Simplicity. Treat close to the front lines, quickly and simply, with an expectation of return to duty.

Every military behavioral-health practitioner knows the basic principles of far-forward mental health treatment. Of course, there are variations in the way patients present, which influence the evacuations decision. Normally the patient gets a trial of treatment in the war zone. If patients do not improve, or are dangerous, then they are evacuated.

I directly practiced the policy of minimizing evacuations while serving in Korea and in Somalia. The military followed that policy in Iraq and Afghanistan. It seemed to work well.

At least in the beginning.

But now that the Army is withdrawing from Afghanistan and downsizing, is it still the right approach? The Army is still concerned about retaining skilled Soldiers. And to be sent home still usually ends a career. Perhaps not immediately, but the chances of promotion are poor.

Now military psychiatrists have a new challenge. If someone has developed PTSD from combat, is it ethical to send them back into a war zone?

The Mental Health Advisory Teams showed that the prevalence of PTSD symptoms increased in those who had been deployed several times. However, fighting two wars, an overstressed Army had little choice other than to repeatedly deploy Solders.

It is different now; far fewer Soldiers are deploying.

So if you do send them back, then likely they will be experiencing the same stressors that led to PTSD before.

If you do not allow them to go, then they are eventually discharged from the Army for being non-deployable. The discharge may be medical or administrative, but either way it means losing their jobs, and military identity in a time with very high unemployment, especially for young veterans, is no good thing.

Another part of the discussion: there are many service members who deliberately keep PTSD symptoms hidden, so that they can deploy back into combat. They want to go back.

So they ignore the posters saying, “It’s a sign of strength to seek help.”  Instead, they embrace the Army’s traditional mantra: “Suck it up and drive on.”

What we lack are data on how these combat veterans do in terms of overall mortality. Does their hyper-vigilance help keep them alive? Or does their irritability get them in trouble?


Another article I have read that has absolutely nothing to do with helping Soldiers.  It is a blatant "look at me and what I do", and serves no purpose to HELP THOSE OF US IN NEED.

The real reason Soldiers are killing themselves is that people like you are busy "balancing the needs of the Soldier and the needs of the organization".  In a sense, you're playing God with people's livelihood and mental health, and now that things are slowing down, you magically decide that "Meh, it's ok to send this Soldier home or not let him deploy."  

Every day, we lose an average of 22 veterans to suicide.  The military sees fit to train us for war, train us to take lives and save our friends and ourselves WHEN THE COMBAT TRAIN IS ROLLING.  When that train gets derailed (i.e.- coming home, getting out of the military), there is NOTHING.  Nothing.  Granted, I understand that we are an Army, designed to fight and conquer, but people like you continue to bloviate about what you do and how you decide.  Meanwhile, an article could be written to use your VAST experience in trauma and psychology to educate the public on how to help veterans who are struggling.  You could be spreading a word of ADVICE, instead of "Well, this is what I've done as a professional..."

Way too many people are sitting in the media saying "our veterans are killing themselves...what a shame".  Instead, they could be teaching people how to notice when it is time to get help.  Define the alarms that go off...the alarms that get tripped with certain buzzwords or actions by a suicidal person.  It would SAVE LIVES...


I concealed the symptoms of my PTSD so I would be allowed to deploy. I stopped taking my medication. I stopped therapy. All because I was desperately afraid of losing my job or my security clearance in this economy (you do not have to disclose combat related PTSD counseling on your security clearance form. Unfortunately, mine is related to sexual assault.) Now I am walking around Afghanistan, terribly depressed, with nightmares, just trying to get through the day.


Sun . 10/28/12

ONLY Our Military & Their Families, ONLY Our Veterans & Their Families are Fighting this War.

The Rest of America is "At the Mall" & can't be concerned. They could Care Less about Afghanistan.

Don't believe that is True? Just mention the word Afghanistan & witness how fast they turn & walk away.

My experience with Our Troops is that they are deleberately Keeping the symptoms of PTSD hidden so that they can be Deployed again.


Much of this is the responsibility of the Troops Themselves. This is Important :The Doctor/Patient relationship is Confidental & NOT to be Shared. It's NONE of Your Damn Business if a fellow Soldier or Marine is seeking Help from the Behavioral Health Clinic.

You BETRAY your fellow Soldier or Marine IF You share that personal information. So Shut the Hell Up already.

Bottom Line : Our Troops have to Have the Balls to ASK FOR HELP !

Failure to Ask for Help Can Get You KILLED or even worse yet, someone from Your Unit or Your Family KILLED.

Being "Too Macho & Stubborn & Selfish to Ask for Help " That is On You & No One Else.



SPW in Alaska "Airborne"   Drafted July 1969


After Vietnam, I had the honor of commanding an American Legion post and saw the unresolved misery of vets.  War is hell.  Sending men to hell is the most serious act a nation can require of its people.   It is being taken lightly

We keep sending soldiers back because we have no draft.  We need a draft so that everyone tastes the war-everyone.  This is not a game and the military knows good and well, including the author of this article, that returning a soldier to a war zone will increase the chances he suicides.  More suicides now in the Army than losses in combat due to PTSD.  

War is hell.   Don't send your kids to hell.


There is a stone cold cure for ptsd.  The military knows it, but because it's not a drug they can't even suggest it.  It's been used and approved for fighter pilots during combat as far back as the Gulf War.  Those of us who know this, can only shake our heads.  If I try to tell you what it is, I could be put in jail.  Every PTSD suicide is more American blood on their hands.  Yours too, now that you know.


A brother in law reenlisted in the Army while in Vietnam. He loved the adrenaline rush while in the field with the Montagnard tribesmen on recon missions deep behind enemy lines.  He called in artillery and air support when needed, including an ac130 once while surrounded by a company of North Vietnamese Regulars - pretty much wiped them out.  His initial source of pride was he could throw a hand grenade farther than anyone might expect.  He was wounded a couple times.  I don't know if he was diagnosed with PTSD, but he was somewhat hard for people to get along with in civilian life after he got out of the Army with an honorable discharge.  He might have come to be that way without having been in combat though.  People generally get more individualistic as they age.  Schizophrenia frequently first manifests in the early 20's as do other mental aliments.  The question would be why do the majority of young men come out of combat mentally unscathed and others with PTSD?  It may be some should have never been sent into combat to begin with because of a predisposition to mental issues.  Even in civilian life it is very clear some people without combat experiences are mentally stronger than others, more able to cope with stress.  Once I worked with a guy who had issues.  At the point I had enough, I told supervision that if they did not get me away from the guy, I was going to grab him by the throat and beat his head against the wall.  I was moved to other work.  About 6 months later my former co worker was committed to a mental hospital with a nervous breakdown.  My opinion is he was just born with issues and all they did was get worse.


It should be "self-evident" that you don't send unstable soldiers back to the front. Apparently not to some.

These mindless wars of attrition are going to go down in history as a blemish on your time.The "greatest generation" knew what they were doing and won. Your generation in the military acts as so many dodos.There will be no VA say anymore then there was a VI day. Future generations will wonder "What were they thinking?" You aren't.


American people are slaves for Jewish who said that they killed the Christ and said he is a magician. As we see United States soldiers are killing themselves for Jewish but The God will defeat United States (occupied by Jewish)  by the eastern army (Russia + China)


@spwright1 I'm sorry you have experienced so much apathy from the citizenry that you served! It is a national shame!! However, it is not completely true that no one besides other military and their families care or are concerned about our troops and veterans. Please check out Soldier's Heart A big part of the Soldier's Heart model involves ordinary civilians willing to support and  "witness" with and for veterans and create venues for veterans to express their experiences through the arts and storytelling. The model also focuses on the moral and ethical issues that are inevitable in the war zone and how they impact the soul. Also, WAR AND THE SOUL, by Edward Tick has been saving lives. He is not a veteran, but he "gets it" and has devoted his life to helping our troops come home - since the Vietnam War.



Sun. 10/28/12   Welcome HOME Sir & Thank You for Your Service !

I sincerely Agree with You.  I believe that there should be a Military Draft like Isreal has. All able bodied Male & Female 18 yr old are Drafted into the I D F no exemptions no excuses.Everyone serves & does their share. The People of Isreal know & respect this Call to Duty.

What would Happen here in the USA If the Military Draft was started again ? Females included & No College Exemptions ?

Why My GrandDaughters would Freak Out if they had to serve in the Military ! Yes they are Spoiled Brats.

This is not such a far away & distant possibility : Isreal Bombs Iran Nurclear Sites, Iran returns w/ Scud Missle Strikes, Isreal returns with Bombing Missions on the Scuds then the entire Arab World joins Iran & a War with Isreal

BOOM You got yourself a World War III  then the Military Draft would be necessary again.

"I Ain't No Fortunate Son"   Drafted July 1969 along with 35,000 Single American Males per month into the Army & Marine Corp.  70% of Nam Veterans were Draftees.Thanks for Listening

Retiree SPW in Alaska "Airborne"



Sun 10/28/12  This Generation of American Warriors are the Best in Our Nation's History Period End of Story   SPW


Your religion, their religion, American religion, Jewish religion, Russion religion, Chinese religion, maybe the problem is just simply "religion".


@Katedahlstedt @spwright1 Mon. 11/5/12  Thank You for a actual Response. That helps to restore my faith in Humanity.

My personal experience is that ONLY fellow VETERANS are able to really Help Combat Veterans. Nothing else seems to work. For me or My Brothers.

Thank You for Listening       SPW in Alaska"Airborne"



Sun 10/28/12  "Believe as I Believe or I Will KILL You"!  That's where it all begins         SPW


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