A few weeks ago, Matt Stevens, the National Guard captain and medic who served in Iraq and whom I mentioned in my Scientific American article, “The Post-Traumatic Stress Trap, wrote me an email about the social unease he often encountered when he showed any behavior that might remind people he had served in Iraq — a greater seriousness, an impatience with petty concerns or inefficiency, or even just talking about the place.
I have begun to think of military PTSD as to some extent a civilian problem rather than a soldier problem. To expand slightly here; civilians/politicians send soldiers off to war. They do their jobs. Which are sometimes horrifically violent, living in a world where violence, both by and against soldiers, is a norm, among people who differ in culture, language, and many beliefs, and then the soldiers return home to the US. The civilian population expects them to come home and re-integrate as if they never experienced these things. They want soldiers to become “normal” again. When soldiers fail to normalize to the satisfaction of whatever civilian population is judging them, they are labeled with PTSD. ….
My analogy that I use to explain this in a few sentences is that; a bunch of sheep dogs are sent away to another land to protect the sheep from wolves. While there they essentially become wolves in order to survive. They return to the herd of sheep as wolves but are expected to live as sheep dogs again — or in the case of National Guardsmen, they are expected to become sheep.
Given the sensitivity of this subject, I should note that Stevens stressed both in that email and later over lunch, when he articulated this again, that he does not mean to say no one gets PTSD, for he knows soldiers who have. Rather he’s saying that the culture he’s returned to, in its unease with the changes soldiers go through, seems overready to declare those changes signs not merely of change but of pathology.
I thought of this when I got this comment from Neuroskeptic on an earlier post about my PTSD story:
The issue of psychiatric overdiagnosis goes well beyond PTSD, I think. Many people would also argue that depression, ADHD, and (increasingly at the moment) bipolar disorder are overdiagnosed, in both adults and children.
The problem, as you’ve discovered, is that it’s much easier to diagnose someone than to de-diagnose them. Saying that someone who has problems is ill is easy, and often seems compassionate: “Your kid’s not a bad kid, he’s a good kid with bipolar” …. I think this is one of the main reasons why diagnoses tend to expand, and never contract.
What we need, I think, is a recognition that someone can have serious problems that require professional help without that meaning that they need a medical diagnosis.
Neuroskeptic has a good point. I would add that we also sometimes medicalize — that is, give a diagnostic label and purely medical response to — behaviors and emotions that rise as much from social problems as from inner pathology. This can and does happen with, say, kids who are distressed because their parents are divorcing, and who act out accordingly, and — when the parents can’t seem to create a more reassuring environment — are diagnosed with ADHD or oppositional defiant disorder. This isn’t to say every such diagnosis happens this way; but some do, and when that happens, we’re substituting a medical diagnosis for a familial or social problem.
It seems clear to me that this happens too with many returning veterans, some of whom face extremely difficult issues re-entering civilian life: Their families just want them to be the same as they were before (as they themselves may wish they could be); they may face intense challenges finding suitable work, or work at all; their departure from the military may rob them of their circle of friends, so that they find themselves socially isolated far too many of them find themselves without access to health care; and they do not get nearly enough assistance finding work, training for work, or getting an education as they should (The the education front, thank goodness, is being addressed by the recent update of the GI Bill. But we have not provided the employment, business, and training assistance we should for soldiers who don’t go to college.)
In short, many vets face problems that can quickly produce or aggravate anxiety, depression, insecurity, or any tendency toward substance abuse or angry outbursts. Do we have a diagnosis for that? No.We offer some programs to help them but not nearly enough. But if they walk into a clinic, they’ll likely be told they have PTSD.
Meanwhile, society itself — a culture that has managed to put our current wars very much out of sight and out of mind — seems to want to put a PTSD label not just on those who really have it (who do need a medical response as well as a broader societal one), and not just on those who don’t have PTSD but who are struggling to make the transition, but even on high-functioning, perfectly health veterans like Matt Stevens.
Why is this? I think it’s because we so deeply want to see these returning soldiers just resume their old citizen selves without a bunch of fuss; and at the same time, we want to express sympathy with them in the way we seem most comfortable, which is to tell them we think they’re sick, and treat them accordingly. This is much easier — and casts us as sympathizers and healers rather than people impatient with war and guilty for starting one. We don’t want to know that they face serious challenges caused by societal rather medical weaknesses. We don’t want to see any sign in them of the war they’ve returned from. We don’t want to face the fact we’ve sent them off to a war we declared — and two-thirds of us cheered for — based on faulty evidence. When they come back changed — and everyone who goes to war is changed — we don’t want to see it, or acknowledge it for what it is. We don’t want to see that a stupid decision we made as country forced you men and women to grow up so fast, to become so serious, to return to a place eager to forget the most transformative force in their lives.
We don’t want to see these changes. So we classify them not as a natural but serious thing that happened because of stupid but serious mistake we made, but as pathology.