Measuring the Psychic Pain of War
PTSD among Vietnam vets is less common than we thought.
Two weeks ago, Columbia University researchers announced that the psychological fallout from the Vietnam War is less extensive than previously thought. For years, mental-health experts had relied upon the 1988 National Vietnam Veterans Readjustment Study, which examined the prevalence of post-traumatic stress disorder in 260 Vietnam veterans. Mandated by Congress, the study originally reported that 31 percent of veterans suffered PTSD at some point after military service. But the Columbia researchers estimated that the real figure is only 19 percent, based on their reanalysis of the original data.
Their new report, "The Psychological Risks of Vietnam for U.S. Veterans: A Revisit With New Data and Methods," published in Science, made use of NVVRS data that received little attention or analysis in the original 1988 report. Most important, by examining military records to allow cross-checking of veterans' reports of exposure to combat, the researchers could confirm when PTSD symptoms—present at base line in any population—were actually linked to war-related threats. The original NVVRS researchers did not parse the causal relationship between symptoms and war trauma with such precision. As a result, they overstated the number of PTSD cases, the Columbia group concluded. In the end, prevalence of PTSD was 40 percent lower than the original estimate.
Why revisit the 18-year-old study now? Because of its potential applicability to veterans returning from the current war in Iraq, the authors of the new study say. As the Columbia team put it, both conflicts "have been wars without fronts, in which it is often difficult to tell peaceful civilians from enemy combatants." But keep in mind that both the 1988 NVVRS and its reanalysis have limits. The major drawback is that much of the self-reported data on symptoms were gathered 10 to 20 years after the traumatic event—and from a modest sample of 260 vets at that. Such retrospective analysis of recall of symptoms inevitably raises doubts about the accuracy of memory. Better projections of the treatment needs of soldiers returning from Iraq will almost surely come from the psychiatric assessments that the Department of Defense is already conducting on Iraqi vets as they return home and again six months later.
There is an even more pressing matter facing the Department of Veterans Affairs: preventing the development of long-term impairment in acutely disturbed veterans who seek care. I am referring specifically to the kind of chronic dysfunction that can be caused, paradoxically, by psychiatric treatment itself. I speak from my experience as a psychiatrist at the West Haven Veterans Affairs Medical Center in Connecticut from 1988 to 1992, a time of blossoming interest in PTSD within both the VA and the mental-health establishment. Good intentions were abundant, but, in retrospect, much of our treatment philosophy was misguided. For example, we spent too much time urging veterans to relive their war experiences in group therapy, individual therapy, and art therapy. Groups of 16 veterans were admitted to the hospital and stayed together, platoonlike, for four months. This practice took them out of their communities and away from their families. I remember some of the men coming back from a day pass with new war-themed tattoos and combat fatigues. Not exactly readjustment! Instead of enabling regression, we should have emphasized resolution of everyday problems in living, such as family chaos, employment difficulties, and substance abuse.
The good news is that most of these inpatient programs are now shuttered. Studies showed them to be largely ineffective. As a result of this, as well as a general shift away from Freudian methods, many VA clinicians are now spending less time eliciting war narratives from patients and urging cathartic re-enactment of war trauma. What remains a lingering threat, however, are clinicians who are too quick to interpret psychological distress as tantamount to incurable PTSD—and then to reach for the permanent disability claims form.
This is where the real trouble for vets often starts. Once a patient receives a monthly check based on his psychiatric diagnosis, his motivation to hold a job wanes. He assumes—often incorrectly—that he can no longer work, and the longer he is unemployed, the more his confidence in his ability for future work erodes and his skills atrophy. By sitting at home on disability, he adopts a "sick role" that deprives him of the estimable therapeutic value of work. Lost are the sense of purpose work gives (or at least the distraction from depressive rumination it provides), the daily structure it affords, and the opportunity for socializing it creates.
Of course, some unfortunate veterans will be too sick to resume work and thus need and deserve disability compensation from the VA. But clinicians can keep this subgroup as small as possible by heeding the lessons of Vietnam. In brief: Don't suggest, don't regress, and don't offer disability benefits too quickly. Think of PTSD as a treatable and time-limited affliction and—this is key—treat it early, when symptoms are most responsive to intervention with cognitive behavioral therapy and, if needed, medication. Focus on practical issues and rehabilitation. And take advantage of the well-established finding that prognosis after trauma greatly depends on what happens to the individual "post-event"—factors such as marital discord, poor physical health, financial stress, and his or her expectation of lasting impairment.
It is always wise to learn from the past, as the Columbia researchers who did the reanalysis sought to do. By revising the number of PTSD cases downward, they have in no way diminished the suffering of veterans who were and still are afflicted. At the same time, the downward estimate is a healthy reminder of the importance of not exaggerating the widespread nature of the disabling impact of trauma. For the new generation of Iraq war veterans, it is imperative that we pair our proper concern over the scope of the care they need with serious consideration of the philosophy guiding that care. Our Vietnam experience doesn't just tell us that some vets will be afflicted with mental illness. It also tells us that if we aren't careful, we can actually make the problem worse by overpathologizing the psychic pain of war.
Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute, is editor of When Altruism Isn't Enough: The Case for Compensating Kidney Donors.