Reaction to DoD Decision Against Awarding Purple Heart to Veterans with Combat PTSD

This week's news that the Purple Heart will not be considered for those coping with the psychological wounds of war has gotten a reaction from many quarters. The military decoration is awarded for "being wounded or killed in any action against an enemy of the United States or as a result of an act of any such enemy or opposing armed forces."

Through August 2008, 2,743 OEF and 33,923 OIF veterans have received the distinguished medal (of ~1.7 million given out since its modern inception in 1932; more Purple Heart history), which brings with it "enhanced benefits, including exemptions from co-payments for veterans hospital and outpatient care and gives them higher priority in scheduling appointments."

In extended, a selection of some of the debate on the matter. These are lengthy and multiple pieces, but are quite enlightening to read through if you have the time. The issue touches upon a slew of concerns dealing with our positions on tradition, progress, science, psychology, honor, equity -- all well worth examining.

In educational interest, article(s) quoted from extensively.

One irony pointed out in the debate over the modern definition of what a combat wound is or is not comes from a Florida mental health counselor, who points out that our present-day enemies are foremost using terror as a weapon against us.

Their attacks are intended to deliver wounds of fear.

Our political and military leaders, therefore, have termed this ideological struggle of our time The War on Terror[ism], finding that descriptor to be the most appropriate for the current generation of war -- an ideological battle to end all battles.

It's quite an interesting insight when considering this debate, since the DoD has ruled that these wounds (the very wounds that our campaigns in the Middle East are named after) don't qualify for the Purple Heart. Interesting paradox, no?

Of course, fear itself does not bleed visibly.

Fear is something felt and experienced in the mind (and the body responds, as well to this emotion). If we know nothing else about traumatic stress, we know that fear borne of terror is the lead quantifiable and diagnosable cause of PTSD.

The first element of PTSD, as defined in the DSM-IV:

309.81 DSM-IV Criteria for Posttraumatic Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following have been present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear, helplessness, or horror.

Terror definitions:

1. Intense, overpowering fear.
2. One that instills intense fear: a rabid dog that became the terror of the neighborhood.
3. The ability to instill intense fear: the terror of jackboots pounding down the street.
4. Violence committed or threatened by a group to intimidate or coerce a population, as for military or political purposes.

From Pauline Jelinek of AP:

The Pentagon on Thursday sought to assure troops that it takes post-traumatic stress seriously despite the recent decision not to award the Purple Heart to those with the disorder.

An advisory committee concluded that troops coming home from the wars with combat stress cases collectively known as post-traumatic stress disorder will not qualify for the prestigious medal awarded to service members wounded in action. ...

The Pentagon decided in November that troops with the disorder cannot be awarded the Purple Heart, but the decision was not known until it appeared Monday on the Web site of Stars and Stripes newspaper.

"The Purple Heart recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member," Defense Department Eileen Lainez said of the decision. "PTSD is an anxiety disorder caused by witnessing or experiencing a traumatic event." It is not "a wound intentionally caused by the enemy from an outside force or agent," but is a secondary effect caused by witnessing or experiencing a traumatic event.

Jeff Schogol for Stars and Stripes:

The matter came up in May, when a military psychologist at Fort Bliss, Texas, told reporters he felt that making troops suffering from PTSD eligible for the Purple Heart would help remove the disorder’s stigma.

"These guys have paid at least a high — as high a price, some of them — as anybody with a traumatic brain injury, as anybody with shrapnel wound, and what it does is it says this is the wound that isn’t worthy, and I say it is," John E. Fortunato said in May.

When a reporter asked Defense Secretary Robert Gates about Fortunato’s comments, Gates said the matter was "clearly something that needs to be looked at," prompting a review by the Defense Department’s Awards Advisory Group.

Based on the group’s findings, Dr. David Chu, undersecretary of personnel and readiness, has decided that PTSD does not meet the requirements for the Purple Heart, Lainez said on Monday. ...

The Military Order of the Purple Heart, a veterans group, responded [when the question was first raised] by saying the Purple Heart should only be awarded to troops who shed blood.

"I don’t think people should get the Purple Heart for almost getting wounded," said Joe Palagyi, the group’s national adjutant.

Many Stripes readers also opposed the idea.

"Every badge hunter and his brother will have this distinguished award in their sights," Army Capt. Matthew Nichols wrote in a May letter to the editor.

But Edward Stump, who said he served in Vietnam with the Marines from 1966 to 1967, wrote that the psychological wounds are just as real as physical ones.

"My wounds do not bleed but they have as many scars as a lot of other wounds," Stump wrote. "These wounds will never heal anymore than the scars, from any that are from combat-related fighting, will disappear."

CBS News segment from June 2008 regarding the issue of possibly awarding Purple Hearts to veterans with PTSD:

Lizette Alvarez and Erik Eckholm, New York Times:

For some soldiers suffering from the disorder, the historical distinction between blood and no blood in an injury fails to recognize the depths of their mental scars. A modern war — one fought without safe havens and with the benefit of improved armor — calls for a new definition of injuries, some veterans say.

Kevin Owsley, 47, who served in the Ohio National Guard in 2004 as a gunner on a Humvee and who is being treated for PTSD and traumatic brain injury, said he disagreed with the Pentagon’s ruling.

Unable to hold a job, Mr. Owsley supports his family on disability payments. This week he told his Veterans Affairs doctor he was fighting back suicidal impulses, something he has struggled with since his return. “You relive it every night and every day,” he said. “You dream about it. You can see it, taste it, see people getting killed constantly over and over.”

“It is a soldier’s injury,” he said, angrily, in a telephone interview on Wednesday.

But many soldiers do not feel that way. In online debates and interviews they expressed concern that the Purple Heart would be awarded to soldiers who faked symptoms to avoid combat or receive a higher disability rating from the Department of Veterans Affairs.

“I’m glad they finally got something right,” said Jeremy Rausch, an Army staff sergeant who saw some of the Iraq War’s fiercest fighting in Adhamiya in 2006 and 2007. “PTSD can be serious, but there is absolutely no way to prove that someone truly is suffering from it or faking it.” ...

Dr. Barbara V. Romberg, a psychologist in Bethesda, Md., and founder of Give an Hour, which offers mental health services to troops and their families, said that she and many other psychologists believed the discussion of Purple Hearts had brought more attention to post-traumatic stress disorder and the seriousness of psychological wounds suffered on the battlefield.

“We’re working to normalize post-traumatic stress as an understandable human consequence of war that can result in very serious damage to some people’s lives, and they deserve honoring for that,” she said. “But I don’t want to be so quick to condemn the decision,” she added.

Many have post-traumatic stress, but only some develop a serious lasting disorder; in both cases, she said, “people deserve to be honored in some way for the injury they received in combat.”

After years of criticism for ignoring the problem, the Defense Department and the Veterans Administration have bolstered their capacity to diagnose and treat PTSD, and those with serious cases may receive substantial disability benefits. Some of those suffering from severe traumatic brain injuries qualify for a Purple Heart because they required medical treatment.

Clincial psychologist Elvira G. Aletta, Ph.D., Psych Central:

This is an interesting decision on many levels. My first reaction was: How typical. Go ahead and ignore all the research and data collected by psychologists, neuropsychologists and psychiatrists the world over to define and develop diagnostic and treatment protocols for this horrible condition. ...

The Times article, placed on the front page above the fold, was uncharacteristically lacking in good reporting. I’d like to learn more about who was on the panel. What experts did they talk to and what are they really afraid of? Was it a hard decision to come to or a ‘non-starter’? The reporters did not have one well-qualified behavioral health specialist speak in favor of awarding the Purple Heart to PTSD victims. How about someone from the National Institute of Mental Health? Was no one willing to go on the record? This seems strange to me. Also the NYT reporters had a layman, someone clearly against such a measure, stating, “PTSD can be serious but there is absolutely no way to prove that someone truly is suffering from it or faking it.”

Really? What makes him qualified to make such a statement? How about a rebuttal?

Addressing the issue of mental health stigma is something that the government has only recently, maybe the last ten years, had the guts to face. Congress took forever but finally came around to passing legislation that advanced third party payer parity for mental health diagnostics and treatments. As a public service this action brought the issue of how mental health is seen and treated to the public. Stigma is all over this Purple Heart decision as illustrated in the position the Military Order of the Purple Heart takes. They are “strongly opposed to expanding the definition to include psychological symptoms, saying it would “debase” the honor.”

That’s what it is all about: the age-old mental illness fear and stigma. All other arguments are excuses for not giving wounded soldiers their due. My opinion.

Here’s an example. Take this argument also from the Military Order of the Purple Heart : Q: “Would you award it to anyone who suffered the effects of chemicals or for other diseases and illnesses?” A: Sure! If it was a result of combat. Q: “How far do you want to take it?” A: As far as we need to to honor our veterans who put themselves in harm’s way for their country.

Living in the 21st century means having the strength to live with ambiguity. Are we going to be inclusive or exclusive? Isolationist or communal? Back in the ’90s the acceptance of gays in the military was a reflection of American society’s struggle as a whole. This PTSD and the Purple Heart thing feels similar. Some day it will be acknowledged that the nature of war and our understanding of its impact has changed radically since the Purple Heart was commissioned in the 1930s.

The people in favor of exclusivity say you have to shed blood to get a Purple Heart. What about conditions like traumatic closed head brain injury? No bloodshed there. Sometimes the injury doesn’t even show on a CAT scan. Our diagnostics haven’t yet caught up with what we know and are on the verge of proving. Why deprive our soldiers of this deserved honor because of our ignorance? PTSD and major depression can also be fatal diseases if untreated. In other words, you can die from PTSD, through suicide, alcoholism or related illness. Not enough?

It’s hard for me not to have a kneejerk reaction to this decision. I’ve treated my share of PTSD cases, combat veterans and civilians. My patients were not faking their symptoms. If I had a doubt I referred them to a well-established expert who provided the testing and diagnostics needed for a conclusive diagnosis.

So the bad news is the Pentagon, a bastion of conservatism after all, decided against giving the Purple Heart to soldiers wounded with PTSD.

The good news is they even considered it.

George Harris, Kansas City Star Reader Advisory Panel:

The general public has long stigmatized people with mental illness. In pre-scientific times, mental illness was believed to result from demons, and in modern times some people still believe that people could control mental illness with more desire and self-control.

But severe mental illness, such as PTSD, is accompanied by actual physical changes in the brain. Brain imaging techniques are improving and revealing areas of the brain that show abnormal activity in these disorders.

Psychological tests can also quantify the severity of PTSD and detect malingering, though no test is perfect in either regard. [Ed. note: it wasn't so long ago, three years to be exact, when the malingering charge was being hurled at some of our veteranas suffering with TBI] ...One problem with identifying PTSD is that its causes can be cumulative. That is, multiple exposures to trauma can ultimately cause the disorder. Another complication is that PTSD can have delayed onset, sometimes decades later as has been seen in Vietnam veterans.

Police officers also often experience cumulative and delayed onset PTSD, and this complicates their disability compensation determinations. But because an illness is complicated is not a justification for denying recognition of it.

For both soldiers and police officers, the standards for medals and disability awards should be updated to include these very real and serious psychiatric injuries. Though they may be difficult to rate, the disorders are a result of service to the nation and community, and it is a slap in the face of these men and women with PTSD to imply that their sacrifices are unworthy.

Opinion piece, Sarasota Herald Tribune:

The Pentagon has decided that the disabled and damaged young people who return from war with post-traumatic stress disorder should not get the Purple Heart, which recognizes the sacrifice that soldiers have made. The Pentagon says this is because the wound is not physical and because the damage was not caused intentionally by the enemy.

Those who say this live in unbelievable ignorance. They need a higher awareness of the nature of warfare today, and a better knowledge of medical science.

Today the weapon of our enemy is "terror," and we have identified our enemies, the "terrorists," not by nation, but by their chief weapon of destruction and the damage it causes. PTSD is a result of contact with not only the enemy's terror, but with the bullets and bombs used to create it. PTSD is a tormenting, disabling condition, caused by direct contact with violent trauma. The enemies' destruction of us is certainly intentional, and the reality of our troops' psychological wounding is not up for debate. ...

William Anderson
Licensed mental health counselor
Sarasota

Stephen Ducat at Huffington Post:

Lesson One: The mind is a property of the brain.

Lesson Two: The brain is located in the body.

Lesson Three: The hippocampus, a part of the brain responsible for our ability to have a conscious history, is one of the neurological casualties of traumatic experiences It is damaged to the point of shrinking when saturated with a toxic flood of stress hormones. This not only leads to impaired memory. It also prevents the hippocampus from putting the brakes on the hair-trigger emotional responses of one of the brain's more primitive structures, the amygdala.

Lesson Four: Traumatic stress is often the result when soldiers are required to risk mutilation or death, to inflict it on others, or witness the maiming or annihilation of friends and comrades.

Lesson Five: Trauma sufficient to cause PTSD is no less physical than a bullet to the head.

Homework: Discard Rene Descartes' disembodied mind. Reread Gray's Anatomy.

Extra Credit: Read The Brain and the Inner World by Mark Solms and Oliver Turnbull, and take it seriously enough to ground your policies in science.

Bill Campbell, [Monroe, La.] News-Star:

That the decision left hundreds of PTSD-suffering Louisiana war veterans with no medal recognizing their agony did not seem to upset the veterans. They tend to have larger issues.

"We've been toting this burden around for 40 years," said R.L. Smith of Monroe.

On a random weekday afternoon some 40 years after their return from Vietnam, these men tell harrowing stories of brutal killings committed as teenagers and the trauma that the memories still cause. They share the frustration that no one outside their circle is listening or could understand if they did.

At Dr. Mitchell Young's clinic on Evangeline Street in Monroe, a different PTSD support group for veterans meets every day of the week. They come from all over the region — hundreds of men who would normally avoid a social setting even among their own families because people and noise make them uneasy.

They come to bond. But they also come to heal.

"I was a squad leader when I was 20 years old," Estep said. "I was the oldest person in my squad. I had two 17-year-old kids who had to have letters signed by their parents just to join the military. One cried himself to sleep every night. What training did I have to deal with him, to help him?"

No one has answers, but everyone in the room can relate to the question.

Again and again, stories of horror are told and are greeted not by disbelief but knowing nods. PTSD might not be sufficient injury for a Purple Heart, but Vietnam vets the first warriors diagnosed with the condition say they would gladly accept almost any physical ailment as a replacement.

"I couldn't keep a job. I've had five DWIs. I slept under a bridge," said Eddie Jackson, of Monroe, who is on 100 percent disability for the disorder. "They trained us to not get killed. But they never talked about the realities. I wish I had lost an arm or leg. I wish people knew, with PTSD, it seems like as you get older, it gets worse."

"They told us we could lose a limb or even die," Estep said. "They didn't tell us we could lose our identity."

"We lost our soul," Byrd said. ...

These days, the support groups are dotted with young men, recent veterans of war in Afghanistan and Iraq. The Vietnam vets invest in them, and hope their struggle will not become the struggle of the next generation of soldiers.

"We hope that 40 years from now, these Iraq and Afghanistan vets aren't dealing with this," Estep said. "I hope they can find some peace."

Stephanie Salter, [Terre-Haute, Ind.] Star-Tribune:

Unlike a shattered limb or ruptured artery, PTSD takes time and expertise to accurately diagnose. And as opponents to its inclusion for Purple Heart qualification status argued, it also can be faked — for a time.

The Purple Heart medal has roots in the Revolutionary War. Since its official creation in 1932, some criteria for the award have been altered and expanded, but the fundamental requirement has never changed. As a May 8, 2008, news release from the Military Order of the Purple Heart declared:

“The memories of far-off battles … are steeped in the blood of Patriots and sends [sic] a resounding pledge that the Purple Heart Medal shall be for those who have shed their blood.”

No blood, no Purple Heart.

Those who carry the internal wounds of PTSD — and the medical professionals who treat them — are all too aware that real blood sometimes is shed because of the disorder. Tragically, that blood comes months or even years after the battlefield from self-inflicted gunshots or sliced wrists, when a combat veteran can no longer survive the emotional and psychological holes inside. ...

(Post-traumatic stress is common among men and women in combat situations but usually subsides. Post-traumatic stress disorder, which affects fewer troops, is a lasting and severe condition that can include nightmares, crippling anxiety, vivid flashbacks, acute depression and suicidal or violent tendencies.) ...

The process pitted vet against vet with groups such as the Military Order of the Purple Heart Medal virtually transforming some of their fellow combat veterans into enemies. In the May 2008 news release, the group’s national service director, Jack Leonard, was quoted: “We must withstand courageously any attempt at downgrading our most prized Purple Heart Medal.” ...

Thanks largely to mental health care activists, veterans and their families, the U.S. military has come a long way in a relatively short time with regard to post-traumatic stress disorder. As knowledge and understanding increase, it seems reasonable to imagine an appropriate medal — not too far in the future — that recognizes the pain and sacrifice of men and women who suffer PTSD in the service of their country.

Blood or no blood, there is honor in their wounds.

Coleman Swierc, KTRE-Channel 9 [Lufkin, Texas] ABC:

"It brings back a lot of bad memories," recalled Purple Heart reciepient Jerry Whiteker. ... "I do feel that there is a mental side to that, and that the regulations should be changed," says retired Army veteran Bennie Moye. Moye served in Korea and Vietnam, and he says the decision is wrong, believing that not only do injuries hurt the body, but also the mind.

"There is a mental side to it, and i do feel that there are a lot of guys who are broken down mentally because of that."

"You dog gone right, (they deserve the honor) that is exactly how I feel."

Jerry Whiteker was awarded a Purple Heart, after being wounded in combat, his thoughts are with those who were mentally scarred.

"I don't think it takes away from their service at all, but [I] think in certain instances that they need to be compenstated." Whiteker continued, "I do not think that it should be limited, I really don't. I know that those injuries exist, they are out there."

Not not everyone shares that opinion, some military vets agree with the decision. The Purple Heart should be for the physically injured.

"People are upset, but the Army made the right decision," said retired veteran Harry Conway. "If you bring in Post Traumatic Stress and other things into it, then you are taking away from what the medal was designed for," Conway stated, "it should be for wounds, if you are shot or hit by shrapnel, that is what the purple heart is for, that you physically bleed."

Justine Judge, [Springfield, Mass.] CBS Channel 3:

For Kevin, Joyce and Debbie Lucey the recent news from the Pentagon is disappointing. On June 22, 2004, their son, 23-year-old Jeffrey Lucey, a former Marine, hung himself after returning from Iraq a year earlier. Kevin Lucey said, "If anybody even questions how lethal or how damaging PTSD can be and whether it's real we would invite them to go down to our son's grave."

The Lucey's say they know first had that not enough is being done to help Veterans suffering from PTSD and denying them recognition is another step in the wrong direction. Debbie Lucey said, "It's reinforcing a stigma that is that is already set that so many veterans and their families are trying to overcome."

Traditionally the medal has been awarded to men and women who have given blood in defense of their homeland and not those who have suffered mental disorders. The Lucey's say their son paid the ultimate price and in the end his blood was shed.

Kevin Lucey said, "Unless you see blood then it's not really a wound, well I can tell you the day that I found our son Jeff was bloody, on his arm and down his shoulders."

Defense Secretary Robert gates says they may revisit the decision. Either way the Lucy's say the fact that it's even an issue has already disappointed many veterans and their families.

Kevin Lucey Said, "If they don't want to give the purple heart, fine, but then shouldn't there be something for the sacrifice that they gave, couldn't there be another type of recognition that could be given."

KLTV Channel 7 [Tyler, Texas] ABC:

"It would be like anyone in theatre was given a Bronze Star or Silver Star for being in theatre, it would diminish what those mean to the heros of the past," said Eric Cook, a U.S. Army Desert Storm veteran and Purple Heart winner. "As a battlefield commander, how could I have expressed to the family of a son or daughter that lost limbs and someone standing their without any physical harm to them at all and awarding them the same award."

William Terry was literally blown off the USS Reid during the air attack on Pearl Harbor December 1941. He lost 103 of his shipmates that day.

"We had 2 kamikazes hit our ship simultaneously and it sank within 2 minutes," said William Terry a U.S. Navy WWII veteran and Purple Heart winner. "I don't believe they should, I can sympathize with the people that have the syndrome. I think it would diminish it. You can have that syndrome and never be in a battle."

Eric Cook was awarded the Purple Heart for action in Desert Storm and says there can be no mistake of who should get the award.

"It's what the medals about, it's about those that are wounded during combat," said Cook. "Awarding medals to people with stress disorders I think really diminishes especially our forefathers people that fought in the great wars."

Some veterans believe as war has changed, so too should our definition of what a wound is.

"Active duty military is stretched very very thin they spend more time in combat theater than ever in our history and exposed to more stress than ever before," said Amos Snow who was in the U.S. Navy from 1981 to 1989. "With post traumatic stress syndrome it might show up for years andI think it does a dis-service to those who are defending our nation that , that is not a recognized combat related wound."

Stephanie Slepian, Staten Island Advance:

It's a decision charged with emotion -- one that has left some of the borough's Purple Heart recipients torn between how to separate the physical scars from the emotional ones, which many times run just as deep. No matter their opinion, however, all agree on one thing: Veterans new and old suffering from PTSD deserve the same benefits and medical care afforded to all injured soldiers.

Joseph Di Giovanni, commander of the Military Order of the Purple Heart, Father Capodanno Chapter, who lost a finger and took shrapnel in the eyes and chest during an ambush in Vietnam, believes the Pentagon should rethink its decision.

"Anybody who served in combat knows it's a tragic thing," said the Great Kills resident. "It just lingers on afterward. It could be a smell, a sight, the sound of a firecracker. It brings you back in an instant."

He just wants to ensure the PTSD has been verified by appropriate medical professionals before the honor is bestowed. William Liell, a Korean War veteran and adjutant for the Capodanno Chapter, shares that view.

"I disapprove of [the Pentagon's] decision," said the South Beach resident. "Anybody who comes back with credited PTSD deserves [the Purple Heart]." ... "There are people who come back without cuts and bruises, but anyone who sees vehicles getting bombed or their friends killed is going to be shaken up," he said.

Every day, Chris DeLisa witnesses the damage, both physical and mental, that the wars in Iraq and Afghanistan have inflicted on today's soldiers as she helps them readjust to civilian life in the Staten Island Supports Our Soldiers Resource Center in Sea View. Mrs. DeLisa, whose son served in Iraq, believes the Pentagon should "re-educate themselves and change the qualifications of the award." ...

When Bob Tamburri visits his father's Bulls Head home, he often pauses to look at the two Purple Hearts hanging from the wall. One belongs to his dad, John Tamburri Sr., wounded on the island of Peleliu during World War II; the other to his brother, John Jr., killed in Vietnam in 1970 at age 19.

"It's a hard call to make," said Tamburri, a Marine who is the commander of AmVets Post 917, which bears his brother's name. "I certainly agree that mental suffering is a wound just as much as a physical wound."

"It's a double-edged sword," said the Eltingville resident and Marine who lost his right leg when a mortar round landed in his foxhole in Vietnam. "There are probably some people who deserve it, but how do you make that determination?

"Until [the Pentagon] comes up with a concrete way of making that determination, it should be reserved for those who shed blood on the battlefield. I recognize the stress and the trauma and they should get everything as far as benefits go, but the actual award?"

Anyone who has served in a combat zone will suffer PTSD on some level at some point in their lives, he said.

Marc Charisse, [Hanover, Pa.] Evening Sun:

I had what I must admit was a singularly undistinguished military career. About the most noteworthy thing you can say about it is that I happened to enlist in the United States Army Nov. 11, 1975. In addition to being Veterans Day, it was also the last few weeks of the last year of what the Veterans Administration officially terms the Vietnam era, so technically I am a "Vietnam-era veteran" with a scar on my shoulder to prove it. ...

The truth is that although I was a squad leader in basic training, a shoulder injury cut my military career short; I ended up spending just two years in the Army, most of it painting barracks or pulling guard duty, all of it as a private far from harm's way. ...

Still, having spent much of my life reading up on military matters, I'll always respect the men and women who willingly and ably serve their country. Their service often comes at great cost. That's why I'm sorry about the Pentagon's decision last week not to award the Purple Heart to soldiers suffering from post-traumatic stress disorder. ...

No doubt, there is legitimate concern among some soldiers that some malingerers might find themselves with a medal. But everything I've read on the combat experiences of real soldiers suggests the Pentagon's decision is half right and half wrong - and likely to be completely misunderstood by many. ...

In his profound study of the psychological effects of combat, "On Killing," Army psychiatrist Lt. Col. David Grossman writes, "Post-traumatic stress disorder has always been with us, but the long delay time and erratic nature of its occurrence has made us like the ancient Celts who do not understand the link between sex and pregnancy."

Grossman writes that PTSD is an inevitable result of the carnage of combat because, he believes, soldiers must overcome a natural psychological barrier humans have against killing their own species. He cites an authoritative World War II study that determined 98 percent of all soldiers would become psychological casualties after 60 days of continuous combat. And a 1988 study of Vietnam veterans indicated the victims of PTSD were "almost solely veterans who participated in high-intensity combat situations."

Real soldiers I've talked to know the vast majority of psychological casualties aren't cowards or malingerers, and armies have long understood that combat wounds the psyche as well as the body. In fact, the purpose of long-range bombing and artillery barrages is as much to produce psychological casualties as to inflict material damage.

So it's hard to fathom how psychological wounds are any less real than physical ones. Or that these casualties are somehow less deserving of our honor than those hurt by enemy lead. A significant contributor to PTSD in soldiers is the guilt they carry over killing, Grossman writes. That's why civilian acceptance and honor when they come home is so important to those soldiers' recovery.

Medals don't mean much, but maybe those Purple Hearts would remind us of the real cost of war, and to honor those who must pay it for us.

Obviously, all combat wounds deserve to be considered and treated with equal respect and dignity and care of the highest quality and order. It's appropriate and good to honor those whose bodies have bled for our nation, but we also have to equally honor those whose hearts bleed from war-pierced wounds of the mind and soul.

Providing the best, easy-to-access care should be a given. Often it is not. Taking care of and showing concern for our military families may be the most tangible way to honor those we've sent to war.

Ribbon or no ribbon.

[UPDATE Jan. 11, 2009]: I've been adding to this post throughout the day and, through handling the material, have found the issue to be a touchstone, a marker of so many things that we grapple with when it comes to the micro issue of PTSD and the macro issue of war in general.

Tyler Boudreau, a 12-year Marine Corps Infantry veteran who served in Iraq, wrote a stunning account

(Packing Inferno: The Unmaking of a Marine) of the external and internal experience of combat when he returned home. It far surpasses most other books of its kind. In it, he speaks presciently in a section of the book subtitled simply, "Purple Heart."

I hope he will allow me to quote the section in full, for it touches on many elements that make this debate so tense:

Purple Heart

Crossing over to war, or crossing back -- I'm not sure which was more thrilling. To make that plane ride home is to have overcome war. It is to have made it through alive. And for that you get the solemn distinction, the enviable title of "combat veteran." There are men who seek the Combat Action Ribbon (CAR) more fervently than any other personal decoration.

It's true, because it means you've been in the shit -- at least that's what it's supposed to mean. The intent we clear enough. A Marine was supposed to have been in a fight, a direct fire fight, with bullets whizzing by, some guys getting shot at, and others shooting back. But then people started scratching their heads as Marines were getting shelled and IED'd, day in and out, without ever having fired their rifles. Could you really tell them they weren't in combat? A guy could have his legs blown off from an IED, but no Combat Action Ribbon. It didn't seem right.

Suddenly the meticulous criteria for a CAR became hazy. Suddenly it was a matter of dispute. So they loosened the regs. And then they loosened them a little more. The next thing we knew, CARs were getting doled out to anybody with the loosest affiliation to combat. To us grunts, that didn't seem right either. Purple Hearts, as a result, took on an interesting new importance. It let people know that you were in a real fight, a fight close enough to feel the heat, close enough to catch some lead. But then the credibility of the Purple Hearts started taking hits too.

There was a corpsman -- a medic -- in my company who was hit in the face with a piece of shrapnel from an IED. But not to worry, it was no bigger than a staple. He didn't even realize he'd been hit. I had to point it out to him. He pulled the tiny piece of steel out of his cheek, tossed it in the trash, and went back to his work. For that, they gave him a Purple Heart.

I remember saying to the Colonel, "What's up with that?"

And the Colonel said, "You know something? A combat wound is a combat wound, no matter how small. So he gets the medal."

Ironically, at the very same time the '04 Presidential elections were in progress. I remember watching Bob Dole on television commenting that John Kerry was a fraud because Kerry's Purple Hearts weren't for any real wounds -- not the life-threatening wounds that Dole had suffered. Then, at the Republican convention, to further ridicule Kerry, they handed out little purple band-aids and called them "Purple Owies."

As I watched all this unfolding from Iraq, I couldn't help but wonder if these people would have the audacity to put a picture up on the screen of our corpsman -- serving in Iraq -- and, in front of America, call him a fraud. I suspected not. But of course you can't have it both ways. Either both men were frauds, or neither of them were.

It was all politics and cheap shots. I knew that. But at the same time I think it was more. Those cheap shots came at a price. Suddenly people were cornered into having to decide which wounded were worth caring for, and which were not. Suddenly every veteran with a Purple Heart was judged by his or her wounds, instead of being unhesitatingly treated for them. What I learned in Iraq from my own reaction and from the reaction I witnessed on television is that the act of privileging one wound over another, the mere distinction, creates a fissure in the consciousness, through which our humanity begins to slip away. That was the price we paid for those cheap shots. They were not so cheap. I think. ...

They said a combat wound is a combat wound, no matter how small, and that every last one rates the Purple Heart. Yet never once has a veteran been awarded the Purple Heart for combat stress. Never once. Perhaps the small token of recognition might have prevented a few of them from taking their own lives. Only through genuine acknowledgment that combat stress is an injury, not a disorder, can we ever give uninhibited affection to the wounded.