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"A Guy Burned Alive in Front of Me": Treating Traumatized Vets

The way we understand and use PTSD tempts all of us -- providers, society, and veterans -- to view the veteran as a victim, which may hurt them more than help.

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Most veterans still firmly believe that only the weak suffer psychological wounds from war. In my work with them, it's clear that they expect to be subject to that judgment by their military peers. Indeed, even physically wounded vets who've been medically evacuated for treatment are reluctant to go back to their units because they feel such shame for having "abandoned" their buddies, and fear that they'll be judged harshly by their fellow soldiers. The shame and fear of being condemned by their fellows is even greater for those who've been removed from their units for "mental problems."

The idea that a "deficit" of character or moral fiber explained why men fell apart during or after battle reigned unchallenged until World War I, when, for the first time, modern psychiatry offered an alternative: war neurosis. As a result of Sigmund Freud's influence, psychiatrists had begun the process of "medicalizing" humankind's response to extreme experience, suggesting that war neurosis was similar to ordinary neurosis: a resolution to an insoluble, intrapsychic conflict. In the case of combat, the conflict was between one's acknowledged duty and the desire to escape the danger and ghastliness of war. Given the ubiquity of that inner conflict, "It's amazing that more haven't succumbed," observed one physician.

After the Vietnam War, thousands of vets complained that dynamically trained Veteran's Administration therapists often focused on problems in their childhood, suggesting that the vets' emotional breakdowns were caused by preexisting psychological issues, and that the war was only a secondary, or triggering, factor. The fact that not everyone who saw combat developed symptoms reinforced the view that those having problems must have been made vulnerable by a precombat deficit. This "weakness" was then attributed to upbringing, rather than to moral deficiency.

Reacting to this profoundly discrediting stance, veterans' advocates during and after the Vietnam War promoted a new view: emotional and behavioral disturbances after combat were a normal response to the grisly realities of war. They asserted that the veterans had been all right before the war, and if they were having troubles afterward, it must be because of the war. This position gained support in the medical community, resulting in the decision by the American Psychiatric Association to adopt the diagnosis of PTSD in 1980 -- another step in the medicalizing process intended to destigmatize the psychological effects of war. At a stroke, life-altering changes in psychological functioning that resulted from the grotesqueries of combat were simultaneously normalized and pathologized: it was expected that vets would come home from war deeply impaired (even though many didn't), with a condition officially deemed a psychiatric disorder.

The Problem

There's no doubt that people who go to war are emotionally affected by it -- the more intense, terrible, and enduring the experience, the more those who return are troubled, and the more deeply troubled they are. But this has nothing to do with weakness or deficit -- moral or psychological -- and everything to do with the brutalities of combat. Central to that experience is the killing of others and the risk of being killed by others, prospects that inevitably stir strong emotions and conflicts -- a truth reflected in the arts from the epic poem The Iliad (ca. 700 BCE) to the film The Hurt Locker in 2009.

War evokes a complicated and conflicted jumble of intense feelings, thoughts, and judgments, which may persist long after, as the person struggles to make sense of it all. The most obvious element of this mix is, of course, fear. Hardly mentioned in The Iliad except by women, fear is somewhat more respectable these days, unless, of course, you're a young man who's motivated to "prove your manhood" or become one of "The Few. The Proud. The Marines," as the recruiting slogan says. No matter how a servicemember deals with the feelings of fear, however, showing fear almost certainly causes shame. So when a servicemember returns to "the world" and finds himself "hitting the dirt" at a loud noise, too afraid of crowds to go to the mall, seeking the seat next to the wall at a restaurant, afraid to drive or cross a bridge, or locking all the windows and doors at night, these fears threaten to become public and hence are powerfully laden with shame.

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