"And could it be," I pressed, "that the problem isn't that no one's trustworthy, but that you've grown afraid to trust yourself? You believed you could trust your father, the sergeant, the commanding officer to live up to their roles, and they let you down. Or perhaps you thought that you were to blame for the way you were treated. To protect yourself from ever having your judgment proven wrong again, you adopted a policy of characterizing everyone in power as untrustworthy. It's safer, but at what cost to you?

"It's easy to write everyone else off, harder to be responsible for your own judgments about who is and isn't worthy of your trust. It's harder still to tolerate the uncertainty and vulnerability that come from making such moment-to-moment judgments."

John was nothing if not a fighter, and he didn't just lie down in therapy. He continued to resist my efforts to challenge his self-protective but ultimately self-defeating belief that he'd been screwed. But as I continued to challenge him and remind him of his courage and resiliency, given what he survived in childhood, occasionally he'd let go of his defenses and grieve his losses. Eventually he began to see his symptoms as solutions to the problem of how to prevent the reccurrence of the pain he'd suffered. By extension, he began to view "having PTSD" as a way of coping with more than he could handle at the time.

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. This is central to my point. I believe all therapy is a dialogue between two people trying to determine what works and what doesn't as we try to live the best lives we can. I think that when we use any of our limitless ways of avoiding difficult experiences, however self-protective initially, it keeps us from taking responsibility for our lives and ultimately is costly because we become powerless to change. The "injury" of PTSD, like bad parenting, can become the reason a life is the way it is. If so, patients become as calcified and stuck with the lives that bring them to our offices as they are with the diagnosis we may "give" them.

A major point of my argument, however, is that it isn't enough for us to know about these issues as they affect the PTSD patient. Because we're all subject to the fearsome risks of life, we all share the combat veterans' vulnerabilities and temptations. Population surveys indicate that roughly 80 percent of Americans have experienced an event qualifying as "traumatic." A survey conducted at an ordinary meeting of highly qualified and experienced therapists revealed that they scored, on average, almost two standard deviations above the mean on a measure of adverse childhood experiences.

Thus these are our issues too: they're everybody's issues. But we're as guilty of avoidance as our patients are if we, as a field, continue to label common, profound, terrible, human experience as a "disorder." The pathologizing language of PTSD invites us to see others, and ourselves, as damaged, injured, or disabled. Even more dangerous is the risk that this way of thinking about life's most challenging events undercuts our efforts as therapists to help our patients. Indeed, it tempts us to unknowingly collude with patients in their natural but misguided effort to solve one problem by adopting a far more costly solution.

The stakes are high, for both our soldiers and us. To prepare young men and women for combat, we teach them unnatural ways of thinking, feeling, and behaving. Then we send them into the killing fields, where they're exposed to terror, death, and mayhem beyond imagination. While there, they may begin to feel like gods with power over life and death; they may experience a raging blood-lust for revenge, and possibly develop an appetite for destruction and living at the edge, as they constantly confront their powerlessness and vulnerability.

When they return—bloodied, shaken, defended, cut off—they feel that they don't fit in with those who haven't done what they've done. And they don't. They're at huge risk for alienation, isolation, bitterness, and cynicism. We owe it to them to give them a form of help that fully acknowledges their experience of unimaginable terror and horror. More than this, however, we must convey to them that they're affected, but not damaged, and they're capable of responsible, rather than simply reflexive, behavior. In doing so, we may help reignite what's strongest and most capable in them. They survived war: they can do anything.

Roy Clymer, Ph.D., attended the United States Naval Academy, followed by four years of active duty, including a tour in Vietnam on river patrol boats. He's been a researcher and a clinician in both the public and private sectors, and is presently employed as a contractor. For the previous 13 years, he directed a program at the Walter Reed Army Medical Center that treated veterans returning from combat deployments. Tell us what you think about this article by e-mail at letters@psychnetworker.org, or at www.psychotherapynetworker.org. Log in and you'll find the comment section on every page of the online Magazine section.

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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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