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Column: PTSD, The Moral Dimensions

8:05 AM, Nov 12, 2012   |    comments
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By Warren Kinghorn, USA Today

On this Veterans Day, hundreds of thousands of veterans suffer from combat-related post-traumatic stress disorder (PTSD). That medical diagnosis shouldn't disguise that this is more than a medical problem.

Combat in Iraq is over, and in Afghanistan it is winding down, but its heavy emotional toll remains. In 2012, more Army soldiers have died by suicide than have died by hostile fire in Afghanistan. An estimated 10%-20% of returning combat veterans meet criteria for PTSD.

When these veterans come to Department of Veterans Affairs (VA) health care facilities or other medical providers, they are often treated with medication and, increasingly, by short-term courses of talk therapy, which are known to be effective in reducing PTSD symptoms.

That is far from enough.

As a VA psychiatrist, I frequently diagnose veterans with PTSD and offer treatments that I believe to be helpful, even lifesaving. But I am wary of the way medical models often bring with them two assumptions about combat trauma that can be harmful to combat veterans' return to normal civilian lives.

The first common but misleading assumption is that combat trauma happens to a soldier. The official diagnostic criteria for PTSD specify that one must have "experienced, witnessed, or (have) been confronted with" an event involving actual or threatened death or injury to oneself or others, criteria that invite images of soldiers as victims of external situations and events. And in a great many cases - a sudden bomb blast, or an ambush, or the sight of a fellow soldier killed - this is exactly right.

Suffering more than medical

Even so, this assumption that trauma is something that happens only to soldiers obscures the truth: Many veterans suffer most not from what they received or witnessed in war, but from what they did. Psychologist Shira Maguen of the San Francisco VA Medical Center, for example, has documented that among veterans of the Iraq and Afghanistan wars, taking the life of another person is linked both to the severity of PTSD symptoms and to thoughts of suicide.

Maguen and other VA researchers have recently used the term "moral injury" to describe suffering in which veterans encounter inner conflict due to combat-related transgression of core ethical and moral beliefs. Veterans can suffer deeply, in other words, not just from things that happened to them but from an inability to live with themselves knowing all that they have done to others.

The second common but misleading assumption about combat trauma, related to the first, is that post-combat suffering is at root a technical problem in need of a technical solution. Modern medicine encourages technical thinking. If I have pneumonia, I take an antibiotic. If I have a blocked coronary artery, I undergo a cardiac procedure. If I have PTSD, I take medication or a course of psychotherapy.

There are advantages to this understanding of traumatic suffering, but there are also problems. To see traumatic suffering, particularly moral injury, as a technical, medical problem can easily rob it of its moral significance. If I treat a veteran's suffering as a technical problem to be medicated away, I can easily miss the fact that the person before me stands as testimony to the wars in which he or she fought. "Treating" veterans must not obscure the important moral stories that they have to tell.

Civilians' role

So, too, envisioning post-combat suffering as a technical problem places those of us who have not been to war in a far-too-easy position. If veterans' suffering is primarily a technical problem, then our duty to them, as a culture, is to provide them with the right forms of treatment. But this ignores the fact that just as we, as a culture, participated in causing veterans' suffering - we sent them to war, after all - so also we must collectively facilitate their healing and reconciliation upon returning home.

The VA and other health care systems need adequate resources to provide medical and psychiatric care for returning combat veterans. But perhaps even more than good medical care, veterans need individuals and communities who will commit to walk patiently alongside them, allowing them to tell their stories if and when they are ready to do so, even when these stories are distressing or complex or unbearably sad.

Veterans need a civilian culture that refuses to distance itself from them either through reflexive condemnation or, more commonly, through reflexive valorization. Sometimes, they need communities that can offer the non-medical languages of confession, repentance and forgiveness. And above all, they need to be taken seriously as moral beings who have stood for us in hazy and complicated places and who now bear witness to what that commitment entails.

Warren Kinghorn, a staff psychiatrist at the Durham VA Medical Center, is assistant professor of psychiatry and pastoral and moral theology at Duke University Medical Center and Duke Divinity School. The views expressed here are his own.


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