Mind Field: PTSD & the Military

Can the Armed Forces afford to accurately diagnose soldiers--and their families--with psychological issues stemming from war?

Nature calls, even in a war zone. And so, in April 2008, when John Byron Etterlee was stationed at an American military base in Baghdad, working the night shift at an Army tactical operations center, he carried his rifle as he stepped outside to use the outhouse. Suddenly, just as he began to relieve himself, he heard an ominous buzz in the sky above.

Etterlee, a stout Georgia native with a blond crew cut and thick spectacles, hustled out of the portable toilet and gazed up into the darkness. The buzz sounded like a small airplane approaching, but Etterlee, already midway through his second tour of duty in Iraq, realized the white streak tearing through the night was an incoming rocket.

“For a split second I thought, ‘Oh my God, am I going to die?’ ” the 35-year-old soldier recalls matter-of-factly in his slow Southern cadence. “I thought it was coming toward me. Fifteen seconds later I heard a loud explosion that shook the buildings. The rocket hit maybe 50 yards outside the gate.”

Nobody was injured in the attack, and Etterlee’s desert outpost incurred no serious damage. In hindsight, he says, it was just another close call during a span when he and his unit became accustomed to mortar fire, IED detonations, and other random explosions. But for some reason, perhaps because of the embarrassing circumstances, this particular brush with death has stuck with him. “I almost pissed in my pants,” Etterlee says with a halfhearted chuckle. “It wasn’t funny when it happened, but it’s kinda funny now.”

A chemical-weapons specialist tasked mainly with keeping records and maintaining equipment, Etterlee had limited combat experience during his time in Iraq. Nevertheless, his vehicle was once nearly struck by a roadside bomb, and one of his closest friends was killed in action in a separate incident. When he returned home to Joint Base Lewis-McChord (JBLM) in late 2008, the chemical weapons specialist was clearly rattled. His wife forced him to spend nights on the couch because he punched, kicked, and thrashed in his sleep. He was prone to outbursts of anger. He tried to avoid conversations about the war, and, when co-workers inevitably swapped battle stories, his heart pounded and his mind raced.

He says he tried to seek help, but to no avail. “I went to chaplains more times than I can count,” Etterlee says. “I went to my chain of command, and basically got the runaround. Nobody put me on any kind of formal treatment program.”

On top of his mental issues, Etterlee was struggling financially. He and his wife divorced. And then, during a training exercise at Fort Lewis, he suffered herniated discs in his back while dragging a fellow soldier in a simulated rescue situation. Despite the painful back injury, he was briefly redeployed to the Middle East. Back at the base again in 2010, Etterlee was at the end of his rope.

Finally, on July 15, 2011, a Veterans Affairs (VA) psychiatrist interviewed Etterlee and diagnosed him with Post-Traumatic Stress Disorder (PTSD). But five months later the diagnosis was abruptly changed to “adjustment disorder”—a lesser condition—by a forensic psychiatrist at Madigan Army Medical Center in Tacoma. The switch was made even though the clinician merely reviewed paperwork and never spoke with Etterlee or met him face-to-face. Only later did Etterlee learn that he was one of several hundred Fort Lewis soldiers who’d had their PTSD diagnoses downgraded by Madigan doctors.

A controversy erupted after several servicemen stationed at JBLM complained about the PTSD screening team—the only one of its kind in the military—at Madigan that overturned their original diagnoses. Internal memos emerged revealing that the military psychiatrists had been told by higher-ups to consider the long-term cost of a PTSD diagnosis, which qualifies a soldier for a lifetime of increased disability payments. In some cases, the memos noted, the total taxpayer burden could be as much as $1.5 million for a single soldier over the course of his or her lifetime.

“By downgrading me to adjustment disorder,” Etterlee came to realize, “they’re eliminating the medical retirement [benefits] and compensation. I was pretty angry.”

Both the Madigan commander, Col. Dallas Homas, and the leader of the forensic psychiatry team were relieved of their duties earlier this year, and an investigation into the PTSD diagnosis reversals is ongoing. Army leaders ordered a system-wide review of their behavioral health-care practices, and announced last week that they would end the use of forensic psychiatry for disability evaluations. Col. Homas was reinstated as commander of the hospital. 

Partly in response to the spate of suicides and war atrocities committed by soldiers stationed at JBLM that led Stars and Stripes to brand JBLM “the most troubled base in the military,” Washington Senator Patty Murray has introduced legislation that would overhaul the military’s PTSD assessment processes and significantly expand eligibility for government-funded mental-health counseling to include soldiers’ immediate family members.

Both the Madigan scandal and Murray’s proposal point to a dramatic shift in the way the armed forces, and the country as a whole, perceive and treat the invisible wounds of war. Even relatively routine war experiences, such as Etterlee’s ill-timed encounter with an Iraqi rocket, are gaining recognition as life-altering events with long-lasting psychological repercussions.

According to the National Alliance on Mental Illness (NAMI), mental-health disorders now affect one in five active-duty service members, and are the most common cause of hospitalization. Even so, Army Surgeon General Lt. Gen. Patricia D. Horoho acknowledged in April that PTSD and related anxiety disorders might actually be underdiagnosed, particularly among the spouses, children, and parents of troops. “We’ve learned over this 10-year conflict that we just can’t treat our warriors,” Horoho told the Senate. “We absolutely have to treat the family, because it impacts both.”

These days, Americans don’t need to witness or participate in the carnage of war to experience post-traumatic stress. The strain that comes with being deployed or having a loved one on the front lines can cause “secondary PTSD,” a little-known, vaguely defined condition something like the mental-health equivalent of secondhand smoke. The symptoms are similar to those of regular PTSD, but the triggers are indirect. Combined with depression, anxiety, and other mental issues alarmingly prevalent in servicemen and their spouses and children, the emerging issue of secondary PTSD raises a critical question: Can an already-inundated system designed to care for ailing soldiers also handle their entire families?


On April 30, an Army nurse in Afghanistan was in the middle of a Skype video chat with his wife in El Paso, Texas, when he suddenly lurched toward the camera and slammed face-first into his desk. Beside herself, the wife swore she could see a fresh bullet hole in the closet door behind him. With the live video feed still running and his motionless body just outside the frame, she frantically phoned the base saying her husband had been shot.

A subsequent Army investigation concluded that the nurse, 43-year-old Capt. Bruce Kevin Clark, did not die from a gunshot. There was no bullet hole in the room and no wound on his body. The cause of death has not yet been determined, but the Army says foul play is not suspected. Clark’s wife, Susan Orellana-Clark, has communicated to the press only through official statements (while Clark’s mother declined to comment for this story), and in May she stood by her version of events. Barring an Army cover-up, the wife simply imagined the worst after her husband’s inexplicable collapse.

Clark’s death was a uniquely bizarre incident, but modern communication technology is increasingly beaming the stresses of the battlefield into American homes. Deployed soldiers are now able to keep in close contact with their loved ones. This is a welcome change, but Vladimir Nacev, a clinical psychologist for the Defense Centers of Excellence for Psychological Help and Traumatic Brain Injury, says “the technology is a double-edged sword.”

“Nowadays you can text and e-mail and Skype,” Nacev says. “They’re great. But they’re also a great source of trauma because if you don’t call when you’re supposed to call, or your line goes dead, or you hear background noise and the picture disappears—that can throw you for a loop.”

Experts agree that, barring extreme circumstances like witnessing a death via Skype, the worry that comes with having a family member deployed is unlikely to cause full-blown PTSD. But the strain takes an undeniable toll, and doctors are still working on what to call the result.

For nearly as long as America has waged war, its troops and citizens have realized that combat irreparably changes people, though the name applied to that change has shifted over the years. In the Civil War era it was called “irritable heart.” Prolonged exposure to the trench-warfare terrors of World War I caused “shell shock.” Now, after Vietnam and advancements in behavioral health, the condition is known as Post-Traumatic Stress Disorder.

But exactly what constitutes PTSD is somewhat subjective. As psychiatrists like to say, PTSD is “a normal reaction to abnormal circumstances.” It is by no means strictly caused by war experiences; any type of violence or near-death encounter, such as a bad car accident, can lead to PTSD months or years down the road.

According to the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the official guide used by doctors to diagnose mental illness, PTSD can occur after a person has “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury.” A PTSD sufferer responds to such scenarios with “intense fear, helplessness, or horror.”

Owing to pop-culture portrayals, the symptom most commonly linked to PTSD is a vivid, dreamlike flashback prompted by some sort of noise or image associated with the haunting event—a ceiling fan that calls to mind a helicopter’s whirling rotor blades, to borrow Francis Ford Coppola’s example in Apocalypse Now. Indeed, “re-experiencing” is a marker of PTSD, but much broader and less-intuitive indicators also exist, such as “markedly diminished interest or participation in significant activities” and “difficulty concentrating.”

Of course, such common problems alone do not qualify as PTSD. Dr. Barbara Rothbaum, a nationally recognized PTSD expert and the associate vice-chair of the Emory University School of Medicine’s Psychiatry Department in Atlanta, says, “The line in the sand is functioning. Somebody who has mild PTSD symptoms, but without any interference with life and functioning, doesn’t meet the criteria for a diagnosis. The same goes for family members. Everybody is going to be a little bit scared or a little bit worried, but if it’s not interfering with their functioning, they don’t meet criteria for a diagnosis.”

When depression, substance abuse, and other factors are factored in, the situation becomes even more muddled. There’s no X-ray, blood test, or surefire way of spotting PTSD, so psychiatrists rely almost entirely on a patient’s testimony. “A good clinician who has experience with PTSD is going to know it when they see it,” Rothbaum says. “But you can miss it, and if people want to hide it, they can hide it.”

The National Vietnam Veteran Readjustment Study, conducted in 1983 in response to a congressional mandate, found that about 30 percent of all soldiers deployed to Vietnam had PTSD some time after their deployment, and 15 percent—about 450,000 men and women—still met criteria for PTSD nearly two decades later. An additional 19 percent had something termed “partial PTSD.”

“They didn’t have the full syndrome, but were clearly affected psychologically by their war experience and were very symptomatic and reporting functional problems,” says Dr. Matthew Friedman, executive director of the VA’s National Center for PTSD and a professor of psychiatry and pharmacology at Dartmouth’s Geisel School of Medicine. “We never had a good place to put those people, except to call it adjustment disorder. And the problem with that is there’s a lot of variants for adjustment disorder.”

To a layperson, adjustment disorder—Etterlee’s affliction, according the Madigan psychiatrists—sounds an awful lot like PTSD. It is defined as “the development of emotional or behavioral symptoms in response to an identifiable stressor,” followed by “marked distress” and “significant impairment in social, occupational, or other important areas of functioning.”

“They’re significantly worse than non-affected people and significantly better than people above the threshold for PTSD,” Friedman says. “There’s never been a good place in the DSM for the sometimes life-changing fact that it doesn’t have to be an event that might kill you that could be the worst thing that ever happened to you.”

Friedman lists several synonymous terms for secondary PTSD—secondary traumatization, vicarious PTSD, compassion fatigue—but says none of them are officially recognized by the American Psychiatric Association. “People recognize the phenomenon, but exactly how to characterize it is still a matter of discussion,” he says. The symptoms include many of the hallmarks of regular PTSD, such as withdrawing into one’s self, mood swings, and anxiety, but the critical difference is there’s no direct exposure to a traumatic event. Rather, the causes can include learning that a traumatic event occurred to a close family member, secondhand knowledge of some horrific incident, or the cumulative stress of constant vigilance.

“It’s something of a misnomer,” Nacev says, referencing the secondhand-smoke analogy. “It’s not contagious, where you’ll get it from associating with somebody who has PTSD.”


Randi Jensen, director of The Soldiers Project Northwest, a nonprofit that offers free, confidential mental-health counseling to Washington service members, veterans, and their families, says she has encountered several Army wives who are worried sick.

“I’m dealing with a young lady right now whose husband is in Afghanistan,” Jensen says. “He calls her from a forward operating base, they’re on the phone, and she can hear mortars in the background. That is terrifying. You’re bringing the war directly into your living room. I’m trying to explain, ‘Your fear for his life is overwhelming you.’ There’s a sense of having no control over it at all.”

Michele Smith is familiar with that feeling. Shannon, her husband of 22 years, deployed to Iraq in 2008 as part of an Army special-operations unit. The couple chatted regularly via Skype, and Smith says her husband took pains to make it seem as though he was never in harm’s way.

“I did start to get worried,” Smith says, “not because of what he was telling me, but because of the changes in his personality. I’m 8,000 miles away, I can see my husband having a nervous breakdown, and there’s nothing I can do.”

Smith, the moderator of a 16,000-member Facebook page called “Military with PTSD,” recalls how her husband became obsessed with seemingly insignificant details about his deployment. His sense of humor was supplanted by a surly temper. He complained of stomach pains and insomnia. Only months later did she learn his secret: He’d suffered a head injury.

When the Smiths were reunited in early 2009, Michele recalls that it seemed as though Shannon was “like a lit rocket about ready to launch in every direction.” His anger intensified, and his behavior became increasingly bizarre. He experienced panic attacks and became unnerved by thunderstorms, which he had once enjoyed. Smith says the Army warned her to expect an “adjustment period” upon her husband’s return home, and for months she assumed the changes in his behavior would be merely temporary. The couple briefly separated, but were able to patch things up after the soldier sought counseling.

“They go out and deploy and we’re holding down the fort,” Smith says. “We’re taking care of everything: the bills, the kids, everything that needs to happen while they’re at war. They come back with PTSD, they’re in the house, but they’re checked out. They can’t help because their response requires a level of patience they’re just not capable of . . . It’s an unbelievable amount of pressure to be that spouse.”

In years past, that pressure was brushed aside as an expected hazard of being a military wife. But now there’s a push to recognize the impact of war on entire military families and to help them cope. “The running joke in the military back in the ’50s and ’60s and ’70s was, ‘If we wanted you to have a wife and family, we would have issued you one,’ ” Nacev says. “The service member’s physical well-being was the focus. We’re shifting away from that and looking at service members as a total package: physical well-being, mental health, spiritual well-being, and now including family well-being.”

According to NAMI, mental-health conditions such as depression and post-traumatic stress are as prevalent in families as in service members. A study of more than 250,000 military spouses showed that 37 percent had been diagnosed with at least one mental disorder, most frequently anxiety, depression, or sleep disorders. Of the 776,000 children with active-duty parents, roughly one-third have reportedly suffered from a psychological or behavioral disorder. And yet, a recent NAMI report entitled “Parity for Patriots” found that military families have “scant health-care coverage and scarce access to military-informed care.”

A spokesperson for the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury lists multiple resources available to military families—including, on each base, “family support centers, a one-stop shop for service members and their families to access information on key resources that enhance the readiness of military families.” But most resources are available only by phone or online, and require “self-assessment.” (Spouses are eligible for military health care, and the web service Military One Source—militaryonesource.mil—provides referrals for up to 12 in-person sessions with a mental-health professional.)

Smith, for instance, was living in Utah when her husband returned from Iraq, their home more than 500 miles from the nearest Army base. She used Military One Source and was able to get a counseling referral, but says she ultimately learned that “it’s really hard to find a professional that knows what PTSD looks like in the home.”

At the VA and elsewhere, Friedman says, there’s no question there are “people who are dealing with the consequences of a traumatic event even though they themselves have never been in danger,” but researchers have not carried out many studies on the subject. As a result, relatively little is known about so-called secondary PTSD. “The time has come,” Friedman says, “to look at the sub-syndromal or partial expressions of PTSD, and see what we can learn about them and what treatments will work for them.”

But who would qualify for such treatments, and, more dauntingly, who would pay for them, remains to be seen. “I don’t think we’ve even touched the tip of the iceberg when it comes to secondary PTSD,” Jensen says. “There are a lot of cases of civilians and family members dealing with it, and they don’t quite get it. They’re not sure why they feel anxiety, or aren’t quite positive what’s going on. As they learn about this, the system is going to be even more overwhelmed.”


When Etterlee’s PTSD diagnosis was downgraded to adjustment disorder last December, the psychiatrist responsible, Dr. Thomas Danner, left a brief written explanation in Etterlee’s medical records. The files, shared by Etterlee with Seattle Weekly, show that Danner was skeptical because the previous diagnosis was “based solely on the service member’s subjective report of alleged events to the clinician and unverified by any collateral source of information.”

In other words, Etterlee stood accused of exaggerating, perhaps even fabricating, his war experiences.

The allegation is insulting, the soldier says, because it took him months to muster the courage to come forward and seek treatment. At first Etterlee thought his insomnia, irritability, and other symptoms were normal. Then he feared being branded as weak or “broken” by his Army peers. He recalls a common blunt response from non-commissioned officers when he told them he had PTSD issues: “So do I. Everybody does. What makes you so special?”

“It goes back to the mentality in the military that everybody goes through this,” Etterlee says. “You get so used to thinking that it’s normal, but it’s not normal. I held everything inside for a long time. I got tired of holding it inside and not doing anything, just being miserable.”

Records show Danner was also mistrustful because Etterlee showed “an understanding of the secondary gain potential” of being diagnosed with PTSD—insinuating that Etterlee may have concocted his story so he could pocket the extra disability money that accompanies a PTSD diagnosis.

Under pressure from Congress, the Department of Defense agreed in 2008 to grant minimum 50 percent disability ratings to soldiers diagnosed with PTSD, a substantial increase from the 10 percent or less rating the diagnosis previously garnered. (Under the VA system, a 50 percent disability rating is currently worth $770 per month, plus additional allowances for dependents; a 10 percent rating pays $123 per month with no allowances.) With some exceptions, adjustment disorder and similar afflictions typically qualify for a rating no higher than 10 percent. While noble in its intent, the monetization of PTSD diagnoses has created a classic catch-22.

“There may be disincentive from the point of view of the patient to have symptoms lessen and get a diagnosis like adjustment disorder,” says Dr. Elspeth Cameron Ritchie, a former top Army psychiatrist now serving as the chief clinical officer for the District of Columbia’s Department of Mental Health. “PTSD naturally waxes and wanes over time, and is also responsive to medication. If somebody gets better and their symptoms are in remission, normally that’s a good thing.”

Predictably, the financial incentive also arouses suspicion that soldiers like Etterlee are faking it. The disability system isn’t especially lucrative; the $1.5 million lifetime figure cited in the Madigan memos assumes a 100 percent disability rating (meaning that an individual is unable to work because of his or her handicap), which pays $2,673 per month. Nevertheless, there is legitimate concern that opening the military’s disability system to a broader range of mental issues could be extremely costly.

Two pending proposals could prompt such a change. The American Psychiatric Association is currently in the process of revising its DSM, and one probable outcome is a reclassification of PTSD and its cousins. Currently, PTSD is lumped in with a broad range of anxiety and adjustment disorders; next year, it’s likely that PTSD will have a separate new category of “Trauma and Stressor-Related Disorders.” The redefinition calls for recognizing “the development of emotional or behavioral symptoms in response to an identifiable stressor.” The term “secondary PTSD” isn’t mentioned, but it doesn’t need to be.

“It’s going to open the door,” Ritchie says. “Whether it opens all the way to somebody hearing about secondhand events, this has again been an area of contention for a long time. What if you hear about a train crash or see a picture of a train crash, or pictures of people jumping out of the windows of the World Trade Center over and over? What is the impact on the disability system?”

In June, Sen. Murray introduced the Mental Health ACCESS Act of 2012 in the wake of the scandal at Madigan and the appallingly high suicide rate in the military. (On average, one active-duty service member commits suicide each day, and, since the war in Afghanistan began, more U.S. military personnel have died by suicide than in combat there.) Murray’s legislation proposes comprehensive, standardized suicide-prevention programs, expanded peer-counseling opportunities for veterans, and increased oversight of the military’s mental-health system. One section of the bill would expand counseling services to cover soldiers far removed from the battlefield, including pilots of remote-controlled, unmanned aerial drones; military morticians working “outside the theater of combat operations”; and the mental-health professionals who themselves tend to the troops’ psyches.

“From World War II and the Korean War to Vietnam, we’ve never gotten this right,” said Murray, the chair of the Senate Veterans’ Affairs Committee, while introducing her package at a July 2 press conference in Seattle. “I believe that in this day and age, we should be much further along in dealing with military mental-health issues.”

Murray also suggests that the family members of deployed troops be eligible to receive access to mental-health-care services at community “Vet Centers,” VA medical facilities, and local civilian hospitals. The senator says the change would help families “cope with the stress of deployment and strengthen their support network.”

The Congressional Budget Office did not determine the estimated cost of Murray’s expanded military mental-health programs. Although it generated bipartisan support, the bill was introduced near the end of the legislative session, and lawmakers never had the opportunity to vote on the measure. Murray spokesman Matt McAlvanah says the Veterans’ Affairs Committee will likely vote on the issue after the August recess, and the Senator “will absolutely continue to pursue these reforms through the end of the year and into next year if necessary.”


In the wake of public and political outcry over the diagnosis reversals at Madigan, the Army is currently reviewing PTSD diagnoses made at all Army medical facilities dating back to October 7, 2001, the official start of the Afghan war. The Army Surgeon General identified more than 300 reversed diagnoses, and while the results of the internal inquiry have not yet been released, Sen. Murray said in May that at least 100 soldiers have already had their original diagnoses reinstated.

Count John Byron Etterlee among that group.

Clad in his camo fatigues at Coffee Strong, a Veteran-run antiwar cafe across the street from JBLM, Etterlee says he was re-evaluated in March by an Army doctor from a base in Texas. But while his PTSD diagnosis has been restored, Etterlee’s ordeal with the Army medical system continues. He recently completed a seven-week “symptoms management” program for his anxiety and irritability issues, but left less than impressed.

“It was the same thing as me sitting here talking to you about it,” Etterlee says. “It was bull. It just seems like you get lost in the system.”

Etterlee underwent surgery for the herniated discs in his back last year, but has not recovered. Often in pain, with his mobility severely limited, he sometimes needs a cane to walk and cannot participate in most training exercises with his unit. Eligible for a medical discharge, he says his case file was “sent through the wrong communications and has been sitting doing nothing for two months.” He is still awaiting a ruling, but his days as an enlisted man are likely numbered.

Discussing Robert Bales, the Fort Lewis soldier accused of going berserk and massacring 17 Afghan civilians earlier this year, and reflecting on his own tribulations seeking treatment for both his brain and his back, Etterlee says he understands how navigating the Army’s bureaucratic labyrinth could push someone over the edge. “I can imagine driving home from work, being frustrated you’re not getting the help you need, and thinking about driving your car into a wall or something like that,” Etterlee says. “I’ve had that thought a couple times. But I know personally I’d never do something like that.”

A recent study by the VA Inspector General found that more than half of veterans seeking mental-health care for the first time waited 50 days for an assessment, and that the VA had a backlog of nearly 900,000 disability claims—two-thirds of them pending more than 125 days. Several soldiers and veterans interviewed for this story complained of an impersonal, byzantine system that sometimes does as much harm as good.

Greg Miller, a former Army infantryman stationed for three years at JBLM, recalls facing “endless hurdles” when he sought help for PTSD issues after his return from Iraq. “Those buildings [at Madigan] may as well be empty,” Miller says. “It’s meaningless help. It leaves you with few choices. I can kill myself, I can go AWOL, or I can bury myself in substance abuse that will probably put me in prison. The Army touts these services, but if you can’t get to them, and if once you do they’re meaningless, what good is that?”

Nathan Sutton, an eight-year Marine veteran, was among the first boots-on-the-ground American troops in Baghdad, an experience he compares to “the Fourth of July on crack.” During his second deployment, more than 80 percent of his company was either killed or wounded. He says he struggled mightily with PTSD upon his return home in 2009, and his first visit to the VA hospital only made things worse. “I walked out a little more messed-up than when I walked in,” Sutton says. “It’s just confusing. It’s a big organization.”

Sutton eventually found his way to the Everett Vet Center, one of several community-based treatment centers financed by the VA but independently operated. There he found support from fellow veterans who’d dealt with the same issues, and his condition improved to the degree that he now works as the Vet Center’s outreach coordinator. The Marine says the VA and the armed forces as a whole have made tremendous progress when it comes to PTSD.

“They recognize they have a problem and I think they’re making the right changes,” Sutton says. “It’s just a slow process, and it’s hard to get it through some people’s skulls, as far as old-school Army and Marines, that this exists. Those old terms, where we used to call it ‘wussy syndrome’ and things like that—that will naturally weed itself out.”

Other experts and doctors outside the military likewise say that several VA and Department of Defense PTSD programs offer comprehensive care and cutting-edge treatment techniques, including virtual-reality exposure, that are sometimes ahead of the curve relative to civilian care. Even the much-maligned Madigan has its supporters—including Emory University’s Rothbaum, who praises the facility’s clinical research and use of outside collaborators (Rothbaum included) to evaluate its work. “My experience with Madigan is they’re doing it the right way,” she says.

But 35 percent of soldiers who served in Iraq and Afghanistan either already have PTSD or will develop it eventually, according to a recent estimate by Stanford University researchers, and even more will struggle with adjustment disorder and the other psychological problems that fall under the broad umbrella of secondary PTSD. The ways the military perceives and addresses PTSD are certainly improving, but cases like Etterlee’s prove that soldiers struggling with the aftereffects of “general combat stress,” as one doctor described the root cause of his condition, still have a hellish time getting help after they’ve been to hell and back.

“Honestly, man, it’s just a pain in the ass,” Etterlee says. “I had to go through all this crap just to prove something is wrong with me, just to get help.”


Greg Miller faced "endless hurdles" when seeking post-combat treatment.

Greg Miller faced “endless hurdles” when seeking post-combat treatment.