Most veterans still firmly believe that only the weak suffer psychological wounds from war. In my work with them, it's clear that they expect to be subject to that judgment by their military peers. Indeed, even physically wounded vets who've been medically evacuated for treatment are reluctant to go back to their units because they feel such shame for having "abandoned" their buddies, and fear that they'll be judged harshly by their fellow soldiers. The shame and fear of being condemned by their fellows is even greater for those who've been removed from their units for "mental problems."

The idea that a "deficit" of character or moral fiber explained why men fell apart during or after battle reigned unchallenged until World War I, when, for the first time, modern psychiatry offered an alternative: war neurosis. As a result of Sigmund Freud's influence, psychiatrists had begun the process of "medicalizing" humankind's response to extreme experience, suggesting that war neurosis was similar to ordinary neurosis: a resolution to an insoluble, intrapsychic conflict. In the case of combat, the conflict was between one's acknowledged duty and the desire to escape the danger and ghastliness of war. Given the ubiquity of that inner conflict, "It's amazing that more haven't succumbed," observed one physician.

After the Vietnam War, thousands of vets complained that dynamically trained Veteran's Administration therapists often focused on problems in their childhood, suggesting that the vets' emotional breakdowns were caused by preexisting psychological issues, and that the war was only a secondary, or triggering, factor. The fact that not everyone who saw combat developed symptoms reinforced the view that those having problems must have been made vulnerable by a precombat deficit. This "weakness" was then attributed to upbringing, rather than to moral deficiency.

Reacting to this profoundly discrediting stance, veterans' advocates during and after the Vietnam War promoted a new view: emotional and behavioral disturbances after combat were a normal response to the grisly realities of war. They asserted that the veterans had been all right before the war, and if they were having troubles afterward, it must be because of the war. This position gained support in the medical community, resulting in the decision by the American Psychiatric Association to adopt the diagnosis of PTSD in 1980—another step in the medicalizing process intended to destigmatize the psychological effects of war. At a stroke, life-altering changes in psychological functioning that resulted from the grotesqueries of combat were simultaneously normalized and pathologized: it was expected that vets would come home from war deeply impaired (even though many didn't), with a condition officially deemed a psychiatric disorder.

The Problem

There's no doubt that people who go to war are emotionally affected by it—the more intense, terrible, and enduring the experience, the more those who return are troubled, and the more deeply troubled they are. But this has nothing to do with weakness or deficit—moral or psychological—and everything to do with the brutalities of combat. Central to that experience is the killing of others and the risk of being killed by others, prospects that inevitably stir strong emotions and conflicts—a truth reflected in the arts from the epic poem The Iliad (ca. 700 BCE) to the film The Hurt Locker in 2009.

War evokes a complicated and conflicted jumble of intense feelings, thoughts, and judgments, which may persist long after, as the person struggles to make sense of it all. The most obvious element of this mix is, of course, fear. Hardly mentioned in The Iliad except by women, fear is somewhat more respectable these days, unless, of course, you're a young man who's motivated to "prove your manhood" or become one of "The Few. The Proud. The Marines," as the recruiting slogan says. No matter how a servicemember deals with the feelings of fear, however, showing fear almost certainly causes shame. So when a servicemember returns to "the world" and finds himself "hitting the dirt" at a loud noise, too afraid of crowds to go to the mall, seeking the seat next to the wall at a restaurant, afraid to drive or cross a bridge, or locking all the windows and doors at night, these fears threaten to become public and hence are powerfully laden with shame.

Fear is a powerful emotion, but it comes and goes: vulnerability, however, is an unchanging, existential fact of life. As thinking, feeling human beings, we all suffer and die, sooner or later. At the same time, if we're young, healthy, and cocooned by privilege (as we tend to be in the West), we can ignore our susceptibility to pain and death. Young males especially seem to wear the invisible armor of assumed invulnerability. But genuinely terrifying experiences—close calls that directly threaten life and limb—evoke the undeniable feeling of fear, which, if intense and sustained enough, can pierce that armor, often permanently. It's common for combat soldiers to hold lost-their-cherry ceremonies for inexperienced soldiers after their first firefight. The change in perspective celebrated in these events is at least as profound as that of the physical loss of virginity, if not more so. Never again will that young man walk quite as freely, with quite the same sense of careless invincibility.

When you're being shot at, you're vulnerable and you know it, but getting angry and shooting back is more adaptive than cowering in fear. After a tour of duty, when his vulnerability has been repeatedly rubbed in his face, a vet frequently has a low tolerance for feelings of vulnerability back in the world. When he reexperiences those feelings by seeing his children running into the street, or even by recognizing his affection for his wife or girlfriend, memories arise of other times he felt vulnerable. If he's unwilling to tolerate the fearfulness associated with vulnerability, he may become angry—yelling at his children and scaring them—yet remaining unaware of what caused him to do so. After such incidents, feeling confused and ashamed, he's likely to withdraw from his family "to protect them."

Then there's killing per se. In his 1995 book, On Killing: The Psychological Cost of Learning to Kill in War and Society, Lt. Col. Dave Grossman presents evidence suggesting that humans are strongly disinclined to kill others of their species, and must be trained to do so. Other evidence indicates that war encourages altruism and cooperation because it causes individuals to "selflessly" risk their own lives to fight those who threaten the well-being of the whole group, thus furthering the evolution of the species. However, killing others is probably the most proscribed human behavior—except, of course, when it's justified by self-defense or war. In the fog of battle, these justifications can become extremely tenuous. John's story suggests a conflict within himself about the legitimacy of killing and the justification for dying when he perceives that he and the other soldiers are being forced to fight, not for the common good of the group, or even for their individual survival, but to further their commanding officer's personal agenda.

Another problem a veteran may face when returning to civil society is rage. Combat is a powerfully ambivalent, emotional experience. Being threatened evokes an intense consciousness of personal vulnerability, which usually triggers some degree of fear. However, fear feels, and often is, disempowering, so during combat, soldiers are likely to tap into their anger, choosing to fight, rather than freeze or flee. In the immediacy of a life-and-death firefight, anger can quickly elevate to an all-consuming rage. Take the need to avenge a fallen comrade, add lethal weapons operated by a soldier whose only constraining authority is that of his immediate comrades, and the result is an intoxicating, powerful, often deadly cocktail, with little accountability because what a soldier and his buddies say happened is usually accepted as what did happen. That's a lot of power, with a lot of potential for abuse.

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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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