The Puzzle of PTSD

Does the PTSD diagnosis do more harm than good?

By Roy Clymer

At eight o'clock on Tuesday morning, I walk into a nondescript room at Walter Reed Army Medical Center to greet seven soldiers and marines who've been back from Iraq or Afghanistan for a year. Sprawled around a large, coffee-stained table, looking wary, the vets are here because they, or someone else, said they have post-traumatic stress disorder (PTSD).

This is the first meeting of an exposure therapy group I'll be facilitating, and I'm anxious because if the treatment goes well, it'll be painful for them, and everyone prefers to avoid pain. These men and women have been treated with medications or intermittent counseling to help them deal with the emotions and conflicts they fear, but they remain symptomatic. Now they've landed at Walter Reed's Deployment Health Clinical Center to participate in a three-week, multidisciplinary program that helps vets adjust to life after combat. They're guarded, skeptical, but not without hope.

I meet their hope with my faith that I know how to help them. My approach is different from most because it's premised on the belief that the way the field currently understands the effects of war and communicates that to veterans can, however unintentionally, undermine their recovery. I believe the diagnosis of PTSD actually hampers our ability to help these vets do the hard work of facing their demons, coming to terms with their experience, and ultimately healing.

I start the group by explaining how exposure therapy came to be the treatment of choice for people suffering the ill effects of horrible events. I describe it as a process by which people can begin to contact their feelings about the devastating events they've experienced, and how embracing those experiences eventually enables them to move on with their lives. When I finish, John, a wiry guy with a blond crew cut, thumps his fist on the table. "Move on?!" he asks incredulously. "What's that about? I will never forget! I'm a living shrine to all my buddies who died in Iraq. They can't be forgotten!"

Before I can respond, he launches into his story. Last year, just outside Baghdad, an Improvised Explosive Device (IED) shattered the truck in front of him. He raced to pull the bloodied soldiers from the vehicle. One of them, his best friend, Larry, was barely alive. John rendered first aid, but Larry died on the medevac flight out.

That was just the beginning. As John picked up another friend's dismembered body and asked a soldier to help him recover the pieces, the soldier croaked, "I can't!" and ran off. Meanwhile, John's platoon sergeant, who should have taken charge, sat frozen in the seat of his Humvee, unable to move or speak. John had to take charge of the rescue and arrange the medical evacuation on his own.

Amid this barely contained chaos, the Quick Reaction Force arrived. At last! John thought with relief. Then he watched in horror as their vehicle was almost immediately hit by another IED, engulfing it in flames. "I ran back and forth, trying to approach the men in the truck, but then I had to jump back when the heat became unbearable," he recalled. "Only one man made it out." He stopped, fighting tears. "And that guy burned alive in front of me."

Ann spoke next. She'd come into the program after two years of treatment for third-degree burns that had covered 30 percent of her body, especially her face and arms. She'd suffered the burns in Kunar Province, Afghanistan, when she'd poured gasoline on a 50-gallon drum of human waste, causing the pile to spontaneously ignite. She told us that she'd been directed to burn the waste by a sergeant "who ignored my statement that I'd never done this task before and had no idea how to do it." In fact, the policy at the time explicitly prohibited soldiers from burning such waste, due to numerous reports of burning accidents. "He should have known this," she said angrily. "Actually, I think he did. He already had problems with me. Maybe this was payback."

While in the hospital recovering, Ann discovered that the day after she'd left her base, a vehicle loaded with explosives—in Army parlance, a Vehicle Borne Improvised Explosive Device (VBID)—had crashed the base's gate, killing many of her friends. She still felt guilty for not being there to help. Then, taking a shaky breath, she added in a near whisper: "But I'd rather have been burned than gone through another VBID."

As we sat digesting the horror of such a choice, Ann continued. Two months earlier, she'd just come off watch when a VBID destroyed the tower she'd just left, killing, among others, the sergeant who was her mentor and best friend. "He'd protected me from harassment in the unit. He always stood by me," she explained. She'd given first aid to this sergeant, but he died in her arms.

While recovering from these horrors, she reached out to her family for support. "But every time I tried to explain what had happened and how bad I felt, my parents and husband got angry with me, telling me to get a grip; that what was past was past. So I shut up," she said. Not long afterward, she became deeply depressed.

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clieb   |Registered |2011-03-27 08:58:52 "The knowledgeable reader will note that the therapy I describe above is hardly specific to treating PTSD. Indeed, it's nothing other than basic psychotherapy." I currently work on a PTSD team in a VA clinic where all traditional therapy as you describe in this excellent article has been replaced by so-called "evidenced-based", manualized treatments which are solely focused on diagnosis and symptom reduction. My impression is that the author would find very few "knowledgeable readers" left within the VA or DOD who have had any training or practice in the type of non-straight-line therapy you describe. Am I right about this? I hope not. docsoc70   |Registered |2010-12-26 13:36:48 I appreciated Roy Clymer's article. I worked, as a psychologist with Vietnam veterans for 20 years and then wrote my PhD thesis on 'The Discursive Construction of PTSD'. I looked at the way the veteran constellation, ie veterans, the variety of mental and physical health providers, and the practices of our Veterans Administration, actually thought and talked about the disorder. I concluded 'Perhaps the reason for the conformity of opinion of those who judge the disorder (PTSD) as an 'already there' reality is that the communities of mental and physical health providers, in our secure consulting rooms, are circumscribed by the monocularaties of our practice. It is perhaps that we, who treat this disorder are trained to see and interpret what we are looking for, to satisfy the requirements of a needy population; the realities of government policy, and the dictates of VA practices specifically designed around 'Care, Compensat... ruffing  - The Puzzle of PTSD byn Clymer   |Registered |2010-11-30 10:24:28 My hat is off to Dr. Roy Clymer. He is not only insightful, honest and professionally ethical, but also daring. His excellent article will surely draw fire from those deriving benefits from their involvement with indivduals diagnosed as such. Dr. Clymer can surely take a place beside other brave insightful professionals such as Dr. William Glasser and James S. Gorden who challanged the diagnoses of depression as being a medical disorder and provided working solutions in their books Choice Theory and Unstuck. I am fortunate to have spent time as a student of the Dutch priest, Dr. Father Adian VanKaam, he often stated, "if you do not have an established self, you will seek a pseudo self". One of my assignments in the fifty five years of involvement in this fiel was to examine individuals seeking employment in law enforcement. It became very clear that individuals with no concept of self were seeking a pseud...

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