Posted Thursday, May 15, 2008, at 12:24 PM
The decisive battles in American culture wars often take place in the armed forces. That was true of racial integration decades ago, and it's true of homosexuality today. Now it's happening to mental health. If psychiatric disorders end up being culturally accepted as medical conditions, with all the attendant insurance coverage and workplace protections, the decisive player in this revolution will probably be the military.
The transition is taking place in three steps. First, mental illness has to be destigmatized. As Yochi Dreazen reports in the Wall Street Journal , this is already underway: Defense Secretary Robert Gates has changed department rules so troops with PTSD can seek counseling without losing their security clearances.
The next step is to treat mental illness like physical illness as an insurance matter. This is harder, because it's expensive. Dreazen reports that legislation in the Senate would take this step by opening Veterans Administration facilities to active-duty troops with psychiatric problems. The bill's architect argues that the expense is worth it because soldiers' mental wounds, like their physical wounds, can be fatal. Specifically, post-traumatic stress disorder (PTSD) can lead to suicide.
Now there's talk of a third step: awarding the Purple Heart for psychic wounds. Dreazen notes that earlier this month, Gates called it "an interesting idea" and "clearly something that needs to be looked at."
The argument against expanding eligibility for the Purple Heart is that mental wounds, unlike visible physical wounds, can be faked. Or they can be unrelated to combat, even if the affected service member thinks they are. In response, proponents of the change point out that PTSD is an officially certified disorder and that research has linked it to combat incidents.
The debate won't be settled overnight, any more than integration or homosexuality were. That's because the medicalization of mental health is in part a social issue. Yes, it's medical. But it's also defined and complicated by the problem of invisibility. You can't see psychic wounds the same way you can see physical ones.
Fortunately, science has already encountered and worked through this problem in other contexts. We can't see molecules, but we can measure their effects and correlate their existence with physical conditions. The same should be true of mental illness, even if the variables and data are far more complicated. My guess is that as research progresses, it will satisfy neither side. We'll find that PTSD is as real as any visible wound but that, like attention-deficit hyperactivity disorder, it's also widely overdiagnosed.
So let's be careful with the Purple Heart. People who want to award it for psychic wounds argue that this will eliminate stigma and encourage counseling. That's the wrong way to look at it. The Purple Heart isn't a policy instrument. It's an honor. In the words of George Washington's original order, it denotes " meritorious action ." And honor isn't the first step in a cultural transformation, no matter how worthy that transformation may be. It's the last.