In her new book, When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans, Paula J. Caplan, Ph.D., a clinical and research psychologist, says it is harmful to tell war veterans with emotional difficulties that they have a mental illness.
“If a lasting emotional reaction to the horror of war is a mental disorder, what would be a healthy response to war?” she asked people attending a mental health conference June 10, 2011, at Endicott College in Beverly, Mass .
Post-Traumatic Stress Disorder (PTSD) is a mental illness listed in the Diagnostic and Statistical Manual of Mental Illnesses (DSM), which lists all mental health disorders, and the observable signs connected with them. We’ve been giving troubled veterans the label PTSD since the Vietnam era, Dr. Caplan’s book says.
Why the Label "PTSD" Harms Veterans
Here are some reasons why she thinks diagnosing troubled war veterans with a mental illness is wrong:
1. A disturbed, lasting emotional reaction to the horror of war is not a disease. Telling a troubled war veteran that his troubles mean he is "mentally ill" makes him more isolated than he already is, and lowers his self-confidence and self-esteem.
2. The term PTSD hides the cause of the trouble - war, Caplan says. The same thing has been called combat fatigue, battle fatigue, and shell shock, In the Civil War, it was called Soldier's Heart, she says. Each of those names squarely identifies the cause of the person's suffering.
3. Many veterans think the label PTSD means they're “sick” or "crazy," instead of having a normal reaction to something horribly abnormal. They rebel against the idea, and refuse to accept help, often with disastrous, even fatal, results, or they buy into it and become permanent, disabled victims.
4. Since treatment for war shock in the military or Veterans Administration is delivered by mental health professionals in medical settings, the treatment itself reinforces the message that the sufferer is sick or mentally ill.
5. Many in the military view suffering veterans as weak, or cowardly. Many soldiers and veterans think this about themselves. Going for help, or saying they need it, is a sign of weakness that would hurt their careers and relationships with fellow soldiers, they fear.
6. PTSD puts war stress on the same plane with rape or surviving a tsunami. As horrible and lasting as those traumas can be, she says, “People do not come to you, like they do after a rape or tsunami, and ask how they can help you heal.” Ordinary people often feel they can’t help a vet with his “illness,” because they do not have clinical training. They might even harm him if they get involved, many fear.
Dr. Caplan acknowledged that many veterans liked the "sickness" label. "It was better than being told to buck up and soldier on," she said, but stood by her contention that veterans are not mentally ill, and should not be told they are.
Dr. Caplan's Guide to Listening
Dr. Caplan’s book says each of us can help a vet, one on one, by listening. Her book presents advice and guidance for people who want to help by listening, For a troubled vet, telling his story to a person who cares -- being listened to without being judged -- is part of healing, Caplan says. Clinical training is not necessary.
Start by making a connection with someone distant, not a family member, she suggests. Troubled vets might find it harder to open up to their families. They fear they might damage the relationship, might be misunderstood, or judged, or will place too heavy a burden on people they love.
Give the person all the time he or she needs to say everything they need to say. Don’t rush the person, or try to do it all in one session. Everything will come out in time. Expect some resistance, and come prepared with ways to overcome it. The book lists the most common reasons for resistance, and ways to overcome it..
“Do you mind if I ask how you’re doing now?” If he gives you a perfunctory “I’m fine,” stay engaged, but don’t push, she says.
Establishing trust can take several meetings. Let him know that what he says to you is confidential. You want to know, not gather information to spread to other people. You’ve read about troubled veterans, and want to learn more.
“As an American, I feel it’s my responsibility to learn all I can about how these wars affect Americans who serve, and help if I can, even if all I can do is listen.” If he is not ready to talk about hard stuff right away, talk about easier stuff while he gets used to talking, being listened to, and trusting you.
What was your life like before you joined? Why did you join? What surprised you most when you first arrived over there? What was it like coming home? How are you feeling now?
Don’t underestimate silence, she says. Don’t fill every gap in the conversation with words. Sit quietly and reflect with him. Don’t give advice. Don’t promise to understand what it was like. Promise to do your best to understand, and promise not to judge, or be scared into stopping the conversation. Don’t ask if he ever killed someone, or saw a dead body, as it’s his decision to talk about that or not. Let him know that it's okay to be scared. Being scared doesn’t mean you’re crazy.
There are many more suggestions and scenarios.
Fighting Words
Unfortunately, Caplan does not start telling people how they can help until Page 179. Many people won’t get that far. They’ll become angry and defensive, and stop reading before they get that far. The people most likely to do that will be military officers, VA officials, and clinicians who counsel troubled vets.
Before she starts telling individuals how they can help, she writes two chapters on what the military and VA are doing wrong. The first ten pages of the “How Individuals Can Help” chapter is a list of all the ways ordinary individuals are better than professionals.
Regardless of how valid these criticisms are -- and they make a lot of sense for the most part -- her suggestions about how individuals can help would be more effective without the fighting words.
Even so, the book was still strong enough to motivate me to try to help a vet, convince me I might be able to, and tell me how vitally important it is for ordinary people like me to help.
Dr. Caplan is a clinical and research psychologist at Harvard University's Kennedy School and Dubois Institute. This is her 11th book.
Paula J. Caplan responds
I want to congratulate Ken Braiterman on the use of his excellent review of my book on Psychology Suite 101. I am very happy for his success, and it is indeed a well-written review. Here is my one concern: I remain extremely uncomfortable about the total misrepresentation of part of my book as allegedly so angry that it will supposedly alienate the military, etc. No one else has described any part of the book that way, and in fact the military and VA people -- every single one I have heard from, including higher-ups in the Pentagon and toughened, older veterans -- have uniformly said things like, "I support 1000 percent what you are saying."
- Sources
- Caplan, Paula J., When Johnny and Jane Come Marching Homne: How All of Us Can Help Veteran, 2011, MIT Press, 282 pp.
- Keynote Presentation, “Losing Labels to Find Ourselves: Leaving Behind Psychiatric Labels to Learn Who We Really Are,” sponsored by the National Empowerment Center ( Power2u.org), Endicott College Beverly MA, June 10, 2011.
Ken Braiterman - Ken Braiterman writes columns for the Concord (NH) Monitor print and online editions. He also writes and lectures on recovery from ...
