War’s hidden legacy

The death of his comrade - that’s the moment Johannes Clair says was the trigger for his life to be turned upside down, although he didn’t know it at the time.

It was October 2011, and the now 29-year-old had been serving in the German army in Afghanistan for just over a year when it happened. Sergeant Florian Pauli got out of an army vehicle in Baghlan, in the north of the country to help a wounded farmer laying in the road. The ‘farmer’ blew himself up and Pauli became the 44th German soldier to die in Afghanistan.

From then on things for Johannes in Afghanistan changed: “I was struggling with anxiety, but I had no idea how to handle it...I vividly remember the feeling of failure when I was too scared to shoot, and couldn’t lift my head up on the field. Things got worse from then.”

What was meant to be purely a civil operation for German troops had taken on what the German government described as “warlike conditions”. But while some troops decided to return home because they couldn’t handle the pressure of the deployment Johannes made the decision to stay.

It was only when he returned to Germany that he was diagnosed with post-traumatic stress disorder (PTSD), a mental health condition triggered by a terrifying event.

PTSD’s hidden figures

Johannes is one of 431 German soldiers with PTSD officially, although actual figures are thought to be significantly higher - researchers looking into these “hidden figures” have found that 2.9 percent of German soldiers returning from deployment develop PTSD within 12 months. Each year around 300 cases develop per 10,000 German soldiers indicating that actual numbers of those afflicted may run into the thousands. And yet researchers say that around half of all PTSD cases are neither diagnosed, nor treated.

Still, as a result of Germany’s military reluctance, the numbers are relatively low compared to those of the US which sent the highest of troops to Afghanistan and Iraq and has around 20 percent of US troops diagnosed with PTSD.

PTSD is a condition traditionally associated with war veterans, but that can be caused by any terrifying experience: rape, the death of a loved one, robbery, assault, an accident or natural disaster.

“The reason someone develops PTSD is that the incident cannot be processed because the emotions are blocked, therefore symptoms like nightmares, flashbacks and aggressive behavior typically follow afterwards,” explains Norbert Kröger, a Berlin-based psychologist, who treats military and civil cases of PTSD and used to lead the psychology department at the military hospital in Berlin.

No soldier is immune

Symptoms of PTSD can occur at any point following the particular incident that triggered a trauma. This can be weeks, months and sometimes even years after soldiers have returned home, which makes it more difficult to be recognised from outside straight after the deployment.

“While out there, everyone has set agendas and automatisms. Everything’s organized, you’re part of a hierarchy and have to carry out your assignments. I’ve heard from comrades that often problems only reach the surface once soldiers find some rest and have time to reflect”, says a Lieutenant Colonel, who spent 13 months in Afghanistan training Afghan officers in 2012, and asked to remain anonymous.

He believes no soldier is immune to PTSD: “You see children dying in front of your eyes, you see car accidents, you see people in extreme poverty - if that doesn’t move you, you’re lying. You’re always exposed to challenging situations during a mission.”

In the UK, the European country that sent the highest numbers of troops, around seven percent of combat troops report PTSD. One of those is British veteran David who told his story in the Life Links episode #stillbreathing. After coming back from Iraq and Afghanistan, he experienced outbursts of anger, sleepless nights for days on end, and if he managed to find sleep, recurring nightmares about the one mission that nearly killed him awaited him. His marriage failed, he turned to alcohol.

“We assumed there were no PTSD cases”

In a world shaped by wars, civil unrest and political instability, situations that could trigger PTSD can hardly be eliminated. Still, while some argue that government have a responsibility to improve the procedures in place for when troops return home bringing with them their internal battles, others say there are reasons as to why PTSD often isn’t diagnosed or treated.

“In the past we assumed there are no PTSD cases in the German army because soldiers didn’t approached us. Over years they [soldiers] tried to cover up that this was an issue - not just in Germany, everywhere,” says Hellmut Königshaus, parliamentary ombudsman for the armed forces in Germany. In February 2015, the official figures stated the number of PTSD cases in the army had increased by 26 percent in 2014, compared with 2013.

Johannes says it took him two-and-a-half years to realize he had a problem. Back in Germany, he had nightmares, tried to go to university and then stopped after three months and his girlfriend broke up with him.

“It was a fight against myself,” he says. “I struggled hard to accept that I needed help. In my view, soldiers are people who are meant to improve life for others, and not become victims themselves. It’s hard for soldiers to talk about PTSD. It doesn’t fit the job. Men have even more trouble discussing it.”

But, the veteran, who wrote a book “Four Days in November” about his experience, adds: “If I’m honest, I don’t know if that would have helped. Each individual needs to realise they have to change something. That’s the same with any mental illness or alcoholism.”

Waiting for change in the army

But it’s not only soldiers themselves who are responsible for a lack of understanding the issues surrounding the diagnosis and treatment PTSD. Three years after the report on “hidden figures” was released, Hans-Ulrich Wittchen, professor of psychology at the university TU Dresden and one of the report’s authors, is still awaiting change within the army: “We need to be more open towards new research, we need to independently look at the problems and implement solutions. After we published the study about the PTSD hidden figurea, structures in the army largely haven’t changed.”

Currently, the German army ‘screens’ all soldiers for existing physical and mental conditions before they are taken on for service. Psychologists educate troops about the potential psychological consequences of war before they are being deployed and once out there, troop psychologists are the point of first contact if something happens. Afterwards there a rehabilitation seminars and if PTSD is diagnosed, a long process of stabilisation therapy begins.

But Wittchen argues that the treatment in place is inefficient and that in fact PTSD is a highly treatable disorder and often doesn’t need years of stabilisation and ambulant treatment.

“There are doubts as to whether the common practice, a stationary regime over several months, is effective. An intensive psychotherapy with ambulant treatments where the patient is being handled frequently and for at least 50 minutes per session seems more efficient. But usually that’s not being offered,” he adds.

Former army psychologist Kröger says it usually takes him five to 10 sessions of intense dynamic short-term therapy (IS-TDP) to heal symptoms of the disorder. He encourages patients to view it like a condition that can and will be healed: “I always tell patients that it’s great to have symptoms of functional nature because that means you can work on and get rid of them. In many ways, that’s easier than being organically ill.”

He views post-traumatic disorders as a wound on the human soul: “If the experience causes for the soul to get wounded, it’s our responsibility to treat it like an actual wound and make sure it doesn’t suppurate and gets infected. Obviously even fully healed scars can still hurt sometimes,” Kröger says.

Pacifist Germany

However, its not just the treatment in place that is a problem. Shaped by its bloody history and determination to stay out of military conflict ever since, public sentiment in Germany could be adding to the difficulty in dealing with PTSD more effectively. Two thirds of Germans are “opposed to overseas troop deployment” according to the non-profit social development Körber Foundation. Moreover, support for the operation in Afghanistan dropped significantly from 65 percent in 2005 to 37 percent in 2011.

So does pacifism create a stigma that keeps soldiers from seeking the help they need? “I think the stigma lies in the fact that deployed soldiers aren’t being appreciated. This lack of acknowledgment is one risk factor in developing a mental illness - and an obstacle in admitting weakness,” Wittchen tells Life Links.

Johannes comes across this sentiment in his work at the Association of German Veterans (Bund Deutscher Veteranen), where he campaigns to give former troops their own legal status, and online. In regular army and war-related debates on his public Facebook account, “there are always a few people who say ‘It’s their [soldiers’] own fault, stop crying’. But that’s not realistic. It’s like saying a car crash victim shouldn’t have been on the road in the first place,” he says. “There’s no understanding here that war doesn’t end when soldiers get on a plane back home.”

These factors turn PTSD into a bigger problem than it would be from a purely medical perspective. Structural inefficiencies in the army, a reluctance to use existing research and particularly in German society, the stigma that’s attached to military action abroad, causes soldiers to not view PTSD as a condition that can be treated and healed - often, they end up battling with it for years, turn to alcohol or crime and are unable to find their place in life again.

“I would go back to Afghanistan in an instant”

Johannes has been in therapy for a-year-and-a-half. He does a combination of psychotherapy, conversational therapy and in-patient treatment. But he still experiences relapses: “I think part of the accepting process is that I stop thinking in categories like ‘healed’ or ‘not healed’ but focus on living with the consequences instead. I would go back to Afghanistan in an instant - of course, that would be pointless from a medical perspective. But I feel like I’ve left something over there, left things undone. The mission wasn’t finished.”

What Johannes left behind is part of himself - his naivety, his mental stability, his heart - he went out as one person and returned as something different. Still, despite everything he’s lost since being a soldier in Afghanistan, he misses it every day: “I remember the sunrises when we were out keeping guard - they were beautiful. And the people I’ve met there, the friendships that I’ve made - all of that was part of it despite the fact that it was a deployment of extremes.”