Invisible wounds plaguing men and women in the military -- post-traumatic stress disorder, traumatic brain injury, suicidality -- can be difficult for civilians, and even military professionals, to understand.
One play, "Re-Entry," hopes to change that. Written by K.J. Sanchez and Emily Ackerman, the documentary theater piece is based on real people: active duty and retired Marines, and their families. Each struggle with the aftermaths of war. The names have been changed, but the dialogue comes directly from the 100-plus interviews conducted by the playwrights, both of whom have brothers who've served in the armed forces.
Originally intended not for military audiences, "Re-Entry" is now touring military bases and hospitals, educating civilians and service members on what to expect from family members and friends just returning from war. On Thursday, the Department of Veterans Affairs hosted a special performance for caregivers of wounded veterans in Washington, D.C.
"If you're going to do something, it's gotta come from [the heart], and it shouldn't be clinical all the time," said Michelle Stefanelli, VA's program manager of caregiver peer support mentoring, who saw "Re-Entry" when it played in the N.Y. area.
When it opened in 2009, The New York Times called the play "provocative and powerfully resonant."
"Re-Entry" reveals what it's like to be severely wounded in war and how it feels to be determined unfit for duty. Or what it's like to be sitting on a balcony back home in San Diego and subconsciously scanning for snipers. Eating in restaurants facing doorways to check if the enemy's entering. Burying the emotions of seeing an Iraqi mother holding her injured four-year-old son along the side of the road, begging for help that isn't going to come. Or being responsible for the lives of 40 men and women in Afghanistan and return home only to overhear people griping about their Starbucks orders or the latest reality show, unaware of your sacrifice.
Military wives who attended the conference said the play hit close to home.
Caregiver and founder of Familyofavet.com Brannan Vines recalled a scene in which an officer discusses rituals upon returning from a battle; his would be to wash his hands clean. Vines said she remembers having a similar discussion with her husband, an Operation Iraqi Freedom vet.
"Sometimes [the veterans] don't reach out because they don't feel like they deserve the help," Vines said. Or sometimes they feel guilty about asking for help, feeling as if they didn't see the worst of it, or weren't as badly injured as another, she added.
The military is racing to figure out how to tackle these invisible wounds, with an estimated average of 18 veteran suicides per day, according to the Center for Disease Control. In 2009, the services reported 381 suicides by active-duty personnel, and in 2010, the number jumped to 434, just 28 fewer deaths than those that occurred in hostile combat that year. Last year marked the sixth consecutive year the Army's suicide rate has increased.
Still, combat doesn't provide the full picture. A rising number of suicides are among reservists and National Guardsmen who have not deployed.
Last Saturday in Afghanistan, outgoing Joint Chiefs of Staff Adm. Michael Mullen told troops, "We have an extraordinarily high suicide rate right now.... There's an awful lot of work going on to try to get our arms around that. But we by no means have our arms around that."
"Can you get ahead of your buddy who's thinking about suicide?" he asked.
"This type of focus was not in existence after Vietnam," said Bill Outlaw, a director of communications for the Veterans Health Administration and a Vietnam War vet. "PTSD did not even get recognized as something that was really worked on by mental health professionals until the mid to late 1980s. The fact that this kind of powerful play [is out there], I think is incredible."
According to the VA's definition, PTSD is a condition resulting from exposure to direct or indirect threat of death, serious injury or a physical threat. Symptoms include recurrent thoughts of a traumatic event, reduced involvement in work or outside interests, emotional numbing, hyper-alertness, anxiety and irritability. Between 2002 and March 2011, 177,149 veterans received a provisional diagnosis of PTSD by the VA.
A traumatic brain injury (TBI) is any traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force, followed by symptoms such as memory loss, reduced motor skills or change in vision. Since April 2007, more than 97,000 post-9/11 veterans have screened positive for TBI. More than 40,000 have been diagnosed with having sustained a mild TBI.
With 23,000 more service members due home from Afghanistan by the end of this year, and more due home each year until 2014, these numbers may only increase.
"We're just at the start of this. We still have decades to go and if we don't figure out a way to deal with that, we're going to be in trouble," Vines said.
Yet at a time of Defense Department budget cuts, the costs of taking care of post-9/11 veterans will only skyrocket, according to a study published by Brown University in June.
"The history of previous wars shows that the cost of caring for war veterans rises for several decades and peaks 30 to 40 years or more after a conflict," the study states.
"This will be especially true for veterans of the current wars. Veterans from Iraq and Afghanistan are utilizing VA medical services and applying for disability benefits at much higher rates than in previous wars," notes the study.
"Although veterans' care comprises the fourth largest category of government spending, the magnitude of Iraq and Afghanistan veterans' costs is grossly understated in government projections. There is no provision set aside to cover these future obligations."
A federal class action settlement recently awarded lifetime health-care benefits to more than 1,000 disabled veterans discharged because of PTSD. Before now, PTSD did not qualify one for disability retirement benefits. And beginning just last month, full-time caregivers for wounded post-9/11 service members needing home care (usually family members) became eligible to receive compensation of up to $1,600 per month. The Caregivers program is estimated to cost between $140 million and $150 million this year.
"In 2000 ... [military] health care was about $19 billion," said Mullen. "This year it's $51 billion. In three or four years it's going to be $64 billion. That's not sustainable. We're going to have to figure out how to contain that."
Caregivers say the costs of ignoring invisible injuries such as PTSD and TBI is even greater.
"We have a model of what we did wrong after Vietnam. This is like turning the Titanic before the storm," said military wife and advocate Kristina Kaufmann, who has known at least three military wives who have committed suicide themselves due to the stresses of war. "It's pay now or pay later."
Dr. Kimberly RyAnne Noss, military wife of a severely wounded veteran, said the play hit home for her, too, especially the scene in which a military wife says she never cries in front of others -- always alone in the bathroom.
"Our civilian counterparts are finally getting it," Noss said. "They're finally getting what we're going through."
"Re-Entry" has been perfomed at the Walter Reed Army Medical Center; the Marine Corps Base in Quantico, Va.; and the Marine Corps Recruit Depot in Parris Island, S.C., where the command made attendance by its 750 Marines mandatory. In September, the play will run at Camp Lejeune, N.C. Sanchez says that will be the real test for the play, since Marines there have served the most deployments to Afghanistan. Sanchez herself is the youngest of 12 children, with five brothers who served in the military.
Sanchez says that so far, military audiences have been supportive -- "lots of huahs, hoots and hollers." The play has received standing ovations at all but one base. She said that although generals have attended the performances, the most important audience members were the service members who were dealing with the very things in the play. Sanchez said one retired Marine brought his family, because he couldn't directly discuss the issues with them.
"I always believed that theater could have a restorative role in society. I just never imagined it would be this literal," said Sanchez.
The play will return to the Washington, D.C. area in October, to the Roundhouse Theater in Bethesda.