In the United States and other countries that have a military, there is often a great deal of talk about supporting veterans, but way too often, research aimed at learning what will be helpful is misguided and can even be harmful. The same applies to nonveterans who have been through traumatic experiences. Two new studies exemplify such wrongheaded approaches.
Before we consider these studies, I invite you to imagine for a moment that all you know is that a person has moved abruptly from their initial environment to one where they are strenuously trained to think, feel, and act in vastly different ways, and then some years later, moves abruptly back to the initial one, with little or no assistance in readjusting to that second culture shock.
It would be reasonable to assume that that person might feel confused, unsettled, deeply apprehensive, and isolated at the time of the first change and/or at the time of the second. That is what tends to happen to people who move from civilian life to the military and then back to civilian life. Add to that the facts that while in the military, many serve in war zones and are often deployed a staggering number of times, many are sexually assaulted, many servicewomen experience sexual harassment and other forms of sexism, and many servicemembers experience other kinds of mistreatment due to racism, classism, homophobia, or abuses of power by people above them in military rank.
It would be expected for veterans to have feelings ranging from uneasiness and worry through to intense fears, grief, moral anguish, and loss of innocence. Unfortunately, way more often than not, these deeply human feelings are classified as signs of psychiatric disorders, and the “treatments” recommended largely consist of two or three forms of psychotherapy and psychiatric drugs—not uncommonly up to a dozen at the same time (see When Johnny and Jane Came Marching Home and the film “Is Anybody Listening?”). In my work for more than a decade of listening to military veterans, I have learned that, as with people labeled “mentally ill” who have not served in the military, to receive a psychiatric disorder label is to carry an additional burden.
There are several reasons that getting a label is sometimes immediate cause for some relief: (1) sometimes, people feel this is the first time anyone has believed they are suffering, but that aim can be achieved if we say we believe they are suffering; (2) they cannot get certain benefits and services without getting such a label, but as some veterans have said, “We ought to get benefits we deserve without having to agree to be called mentally ill,” and as for the “services,” too often (though of course not always) they range from ineffective to damaging.
Furthermore, the longer-term consequences of getting such labels can include plummeting self-confidence, loss of hope (veterans have told me that VA doctors have said, “You have PTSD and will never get better”), loss of employment or custody of children, loss of the right to make decisions about one’s medical and legal affairs, and even death. Physical problems and deaths can result from the psychiatric drugs and from professionals’ and family members ignoring of the person’s real, physical illnesses and injuries on the grounds that their “psychiatric disorder” leads them to fabricate them.
In the field of researchers who assert that they are searching for the causes of veterans’ suffering, it is astonishing how often they operate on the basis of a trio of misleading and ultimately harmful assumptions. These are (1)That the common military experiences described above and the sequential culture shocks play no role, (2)That nonveterans’ documented lack of interest in and unwillingness to listen to veterans play no role, and (3)That the real causes of veterans’ suffering are not experiential but rather are biological.
Major VA Study
A recent Yale University press release (“Study of veterans details genetic basis for anxiety, links anxiety and depression”) was a report of “A massive genomewide analysis of approximately 200,000 military veterans” from the U.S. Veterans Administration’s Million Veteran Program, whose primary goal was described as “finding the genetic underpinnings of mental health disorders.” The study’s authors said they had discovered the genetic basis for “anxiety” as well as links between “anxiety and depression” [my quotation marks].
Thus, first of all, their implicit assumption is that these emotions are genetically based or at least that in veterans, what matters is to look at their genes rather than the traumas they have experienced. What is the purpose of that? It certainly draws the focus away from military trauma, whether or not that was the researchers’ conscious intention. But any researchers who have at their command what must have been a huge budget have a choice of what to study. These researchers chose to study genes.
It is not clear from the press release whether or not they looked at the military—or life—experiences of the veterans at all, but if they did, these are not mentioned, thus giving the impression that they are not relevant. Of even greater concern is that by focusing on genes, they give the impression that the causes of the problems lie within the individuals, thereby making it easier for the real, experiential, traumatic causes to be ignored.
There are other, major problems with the study. One involves the use of the terms “anxiety” and “depression,” words that most people in the U.S. would say apply to their feelings at some times in their lives, so why are only veterans studied here? Another is that both terms are extremely vague and applied to such broad arrays of feelings that they come to mean little more than “I’m not feeling calm and happy.”
David Cohen and David Jacobs address this problem with regard to “depression” in a classic paper.1 In my own clinical and everyday experience, when people tell me they feel anxiety, if I ask them what word they would use if they were not going to use that one, it is usually fear. Fears of many types are understandable reactions to many military experiences noted above, and it is unwarranted, offensive, and often damaging to call them signs of mental illness.
The VA/Yale researchers’ press release includes explicit naming of anxiety and depression as “mental disorders,” with alleged possible links to “bipolar disorder, posttraumatic stress disorder, and schizophrenia.” By listing those three psychiatric labels that sound more alarming even than “anxiety” and “distress,” even though none of the three represents a solidly scientifically grounded entity, the press release furthers the apparent purpose of making this research sound serious and important.
A Harvard study of “PTSD”
A report of another recent study appeared in Harvard Magazine and was titled “A blood test for PTSD?”. The article’s author, Erin O’Donnell, presented the study as reflecting “nearly a decade’s study of PTSD by more than 75 researchers, including [dean of the Harvard Paulson School of Engineering and Applied Sciences] Frank Doyle” and others from New York University, Columbia University, the University of California, San Francisco, and the United States Army.
It’s noteworthy that O’Donnell introduces the study by writing that Vietnam War veterans were suffering from problems like flashbacks, nightmares, and hypervigilance, and when some people began calling “the condition post-traumatic stress disorder,” this diagnosis “was viewed by some with skepticism.” She says that “the doubts and stigma made many veterans hesitant to report symptoms.”
In that context, she presents the new study as though it is helpful to veterans, proving that the “condition is not just ‘all in the head.’” As a result, readers may be predisposed to feel grateful for this research, assuming it will be helpful for suffering veterans to be told that a blood test can prove that their problem exists.
There is a parallel between that presentation and the appeal of the National Alliance for the Mentally Ill, which is heavily funded by Big Pharma, to parents of deeply troubled or different people, i.e., “You are not to blame. Your child has a chemical imbalance in the brain.” It is problematic and raises moral and ethical questions to focus on finding an allegedly physiological cause of suffering in order to justify showing compassion for, and offering help to, those who suffer and to their parents.
Beyond that concern, there are serious methodological problems with the study in question. To begin with, like the other diagnoses in psychiatric use, the construct of “PTSD” is not scientifically valid. It was composed by well-meaning people who hoped that creating a psychiatric category and getting it into the Diagnostic and Statistical Manual of Mental Disorders would encourage people to take veterans’ suffering seriously. They included in the list of “PTSD” criteria some of the common consequences of trauma but by no means all.
As a result, some traumatized veterans (and traumatized nonveterans) fit the “PTSD” requirements, but many do not. Responses to trauma vary widely from one individual to another. As Linder has shown, even well-intentioned therapists who work with trauma survivors apply the PTSD label to anyone who has been through something horrible and is suffering, whether or not they meet the DSM criteria for PTSD.2 So the category itself was not scientifically grounded when it was created, and in addition, it is not even consistently applied.
Thus, the very—unspoken—basis of their study, that “PTSD” is a clearly defined entity that applies to veterans, is just wrong. Furthermore, when that label first went into the DSM, the category included the specification that it was a normal response to an abnormal situation. But in the DSM-IV edition whose Task Force was headed by Allen Frances, that specification was removed, so that people’s deeply human responses to war, sexual assault, and other horrible experiences are thereby further pathologized. As noted, this is damaging in adding to the burden of those who are already suffering.
Even if “PTSD” were a valid construct that characterized all veterans or all traumatized people, this study is deeply flawed in other ways. For one thing, the researchers studied a small number of people: 83 combat veterans with a PTSD diagnosis and 82 who experienced combat “but did not have PTSD,” the latter supposedly constituting a contrasting group of people. Given the lack of validity of the PTSD construct, it is hard to know how people in these two groups actually differed from each other, since even those without the PTSD label surely were affected by having been in combat. As psychologist and veteran Dr. Kathy Platoni says of having been in combat, and as many other veterans have said, “Not one of us comes back unscathed” (in “Is Anybody Listening?”). So the absence of two clearly different groups to begin with is another foundational error of the study.
The researchers took blood samples, heart rate readings, and did other tests that yielded “more than a million data points” for each person. Of this vast number, they found “28 indicators highly predictive of PTSD.” When that many data points are thrown into the hopper, on the basis of probability, one would expect that far more than 28 indicators will appear to be significant, even though 28 could turn up just because of chance.
The researchers’ next step was to test those 28 factors on a new group, but that new group was also divided into 29 male veterans diagnosed with “PTSD” and 29 not given that label, so the same problems apply as to the original sample. With those 58, the blood test “accurately diagnosed the disorder [sic] 77 percent of the time.” If one were to ignore the foundational and definitional errors, that 77 percent might sound impressive, but consider that it means that after collecting more than a million bits of data about each of the original 165 veterans, they came up with a method that incorrectly classified nearly one-quarter of the second sample as having or not having been labeled with “PTSD.” That is no small concern for people who consider it important to “get diagnosis right,” however misguided that aim is.
They report that the 28 markers include “immune signatures, stress signatures, and markers of cardiovascular health,” and say that this is important because “Evidence suggests links between PTSD [sic] and Type 2 diabetes and cardiovascular disease,” according to Harvard graduate student Kelsey Dean, a member of the research team.
The usual assumption these days about cause-effect relationships in topics like these is that if one finds a physiological factor, that must have been a cause of the alleged mental illness. But having Type 2 diabetes or cardiovascular disease are themselves sources of considerable life pressures (these researchers use the vague term “stress”), and those could have led to or contributed to therapists diagnosing people with those conditions as having “PTSD” more than people without diabetes or cardiovascular disease.
In summing up what they consider the importance of their study, Doyle and Dean say that their results “mark the beginning of new approaches for a variety of psychiatric illnesses,” because current diagnostic surveys “require that patients accurately report their symptoms.” This is a striking statement for two reasons. One is that it is based on the false notion that psychiatric illnesses are scientifically created and validated and thus that identifying their characteristics accurately means that people get the “correct” diagnoses. The other is that the implication that veterans or suffering people in general do not accurately report their symptoms reflects a marked dismissiveness of them—but remember that such dismissiveness was used at the beginning of the article to try to justify seeking physiological factors in this study. Clearly, claiming to have found a blood test for “PTSD” is no better or more justifiable as a way to dignify understandable responses to trauma than was creating “PTSD” and getting it into the DSM.
What Would Be Helpful
It is crucial to note that life is filled with traumas of various kinds, and people who serve in the military tend to experience additional, unique kinds of trauma. It is crucial to stop the knee-jerk pathologizing of responses to trauma, whether by diagnosing the sufferers with “PTSD” or other psychiatric labels. It is crucial to listen to people in our communities who have been traumatized, whether they are veterans or nonveterans, rather than to flee from hearing what they have been through and rather than assuming that only therapists can and should try to help. It is crucial to resist the temptation to think that research containing words like “brain,” “chemical imbalance,” “genome,” and “blood test” tell us more about the causes of human suffering and the ways to help reduce it than does looking to our common humanity and responsibility to help.
Anyone interested in finding nonpathologizing, low-risk or risk-free ways of helping to reduce the suffering of veterans or nonveterans may find helpful some of the approaches found here.
- David Cohen & David Jacobs. (2007). Randomized controlled trials of antidepressants: Clinically and scientifically irrelevant. Debates in Neuroscience 1, 44-54. ↩
- Meadow Linder. (2004). “Creating Post-traumatic Stress Disorder: A Case Study of the History, Sociology, and Politics of Psychiatric Classification,” in P. Caplan & L. Cosgrove (Eds.), Bias in Psychiatric Diagnosis. Rowman & Littlefield, pp. 25-40. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.