08.23.13 8:45 AM ET
How The Purple Heart Can Help Heal Veterans with PTSD
Criteria for the Purple Heart medal seems straightforward: “any action against an enemy of the United States” in which a service member is “wounded or killed” merits the award. But in practice granting of the award is a contentious issue among combat veterans and a charged field for both the wounded and those who judge the wounds.
In Afghanistan, I knew soldiers who earned Purple Hearts for very minor wounds sustained in combat. Bruises and small lacerations that required no stitches were technically eligible, and soldiers who received them were rightly issued the medal. But technical criteria aside, most soldiers look down on awards given for minor injuries, arguing that doing so cheapens the Purple Heart’s significance for those who were killed or more gravely wounded.
Today, even while the Department of Defense wages a full-scale campaign to educate service members on the legitimacy of mental health injuries caused by war, many veterans are still discouraged from seeking treatment for post-traumatic stress disorder (PTSD) by a fear of being stigmatized. Current DoD policy, though a step in the right direction, has not been enough to change a culture, both in and outside the military, that still views PTSD as somehow less real than physical traumas.
Given these DoD attempts to promote understanding within the ranks that PTSD is a legitimate product of war, the question before us is this: should PTSD meet the criteria for the Purple Heart?
When I posed this question to a wide range of veterans from Vietnam to Afghanistan they universally answered “NO,” PTSD does not merit the Purple Heart. I myself shared their opinion, until I began to investigate the issue more closely and found that the reasons cited for denying Purple Hearts for PTSD were fundamentally flawed and inconsistent with other military award practices.
The first issue of contention with PTSD is whether it’s a real “wound,” but the answer to this is obvious and well documented by the fact that more combat veterans from Iraq and Afghanistan die from suicide related to wartime service and mental health issues than from enemy bullets and bombs. That should offer grave and definitive proof that PTSD is very real and that its consequences can be as deadly as an IED.
Another false premise used to undermine awarding the Purple Heart for PTSD is that the mental disorder causes no physical damage nor changes to the structure of the body. But the regulation for the Purple Heart never makes any distinction between internal wounds or external wounds. The precedent for awarding the Purple Heart for an internal mental wound is in the case of traumatic brain injuries (TBIs), which cause no visible disfigurement but still qualify for the Purple Heart. Finally, it is important to note that although PTSD isn’t detectable from the surface, the disorder does have a physiological signature and can be detected in brain scans that show changes to the brain’s structures and wiring, much like with TBIs.
Then there is the argument that there is no clear chain of evidence linking an enemy action to the onset of PTSD. The disorder can take months or years to fully manifest and may be caused by more than one incident, including traumas other than wartime service. Again, this objection is moot given that the same argument can be made about TBIs, which can also be cumulative and triggered by multiple causes that may have occurred prior to war. No distinction is made for a wound that is initially precipitated by falling off a bike as a child and later aggravated during an IED explosion that culminates in a TBI when issuing the Purple Heart to affected service members.
Finally, the most frequent and emotionally charged objection to awarding the Purple Heart for PTSD is the fear that people will fake symptoms to earn the award. Sadly, fakery can occur in any military award and that is why the current award system requires multiple witness statements to corroborate the award narrative. The same stringent review would be required for service members being submitted for PTSD-related Purple Hearts: corroborating witness statements documenting combat exposure, as well as statements from professional mental health clinicians.
The case for reconsidering PTSD and the Purple Heart might be made best by turning from argument to the story of one of my combat veteran friends from Afghanistan. My buddy, I’ll call him Ralph, was by my side in combat many times, and in the course of these violent and harrowing events he had a series of wounds inflicted on him. The first occurred when a pebble-sized fragment of shrapnel ricocheted off his machine gun shield and hit him in the fleshy part of his earlobe. There was minor bleeding but within days the wound had healed. In accordance with the regulations he was correctly and rightly awarded the Purple Heart because the wound was incurred during combat and clearly caused by enemy action. Some hardliners may scoff at this, but had the shrapnel hit two inches to the right it could have taken out his eye and lodged in his brain.
Months after receiving the Purple Heart for the wound to his ear, Ralph suffered a far more grievous injury that put him in the hospital for months, mostly in a coma, where he was expected to die from the head injuries he had suffered. After being released from the hospital he was deemed unemployable for life and granted 100 percent disability status by the Veterans Administration. Ralph now walks with a cane, is riddled with scars, and is dependent on a wide range of medications to survive and manage his pain. Yet for this second wound, by any measure more severe than the wound he suffered to his earlobe, there will never be any Purple Heart, because this second wound was PTSD.
Upon returning home from war, Ralph was haunted by the comrades he lost and the enemies he killed. In an attempt to escape his pain and grief Ralph turned to drinking and long periods of solitary confinement, barricaded in a small room in his father’s house. Some days when he felt especially hopeless he would get behind the wheel of his car and drive fast in an effort to flee and find relief. On one such day, craving the adrenaline rush of combat, and fueled by rage and alcohol, he drove his car right into a telephone pole and suffered the injuries that caused his coma and continue to limit his mobility and physical health today.
Ralph’s experience, taken together with the large and growing body of clinical literature on PTSD, ought to be enough to finally dispel any lingering notions that PTSD is any less legitimate or serious than other battlefield wounds. A serious consideration should be given to revising the award criteria to make those with mental and psychological injuries caused by direct combat exposure eligible for the Purple Heart.
Granting the Purple Heart is just the first step in fully legitimizing and addressing PTSD. We also need systemic reform of the VA and a better system for providing the long-term clinical treatment that its casualties deserve. But awarding the medal in cases of PTSD will accomplish one essential goal: giving the respect and acknowledgement to those who are suffering from invisible wounds that we already bestow on those with scars we can see. By doing this, we would acknowledge that the anxiety, rage, depression, and disrupted emotional and social lives that veterans with PTSD experience are a result of war, and not some personal defect. By honoring them like we honor those scarred by bullets and IEDs we may be able to alleviate some of the shame and fear that have led so many to suicide.