Controversies about those traumatized by serving in combat

When we think "ill" or worse, "mentally ill" we think two destructive things. First, there is a professional [who is] handling that, so I need not act. Second, they are unlike healthy me, but if I get near I may catch it. This is obviously awful, too.
- Jude McGee

This essay grows out of responses readers sent to my two previous ones here about people traumatized by war: "What is a Healthy Response to War?" and "Why NOT Call War Trauma a Mental Illness?"

In response to those two essays, some readers posted comments publicly on the Psychology Today website, and several friends and colleagues who sent private emails pursued these topics and raised important, related ones. If you have not read those posted on this website, I urge you to do so before finishing this essay.

Q: What to call war-traumatized people?
A: How about calling them "war-traumatized people"?

In response to the concern I expressed about harm that we do to war veterans (and often to other traumatized people) by construing the traumatic effects as mental illness, two people said that they had been relieved to receive a label. It is true that we must acknowledge the potentially positive effects of putting in words what a person is experiencing as overwhelming, fragmenting, and bewildering. It can help initially to be told, "You have Post-traumatic Stress Disorder" (PTSD) or "Major Depressive Disorder," for instance, because the labels are neat, the number of words is few, and most people (mistakenly) believe that once a professional has diagnosed them, that professional will know how to make them feel better.

In my play, WAR&THERAPY, the woman veteran asks to be labeled with PTSD, and the therapist replies: "Yes, because that sounds clean and clinical. For one moment you'll feel relief. But after that, it will bring you nothing but harm, keep you thinking you should be over it by now."

One reader said that every word in the term "Post-traumatic Stress Disorder" applied to her. But my point is that it does not tell others what she has been through in the way that such terms as "war trauma" or "rape trauma" would.

One reader presented the Catch-22 that, whereas being labeled mentally ill can add to veterans' burdens, not to name their suffering can leave them "feeling crazy." There is a third option, however, and that is to name it as accurately as possible, in everyday language, such as: "This person was traumatized by being in combat and now is plagued by fear and guilt."

To label or not to label?

Someone with the username Sebastian said in a comment on this site that he finds "all this talk about stigma and labels" annoying. He thinks that people should just ignore what others say about them, because "99% of stigma is all in your head," and anyone who is unable to ignore that has a weak sense of self. As Anonymous replied, however, it is hard to be told that it's easy to ignore psychiatric labels when they have been used to deprive you of your freedom and your rights. Anonymous described having been detained without charge or trial, then forcibly drugged. And Anonymous asked, "Is it my weak sense of self that means I'm now labeled and defined as incompetent and have my every word and action second-guessed and run through a filter of received prejudice? .... I could never be elected to high office, I know I could never get security clearance and work for example in the intelligence agencies." I urge readers to read the rest of Anonymous's comment, which was posted May 5, 2011, at 12:01 p.m. It will break your heart, but it shows the realities of the lives of many because they have been so categorized. And psychdiagnosis.net includes 53 stories of people whose lives were ruined in various ways by psychiatric diagnosis.

To read such first-person stories should alarm us all the more, given that the research simply does not show that labels help therapists help their patients (in fact, it often gets in the way) and given that a vast array of kinds of harm have come to people just because they have received virtually any psychiatric diagnosis, no matter how mild the label might seem. (Please see the two essays mentioned above and the references cited therein.)

For every person who has told me that they were relieved to get a label, far more have told me either that getting a label hurt and did not help or that they were relieved at first and expected it would help but were disappointed to learn that it did not.

If you receive such a label and are fortunate, the fact that you have the label may lead some people to take your suffering more seriously - i.e., "John/Jane is not just complaining but is experiencing severe emotional pain." But since labeling does not improve treatment or prognosis, how about if we take it seriously when a person tells us they have been through hell and are still suffering...without having to declare them mentally disordered? And isn't that all the more important when the kind or severity of the trauma (such as being in combat, being sexually abused as a child, being held hostage) is such that most of us would react as the sufferer is reacting? Surely we do not want to withhold from people in emotional pain our care, compassion, respect, and help unless they agree to be labeled mentally ill.

War veterans who have told me they were relieved to be diagnosed with PTSD have invariably explained that that was because it seemed that someone was finally listening to them and was telling them that they were not unique. Right. Not unique but nevertheless mentally ill. I would not want anyone I cared about who had been through war to be told that their sleepless nights, their grief, their fear, and their moral conflicts and existential crises were signs that they were mentally ill. As I have asked before, if those kinds of reactions to war are evidence of illness, what exactly would we call healthy reactions?

Some readers pointed out that diagnostic labels are important, because without them, patients have to pay for therapy out of their own pockets. I lived in Canada for nearly two decades, at the end of which I believed even more fervently than before that people deserve help when they are suffering and that professional help should be covered by insurance. Since some therapists are helpful, and there are sometimes reasons that a person wants to talk with a therapist rather than anyone else, that insurance coverage is extremely important. Until we can change our system so that payments are based on helping people with the problems they describe rather than relying on unscientifically-derived psychiatric categories, many people will want to be psychiatrically labeled so their insurance will pay for their therapy. All the more reason, then, to make sure to put in place protections of those rights that the diagnosed often lose, and all the more reason to make sure we tell war veterans and other traumatized people that, even though they have been labeled mentally ill, we really do not believe they are. This comes with a sigh that such machinations are necessary now and for the foreseeable future.

I am glad that some who wrote to me found helpful therapists, and I do not doubt their reports. But I wish to raise the question of whether the people who helped them could have done so without labeling them mentally ill. It is possible to say, "I see that you are suffering, it's understandable in light of what you have been through, and I will try to help you" without saying, "And this makes you mentally ill." In fact, those who write the psychiatric diagnostic manual have said repeatedly and publicly that they have not even been able to come up with satisfactory definitions of mental disorder. [2] This makes it all the more troubling to watch the rush to assign the labels.

The fact that therapists have helped some people is wonderful for them but does not mean that all or most therapists could have helped, and it does not mean that what their therapists did could only have been done by therapists. In fact, the finest therapists I know have told me that they believe that compassionate, intelligent people who are not trained therapists can do what they do. Indeed, research has shown that social support, including but not limited to self-help groups, is remarkably effective. And virtually everyone who tells me that therapists helped them also describe having been helped by other caring people and/or groups besides therapists.

I used to have a psychotherapy practice, and I was surprised that every time a patient told me I had done something helpful, something they were sure no one else could possibly have done, it was either nothing that I had learned in my training but only what would have been done by any caring, respectful person who thought carefully about what the speaker said, or it was something I had learned but that could fairly easily be taught to other therapists and non-therapists.

Does it help to talk with someone who has either been there literally (e.g., in Vietnam or Afghanistan) or been in similar situations (e.g., repeatedly molested by a close family member)? It certainly can. But so can talking with people who are willing to listen carefully and respectfully and to learn what it has been like for the speakers. It is one thing to say that some therapists are really helpful but another thing to say that no one but a therapist could help that much, and for humane and political reasons, it is important to demystify therapy and therapists. And to talk to a friend or other caring person, one does need to be slotted into a category of mental disorder.

I responded to one reader: "I am happy for you that you had a therapist who was right for you and smart and caring and effective. Part of what scares me is that, although there are wonderful people...working with survivors of the worst kinds of trauma, there are also therapists I have known who were so voyeuristic, self-absorbed, [or] slapdash in dealing with people they had diagnosed with [serious psychiatric labels] that ... since the people who seek help from those identified as trauma experts are already so vulnerable, it is scary to think of recommending they see even a ‘trauma expert'...unless they can get to someone [who is proven to be good]." The problematic therapists may represent only a fraction of those who are out there, but the sad fact is that one cannot assume, when desperately needing help and support, that the therapist into whose office one walks will be both helpful and safe.

It is sad that even some of the therapists one would think would be most likely to help those traumatized by war can do great damage. One of the veterans I interviewed for my book [3] told me that the therapist he saw at a VA Hospital said the vet could tell him anything about the war, and he would listen. But when the veteran told him a story that, while harrowing, was hardly rare as war stories go, the therapist cut him off, saying, "Please stop." The veteran was so shaken to learn that he could not even tell his story to someone paid to help and paid to specialize in working with war-traumatized individuals that he wandered around for hours in the parking lot, too disoriented and devastated to be able to locate his car.

I need to repeat here: Some therapists are wonderfully helpful. I hope it is clear by now that that I have never even questioned that. But with the enormous numbers of military and non-military therapists across the United States and based in combat zones, the fact remains that hundreds of thousands of veterans are homeless, jobless, addicted to drugs or alcohol, violent (whether suicidal or otherwise), or serving time in prison because whatever is being done to help them has not been enough.

It is time to stop expecting that therapists can fix all the carnage of war, with or without therapy and with or without medication.

In my next essay, I will address further the question of what else can be done to help those suffering from war and other kinds of trauma.

(Interviews ranging from 7 to 60 minutes may be heard at http://whenjohnnyandjanecomemarching.weebly.com/articles--interviews.html)

©Copyright 2011 Paula J. Caplan All rights reserved

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[1] Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press.

[2] Paula J. Caplan. (1995). They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Addison-Wesley.

[3] Caplan, 2011.

About the Author

Paula J. Caplan, Ph.D.

Paula J. Caplan, Ph.D., a clinical and research psychologist, is an associate at Harvard University's DuBois Institute and former fellow in Harvard Kennedy School's Women and Public Policy Program.