The Wars toll on Soldiers Minds is Tremendous

Little Relief on Ward 53
By Anne Hull and Dana Priest
The Washington Post

Monday 18 June 2007

At Walter Reed, care for soldiers struggling with war's mental trauma is undermined by doctor shortages and unfocused methods.

On the military plane that crossed the ocean at night, the wounded lay in stretchers stacked three high. The drone of engines was broken by the occasional sound of moaning. Sedated and sleeping, Pfc. Joshua Calloway was at the top of one stack last September. Unlike the others around him, Calloway was handcuffed to his stretcher.

When the 20-year-old infantry soldier woke up, he was on the locked-down psychiatric ward at Walter Reed Army Medical Center. A nurse handed him pajamas and a robe, but they reminded him of the flowing clothes worn by Iraqi men. He told the nurse, "I don't want to look like a freakin' Haj." He wanted his uniform. Request denied. Shoelaces and belts were prohibited.

Calloway felt naked without his M-4, his constant companion during his tour south of Baghdad with the 101st Airborne Division. The year-long deployment claimed the lives of 50 soldiers in his brigade. Two committed suicide. Calloway, blue-eyed and lantern-jawed, lasted nine months - until the afternoon he watched his sergeant step on a pressure-plate bomb in the road. The young soldier's knees buckled and he vomited in the reeds before he was ordered to help collect body parts. A few days later he was sent to the combat-stress trailers, where he was given antidepressants and rest, but after a week he was still twitching and sleepless. The Army decided that his war was over.

Every month, 20 to 40 soldiers are evacuated from Iraq because of mental problems, according to the Army. Most are sent to Walter Reed along with other war-wounded. For amputees, the nation's top Army hospital offers state-of-the-art prosthetics and physical rehab programs, and soon, a new $10 million amputee center with a rappelling wall and virtual reality center.

Nothing so gleaming exists for soldiers with diagnoses of post-traumatic stress disorder, who in the Army alone outnumber all of the war's amputees by 43 to 1. The Army has no PTSD center at Walter Reed, and its psychiatric treatment is weak compared with the best PTSD programs the government offers. Instead of receiving focused attention, soldiers with combat-stress disorders are mixed in with psych patients who have issues ranging from schizophrenia to marital strife.

Even though Walter Reed maintains the largest psychiatric department in the Army, it lacks enough psychiatrists and clinicians to properly treat the growing number of soldiers returning with combat stress. Earlier this year, the head of psychiatry sent out an "SOS" memo desperately seeking more clinical help.

Individual therapy with a trained clinician, a key element in recovery from PTSD, is infrequent, and targeted group therapy is offered only twice a week.

Young Pfc. Calloway was put in robes that first night. His dreams were infected by corpses. He tasted blood in his mouth. He was paranoid and jumpy. He couldn't stop the movie inside his head of Sgt. Matthew Vosbein stepping on the bomb. His memory was shot. His insides burned.

Calloway's mother came to Walter Reed from Ohio and told the psychiatrist everything she knew about her son. Sitting in the office for the interview, Calloway jiggled his leg and put his head in his hands as he described his tour in Iraq. His mental history was probed and more notes were taken. The trivia of his life - a beagle named Zoe, a job during high school at a Meijer superstore, a love of World War II history - competed with what he had become.

"I can't remember who I was before I went into the Army," he said later. "Put me in a war for a year, my brain becomes a certain way. My brain is a big, black ball of crap with this brick wall in front of it."

After a week in the lockdown unit, Calloway was stabilized. They gave him back his shoelaces and belt. On the 10th day, he was released and turned over to outpatient psychiatry for treatment. And Calloway, a casualty without a scratch, began the longest season of his young life.

Inside Walter Reed

The Washington Post began following Calloway after he was brought to Walter Reed last fall with an initial diagnosis of acute stress disorder. He had all the signs of PTSD, but it would be the hospital's job to treat him and then decide whether he met the Army's strict guidelines for a PTSD diagnosis - which required a certain level of chronic impairment - and whether he could ever return to duty.

Calloway's physical metamorphosis was rapid. The burnished soldier turned soft and fat, gaining 20 pounds the first month from tranquilizers and microwaved Chef Boyardee. He lived at Mologne House, a hotel on the grounds of Walter Reed that was overtaken by wounded troops. His roommate was another soldier from Iraq with psych problems who kept the curtains drawn and played Saints Row video games all day until one day he vanished - poof, AWOL, leaving nothing behind but empty bottles of lithium and Seroquel.

For the first time in almost a year, Calloway had a plush bed and a hot shower, but he was too angry to appreciate the simple comforts. On an early venture outside Walter Reed, he went to downtown Silver Spring and became enraged by young people laughing at Starbucks. "Don't they know there is a war going on?" he said.

Wearing a rock band T-shirt, Calloway looked like any other 20-year-old on the sidewalk, but an unspeakable compulsion tore through him. He said he wanted to hatchet someone in the back of the neck.

"I want to see people that I hate die," he said. "I want to blow their heads off. I wish I didn't, but I do." He made similar statements to his psychiatry team at Walter Reed.

Violence seeped into his life in a thousand ways. When he cut himself shaving, the iron smell of blood on his fingertips gave a slight euphoria. But it was the distinct horror of his sergeant's death that was encoded in his brain. The memory made him physically sick. He would sweat and shake as if having a seizure, and sometimes he felt as if he were back in the heat and sand of Iraq.

The recognized treatment for PTSD is cognitive behavioral therapy, in which patients are encouraged to face their feared memories or situations and to change their negative perceptions. A key technique is known as prolonged exposure therapy. It involves revisiting a traumatic memory in order to process it. The idea is not to erase the memory but to prevent it from being disabling. Highly structured, one-on-one sessions over a limited time period have proved most effective, according to Edna B. Foa, a professor of psychology in psychiatry at the University of Pennsylvania, who has been contracted by the Department of Veterans Affairs to train 250 therapists who treat PTSD.

But Calloway and a dozen other soldiers from Iraq and Afghanistan interviewed by The Post described a vague regimen at Walter Reed's outpatient psychiatric unit, Ward 53. They get a heavy dose of group sessions such as "Reflecting with Music," "Decisions," "Feelings Exploration" and "Art Expressions." Calloway reported to his "Reel Reflections" class one morning for a screening of "The Devil Wears Prada." Only two hours a week are devoted to a post-traumatic recovery group, according to a copy of their schedule.

These soldiers said they are over-medicated and treated with none of the urgency given the physically wounded. One desperate patient, a combat medic who broke down after her third tour in Iraq, said she begged her psychiatrist: "We are handicapped patients, too. Cut off both my legs, but give me my sanity. You can't get a prosthesis for that."

In an interview this month, Col. John C. Bradley, head of psychiatry at Walter Reed, said soldiers with combat-stress disorders receive the accepted psychotherapeutic treatment there. He said they are placed in a specially designed "trauma track" and are given at least an hour of individual therapy a week and a full range of classes to help them cope with their symptoms. Exposure therapy is as effective in group settings as in individual sessions, he maintained - a belief that runs counter to the latest clinical research.

Bradley acknowledged staff shortages and said vacancies in his department go unfilled for as long as a year because of the Army pay scale and the high cost of living in the Washington area. He recently asked to increase his staff by 20 percent, and last month he brought on a reservist to help doctors with the time-consuming duties of preparing reports for the soldiers' medical evaluation board process. "We are constantly looking for innovative ways to provide service and outreach and support to soldiers," said Bradley, who deployed to Iraq last year with a combat-stress unit.

One of the country's best PTSD programs is located at Walter Reed, but because of a bureaucratic divide it is not accessible to most patients. The Deployment Health Clinical Center, run by the Department of Defense and separate from the Army's services, offers a three-week program of customized treatment. Individual exposure therapy and fewer medications are favored. Deployment Health can see only about 65 patients a year but is the envy of many in the Army. "They need to clone that program," said Col. Charles W. Hoge, chief of psychiatry and behavior services at the Walter Reed Army Institute of Research.

Instead, Deployment Health was forced to give up its newly renovated quarters in March and was placed in temporary space one-third the size to make room for a soldier and family assistance center. The move came after a series of articles in The Post detailed the neglect of wounded outpatients at Walter Reed. Therapy sessions are now being held in Building T-2, a rundown former computer center, until new space becomes available.

Joshua Calloway reported to Ward 53 five mornings a week in his uniform. He was a tough patient from the start, angering easily and impatient with anyone who had not experienced combat. He was irritated that he had to attend groups with soldiers who had bombed out of boot camp or never deployed. He participated in processing exercises using work sheets to help him manage his fears. ("For example, original thought: 'I'm in a crowd, they're looking at me, they're all going to jump me, the enemy looked at me in Iraq and shot me, I leave.' Feelings: Anxious. Behavior: Leave situation.")

With the exception of the post-traumatic stress group run by Joshua Friedlander, a clinical psychologist and former Army captain who had served in Iraq, most of the classes felt like B.S. sessions to Calloway. "Civilians reading from a booklet," he said.

Ultimately, his treatment was in the hands of a civilian psychiatrist. Before taking a contract job at Walter Reed in 2005, the doctor had worked at Washington's St. Elizabeths Hospital and specialized in addictions and pedophilia. On Ward 53, he was responsible for about 30 soldiers, many back from Iraq. Calloway felt little validation from the psychiatrist. Sometimes the doctor typed on his computer while Calloway talked.

There was another, more delicate, problem. The psychiatrist was Indian. Calloway had a gut reaction to anyone he thought looked Iraqi, a paranoia shared by many of Walter Reed's wounded.

"You are seeing a [expletive] Pakistani?" asked Spec. Isaac Serna, a fellow war-wounded soldier in the 101st Airborne. "I'd freak, dude."

Calloway confessed his bias to the doctor. "I want to kill Arabs," he said.

"Does that include me?" the Hindu doctor asked, according to Calloway. "You can say it."

Antidepressants are most commonly used to treat PTSD, and Calloway was on a total of seven medications by Christmas, including lithium, used to treat bipolar disorder. He had now gained 30 pounds and was too lethargic to exercise. Bored one night, he took out the sweat-stained spiral notebook he had carried in Iraq. Grains of sand were still between the pages scribbled with Arabic commands. He repeated the phrases that loosely translated to "don't speak" and "shut up."

"Balla hashee!" he said. "In chep!"

He spent the holidays reading "The PTSD Workbook" and eating Starbursts in a room piled high with goody boxes from his church back home.

"You are in our prayers, Josh," one card read. "We are so proud of your service to your country."

Unabating Anger

In Iraq he was infected with MRSA, a microbe that makes the skin boil, and at Walter Reed he suffered a painful outbreak that landed him in the hospital. Festering sores brought a respite from Ward 53. In the hospital, he got Percocet and "The Daily Show," and late at night he read a memoir by a soldier who served in Iraq called "The Last True Story I'll Ever Tell." A friend in the 101st lent it to him with underlined passages, and Calloway read aloud the one on Page 172 about trying to fit back in after war.

I spent most of my time watching the rooftops and side roads, looking into my rearview mirror to make sure no one was creeping up on my car from behind.... Every time I saw someone sitting contently inside a coffee shop or restaurant, I wanted to yell at them, wake them up.

A social worker with a clipboard came to his room the next afternoon. "The surgeon general is concerned about all the soldiers coming home with smoking habits," he said.

Calloway said he never smoked before Iraq but smoked three packs a day in theater.

"Have you ever considered a patch?" the man asked.

By his fourth month as an outpatient on Ward 53, Calloway had learned breathing techniques to ease his panic. He had been asked to recite statements of self-love in group therapy. He had learned to cook in occupational therapy. But his core anger was as high as ever, made worse by the relationship with his psychiatrist. They met once or twice a week, mostly to discuss meds and argue. "Why don't you ever come in here and smile?" the doctor asked, according to Calloway. "Why don't you ever come in here and think today will be a good day?"

Walter Reed officials refused to discuss individual patients for this story, citing privacy concerns.

Calloway wanted to scream. Disillusioned, he stopped faithfully attending the combat-stress group he first found helpful. In the cold of winter he went down to Capitol Tattoo on Georgia Avenue, where the milky skin of his arms became a canvas of colors and death poetry. In honor of Vosbein, he had a silhouette of a soldier drawn on, with the words: "Lay down your armor. And have no fear. I'll be home soon."

Even with his nihilistic markings, Calloway still saw himself as a soldier. On Sunday mornings he attended a VFW brunch in Arlington, feeling at home with the snowy-haired veterans who sipped coffee under an American flag. As an Iraq vet, he was treated as part of the newest generation of warriors. One Sunday, he was accompanied by a girl from Ohio who'd come to visit him at Walter Reed. She wore his dog tags, and his eyes were full of light. "Thank you, ma'am," he told the waitress who brought his biscuits and gravy.

But the girl went back to Ohio and Calloway came to the next brunch alone, secretly terrified that in 30 years he'd be sitting in a support group like the Vietnam guys. With his nightmares and balled-up fists, what woman would want him?

"I'm not getting any better," he told his mother on the phone.

His step-grandfather in Ohio spent a morning making calls, trying unsuccessfully to reach anyone at Walter Reed. "He's meeting with people 15 minutes a day, he's been written off," said Greg Albright. "Josh has not been cooperative, he's been insulting to the doctor. But that's a function of the place he's been." Albright met with an aide from the district office of Rep. John A. Boehner (R) in Ohio. He wanted help bringing Josh home for treatment, and the family was willing to pay for it. But Calloway was still in the Army.

One night in his room, Calloway put in a DVD and watched the opening scene of "Saving Private Ryan," the American G.I.s coming onto Omaha Beach, retching in fear as they unloaded from the boats and faced a rain of German bullets. Limbs severed, necks punctured, foreheads blown open, but the grunts kept charging.

"See why I picked infantry?" Calloway said, his leg furiously twitching. "There's no other place in the world where you can have a job like that. It's a brotherhood that's deeper than your own family."

His romanticized ideals clashed with reality. His anti-nightmare medication made him a zombie in the morning, and he slept through his alarm. After missing morning formation, he was ordered by his platoon sergeant to pick up trash, but in the middle of his work duty he had an anxiety attack; shaking and unable to focus his eyes, he was taken to the ER, where he overheard his sergeant tell the doctor that it seemed to be a big coincidence that Calloway had an attack while doing work.

"I Can't Handle Another Day"

He often wondered why he snapped. Several factors make PTSD more likely - youth, a history of depression or trauma, multiple deployments, and relentless exposure to violence. Calloway hit most of the criteria. He had been depressed in high school, and four months out of basic training he was in one of the most dangerous sectors of Baghdad.

Alpha Company, 2nd Battalion, 502nd Infantry Regiment got to Baghdad in the fall of 2005. The roads around Yusufiyah, where they patrolled, were littered with bombs. A first sergeant was lost right away, and the casualties never stopped. Living in abandoned Iraqi houses, Calloway went weeks without bathing and days without sleep. He went on raids at night, kicking in doors and searching houses to the sound of gunfire and screams.

Calloway had never felt such excitement or sense of belonging. His best friend was Spec. Denver Rearick, a grizzled 23-year-old on his second tour. In his Kentucky cowboy wisdom, Rearick warned Calloway: "Your entire body is a puzzle before you go to war. You go to war and every little piece of that puzzle gets twisted and turned. And then you are supposed to come back home again."

The pressure and dread and exhaustion began to smother Calloway. He survived several bomb blasts. Some soldiers were sucking on aerosol cans of Dust-Off to get high, and one accidentally died. Sleep deprivation mixed with the random violence scrambled Calloway. He wore it on his face. One of the sergeants asked him, "Are you gonna kill yourself, Calloway?"

Music was his escape. On rare nights on base, Calloway, Rearick and Vosbein would strip off their armor and climb up to the roof to play guitars and harmonica. Vosbein loved Johnny Cash. He was from Louisiana, free and easy with his affections, and at 30 he treated Calloway like a kid brother.

The day Vosbein died was sunny and hot. A convoy patrol in three Humvees pulled over to check a crater in the road. As Calloway was opening his door, Vosbein was already moving toward the crater. The force of the explosion rattled Calloway's teeth and knocked two other soldiers to the ground. Vosbein - whistling, happy Vos - was eviscerated. Parts of him were everywhere.

Calloway buckled and puked. Then rage. He wanted to shoot the first Iraqi he saw, but his legs weren't working. He was useless to help clean up the scene. Later that night as the chaplain gathered the platoon to talk, Calloway stood off to the side with two sergeants, crying. They confiscated his weapon. Rearick sat up with him in his room until he fell asleep. His commanders watched him closely. "We want to do what's best for you," the company commander told him with compassion. "You need to tell me what you need."

"I can't handle another day of this place," Calloway answered. He was sent to the combat-stress control trailers, where the decision was made to ship him to Walter Reed.

In his room at Mologne House, Calloway kept photos from Iraq on his computer: Vosbein grilling steaks at their patrol base. Calloway's gang piled on a tank with their guitars. Driving through a blinding orange sandstorm. Rearick, wiry and invincible, smiling in a dirty cowboy hat.

"He was able to handle it," Calloway said.

But Rearick was in bad shape. While Calloway was at Walter Reed, Rearick was home in Waco, Ky., sleeping with a .45 and the furniture pushed in front of the window. He was so anxious in crowds that he no longer went to bars or restaurants, ordering his meals at the drive-through window. To rouse him in the morning, his father tossed a boot from the doorway because he startled so violently when touched.

Rearick had sought help after coming home from his first tour in Iraq. While asleep one night, he knocked his girlfriend to the floor. "I damn near broke her nose," he said. Without telling his commanders at Fort Campbell, he went to the VA hospital in Lexington, where he was prescribed antidepressants. He didn't like the pills, so he drank himself to sleep, while gearing up for his second tour.

"All the banners said 'Welcome Home Heroes,' " Rearick said. "But the moment we start falling apart it's like, 'Never mind.' For us, it was the beginning of the dark ages. It was the dreams. It was going to the store and buying bottles of Tylenol PM and bottles of Jack."

Rearick retired from the Army earlier this year. In the bucolic green of Kentucky, he threw himself into the physical work of breaking horses and moving cattle. The only places he feels safe are the pastures and his barricaded room.

"At least Calloway doesn't try to sugarcoat it," he said. "He's like, 'I'm [expletive] up and I'm pissed off.' "

Rearick knows his outlaw paradise of guitars, guns and Willie Nelson is just a cover.

"Everyone thinks you are a badass," he said. "But you are scared of the dark."

Going Home, Far From Cured

Calloway put a Johnny Cash song on his cellphone to describe his sixth month on Ward 53.

I'm stuck at Folsom Prison

And time keeps dragging on

One night he mixed Monster energy drink and Crown Royal and got so drunk he was taken to the ER at Walter Reed, which landed him in the Army's alcohol counseling program. He had to submit to a breathalyzer test at 7 each morning. "I am losing my mind more and more while I'm here," he said.

His psychiatrist had referred him to the Deployment Health Clinical Center, but Calloway blew his chance at getting into the coveted program when he missed appointments. He blamed his meds and memory problems. He had been exposed to multiple bomb blasts in Iraq, but after seven months at Walter Reed he had not been tested for traumatic brain injury, which affects memory. Instead he was given a Dell PDA to help him remember appointments.

The relationship with his psychiatrist was barely tolerable. The frustration seemed mutual. "He complained about his problems but did not seem eager to listen to any suggestions I provided him," the doctor noted in Calloway's records. He added that Calloway showed up to Ward 53 not in uniform but in cutoff shorts with his tattoos showing.

Even on high doses of sedating drugs, Calloway's rage crackled, and one night he started breaking things outside Mologne House. He was again taken to the ER, where he screamed that he wanted to kill his psychiatrist.

Finally, Calloway got what he wanted - a new doctor. Lt. Col. Robert Forsten had served in Iraq and had published studies on combat stress. Right away, Calloway noticed Forsten's combat badge and his listening skills. Forsten agreed that the violence of Iraq was transforming and harrowing but said it should not define the rest of Calloway's life. The doctor also tried to reframe the experience. "You're a soldier," he said, according to Calloway. "You went to Iraq. You did your job.' "

Something clicked for Calloway. But it was so late in the game. His physical evaluation board process was nearly complete, and he would be going home soon. His worries turned to what diagnosis the Army would give him and how he would be rated for disability pay. His case worker had told him that she could not locate anyone at Fort Campbell to provide written proof that he had witnessed a traumatic event in combat. Forsten picked up the phone and within days had an official statement:

"During a routine route clearance in August 2006, PFC Calloway's team leader (SGT Vosbein) was clearing a suspected IED crater while PFC Calloway was inside his M1114. SGT Vosbein stepped on a crush wire that detonated 2X155 mm artillery shells. The detonation killed SGT Vosbein and knocked the remaining soldiers to the ground. PFC Calloway came to the site and saw his team leader blown apart into several pieces."

Forsten would soon get another assignment and leave Walter Reed.

The evaluation board diagnosed depression and chronic PTSD in Calloway, and ruled that his conditions had a "definite impact" on his work and social capabilities. He was given a temporary disability rating of 30 percent, which meant he would get $815 a month. He would be reevaluated in 2008. He would report to the VA hospital in Cincinnati for treatment when he got home.

After eight months at Walter Reed, Calloway showed "some improvement of his symptoms," according to his medical records. But his step-grandfather, Greg Albright, who came from Ohio to help him pack, was astounded at his volatility. "He's a grenade with the pin half-out," Albright said.

Even on his last night, Calloway avoided the open grassy spaces in front of Mologne House. He chain-smoked under the awning. He wondered what home would be like.

At dawn the next morning, he set out for Ohio, a combat infantry sticker on the bumper of his car.