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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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Thus, at some arbitrary point, stress becomes trauma, a response becomes damage, the temporary becomes enduring, and the subjective ("I feel stressed") becomes objective ("You have PTSD"). Then the power to define what's happened shifts from the person to the mental health provider, and the person's self-perception shifts from responsible agent to damaged victim of terrible circumstances who's in need of help, now and probably in the future.

What's in a Diagnosis?

It's this implication of passively received damage implied by the word trauma in the PTSD diagnosis that I directly challenge. Indeed, the severely stressed person has shot out a lot of adrenaline and cortisol, experienced multiple, intense emotions, and perhaps lost someone close -- all of which is shocking, frightening, painful, difficult, and a huge challenge to cope with. But how is it inherently damaging? Undeniably, we have increasing evidence that neurobiological changes can reflect intense or repeated exposures to threats, but the relationship between these changes and the symptoms of PTSD remains unclear.

Unlike any other mental health condition, PTSD requires an external event to obtain the diagnosis. Since the experience of an external threat of death or serious injury is necessary for the diagnosis, it's a quick step to assume it's also sufficient to cause symptoms, but it isn't. Many vets whose stressors don't meet the criteria of "traumatic" nonetheless meet symptomatic criteria for PTSD. More troubling still, many people who've endured what most people would consider profoundly horrific experiences never show significant symptoms.

So when our struggling, troubled veteran is told by a professional (who should know) that he "has PTSD," I believe he's being offered a nearly irresistible solution to his problems: his symptoms don't mean he's weak or crazy or screwed up -- he's been "traumatized" by events that would damage anyone. If the choice is between weak or sick, he'll take sick.

Thus my main objection to the way we understand and use PTSD is that it tempts all of us -- providers, society, and veterans -- to view the veteran as a victim. It provides the false balm to the soldier that he's this way because of what happened to him. He's offered a disabling but clearcut condition, which, with the doc's help, he can try to overcome. Imagine the strength it takes to refuse such an offer!

The PTSD diagnosis provides what appears to be an easier way out of pain and conflict than struggling with the existential, often terrible, realities of life. The fundamental, universal human dilemma -- how to cope with overwhelming feelings, come to terms with inherently opposing realities, find meaning in meaningless chaos -- is turned into a "psychiatric disorder" that can be "treated." Like the rest of us when we have an "illness," the veteran hopes that there's a pill that'll fix him and send him on his way. But of course there isn't. Nor is any therapeutic approach that's geared just to alleviating his symptoms likely to work. True healing requires knowing and accepting all our experience.

A Different Approach

By the time a patient presents at my clinic, he's usually adopted a solution that compounds the problem: he presents as a sick person, with a condition that I, the doctor, am supposed to fix. So before therapy can proceed, I must reeducate him. This requires that I challenge his belief that he's ill, his symptoms are the inevitable result of his experiences, and his injury is permanent. Challenging a veteran in this way enables him to experience more options for himself. It holds him accountable, and is an essential part of his recovery.

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