I Watched Friends Die in Afghanistan. The Guilt Has Nearly Killed Me.

It took me years to realize this feeling had a name: survivor guilt.Credit...Illustration by Jesse DraxlerSupported byBy Adam LinehanWhen my grandfather Michael Linehan Jr. arrived in North Africa in December 1943 to begin his tour of duty with the 15th Air Force, the average life expectancy of an Allied heavy-bomber crewman was roughly six combat missions, less than a fourth of what he was required to fly. B-24 crew members had such a high fatality rate during World War II that the aircraft was nicknamed “the flying coffin.” Between the Luftwaffe and the German 88s, there was only so much a crew could do to avoid being blown out of the sky. “The flyer who returns to his home and is lionized for heroic exploits may still torture himself with the feeling of unworthiness and guilt,” the sociologist Willard Waller cautioned in his landmark 1944 book, “The Veteran Comes Back.”My grandfather’s brother, Jack, served with the Navy in the Pacific, and after the war the two men bought adjacent homes in their native Dallas, where their father emigrated from County Cork, Ireland, as a teenager. “On this 5th day of July, nineteen hundred and forty four, the fickle finger of Fate has traced on the rolls of the Lucky Bastard Club the name of Michael Linehan Jr.,” states the certificate my grandfather kept on a shelf to remind him that he had “achieved the remarkable record of having sallied forth, and returned, no fewer than 50 times, bearing tons and tons of high explosive Goodwill to the Feuhrer and would-be Feuhrers.”I grew up thinking of my grandfather as a drunk. They reported that “one of the most amazing revelations derived” from their clinical work was “the universality of guilt reactions,” which were “related to the most varied, irrational and illogical experiences.” They continued: “Hundreds of little acts which the patient did or did not do are the bases of self-accusations, and we often hear the guilty cry, ‘I should have got it instead of him!’ The intensity of these guilt feelings is proportional to the severity of the inner conflicts.”Grinker and Spiegel were describing the phenomenon generally known as “survivor guilt,” which has been defined by the A.P.A. as “guilt about surviving when others have not, or guilt about behavior required for survival.” In the decades since, psychologists have found survivor guilt to be very prevalent across a wide range of traumatized populations, from Holocaust and Hiroshima survivors to refugees and H.I.V.-negative gay men. “Often, the survivor works hard in business relationships, but does not enjoy the work or its product because of ongoing feelings of unworthiness and impending doom,” states the “Encyclopedia of Death and the Human Experience.” “There can be a sense that the only answer to the internal pain is personal death, a resolution to the issue of having survived the original event.”Clinical studies found survivor guilt to be so pervasive among Vietnam veterans that the A.P.A. initially listed it as a core symptom of post-traumatic stress disorder, which itself became a formal diagnosis in 1980. Unless I started seeing insurgents crawling out of the walls or went totally Rambo, I was going to be O.K. I did experience some notable effects, however, like the severe fear of flying I developed about halfway through the flight home from Afghanistan. It is always the same scenario: We are standing face to face, and I am trying to explain something to him, I’m never sure what, and he just stares at me blankly, as if he’s annoyed or disappointed, or as if I’m making excuses, dancing around the point, and his impatience is an unnecessary reminder that I’m living on borrowed time.My battalion arrived in Afghanistan’s Kandahar Province in the early summer of 2010, tasked with securing the district of Zhari, situated along the northern banks of the Arghandab, west of Kandahar City. “Doc,” he said, “I really don’t want to die.” He said it several times, as if he saw death coming and wanted me to stop it. “Upon further questioning, patient reports that for the past year he feels like he’s been ‘in the weeds’ and endorses feelings of depression; admits to difficulty sleeping, decreased concentration at work, decreased interest in writing and passive feelings of suicidality,” she noted in my mental-health in-processing report. “I’m telling you, though, the B.C. sounded serious,” I said, and that’s where I left it.At least one soldier remembered my warning in time to shoot the bomber as he approached our squad leader and shouted, “Allahu akbar!” I’m not sure what it was exactly about how the sky looked that led me to this conclusion, but it dawned on me with profound clarity as my eyes turned upward from Jake Carroll’s body: I could have stopped this attack. Some psychologists acknowledge this by subcategorizing the condition into two types: “content survivor guilt” and “existential survivor guilt.” Essentially, the former describes the guilt people experience when they believe that something they physically did or failed to do directly contributed to another’s death. Frankl, a Holocaust survivor himself, preferred the notion of “survivor responsibility,” and believed that the best way to recover from trauma is to pursue a life of redemption. “What is called self-actualization is not an attainable aim at all.” A more pathological interpretation that was embraced by many psychologists when survivor guilt was more widely recognized is that the guilt functions as a sort of buffer against nihilism. “The essential psychic process underlying survivor guilt is self-blame, which is a defensive omnipotent phantasy,” wrote the British psychotherapist Dr. Alfred Garwood in a 1996 study of Holocaust survivors. “I’ve found that most of the time the patient knows they are not responsible for anyone’s death but still feels that it is wrong or unfair that they survived, so they are stuck in this whirlpool, looking for answers that don’t exist,” says Dr. Hannah Murray, a clinical psychologist specializing in PTSD at the University of Oxford’s Centre for Anxiety Disorders and Trauma. “I believe some people have emotional consequences from trauma that aren’t PTSD, and because of the way the health care systems work here and in America, they won’t get taken care of,” she noted. “So I think there are a lot of people coming home from war who don’t get treatment and end up making bad decisions.”Dr. William P. Nash, the former director of psychological health for the U.S. Marine Corps and a veteran of the Second Battle of Falluja, says the lack of awareness about survivor guilt extends specifically to the V.A. Nash himself currently works as a clinical and research psychiatrist with the V.A. in Los Angeles. He describes survivor guilt as “unrelenting and corrosive,” and agrees with Murray that it should be recognized as more than just a feature of PTSD. “It has not been studied enough, it has not been characterized, no one has figured out yet what its relationship is, if any, to depression, anxiety, PTSD or anything else,” he said.For veterans of the war on terror, PTSD is one of the most common diagnoses by the V.A. More than 340,000 of us were receiving disability compensation for the disorder in 2017. I told my friends that if I started blabbering about Afghanistan at the bar, it was time for me to go home. That epiphany occurred about a week later, when I finally got around to rewatching HBO’s police drama “The Wire.” Toward the end of the first season, the protagonist, Detective Jimmy McNulty, becomes stricken with guilt after his partner is critically wounded during a drug bust. I had.Jan Scruggs, the former enlisted grunt who helmed the campaign to build the Vietnam Veterans Memorial, struggled with survivor guilt after returning home in the spring of 1970 full of shrapnel. Twelve years later, he stood before tens of thousands of Vietnam veterans on the National Mall and officially unveiled a monument to every American who fought and died in the war. “That is what war is like,” Scruggs told me. As a graduate student of psychology at American University in the mid-1970s, Scruggs consumed the available literature on survivor guilt and believed the memorial could address the syndrome directly in individual veterans and catalyze a healing process. Scruggs, however, was more concerned with helping veterans “who had experienced multiple K.I.A.s in a single action,” he told me. There were a total of 12 fellows, all former combat medics or Navy corpsmen.Had I read The War Horse Fellow Handbook, I would have known that the program was for veterans “who want and need to tell stories from their time in service.” My book is about soccer in the Middle East. Now, standing in a room full of people who would happily help get me over the finish line, I wanted to turn back in the other direction.As introductions began, I was brainstorming excuses when one fellow, an Air Force veteran named Jen, said something that caught my attention.