The Weight Doesn't Lighten

Veterans, Aging, and the Wars We Keep Fighting

As I write this, the United States and Israel have launched what the administration is calling "major combat operations" against Iran. The Minab girls' school is rubble. Somewhere between 80 and 148 children — the numbers are still coming in, contested by Iranian state media, verified in fragments by human rights monitors — were at their desks when the missiles hit. That number will settle. The fact of it won't.

I'm an old lefty. I've been protesting American wars since Vietnam, which means I've been doing it most of my adult life, and I've gotten pretty good at holding the terrible arithmetic of it — the civilian dead counted and uncounted, the geopolitical rationale always clean in the press conference, always messier in the field. What I've been thinking about this week, though, isn't only the Iranian children. I'm thinking about the men and women we will continue to send to do this, and the ones who've already done it, and what they carry as they age.

Because here is what we don't talk about nearly enough: the weight doesn't lighten with time. For a significant number of veterans, it gets heavier.

The research on PTSD and aging has been quietly accumulating for years, mostly in VA journals that don't get the kind of circulation they deserve. What it shows is counterintuitive: many veterans who managed to hold things together during their working years — raising families, holding jobs, staying busy enough to stay ahead of it — find that retirement, the slowing down of life, the narrowing of daily distraction, brings the war back. A 2019 review in the Journal of Psychiatric Research found that PTSD symptoms can first appear or intensify in later life, often triggered by the proximity of mortality, by medical procedures, by the enforced stillness of aging. The VA's own literature acknowledges that the end of life can become a reopening of old wounds.

Thoughts associated with morbidity and mortality can trigger an increase in PTSD symptoms. For a veteran, what that often means is that the thing they managed for decades — the images, the sounds, the moral inventory they never quite finished — comes back with a force that surprises everyone, including them.

And yet fewer than half of veterans who need mental health care receive it, and among those who do, less than one-third get evidence-based treatment. Half. Of those who need it. And that's not even counting the veterans who don't know they need it, who've normalized what isn't normal, who've explained away the sleeplessness and the hair-trigger anger and the tendency to sit with their back to the wall as just who they are now.

I want to talk about something the VA still doesn't fully know what to do with, which is the distinction between PTSD and what researchers have been calling "moral injury." The term was developed by Dr. Jonathan Shay, a VA psychiatrist in Boston who spent twenty years working with Vietnam veterans and wrote two essential books — Achilles in Vietnam (1994) and Odysseus in America (2002) — that deserve to be on every shelf in every gerontology program in this country. Shay argued that veterans can usually recover from horror, fear, and grief once they return to civilian life, so long as "what's right" has not also been violated. When it has been — when a soldier has witnessed or participated in something that transgresses their own deepest sense of what is permissible — the wound is of a different character. It's not fear. It's conscience.

Moral injury shows up in research as distinct from classic PTSD, though the two often travel together. A nationally representative study of U.S. combat veterans found that most veterans with probable PTSD — 72% — also endorsed experiencing potentially morally injurious events, including perpetration, witnessing, and betrayal. The categories matter. "Perpetration" means having done something. "Witnessing" means having seen it. "Betrayal" means having been led into a situation by commanders or policy-makers that felt, from the inside, like a violation of what war is supposed to be about.

Those Iranian schoolchildren are going to live inside someone's moral ledger for the rest of their life. I'd put money on it. The pilot who flew the mission may support the policy. May believe, and not without reason, that the strike was aimed at a legitimate target and the school wasn't the plan. And he'll still see them. That's not PTSD in the clinical sense. That's conscience doing its job — and conscience doesn't respond to antidepressants, doesn't resolve through exposure therapy, doesn't file neatly under a DSM code.

The veteran community has fought hard for better mental health infrastructure. The RAND Center for Military Health Policy Research puts the number plainly: fewer than half of veterans who need mental health care receive it, and among those who do, less than one-third get evidence-based treatment. And that's only counting the veterans inside the VA system — which itself enrolls only about half the total veteran population. For those struggling with substance use alongside their trauma, the gap is even more stark: more than nine in ten receive no treatment at all.

While the system reaches half the veterans, it's almost entirely oriented toward younger veterans, toward the acute phase, toward getting someone functional enough to hold a job and a relationship. What it is not oriented toward, in any serious way, is the older veteran — the Vietnam-era man now in his seventies, the Gulf War veteran approaching sixty, the post-9/11 veteran who is beginning to understand that forty is not as young as it used to feel. Assessment, diagnosis, and treatment of PTSD can be challenging in older adults for numerous reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. And yet most of the research literature doesn't include substantial numbers of adults over 65.

From where I sit — as someone who spent four decades in story work, who has sat in story circles with veterans and their families, who has watched people unlock things in a two-hour workshop that decades of silence had sealed — I think there's something the mental health system keeps missing that the storytelling world has always understood. Moral injury needs to be heard, not just treated. The veteran who watched something he can't unsee needs to be able to say what he saw to someone who won't flinch. Not to be fixed. To be witnessed.

Jonathan Shay called it "communalization of grief." The idea, borrowed from Homer and from clinical experience both, is that any blow in life will have longer-lasting and more serious consequences if there is no opportunity to communalize it. You have to be able to bring it back to someone. You have to be able to say: this is what happened, and this is what it cost me, and I need you to hear that.

We are, as I write this, making more of these wounds. More Minabs. More ledgers that young men and women will carry quietly into old age, where the system will probably not be ready for them when the weight finally gets too heavy to hold alone.

The least we can do is build the infrastructure to receive them. And maybe — I'm an old lefty, I hold out hope for things that haven't happened yet — to think harder about whether we want to keep generating the wound in the first place.

You can donate to the International Red Crescent efforts in Iran, to assist those affected by the current bombing campaign.