In May, 2008, former Defense Secretary Robert Gates was asked at a news conference whether he would support awarding the Purple Heart Medal to combat Veterans afflicted with Post Traumatic Stress Disorder (PTSD). Cognizant of the frequency and severity of PTSD among returning Iraq and Afghanistan veterans, Gates said the idea was “clearly something that needs to be looked at.” Gates’ proposal was followed by an outcry not from VA Administrators or clinicians but from military personnel and veterans, many of whom were aware of the tragically high rate of PTSD and suicide among their returning brothers and sisters. Many were aware as well of the seriousness of the injury and the stigma of mental illness as a “barrier to care” and, paradoxically, had labored long and hard for PTSD to be recognized and taken seriously as a consequent of serving in combat.
Typical of the reaction by veterans and military members was illustrated in an article in the Army Times. A Marine noted that awarding the Purple Heart Medal to combat PTSD injured veterans “would lessen the meaning of the award.” Another soldier quoted in the article, expressed that he would be ashamed to wear the medal were it awarded to PTSD vets. An Army Intelligence officer observed that it would be “an insult to those who have suffered real injury on the battlefield” (italics mine). A combat veteran friend of mine who, by the way suffers from PTSD himself, even wrote a letter to the editor of a local paper arguing that the Purple Heart Medal needed to be “protected” from those who would “demean it” by awarding it to combat veterans suffering from PTSD.
The Military Order of the Purple Heart (MOPH), an organization exclusively of Purple Heart recipients also opposed awarding the Medal to PTSD injured. According to their spokesperson,
“The criterion for this particular medal, however, is the suffering of physical wounds on the battlefield as the result of combat action by the enemies of the United States. Moreover, PTSD is a treatable disease — loss of a limb, or any combat wound for that matter, is permanent. And, what about those who feign the illness just to receive VA medical treatment; or, what about a group who witnesses a battlefield trauma together, but only one or two suffer from PTSD; should they all receive the Purple Heart?” 
After conferring with the Awards Advisory Group, which included experts from the Pentagon, the Center for Military History and Institute of Heraldry, Gates’ personnel chief, David S.C. Chu, decided against PTSD eligibility. In January 2009, Pentagon spokeswoman Eileen Lainez explained the decision. 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.” Consequently, Lainez continues, PTSD does not satisfy these criteria as it “is not a wound intentionally caused by the enemy from an outside force or agent, but a secondary effect caused by witnessing or experiencing a traumatic event.” 
Psychological, Emotional, and Moral (PEM) Injuries
Over the history of warfare, what I have termed “Psychological, Emotional, and Moral (PEM) Injuries” have had many incarnations, as “Soldier’s Heart” during the Civil War, “Shell Shock” during World War I, and “Battle Fatigue” and “Combat Exhaustion” during World War II. Most recently, following the Vietnam War, the designation lost its poetics, been stripped of its reference to war and battle and has morphed into a clinical diagnosis of mental illness. People who are psychologically, emotionally, and morally wounded as a result of their combat experience are instead given a diagnosis of Post Traumatic Stress Disorder. PTSD, according to the National Institute of Mental Health, is an anxiety disorder that can develop “after exposure to a terrifying event or ordeal in which grave harm occurred or was threatened.”
Though space prevents a more thorough discussion of my concerns here, I have argued elsewhere that the elimination of any reference to war and battle in the current designation is unfortunate and detrimental to veteran healing. Second, to subsume all PEM injuries suffered by members of the military who have experienced the brutality and insanity of the battlefield under the diagnostic umbrella of PTSD addresses only one aspect of the experience, the trauma, and fails to recognize the entire scope and complexity of combat injuries. Language, how we characterize the human cost of war, its effect on the warrior, is critical both to our understanding of the institution of war and to veteran treatment and healing. Consequently, to adequately meet the rehabilitative needs of veterans, a more encompassing and holistic understanding and treatment protocol is required, one that addresses not only trauma but the psychological, emotional, and moral injuries as well.
The Invisible WOUNDS of War
A recognized intent of all combat action is to neutralize the enemies’ ability to wage war. The primary means in war-fighting of accomplishing this end is to create casualties, that is, to render the enemy incapable of continuing the hostilities. This will include, of course, not only killing and physically injuring enemy combatants but psychologically, emotionally, and morally injuring/incapacitating them as well – what has been aptly and correctly termed the “invisible wounds (not illness) of war”. Consider for example the endless artillery bombardment experienced by soldiers fighting in the trenches of the Western Front during World War One. As a consequence of these bombardments, many individuals were killed and many others incapacitated both physically and psychologically/emotionally (then termed “Shell Shock”).
According to Military Awards criteria, the Purple Heart is awarded in the name of the President of the United States to any member of an Armed Force who, while serving with the U.S. Armed Services after 5 April 1917, has been wounded or killed, or who has died or may hereafter die after being wounded;
(1) In any action against an enemy of the United States.
(2) In any action with an opposing armed force of a foreign country in which the Armed Forces of the United States are or have been engaged.
(3) While serving with friendly foreign forces engaged in an armed conflict against an opposing armed force in which the United States is not a belligerent party.
(4) As the result of an act of any such enemy of opposing Armed Forces.
(5) As the result of an act of any hostile foreign force.
(6) After 28 March 1973, as the result of an international terrorist attack against the United States or a foreign nation friendly to the United States .
b. A wound is defined as an injury to any part of the body from an outside force or agent sustained under one or more of the conditions listed above. A physical lesion is not required, however, the wound for which the award is made must have required treatment by medical personnel and records of medical treatment for wounds or injuries received in action must have been made a matter of official record.
I believe it safe to say that anyone who has ever worn the uniform respects the Purple Heart Decoration and holds in highest esteem those individuals whose sacrifices it acknowledges. While it is understandable for veterans and members of the military to be cautious and “protective” of the award, I think their, and the Pentagon’s, opposition to PEM Injury eligibility is misguided, based upon a misconception or lack of understanding or appreciation of the nature and reality of these injuries.
After years of activism in behalf of veteran issues, I can’t help but think that in opposing PTSD eligibility veterans and members of the military are working against their own interest. What is it about recognizing PEM injuries that threaten the dignity of the Purple Heart and from which it needs to be protected? Why would a physically injured veteran be insulted or ashamed to wear the Medal were it also awarded to the PEM injured such as those who endured the horrors of the Western Front? Are PEM injuries a source of embarrassment and shame, the consequent not of great personal sacrifice in behalf of one’s nation but of some personal flaw or weakness? What is a PEM injury if not real?
Certainly, the injuries sustained by veterans such as those at the Western Front and elsewhere do satisfy the eligibility criteria for the Purple Heart. First, such injuries “were the intended effects of a specific enemy action to kill or injure” and did require treatment by medical personnel. Second, though the criteria for the Purple Heart is clear that a physical lesion/injury or bloodletting is not required, PEM injuries do have physiological indicators in the hippocampus, amygdala, and the medial frontal cortex of the brain that are detectable by neuroimaging. Third, specifically in reference to the concerns of the MOPH, the criteria do not require the injury to be permanent and untreatable. Many have received the award for injuries that were relatively superficial and have totally healed over time and with treatment. Fourth, while there may be those who would feign injury just to receive the award, I think it safe to say that most who present PEM symptoms are legitimately injured in combat. Besides, after years of working with the PEM injured, the Veterans Administration clinicians and medical professionals have become very proficient at documenting combat exposure and identifying and screening out fraudulent claims of PTSD. Consequently, it would be misguided in such situations to differentiate between a physical wound and a psychological/emotional/moral injury, regarding the former as a “real” combat injury while the latter as something less than real, perhaps as an illness or as a “secondary effect” of the artillery barrage. It is undeniable that all who sustained injuries in situations such as that at the Western Front, whether physical or PEM, were combat wounded and that their injuries were real, serious, and worthy of recognition and respect.
Members of the military, even those serving in a war zone, can suffer physical and PEM injuries that are not combat related, a vehicle/aircraft accident, etc. It is clear that such injuries, though real and serious do not warrant the Purple Heart. The distinction that needs to be made in determining eligibility, therefore, is not between physical and PEM injuries, but rather between combat and non combat injuries.
Before taking his own life on June 10, 2013, Iraq war veteran Daniel Somers wrote in a suicide note,
“Is it any wonder then that the latest figures show 22 veterans killing themselves each day? That is more veterans than children killed at Sandy Hook, every single day . . . Where are the huge policy initiatives? Why isn’t the president standing with those families at the state of the union? Perhaps because we were not killed by a single lunatic, but rather by his own system of dehumanization, neglect, and indifference.”
Despite the Pentagon’s recent claim to the contrary, Somers and many, probably most, of the 22 veterans who commit suicide every day and the 325 active duty military who took their own lives in 2012 (more than the number killed in combat) suffer from PEM Injuries.
Awarding PEM injured veterans the Purple Heart will prove an effective first step in recognizing such injuries as combat wounds (not as mental illness), that they are real, serious, and life threatening, that PEM injured veterans are not cowards, whiners, lesser or weaker soldiers, and no different from the victims of say an Improvised Explosive Device or a gunshot wound. It will end an era, a Pattonesque mindset, tragically still prevalent today even among veterans and members of the military, of explicit or implicit insensitivity, prejudice, and ignorance regarding the nature, validity, reality, and seriousness of PEM injuries. Further it will recognize and honor those who have sacrificed their psychological, emotional, and moral well being in combat in behalf of their nation. Most importantly, it will begin the process of eliminating the stigma of PEM injuries and hopefully motivate veterans to seek help rather than refuge and escape in alcohol, drug abuse, and suicide.
When we truly embrace and act upon what we claim to know to be true, that in war it is not only the body but the mind and spirit that can sustain injury, when we acknowledge that PEM injured veterans from the Western Front and elsewhere are not suffering from some illness but combat wounded, when we truly recognize the legitimacy and seriousness of their injuries and not just give it lip service, we will understand that awarding the Purple Heart to PEM injured veterans is not threatening the dignity and tradition of the Decoration, or demeaning to its recipients, but curative, uplifting, and right. Let’s do it.
 According to the current criteria, veterans suffering “concussion injuries caused as a result of enemy generated explosions” (Traumatic Brain Injury [TBI]) are eligible for the Purple Heart Award.
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Posted by Camillo Mac Bica, Ph.D. on August 31, 2013, With 7658 Reads Filed under PTSD, Veterans Administration (VA). You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.