by Michael Swanger

By day, he was the hunted. By night, he was the hunter. And the sights, sounds and smells of war-torn Iraq still permeate his senses.

As a first lieutenant in the United States Army's First Battalion, 41st Infantry, Derik Van Baale of Newton served during the first six months of the Iraq War in the most dangerous sections of Iraq, including Baghdad. He helped liberate cities, clear city blocks, conduct house-to-house searches and he fought in close-quarter combat. During the day he and his fellow soldiers acted as targets, drawing enemy fire to determine positions of Iraqi Army forces and insurgents so they could attack them by night. They called it "shaking the hornet's nest."

"You name it, I probably saw it over there," says the burly 29-year-old soldier with a clean-shaven head. "It was as frontline as frontline can get."

So, too, were the horrific psychological effects. A constant fear of death and rushes of adrenaline kept him awake nights and suppressed his appetite. The pungent smell of death stuck in his nose. Images of the dead and intense firefights, more cinematic than any Hollywood depiction of war, played over and over again in his mind. He even heard a friend die while talking to him on the radio when an RPG (rocket propelled grenade) struck his buddy's tank and blew off both his legs.

"It was scary as hell," Van Baale says. "It's the closest I came to ever wanting to see hell. It was absolute chaos."

While stationed in Kuwait for most of February 2003, awaiting orders from President Bush to invade Iraq, Van Baale says military commanders visited with troops about what to expect when it came to warfare. But nothing, he says, could have prepared him for an impending mental war.

Van Baale won't say whether he killed anyone. He doesn't want to talk about it. It's too painful, judging by the look in his eyes.

Like many veterans, Van Baale has struggled to adapt to civilian life. Upon his return home in July 2003, he befriended a small group of officers with whom he socialized exclusively, jumped from job to job, found it difficult to adjust to the slower pace of civilian life and drank himself to sleep each night. It was, as he says, "the normal thing to do." But the nightmares and daydreams got more intense and not even the voluminous amounts of booze he consumed each night could drive them away. He needed help.

A few months later, a Vietnam War veteran referred Van Baale to the local Veterans Affairs (VA) hospital, a move he credits for turning his life around. Like one in eight soldiers returning from service in Iraq, according to a new study, Van Baale was diagnosed with post-traumatic stress disorder (PTSD), as well as depression. He says he continues to have vivid nightmares and flashbacks, but now he's better equipped to handle them thanks to ongoing counseling.

"Some days are good, some days are bad," he says. "Now I have the tools and I can work through it on my own. But there are days, like Veteran's Day, where I don't want to deal with anybody."

When it comes to helping other vets, however, Van Baale never turns anyone away. Shortly after becoming a client at the VA hospital, he became an employee. Now he's a readjustment outreach technician at the Vet Center in Des Moines, where he talks to Iraq and Afghanistan veterans about their anger, pain and guilt and refers them to professional psychologists.

"I share with them my experiences and let them know it's OK to break down the walls and talk about their problems," he says. "I let them know that readjustment issues are normal, that they're not alone or different from anyone else. I tell them they are a victim of circumstance and that PTSD is a reaction to a traumatic incident and that if left untreated it's an appetite for destruction."

Studying war's effects

Three years ago this week, the United States and coalition forces launched Operation Iraqi Freedom (OIF). The largest military ground operation since the Vietnam War, it has dominated headlines and divided public and political opinion worldwide.

But for veterans of Iraq and Afghanistan, the Iraq War isn't something that's seen for a few minutes each night on television and forgotten by morning. The effects of exposure to combat are serious and prolonged, according to the most comprehensive study to date of the mental health of veterans conducted by the Walter Reed Army Institute of Research. The results were published March 1 by the Journal of the American Medical Association.

An evaluation of the military's Post-Deployment Health Assessment - a mandatory screening of more than 300,000 veterans returning from war in Iraq, Afghanistan and other areas between May 2003 and April 2004 - reveals that 79 percent of OIF veterans "reported witnessing persons being wounded or killed or engaging in direct combat during which they discharged their weapon." The study also shows that 35 percent of all OIF veterans accessed mental health services at least once in the year after returning home, and that one in eight OIF soldiers were diagnosed with PTSD or other mental illnesses like depression, substance abuse or functional impairment in social and employment settings, which led to increased use of healthcare services. If left untreated, experts say, those illnesses can lead to a number of problems including suicide, divorce, domestic abuse, unemployment and homelessness.

Because such studies weren't conducted for veterans of the Vietnam War, it's difficult to compare the mental health of two generations of soldiers. However, the number of OIF veterans diagnosed with PTSD and other mental illnesses is slightly higher than those who were diagnosed with PTSD during the Persian Gulf War, which was about 10 to 12 percent.

One expert says increased services and awareness of mental health issues may account for some of the spike in numbers, especially since two-thirds of Iraq and Afghanistan service members who sought care did so within the first two months of returning home. Still, he believes the problem is bigger than what the study shows, citing a recent report by the New England Journal of Medicine that found more than 60 percent of OIF veterans screened positive for PTSD, generalized anxiety or depression, yet did not seek treatment.

"I think these numbers are conservative," says Paul Rieckhoff, executive director and founder of Iraq and Afghanistan Veterans of America (IAVA), a non-profit support group based in New York. "I'm not sure we fully appreciate the scope of the problem."

Locally, the VA Central Iowa Health Care System says, through February, it had received 780 applications from military personnel for healthcare. During that period it treated or is scheduled to treat 574 eligible veterans and servicemen.

Pat Palmersheim, executive director of the Iowa Department of Veterans Affairs and a Vietnam War veteran, says the local VA lacks the necessary staffing levels to help veterans.

"They had no idea it was going to hit this hard with this many people," he says. "A lot of people don't realize PTSD is part of the cost of war and sometimes it can take up to two years to diagnose."

The problem, it would seem, is a national one. Rieckhoff says the government has mismanaged programs designed to assist veterans. President Bush recently asked for a 6 percent increase in the Department of Veterans Affairs budget, but Rieckhoff says it's too little, too late. His group is lobbying Congress to increase funding for mental health services.

"Those increases aren't proportional with the increase in demand," he says. "The system is not prepared for the flood of people and problems. They don't have the staff or the budget to handle it.

"Last spring, the head of the VA testified to Congress that the VA was able to treat 30,000 people comfortably, even when Congress pushed back and said they were hearing about long wait times. Then the VA found out it needed to care for 75,000 soldiers and asked Congress for $1.5 billion to keep the lights on, yet wasn't reprimanded. Every generation that comes home has to revamp the VA, but now we're seeing a nationwide disconnect by people who don't have any skin in the game."

Rieckhoff, who enlisted in the Army in 1998 and served a tour of duty in Iraq as a first lieutenant and platoon leader in the Third Infantry and First Armored divisions, is immersed in the cause. He says he witnessed soldiers under his command struggle with PTSD, depression, anger management and substance abuse. One soldier even shot himself in the leg to be discharged and another committed suicide.

"Either you pay now to treat PTSD or you pay later in the form of drug rehab, prison or homeless services," he says, "because mental health issues could be our generation's Agent Orange."

'Enduring Families'

If there's any truth to the adage "you hurt the ones you love," perhaps no one better understands that than the families of veterans returning home from war. Relatives often are on the frontline of mental illness recognition and bare the brunt of the disorderly behavior. And because Iowa National Guardsmen and Reservists have never been relied upon so heavily before as they are now in Iraq and Afghanistan, including multiple tours of duty, the likeliness of those soldiers incurring mental health problems is greater than ever.

To combat the problem, the Iowa National Guard created a mandatory readjustment workshop for soldiers entitled "Enduring Families." The program is also available to adult family members, including spouses, parents, adult children and significant others.

Following a soldier's "honeymoon period," about 90 days between their return home and their next drill, troops are required to attend the daylong event to help them cope with re-entry.

The program includes confidential debriefing sessions for soldiers (separate for enlisted and command staffs), spouses and parents. About 250 medical professionals from around the state who make up the Iowa Critical Incident Stress Management (CISM) team that is sponsored by Mercy Medical Center of North Iowa volunteer their time to conduct statewide sessions on weekends. They lead workshops on communication skills, stress management and parenting, as well as offer counseling sessions and make referrals for additional care when needed.

Though a few states have similar programs, none are entirely volunteer-driven as is Iowa's. The Guard reimburses volunteers for their expenses, but not their salaries. Often, volunteers spend more than 24 hours during the course of a weekend to counsel veterans and their families.

"The fact that this happens only in Iowa doesn't surprise me," says Pat Wilson, LISW, behavioral services, Mercy Medical Center and member of the CISM team. "People are willing to give their time and talent, and we feel we've made a significant difference because of it."

Becky Coady of Urbandale has seen the program's effectiveness first-hand. She helps coordinate its office and her husband, Mark, is a member of the Iowa National Guard's Homeland Security unit. He was deployed to Michigan last July for a yearlong assignment, where he trains members of the Afghanistan Army.

Coady says being separated from her husband of 14 years is difficult, especially since they have two children, ages 10 and 13. She stays in contact with him through e-mail, but credits the program for helping them cope with their separation anxiety and strengthening their relationship.

"It's fun and games for the first month when they return, then the issues and challenges come up," she says. "It's like starting all over again. My husband and I have had to re-learn how to talk to one another. As a result, we've grown a lot with our relationship, but there are others that don't go so well. If it was a bad relationship before deployment, the troubles don't go away."

Wilson says new habits can be more difficult for young, single soldiers to embrace. Often their civilian peers are still in their 20s and lead a casual, partying lifestyle that is in stark contrast to the structured setting they've become accustomed to overseas.

"Kids over there grow up real fast," she says. "They have a hard time relating to friends who are hanging out, drinking beer on weekends. They think their friends are juvenile and don't understand them."

When that occurs, Wilson says, a young soldier can feel isolated, angry or suicidal. To repress those feelings they sometimes turn to alcohol and drugs.

"If you see someone getting drunk every night or exploding with anger, those are symptoms," she says. "The hard part for us is to sort out what's normal behavior for 19- and 20-year-olds and what's not.

"Civilian life is real boring compared to what they've seen; it's not the same adrenaline rush, so they turn to alcohol and drugs. As a result, we see a lot of bar fights. They erupt if they don't get their way. I think more of that goes on than we realize."

Like young soldiers, children of veterans also suffer, which is why Enduring Families is working on developing a youth program. Depending on their age, deployment may or may not be an issue, Wilson says. The younger the child, the more likely they are to better handle the separation. But when pre-teen and teenage children assume roles in the absence of a parent and relinquish those roles upon their return, problems can arise.

"They act out when a parent returns because they perceive it as a step backwards," she says. "They feel their role has been displaced."

Creating new habits and re-establishing roles can sometimes be difficult for veterans who no longer feel comfortable in their old environments. Wilson says veterans sometimes experience flashbacks and nightmares that are so powerful they don't know where they are.

"Sometimes they'll wake up startled thinking they're in Iraq," she says. "I've heard from soldiers who drive down the road at 70 mph scanning rooftops worried about being ambushed."

Sometimes those problems carry over into the workplace, which is why Coady would like for Enduring Families to develop a program to help employers better learn how to work with veterans.

"I believe employers need to have more training on how to deal with soldiers," she says. "Some people can jump back in to work, others can't."

And because National Guardsmen and Reservists don't have access to the same support network as full-time soldiers and their families who live on military bases, Wilson says the need to help returning veterans is greater than ever.

"I remember guys coming back from Vietnam and not having help in dealing with PTSD," she says. "I think we learned a hard lesson after that when we saw the results of non-functioning men. These folks put their lives on the line for us. Even if you don't agree with the war, it's the ethical thing to do to take care of these soldiers and their families."

Spreading the word

It's a sunny Friday afternoon, but you wouldn't know it by looking at Van Baale's face. He's busy preparing for a conference on Monday in St. Louis where he plans to talk about the importance of assisting veterans with mental illnesses.

Van Baale, who is completing his master's degree in public administration, wants to secure a higher position with the VA that will allow him to continue to educate the public about the needs of veterans. Already, he visits with service groups and college students - anyone who will listen to what he has to say. And the need to tell others is great.

"I don't think the public has a grasp of what soldiers go through in combat," he says. "It gets swept under the rug. But they go through hell when they come home."

Rieckhoff, however, put it more bluntly.

"I hope it doesn't take a vet shooting from a bell tower to make us realize this is a problem." CV

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