The University of California, Irvine study found that combat exposure is almost as likely to cause grief as it is to lead to PTSD.
Jesus Medina hits a black punching bag again and again in the front yard of his home in Lancaster, Cal. He spins around and kicks it, as his Jack Russel Terrier barks and runs around by his feet.
Medina has a regimented morning routine of exercise that he says helps him release energy.
Each time he strikes the punching bag, the words tattooed down the length of his forearms move like lightning. On the right: "Protect." On the left: "And Serve."
Medina is one of nearly 200 post 9/11 veterans who participated in a University of California, Irvine's study of grief in veterans.
Two days after 9/11, Medina picked up the phone and volunteered for the Army. He landed in Iraq in 2005 and eventually found himself on an elite team of soldiers.
"We were basically expected to catch higher tier targets," he said. "Generals. People that make moves."
That meant a lot of time in an armored vehicle. Medina's a small guy, so he drove. Squeezed into a tiny seat, with a tinier window slit to look outside, he saw a lot of violence. Like being hit not once, but twice by an IED.
"I'm turning right, and boom!," Medina said, gesturing with his hands. "And that's when a lot of us got very seriously injured. I woke up in the light. And I said, 'I don't know what's over there, but I need to go back to my family.'"
"All of a sudden it was dark, and then all of a sudden, screams," he said. "And then, all of a sudden, Hell."
Some of his comrades were seriously wounded in that explosion. As his time in Iraq went on, he saw people die - both Iraqis and his fellow soldiers. Days after he arrived, he was involved in a firefight with insurgents where several lives were lost. Another time, a close friend was shot in the neck.
But there weren't a lot of ways to cope with the daily violence. There still aren't.
"A lot of us had to do something so inhumane to be able to stay human. Which was… shut off, everything," Medina said, with tears in his eyes. "I was married at the time. I stopped calling my wife for almost two months."
An often-missed consequence of war
That didn't come as a surprise to Pauline Lubens, the University of California, Irvine researcher who interviewed Medina and other veterans about grief.
"We think of soldiers as these warriors that don't have emotions, but we're dead wrong about that," she said.
A few years ago, Lubens was speaking at a campus Veterans Day event when an Army veteran approached her. He talked with her about friends who died in combat or by suicide.
"And while we were talking, I realized, I never hear anybody talk about grief or loss in people who served in combat," she said.
The study, co-authored with UCI psychological science professor Roxane Cohen Silver, found that post 9/11 veterans who lost fellow service members both to combat and suicide dealt with the losses differently. Combat loss was easier to accept than suicide.
Silver said that Post Traumatic Stress Disorder and depression are well-documented in veterans, but grief is not.
"What we're identifying are very important psychological consequences of serving in the war that are clearly being missed," she said.
The study also found that combat exposure is almost as likely to cause grief as it is to lead to PTSD.
"One of the veterans said to me, 'people are calling me a hero when they don't even know what I did over there,'" Lubens said. "'I mean, if I was such a hero, why did I lose so many guys?'"
Only about half of one percent of the U.S. population serves in the military. Lubens said that contributes to isolation and detachment from the civilian world for many veterans.
"People actually come up to a veteran and ask them, 'Did you kill anybody?'" she said, "which is such a rude question. But it's a question I think based on not knowing what else to ask."
She said instead of asking veterans, "Did you kill anybody," people should ask if they lost anybody.
'There really is nothing that can fix that burden.'
Silver previously conducted a large study focusing on Vietnam veterans a few decades after the war. She said it found that civilians did not want to hear about veterans combat experiences, and that veterans felt most comfortable communication with fellow veterans.
"I think one of the messages of this [current] study is that not much has changed in that regard over the decades," she said.
So what's to be done? Pauline Lubens said clinicians need to talk to their veteran clients about grief. She said there's a need for more research to find effective ways to help troops deal with grief while they're in the service, and afterward.
Lubens, who earned a doctorate at UCI last year and is now with the Institute for Veteran Policy at Swords to Plowshares in San Francisco, said she plans to expand upon her study.
But Jesus Medina isn't optimistic anything will help. He said most veterans he knows are lonely and don't feel understood.
"No matter what, whether you understand grief or not, you have a relationship with it," he said, "and if you don't understand it, it really kills you and your family. And when you get to that point, there really is nothing that can fix that burden."
Since coming home, Medina said he's lost two fellow soldiers to suicide. He said it's because they didn't know what to do with their grief.
This story was produced by the American Homefront Project, a public media collaboration that reports on American military life and veterans. Funding comes from the Corporation for Public Broadcasting.