Friday, January 09, 2009

The Pentagon Dishonors Our Wounded Veterans

After considering the matter, the Pentagon has decided not to award the Purple Heart to veterans who suffer from Post-Traumatic Stress Disorder (PTSD) as a result of their service. The Purple Heart is a medal bestowed upon soldiers wounded or killed in enemy action, entitling its awardees to various benefits, including waiver of co-payments for medical treatment at veterans hospitals as well as high priority in scheduling medical appointments. PTSD is a psychiatric disorder that afflicts many exposed to highly traumatic events (such as war combat) and is characterized by symptoms that can include recurring nightmares, uncontrollable rage, and severe depression. Victims of PTSD often find it impossible to work or otherwise function productively in the ways they could prior to their traumatic experiences.

Those who defend the exclusion of PTSD from the injuries qualifying a veteran for the Purple Heart make some variation on four arguments: 1) it is sometimes difficult to diagnose PTSD with certainty, 2) symptoms may be faked, 3) enemies do not deliberately inflict PTSD, in the way that they deliberately kill and maim with weapons, and 4) PTSD is not a physical wound. These arguments are unpersuasive and demonstrate the continuing vitality of the mind/body fallacy that has plagued societal attitudes toward the mentally ill over the centuries.

1) On the question of ease of diagnosis, the Pentagon could have addressed this matter in a variety of ways, short of disqualifying PTSD altogether. It could, for example, have established criteria under which health professionals would decide -- just in the way that doctors reviewing disability claims decide -- who qualifies for the PTSD diagnosis for purposes of receiving a medal. Just as a person who suffers a stubbed toe as a result of an enemy assault would not thereby qualify for a Purple Heart, so would a soldier who suffers from mild, normal-range sadness after serving in the military similarly not qualify. Though I would not support doing so, moreover, the Pentagon could even require total disability as a prerequisite for the medal. By instead denying all sufferers of PTSD the Purple Heart for their injuries, the Pentagon implies that because diagnosis may be difficult, it is not worth the bother to recognize the sacrifice of afflicted service members.

2) Any time a person must meet criteria for any medal, there is room for fakery. Though it is difficult to fake the loss of a limb, it is certainly possible for a person to pretend that a physical injury suffered in a non-military context was in fact the result of enemy fire. Anyone who appears at work on crutches has had the experience of jokingly inventing heroic adventures to explain what was actually a slip on black ice. Furthermore, the assumption that people who claim to suffer from mental illness are inclined to and can easily "fake" their symptoms is a common misconception that infects lay discussions about the insanity defense as well. The reality is that because of the stigma attached to mental illness, people are much more likely to "fake" mental health than they are to fake a psychiatric disorder. And for those who do wish to engage in such fakery, most are not such talented actors that they can fool professionals who are trained to distinguish the ill from the well.

3) It is quite difficult to identify exactly what an enemy's goal was when we later assess the causal relationship between an assault and the injuries that followed. An army might intend, for example, to destroy munitions through a particular bombing operation but nonetheless know that in the process, soldiers will likely suffer and die. In such a case, no one would argue that the maimed and the dead did not earn Purple Hearts because the enemy did not "intentionally" kill or maim them. Injuries suffered as a result of an enemy assault in war are the foreseeable consequence of such an assault, and so are the mental disabilities that afflict many veterans who return from combat. PTSD, in other words, is -- in its causal connection to war -- not distinguishable from the loss of life and limb in a military campaign.

4) The notion that a psychiatric illness is not "physical" assumes that a person can have an experience in his or her mind without a corresponding physical component. If we ever believed such nonsense, our current capacity to analyze the brain -- through functional MRI studies as well as measures of various chemicals in the blood -- proves it to be false. When a person experiences psychological distress, there is a physical basis for this experience. Indeed, the etiology of PTSD lies in the impact of terrifying events on a person's neurological circuitry. Though psychiatric illness remains less well understood than much (though by no means all) physical distress, we do know that both types of suffering are experienced through an individual's brain and nervous system and -- when the trigger is war -- that both are a physical consequence of service in the armed forces.

In October, Congress passed, and the President signed, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, thus giving legal effect (in the health insurance context) to the notion that mental and physical illnesses are morally equivalent and merit equal societal consideration. It is disappointing that for those who serve in the military, such equality -- like that on the basis of sexual orientation -- remains elusive.

Posted by Sherry Colb


Paul Scott said...

The problem is not helped at all by the American Psychiatric Association; it is currently undergoing a new publication of its Diagnostic and Statistical Manual of Mental Disorders - the "bible" that defines mental illness for many official purposes, including insurance.

I think the prominence of the discussion surrounding this latest update contributes to the notion that these disorders are largely non-sense. Most psychological disorders are described by a series of symptoms that all sound normal. This is true even of many disorders most people would regard as serious and real.

Take, as only one example, antisocial personality disorder (e.g., a sociopath). The definition from DSM IV: "The essential feature for the diagnosis is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood."

The list of symptoms include (among others): Impulsivity, lack of long-term goals and superficial charm.

And that is from a disorder I think almost everyone would recognize as real.

The history of the DSM also does not help - as it once most famously defined homosexuality as a disorder. This year, for DSM V, on the political block is gender confusion disorder. The discussion - at least the public discussion, as the official minutes of the DSM V review board are now and forever kept secret - revolves around politics rather than consideration of mental health. As an example, the transgendered community is split on its inclusion - they don't want it labeled abnormal, but doing so would allow more ready access to surgical procedures through insurance. The religious community takes the same bizarre position it did with homosexuality - they want it defined as a disorder (though how you can hold something as a disorder and simultaneously hold it out as a sin I do not understand).

These are not medical discussions, yet they may be relevant factors as to the inclusion or not of a potential disorder.

Also not a medical discussion is the panoply of medications available for "low-grade" psychological disorders. I am sure the pharmaceutical giants want very much to see things like "social anxiety disorder" maintain a prominent place in the DSM. The more things that can be moved from "normal range of human emotion and experience" into the "disorder" category, the better off pharmaceutical companies will be.

It is these things that I believe are doing a constant disservice to the position of mental health in the general populace.

C.E. Petit said...

I agree with the conclusion that this was improper (as a veteran myself), but I'd like to point out that there's a rather unique complication that makes it virtually impossible to have a reasoned result that satisfies anybody:

Article 115 of the Uniform Code of Military Justice treats "malingering" to avoid duty as a criminal offense.

Frankly, relying on Article 115 is stupid, and reflects distrust in command authority (if a commander at any level must rely on Article 115 to motivate the people under his/her command, there's something seriously wrong with the commander — not with the subordinates) that should have been excised by Congress long ago. It wasn't even necessary in 1968, when the current general list of offenses was adopted.

My point is that to the unsophisticated — like the barely educated and trained personnel specialists who have to process Purple Heart awards — PTSD looks a helluva lot like malingering. Too, there's still a stench of Vietnam-era disdain floating through the senior leadership and military academies that is only reinforced by the very existence of Article 115.

In short, I don't agree with the decision in question, but I do understand it as a "military culture" sort of thing that would require more than just formally allowing PTSD as qualifying for the Purple Heart to make it work.

heathu said...

The post today makes fine rebuttals to the military’s rationale for its disappointing decision not to recognize PTSD with a Purple Heart. I would go Prof. Colb one further though, on her rebuttal to the Pentagon’s #3’s “enemies do not deliberately inflict PTSD, in the way that they deliberately kill and maim with weapons.” If anyone in the Pentagon proffered that reason, the answer is of course they do, or try to, just as we do it to them. Any artillery officer knows that the effects of his weapons are not just physical destruction, but:

the "sheer horror" and the "sense of hopelessness" artillery barrages create among those on the receiving end. For soldiers subjected to massive artillery barrages, artillery is a "monstrous, apparently unstoppable machine, slicing mechanically through earth, rock, flesh, bone and spirit." The "psychological effect multiplies its cold lethality many times.", (quoting British military analyst Chris Bellamy’s book The Red God of War.)
Or consider the recent Iraqi campaign of “Shock and Awe.” Just the name makes it clear we intend to create as much trauma to the enemy’s psyche as we do to his palaces or command bunkers. It’s actually a part of the official doctrine, known formally as “Rapid Dominance,” to “…maintain[] the ability to impose Shock and Awe through continuously surprising and psychologically and physically breaking the adversary’s will to resist.” Harlan K. Ullman and James P. Wade, Shock And Awe: Achieving Rapid Dominance (National Defense University, 1996), XXIV, pp 58-59.
So if an enemy inflicts such trauma on a service member’s mental state to the point they can’t function, they are wounded by the enemy’s intentional actions in the most literal sense, and deserve the same recognition that all wounded service members have.

Sherry F. Colb said...

Heathu makes an excellent point about the intent of bombing raids, with the "shock and awe" language of our outgoing Commander in Chief a perfect illustration. If a war is to end before everyone on one side has been exterminated, it is because at least one of the two sides is psychologically subdued or persuaded that it simply cannot prevail. This is as much a goal of war as physical injury and death, perhaps moreso.

C.E. Petit's point about malingering is well-taken. The word "malingering" in psychological parlance actually refers to a person attempting to "pass" as mentally ill. Psychological tests like the MMPI contain questions intended to flush out malingering from authentic disorders. To treat all disorders as "malingering" is therefore either utterly insulting or extreme (in the way that theories that mental illness is a myth are extreme).

On Paul's post, it is true that the definition of "psychopath" (or "sociopath" or "antisocial personality disorder") is slippery, but I think that is, in part, because of what distinguishes it from most of the disorders that matter to mental health professionals: such people do not want to "get better" and they therefore fall outside of the ordinary definition of illness and disorder. We generally think of people who are said to "suffer" from an illness as experiencing pain or distress, whereas a person who lacks a sense of conscience and socially-oriented guilt and anxiety (as a sociopath does) may very well *like* being that way. The debates about what should qualify as a mental disorder are, at least in part, political and perhaps inevitably so (because defining behavior as "abnormal" or "sick" necessarily judges that behavior in a negative way), but I do think the anti-social personality disorder difficulties are somewhat unusual (as compared, say, to depression, anxiety, and psychosis), by virtue of the apparent lack of distress.

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