Paula J. Caplan's Blog, page 5

Psychiatric diagnosis used to call military rape victims "sick"

Just posted at

By Paula J. Caplan, Ph.D. Created Jul 25 2011 - 10:35pm ©2011 by Paula J. Caplan All rights reserved

Sexually assaulted servicewomen labeled mentally ill

Think you'd heard it all? Being sexually assaulted apparently is not enough. The Service Women's Action Network reports that it is receiving reports from women serving in the United States military or attending service academies who, after being sexually assaulted and reporting what happened, are diagnosed almost immediately afterward by military therapists as having personality disorders. [http://groups.yahoo.com/group/GSN/mes...]

This is not a diagnosis that has the slightest relationship to the assault, certainly is not a label applied with the intention of describing a consequence of being raped. A personality disorder is considered to be a lifelong maladaptive organization of the entire personality, so it would have preceded the assault.

Why does this matter? Let me count the ways. First, it takes the focus off the perpetrator, because the victim who is supposedly mentally ill, and, by applying a personality disorder label, takes the focus off the assault and its consequences, placing it instead on the victim's life way before the time of the attack. Readers of my blog know I am no fan of psychiatric diagnosis in general, but if you want to diagnose an assault victim, how about choosing a label that is connected with the effects of assault, reflecting terror, despair, hypervigilance, hopelessness?

This also matters because, as if being assaulted is not enough to have to bear, now the victim has the added burden of being told she is mentally ill, with all of the shame and fearfulness associated with that, and it makes the attack itself seem so diminished in importance that she may wonder if it really happened or at least if she is over-reacting.

Furthermore, personality disorder diagnoses have been used by the military before now to try to get rid of people it no longer wants. In the same way that family members of someone who reports that a relative sexually assaulted them may try to eject the victim rather than deal with confronting and punishing the perpetrator, so some people with power in the military and in military academies want to do the same.

Finally, applying these diagnoses can be a way to ensure that victims do not receive Veterans Affairs benefits for the care they ask for in order to recover from the emotional effects of the assaults, because whatever they are feeling is alleged to be attributable to their alleged personality disorders rather than to what happened to them in the military.

This is the kind of practice of which few Americans are aware, and its existence is a manifestation of what should properly be called some form of sickness that needs eradication.

Where Has All the Funding Gone for Suffering War Veterans?

©Copyright 2011 Paula J. Caplan                      All rights reserved

Missing money and lack of social support for war veterans

If you are one of those Americans who rests easy, certain that somebody up there in government must be dealing with all those who have experienced the psychological carnage wrought by war, I hope you will read on.

It's major and deeply troubling news that the Government Accountability Office, often called the federal government's "watchdog," found that the Pentagon's Defense Centers of Excellence, set up to help vets with emotional devastation or with traumatic brain injury after the 2007 scandal about appallingly poor treatment at Walter Reed Army Hospital, is riddled with unexplained financial problems and an unclear mission. The GAO found itself unable to determine even what is happening at DCOE, and the DCOE spokespeople themselves acknowledged the problems.

A report published on Propublica.org [1] included this statement: "Because of unresolved concerns with the reliability of funding and obligations data provided by DOD (Department of Defense), we [the GAO] cannot confirm the accuracy of figures related to DCOE." It also included the remark that the GAO report "reproduces this disclaimer no fewer than five times."

This news comes close on the heels of the 9th Circuit Court of Appeals' order for the VA mental health system to undergo a complete overhaul because of its "shameful" workings and "egregious" delays. [2]

As I've pointed out here before, my essays about veterans that appear on my Psychology Today blog receive orders of magnitude fewer hits than my essays about any of the other varied subjects about which I post there. Many Americans believe that they support veterans by putting yellow ribbons on their car bumpers or saying, "Support the troops!" but their support goes no farther. Some cannot think what else to do. Some believe mistakenly that if they are not trained therapists, there is nothing else they should or can do. Some just don't like to think about anything as unpleasant as war experiences.

But as I discovered some years ago, and as a wealth of excellent psychological research has shown, some important steps in helping veterans begin to heal are taken by any civilian who is willing to listen to a veteran's story without judging, interpreting, or even asking much of anything except if the vet would like to talk. [3]

Consider this: People who describe themselves as experts about war trauma — which is usually wrongly pathologized as a mental illness called Post-traumatic Stress Disorder rather than as a common, ordinary, understandable, human response to war's horrors — often express bewilderment about why the signs of suffering often seem to appear some months or even years after the veteran returns home. During the interviews I have done with veterans from all American wars beginning with World War II, I repeatedly learned that those who have the most trouble are often those who have been the most isolated from close, loving relationships with nonjudgmental people. I am not here blaming anyone, certainly not with a broad brush the family members of veterans, who are often (though not always) doing the best they can to be caring and supportive in the face of what are often puzzling, distant, mistrustful, and sometimes violent behavior from the vet. Elsewhere [3] I describe in detail some of the reasons for these kinds of behavior. But the point at the moment is that veterans who struck me as the most isolated, judged, mocked, and rejected were the ones who seemed to have the most trouble moving even a step beyond their trauma.

Today I heard from Dr. Thomas Dikel about some careful research he conducted about war trauma. [4] He and his colleagues found that after the war trauma itself, the next most important predictor — and a strong one — of the continuation of emotional suffering was the absence of deeply caring interpersonal support. Sadly, this important finding, despite fitting well with the ample research showing the importance of social support — or what VA Vet Center (Salem,OR) head Dr. David Collier, a Viet Nam veteran himself and a psychologist, calls the importance of love — is too often ignored.

I hope that everyone who reads this essay will make a commitment to listening to the story of at least one veteran…to listen without judging so that a healing connection has a chance to begin.

[1] http://www.propublica.org/article/gao-raps-pentagon-centers-for-post-traumatic-stress-brain-injuries

[2] http://articles.latimes.com/2011/may/11/local/la-me-0511-veterans-ptsd-20110511

[3] Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press (see especially Chapter 6 for simple guidelines about listening to a vet's story, and see also whenjohnnyandjanecomemarching.weebly.com)

[4] T.N. Dikel, B. Engdahl, & R.Eberly. PTSD in former prisoners of war: Prewar, wartime, and postwar factors.  Journal of Traumatic Stress, Vol, 18, No, /, February 2005, pp, 69-77.

This July Fourth, Listen to a Veteran

Just published in Atlanta Journal Constitution at http://www.ajc.com/opinion/this-july-...
By Paula J. Caplan

8:37 p.m. Friday, July 1, 2011

Veterans Administration officials cite rising rates of suicide, incarceration, homelessness and unemployment. Small wonder a U.S. appellate court recently ordered complete overhaul of VA mental health treatment.

For July 4th, every American can immediately ease veterans' emotional burdens, reducing the terrible isolation of those returning from war with devastating internal conflicts.

The good news: action is simple but remarkably effective. Every civilian can listen to a veteran's story. Many veterans I've interviewed have said, "The night I told my story was my first good night's sleep since the war."

Americans are woefully unschooled about war's lingering effects. Fewer than 1 percent served in the military. Veterans talk little to non-soldiers about war, and few civilians volunteer to listen. Consequently, few of us really understand war's enduring impact.

The appeals court decision found the VA mental health system "incompetent and plagued by egregious delays." While veterans await a transformation, the need is urgent to educate ourselves about slow-healing emotional wounds. Suicide rates for service members and veterans continue to spike despite new VA programs. More than 100,000 veterans are homeless on any given night. The most common reason for hospitalization of military personnel remains serious emotional suffering.

The cost of a nationwide "Listen to a Vet" program: practically nothing. Listening also works better and carries fewer risks than psychiatric diagnosis followed by drugging veterans.

It is hard to learn war's realities when veterans do not want to talk. Many fear if they describe their torment, listeners will "think I'm crazy." Indeed, clinicians and lay people often conclude that those wrestling with war's anguish are mentally ill. What is a healthy response to the carnage of war?

Many fear being judged for their actions in war, for failing — as they see it — to show sufficient valor or both. Others fear upsetting relatives by recounting stories of horror, grief, shame, moral conflict and utter despair. Many sense danger in breaking a cultural taboo against speaking of death by reporting wartime encounters.

Why do few civilians ask veterans about their ordeals? Many fear that we cannot handle what they will tell us. We may think they should "move on" with their lives, which we translate into urging them not speak of war. Far too many non-therapists commit two regrettable errors: They believe that professionally trained clinicians can repair war's emotional carnage (though some can help, there are too many sufferers and too few compassionate listeners), and they believe lay people lack the skills to help. But data show that, even were all the recently hired VA therapists helpful, an order of magnitude more help is needed.

Abundant research shows that social support — not high-powered clinical approaches, but ordinary, compassionate connecting — has enormous healing power. In other cultures, but less so in our own, communities help the traumatized heal by reconnecting them with friends and others.

It's time to challenge cultural biases against showing heartfelt empathy. Across America, citizens either know or sense that veterans are suffering, often alone and in silence.

Let each civilian talk to a service member or veteran. Tell them that as Americans whose country prosecuted a war they were sent to fight, we take responsibility for hearing what they have gone through and how it affects them, that we wish to understand but not judge. Everyone can seek opportunities to tell them we witness their suffering, we would no doubt have responded the same, and above all, we do not believe they are mentally ill because of the trauma of war.

It is remarkable how this can be done by anyone who cares, whether or not they and the speaker share the same views about politics or war. Listening to veterans helps break down the isolation that is one of the most damaging perils of returning home.

Committing to "waging" peace of mind for those who have served at least as much national energy as goes into war, we bring new meaning on the Fourth of July to what it means to be an American.

Paula J. Caplan, author of "When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans," is a clinical psychologist, fellow at Harvard's Kennedy School, and advisor to The Welcome Johnny and Jane Home Fund.

Questioning the Breaking News about War Veterans and Prison

©Copyright 2011 by Paula J. Caplan                      All rights reserved

Care needed to interpret new U.K. study of vets in British prisons

The new issue of the British Medical Journal includes an article described as myth-busting, because it shows that in the United Kingdom, veterans with combat trauma are no more likely than other people to end up in prison. The piece is called "Inquiry 'busts the myth' that combat trauma is linked to criminal behaviour" and is written by Ingrid Torjesen.But we need to go beyond the headline for several crucial reasons.

The headline differs in important ways from what is reported in the article, because the inquiry chair, John Nutting QC is quoted as saying that "Ex-servicemen are not committing crimes shortly after leaving the plane from Helmand" but that "The reality is that most ex-servicemen resettle into the community without problems but that, for some, issues arise later in life which can lead to offending." In fact, the report reveals that the average veteran who ends up in prison usually does so later in life than the non-veteran.

It is also important that the report includes the information that ex-servicemembers are actually somewhat less likely than other people to be in prison but also that those ex-service personnel who are imprisoned "are more likely than other prisoners to be there for sexual or violent crimes." The connection between being trained to defend or attack and even to maim or kill and the commission of violent crimes back home seems to need little explanation.

Based on the BMJ article, it appears that many people in the U.K., like many in the U.S., believe that veterans of war are more likely than other citizens to end up in prison. Certainly, there have been many high-profile cases reported in the media of veterans behaving in violent ways. But as of 2007, U.S. Bureau of Justice statistics showed that in 2004, the rate of incarceration in prisons of veterans was actually about half that for people who had not served in the military. [2] I have not been able to find more recent statistics, so the pattern might have changed, but the 2004 date is important, with most veterans of the current wars returning home since that time.   

As an advocate for veterans, I naturally do not wish to report that the rate of commission of crime and imprisonment are higher for combat veterans than they actually are, but whatever the case, it is tremendously important to make sure that we understand any possible connections between combat trauma and crime commission and learn what we can do to help. Given that in the U.S. study, crimes of violence are described as more likely to be committed by combat veterans than by others and that acts by the former that lead to prison sentences happen later in their lives, perhaps part of what needs careful study is exactly what happens to them in the years when they are trying to readjust to civilian culture. In the British study, trouble adjusting to civilian life was cited as one of the primary factors related to veterans' criminal behavior.

It is rare that militaries anywhere in the world offer assistance with this readjustment, and that is perhaps not surprising, because to do so requires highlighting how vastly different is military culture from civilian culture. In contrast, in some Native American societies, returning warriors are explicitly and ritually helped to make the transition, which is acknowledged to be vast and difficult, whereas in many cultures including dominant U.S. culture, that is not the case.

It is important to understand that this study was done in Britain, whose culture with regard both to the military and to violence is quite different from here, so we cannot assume that this necessarily proves anything about the U.S. Furthermore, Britain has a much stronger social welfare net, and we know that a major factor driving people into criminal behavior is the unavailability of housing, employment, food, and healthcare.

It is also important to understand that whatever percentage of citizens of any nation who have experienced combat trauma end up engaging in criminal behavior, the courts and the whole society need to understand how having been in combat and/or the conditions of their returning home (and in the U.S., we are doing far too little for our veterans in every single realm [1]) might have led to the commission of their crimes. Some of this consideration appears to be starting to happen to some degree with the establishment of special courts for veterans in this country.

[1] Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press.

[2] http://www.nchv.org/background.cfm 

Overcoming Homophobia: Progress Despite the Rocky Road (Homophobia, servicemembers, and the lords of psychiatric diagnosis)

Just posted @ http://www.psychologytoday.com/blog/s...


Created May 18 2011 - 9:40am
©Copyright 2011 Paula J. Caplan All rights reserved

Homophobia, servicemembers, and the lords of psychiatric diagnosis

Note: This essay was written on May 17, 2011, but due to technical difficulties could not be posted until now.

Today is International Day Against Homophobia, a fitting time to look at two arenas in which there have been both rocky roads and some progress in the struggle to end this form of bias and resulting mistreatment.

On May 7, I attended a ceremony to mark the 10th anniversary of the setting of a memorial to LGBT servicemembers who have died. Tom Swann, head of the Palm Springs chapter of Veterans for Peace, a gay man who spearheaded the creation of this memorial in Cathedral City, CA (next-door to Palm Springs) and who led the struggles necessary to get the cemetery's permission to set the modestly-sized obelisk, told us that this is the only such memorial in the United States. Think about it.

Some might object that the memorials to deceased servicemembers also include LGBTs so that there was no need for a separate marker. But being at war is hard enough to get through, so let us consider what LGBT servicemembers have additionally endured...solely because of their sexual orientation. Many had to shoulder the almost unbearable burden of never letting slip the slightest indication of that orientation, lest they be drummed out of the military with a dishonorable discharge, otherwise publicly shamed, beaten, or even killed, as we know that some have been.

A gay veteran I interviewed (Caplan, 2011) told me that, although those who went through basic training with him did not know that he was gay, he watched the horrible beating of a heterosexual soldier whom someone erroneously said was homosexual, and after that, the gay veteran lived in terror that someone would find out or even suspect his orientation.

At the May 7 ceremony, Brigadier General Keith H. Kerr recounted some of the struggles that led to the recent repeal of the Don't Ask, Don't Tell (DADT) policy, including many who lobbied to change the law, the Log Cabin Republicans' filing of the lawsuit that led to a federal court ruling that DADT is unconstitutional, and those who chained themselves to the White House fence to protest discrimination and were arrested. Now, he said, DADT "is in its death throes, and seventy percent of the American public believes that LGBT people should be able to serve openly, not live in fear of their military careers, and share their lives, their partners, and families while serving in uniform." He made the point that "Nothing is as destructive to military cohesion as having to conceal part of one's everyday life and loved ones." This point is particularly important, given that a reason often put forward for keeping gays out of the military or insisting that they conceal their sexual orientation has been that to do otherwise would interfere with military cohesion.

General Kerr said that the military services are scheduled to complete their troop training about "open service" this summer, and he fully expects that President Barack Obama and others in the executive branch of the government will later this summer "certify that open service will not harm [military] readiness." But anyone who has studied bias and mistreatment knows that more struggles lie ahead, because changing laws and practices will help in some ways but will not wipe out the homophobia that lives on in many individuals in the armed forces...or anywhere else.

My regular readers will know that I have written a great deal about problems with psychiatric diagnosis, but they may wrongly assume that I have no concerns about diagnosis and homophobia. That assumption would probably be based on the extensive publicity Dr. Robert Spitzer received in the 1970s, when as head of the then-forthcoming Diagnostic and Statistical Manual of Mental Disorders-III (DSM), he announced that the American Psychiatric Association (APA), publisher of the DSM, had decided - by majority vote - that homosexuality was no longer a mental illness. Homosexuality was in the previous edition of the manual but would be removed for the next one, Spitzer proclaimed (Caplan, 1995).

There was rejoicing in the gay community, which had lobbied hard for that change. Many rejoiced even while taking note of the ironies and problems involved in (1) making such decisions by vote; (2) the fact that one second before the results of the voting were announced, homosexuality supposedly was a mental illness, and as soon as the results were known, it was not; (3) the fact that a lobby group, which is what the APA actually is, had the power to make such declarations and to put enormous influence behind them.

In the 1980s, a gay graduate student at the University of Toronto's Ontario Institute for Studies in Education, where I was teaching, corrected me when I said that homosexuality was no longer officially considered a mental illness. When Spitzer announced that it would not go in the next edition of the DSM, who would have thought to question his claim? Most people believed what he said. This student (I wish I could recall his name, because I have always been grateful to him for educating me) had learned that the DSM-III, published in 1980, listed as a mental disorder "Ego Dystonic Homosexuality." What is ego dystonic is what we do not experience as a part of ourselves with which we are comfortable and about which we feel happy. In 1980, in the intensely homophobic societies that were the United States and virtually all of the dozens of other countries where the DSM was used, how many gays and lesbians do you think were able to grow up feeling totally comfortable with their sexual orientation?

Thus, a socially-created effect of homophobia - gays' and lesbians' (few people then talked much about bisexuals or people we now called transgendered) discomfort about their sexual orientation - was cast as a mental illness. This is particularly disturbing, given that mental illness is so generally construed as a consequence of individual, intrapsychic problems, so to construe social problems as mental illnesses is to mask the harm done by social evils and reduce the chances that people will work to reduce them.

In 1987, the next DSM edition appeared (DSM-III-R), and Ego Dystonic Homosexuality did not appear. However, Sexual Disorders Not Otherwise Specified was there, and that pretty much amounts to whatever your therapist decides is a sexual disorder. So any sexual orientation other than heterosexuality could be given that mental disorder label. And you might want to have a look at dsm5.org to see what they are telling us they have in store at this point. (In a future essay, I will write about what the DSM authors call Gender Identity Disorder.)

In 2003, Spitzer said publicly that he had done some rethinking about homosexuality and mental illness. On what grounds? He had done some research that he called "Can some gay men and lesbians change their sexual orientation?" (Spitzer, 2003). The very title implies that being gay or lesbian is pathological, for a less biased piece of research might have been called, "Can people of any sexual orientation change to another sexual orientation?" A report about this study appears in Thinking Critically about Research on Sex and Gender:

"[Spitzer] carried out some research that he described as gauging the effectiveness of so-called reparative therapy, which is aimed to transform homosexuals into heterosexuals and frequently conducted by members of fundamentalist religious groups. Spitzer (2003) said he conducted 45-minute telephone interviews with 200 people who had undergone such 'treatment' and found that 66 percent of the 143 men and 44 percent of the 57, all of whom he said were 'extraordinarily religious,' told him they had been having heterosexual sex at least monthly for at least five years. On this basis, he reported that reparative therapy was extremely effective. There were major flaws in this research: the practitioners of this program and religious groups helped him find interviewees; extremely religious people may be highly motivated to disclaim homosexual feelings and present themselves as happy heterosexuals; despite the skewed selection of interviewees, fully one-third of the men and more than half of the women did not report switching their sexual orientation to heterosexual; some would question whether having heterosexual sex once a month is sufficient evidence of transformed sexual orientation; and it is not clear whether Spitzer made any attempt to interview people for whom the program had not been effective or had in fact been harmful, despite widely available information about such harm (Boodman, 2005)."
(Caplan & Caplan, 2009, pp. 83-4)

Given the frequency with which mental health professionals and especially those who write the diagnostic manual are considered (wrongly, I believe) to base their conclusions and classifications on well-done scientific studies, it is important to remember the vast number of serious methodological problems with what Spitzer offered as his research.

The road to eradicating homophobia is long enough without those in the mental health professions providing fuel for the fires of this hatred.

Switching from the focus on homophobia to a view of a better future in which sexual orientation will not be used oppressively, let me give the last words to American Veterans for Equal Rights President Danny Ingram, who said at the May 7 memorial commemoration of the small obelisk that honors LGBT veterans, an obelisk that is shaped like the Washington Monument:

"In a few weeks when President Obama, Admiral Mullen, and Secretary Gates certify the repeal of Don't Ask, Don't Tell, America will be more free than she was the day before. That is what we celebrate here today. That is what this monument means. Today this small monument casts a mighty shadow that dwarfs the one cast by the great Washington Monument in our nation's capitol. That shadow not only reaches from one beautiful shore of our nation to the other, but back through the long passages of time. Back beyond the founding of our nation. Back beyond the birth of the great religious traditions. Back beyond the first awkward experiments with democratic government. This monument reaches beyond the shadows of prehistory to the time when two human tribes crossed each other's path for the first time. And different colored eyes, locking there together, would wonder if all people, ALL people, ALL PEOPLE, would ever live as one."

References

S. Boodman. (2005). Vowing to set the world straight. Washington Post. August 16.
Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press.
Paula J. Caplan. (1995). They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Addison-Wesley.
Paula J. Caplan & Jeremy B. Caplan. (2009). Thinking Critically about Research on Sex and Gender. Boston: Pearson.
Robert L. Spitzer. (2003). Can some gay men and lesbians change their sexual orientation? Archive of Sexual Behavior 32(5), 403-17.

Overcoming Homophobia: Progress Despite the Rocky Road

Just posted @ http://www.psychologytoday.com/blog/s...


Created May 18 2011 - 9:40am
©Copyright 2011 Paula J. Caplan All rights reserved

Homophobia, servicemembers, and the lords of psychiatric diagnosis

Note: This essay was written on May 17, 2011, but due to technical difficulties could not be posted until now.

Today is International Day Against Homophobia, a fitting time to look at two arenas in which there have been both rocky roads and some progress in the struggle to end this form of bias and resulting mistreatment.

On May 7, I attended a ceremony to mark the 10th anniversary of the setting of a memorial to LGBT servicemembers who have died. Tom Swann, head of the Palm Springs chapter of Veterans for Peace, a gay man who spearheaded the creation of this memorial in Cathedral City, CA (next-door to Palm Springs) and who led the struggles necessary to get the cemetery's permission to set the modestly-sized obelisk, told us that this is the only such memorial in the United States. Think about it.

Some might object that the memorials to deceased servicemembers also include LGBTs so that there was no need for a separate marker. But being at war is hard enough to get through, so let us consider what LGBT servicemembers have additionally endured...solely because of their sexual orientation. Many had to shoulder the almost unbearable burden of never letting slip the slightest indication of that orientation, lest they be drummed out of the military with a dishonorable discharge, otherwise publicly shamed, beaten, or even killed, as we know that some have been.

A gay veteran I interviewed (Caplan, 2011) told me that, although those who went through basic training with him did not know that he was gay, he watched the horrible beating of a heterosexual soldier whom someone erroneously said was homosexual, and after that, the gay veteran lived in terror that someone would find out or even suspect his orientation.

At the May 7 ceremony, Brigadier General Keith H. Kerr recounted some of the struggles that led to the recent repeal of the Don't Ask, Don't Tell (DADT) policy, including many who lobbied to change the law, the Log Cabin Republicans' filing of the lawsuit that led to a federal court ruling that DADT is unconstitutional, and those who chained themselves to the White House fence to protest discrimination and were arrested. Now, he said, DADT "is in its death throes, and seventy percent of the American public believes that LGBT people should be able to serve openly, not live in fear of their military careers, and share their lives, their partners, and families while serving in uniform." He made the point that "Nothing is as destructive to military cohesion as having to conceal part of one's everyday life and loved ones." This point is particularly important, given that a reason often put forward for keeping gays out of the military or insisting that they conceal their sexual orientation has been that to do otherwise would interfere with military cohesion.

General Kerr said that the military services are scheduled to complete their troop training about "open service" this summer, and he fully expects that President Barack Obama and others in the executive branch of the government will later this summer "certify that open service will not harm [military] readiness." But anyone who has studied bias and mistreatment knows that more struggles lie ahead, because changing laws and practices will help in some ways but will not wipe out the homophobia that lives on in many individuals in the armed forces...or anywhere else.

My regular readers will know that I have written a great deal about problems with psychiatric diagnosis, but they may wrongly assume that I have no concerns about diagnosis and homophobia. That assumption would probably be based on the extensive publicity Dr. Robert Spitzer received in the 1970s, when as head of the then-forthcoming Diagnostic and Statistical Manual of Mental Disorders-III (DSM), he announced that the American Psychiatric Association (APA), publisher of the DSM, had decided - by majority vote - that homosexuality was no longer a mental illness. Homosexuality was in the previous edition of the manual but would be removed for the next one, Spitzer proclaimed (Caplan, 1995).

There was rejoicing in the gay community, which had lobbied hard for that change. Many rejoiced even while taking note of the ironies and problems involved in (1) making such decisions by vote; (2) the fact that one second before the results of the voting were announced, homosexuality supposedly was a mental illness, and as soon as the results were known, it was not; (3) the fact that a lobby group, which is what the APA actually is, had the power to make such declarations and to put enormous influence behind them.

In the 1980s, a gay graduate student at the University of Toronto's Ontario Institute for Studies in Education, where I was teaching, corrected me when I said that homosexuality was no longer officially considered a mental illness. When Spitzer announced that it would not go in the next edition of the DSM, who would have thought to question his claim? Most people believed what he said. This student (I wish I could recall his name, because I have always been grateful to him for educating me) had learned that the DSM-III, published in 1980, listed as a mental disorder "Ego Dystonic Homosexuality." What is ego dystonic is what we do not experience as a part of ourselves with which we are comfortable and about which we feel happy. In 1980, in the intensely homophobic societies that were the United States and virtually all of the dozens of other countries where the DSM was used, how many gays and lesbians do you think were able to grow up feeling totally comfortable with their sexual orientation?

Thus, a socially-created effect of homophobia - gays' and lesbians' (few people then talked much about bisexuals or people we now called transgendered) discomfort about their sexual orientation - was cast as a mental illness. This is particularly disturbing, given that mental illness is so generally construed as a consequence of individual, intrapsychic problems, so to construe social problems as mental illnesses is to mask the harm done by social evils and reduce the chances that people will work to reduce them.

In 1987, the next DSM edition appeared (DSM-III-R), and Ego Dystonic Homosexuality did not appear. However, Sexual Disorders Not Otherwise Specified was there, and that pretty much amounts to whatever your therapist decides is a sexual disorder. So any sexual orientation other than heterosexuality could be given that mental disorder label. And you might want to have a look at dsm5.org to see what they are telling us they have in store at this point. (In a future essay, I will write about what the DSM authors call Gender Identity Disorder.)

In 2003, Spitzer said publicly that he had done some rethinking about homosexuality and mental illness. On what grounds? He had done some research that he called "Can some gay men and lesbians change their sexual orientation?" (Spitzer, 2003). The very title implies that being gay or lesbian is pathological, for a less biased piece of research might have been called, "Can people of any sexual orientation change to another sexual orientation?" A report about this study appears in Thinking Critically about Research on Sex and Gender:

"[Spitzer] carried out some research that he described as gauging the effectiveness of so-called reparative therapy, which is aimed to transform homosexuals into heterosexuals and frequently conducted by members of fundamentalist religious groups. Spitzer (2003) said he conducted 45-minute telephone interviews with 200 people who had undergone such 'treatment' and found that 66 percent of the 143 men and 44 percent of the 57, all of whom he said were 'extraordinarily religious,' told him they had been having heterosexual sex at least monthly for at least five years. On this basis, he reported that reparative therapy was extremely effective. There were major flaws in this research: the practitioners of this program and religious groups helped him find interviewees; extremely religious people may be highly motivated to disclaim homosexual feelings and present themselves as happy heterosexuals; despite the skewed selection of interviewees, fully one-third of the men and more than half of the women did not report switching their sexual orientation to heterosexual; some would question whether having heterosexual sex once a month is sufficient evidence of transformed sexual orientation; and it is not clear whether Spitzer made any attempt to interview people for whom the program had not been effective or had in fact been harmful, despite widely available information about such harm (Boodman, 2005)."
(Caplan & Caplan, 2009, pp. 83-4)

Given the frequency with which mental health professionals and especially those who write the diagnostic manual are considered (wrongly, I believe) to base their conclusions and classifications on well-done scientific studies, it is important to remember the vast number of serious methodological problems with what Spitzer offered as his research.

The road to eradicating homophobia is long enough without those in the mental health professions providing fuel for the fires of this hatred.

Switching from the focus on homophobia to a view of a better future in which sexual orientation will not be used oppressively, let me give the last words to American Veterans for Equal Rights President Danny Ingram, who said at the May 7 memorial commemoration of the small obelisk that honors LGBT veterans, an obelisk that is shaped like the Washington Monument:

"In a few weeks when President Obama, Admiral Mullen, and Secretary Gates certify the repeal of Don't Ask, Don't Tell, America will be more free than she was the day before. That is what we celebrate here today. That is what this monument means. Today this small monument casts a mighty shadow that dwarfs the one cast by the great Washington Monument in our nation's capitol. That shadow not only reaches from one beautiful shore of our nation to the other, but back through the long passages of time. Back beyond the founding of our nation. Back beyond the birth of the great religious traditions. Back beyond the first awkward experiments with democratic government. This monument reaches beyond the shadows of prehistory to the time when two human tribes crossed each other's path for the first time. And different colored eyes, locking there together, would wonder if all people, ALL people, ALL PEOPLE, would ever live as one."

References

S. Boodman. (2005). Vowing to set the world straight. Washington Post. August 16.
Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press.
Paula J. Caplan. (1995). They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Addison-Wesley.
Paula J. Caplan & Jeremy B. Caplan. (2009). Thinking Critically about Research on Sex and Gender. Boston: Pearson.
Robert L. Spitzer. (2003). Can some gay men and lesbians change their sexual orientation? Archive of Sexual Behavior 32(5), 403-17.

Ongoing Labors of Love: Changing Mental Set about How to Help Wounded Warriors and Others

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Ongoing Labors of Love: Changing Mental Set about How to Help Wounded Warriors and Others By Paula J. Caplan, Ph.D. Created May 12 2011 - 3:06pm ©Copyright Paula J. Caplan All rights reserved

Rethinking what steps we can take to help veterans and other traumatized people

Like many people who become therapists, I went into that kind of work in the hope of being able to help alleviate some human suffering. At some point in my Ph.D. program at Duke University, I became aware that the faculty who were training us were not explicitly addressing this pair of pervasive expectations - that we knew or soon would know how to help and that we knew more about patients than they knew about themselves.

What to do in the face of this daunting pair, combined with the apparent practice of not talking about them and certainly not questioning either assumption? Like most graduate students, I assumed that my teachers and supervisors knew both how to help and how to come to know more about patients than they know about themselves. At that point, I was the kind of student who primarily assumed that the authorities had the answers. In fact, I recall wondering to myself, that first year in graduate school, whether perhaps I was spineless, since I noticed that, almost regardless of who said what in class, I would nod as if in agreement. It took some years to recognize that my default reaction (like a well-socialized woman, of course) was to try to find something to agree with in whatever anyone said, to look for commonalities. And I remember my discomfort when a teacher or other expert said something that did not make sense, did not fit with research with which I was familiar or with the behavior we had just observed in patients or "normal" interviewees, or revealed a lack of attention to and empathy for people's suffering.

It was hard to understand that I had entered a field in which some people's primary intention was to help and their approach was caring, honest, and based on the best principles of clinical practice and critical thinking about the relevant research, but that many did not fit that description. So it took many years, decades even, and a gradual process of disillusionment with many arenas related to clinical work, including both practice and research.

Disappointingly often, when I had to teach about a new topic or became interested in a new area and began to read the clinical and related research literature or to attend continuing education and other lectures, my heart would sink when the absence of standards that mattered became evident. I even reached the point at which I dreaded entering into any new field. Thus, part of the context of this essay is that I have learned that the usual methods in the mental health system often fail to help or to be sufficient, and that it is important to listen to what people tell us about what helps and what does not. We can all be in this together, as we struggle to find ways to alleviate pain.

Although in the rest of this essay, the focus is on ways to help war veterans, much applies also to those who have experienced other kinds of trauma, including but not limited to rape, child sexual abuse, and other kinds of physical or emotional violence. And because this is an essay rather than a book chapter or a book, please keep in mind that I will write here only a fraction of all there is to say about ways to help. [1]

When the Iraq War was about to begin, and Dr. Maureen McHugh at an Association for Women in Psychology conference raised the question of whether there was anything specific that we as psychologists might do, I had for almost a quarter of a century been immersed in waves of disheartening discovery of the unscientific nature of psychiatric diagnosis. During that time, the use of diagnosis had skyrocketed in the United States, as had the use of psychiatric medications about which little was known or had been disclosed by their manufacturers but billions of dollars had been spent on advertising them, while the use of plain, old talk therapy had drastically declined. When Dr. McHugh asked her question, I guessed that as Americans went off to war and then came home, devastated, both we as a nation and mental health professionals in particular would rush to classify the effects of war's horrors as mental illness, whether or not the sufferers should by any stretch of the imagination be called mentally disordered.

That was the first seed of more than seven years of listening to veterans from earlier wars and the new ones, and it was the veterans who taught me part of the answer to the question raised by the Rev. Dr. Roger Ray in a comment in response to one of my earlier essays here. He asked: How can we help these suffering souls?

In the rest of this essay, I offer some ways that I know we can help, but I ask readers to recognize that, when I describe an approach that has been helpful to some veterans - much of which applies to other sufferers of trauma - if it has not been helpful to you, or if you have in addition found other approaches to be helpful, I would not doubt your report of your experience. I will say a bit more about that later.

As I have noted repeatedly, there is a vast system of military and Veterans Affairs mental health programs and providers, the overwhelming majority grounded firmly in the "diagnose, medicate, and maybe listen a bit" tradition. In spite of this, millions of veterans have no homes and/or jobs, are substance abusers, have experienced family breakdown, are serving time in prison for violent conduct, have tried to kill themselves, cannot sleep, and cannot form and maintain good relationships with others. So clearly, the traditional approach is failing.

Yesterday, the head of a VA Vets' Center told me that the average patient in the VA's mental health system is seen once every three months. One might conclude that that is the problem, that the VA is far too understaffed. But since the current wars began, the rapid introductions of new programs and hiring of more staff has not even led to decreases in the numbers of serious problems and suicides. In fact, they only increase steadily, and Pentagon spokespersons have publicly expressed alarm about that.

To listen to veterans is to learn that, for the most part, diagnosis has not been helpful, just made them feel "crazier"; drugs have rarely helped and nearly always caused negative effects such as exacerbation of their troubling emotions and moods, sexual problems, dramatic weight loss or weight gain, and the onset of diabetes and heart problems; and even psychotherapy has not helped, because it has too often been based on the notion that they have individual psychopathology, with little or no attention paid to the mammoth shock of returning from a life focused on strict hierarchies and following of orders aimed at least partly at destruction and killing to civilian life in which structures, ways of interacting, and life aims are utterly different. And too rarely have those in therapy found help in figuring out what to do about the loss of the intense closeness of the relationships they formed with those with whom they served in the military, a closeness that - especially for the men - is unequaled by any relationships they have had with others before or since. And many men have been taught to be uncomfortable if they want close and meaningful friendships with other men in civilian life.

A veteran left this comment in response to an earlier essay on this blog: "Depression made me cry and retreat inward. Therapy sessions made me cry and retreat inward. Antidepressants caused unpleasant side effects. Side effects made life with depression more unpleasant. For me, it was all as counterproductive an experience as it sounds." And one of the veterans I met in the course of writing my book, formerly a vibrant human being, has now been on at least three psychiatric drugs for years, is seen regularly in the VA system, and is clearly experiencing dramatic damage to his brain and major and rapid weight loss, while becoming increasingly despondent and feeling increasingly helpless.

Furthermore, as veteran Rick Lawson wrote to me, "Enduring and returning from combat is not a mental illness! And we shouldn't have to be disabled to obtain compensation and assistance upon our return home." In fact, here is a tragic irony: Robert L. Whitaker has shown in his book, Anatomy of an Epidemic, [2] that the use of psychiatric medication (which virtually never happens unless the patient is given a psychiatric label) dramatically increases the chances that the person will end up on disability as a result of the effects of the medication. (And a reader of this blog left a comment about the ways that both nonpsychiatric and psychiatric drugs can cause what look like symptoms of serious mental illness.) So to call all veterans who are suffering emotionally mentally ill is to increase dramatically the chances that they will end up on disability. In spite of this, the courts are filled with cases of veterans who have received diagnoses but still cannot get the benefits to which they are entitled as veterans, given how slowly the system works and the high frequency with which applications for deserved benefits are rejected. So one way to help is to learn and educate others about these major problems in the systems in which veterans are treated and to support individual veterans and veterans' groups as they struggle to get what is coming to them and to improve the system.

There are other ways to help. To listen to veterans is to hear that even when therapists are helpful, the veterans know the therapists are getting paid to help and are not part of the veterans' world outside the therapists' offices. Time and again, when asked what has helped them regain some calm, some peace, the former servicemembers described incidents in which someone from the wider community, often someone they had never met before, asked to hear their story. It is remarkable how many have said such things as, "When I told a bit of my story and was kicking myself for not having done something I thought I should have handled differently, the person listening said I was being too hard on myself. And that night, I slept for the first time since I got back from Iraq."

Since fewer than 1% of Americans have served in the military, the only way we can understand what veterans have been through is to ask. Since it is helpful to them and helpful to us, giving us a way to help our nation heal from the emotional wounds of war, asking to hear veterans' stories is one way to provide some help. [3] I have mentioned this several times on this blog but risk being repetitive, because veterans say it is useful for them and because it goes so strongly against the pervasive assumption that only therapists can help.

Another way to help is with the practicalities of life. Whether someone is unemployed because of having been at war or having been traumatized in some other way, as my friend Alan Rauzin wisely said, "Work roots you in the world." It carries some dignity, some sense of mattering. We can help veterans find jobs. And when it comes to having no home or food, how can one begin to heal from emotional trauma while having to worry constantly about where to sleep or find nourishment? Every program I have ever seen that effectively assists people who are suffering from emotional causes provides these kinds of practical assistance.

An anonymous writer commenting on this site speculated about veterans that "The general community isn't going to be able to help the guy who gets intense panic attacks whenever he's in a car, or who constantly feels in danger when in public." Although some therapists can be helpful to some veterans with such problems, veterans report that many have not. But beyond that, one way of helping veterans to feel at least somewhat safer, if not safe, is in fact to ensure that as many people as possible in their communities understand the reasons for the vets' panic and sense of danger and to let them know that they will not be judged or mocked for not having "gotten over it" yet. Does that kind of community education and support solve all of veterans' problems? Certainly not. It is impossible to think of what kind of drilling and events of positive sorts would be powerful to counteract or undo the effects of the months and years of focus on and exposure to mortal danger that they have experienced in the military. No therapist, no layperson, and no community can provide that. What we can do, though, is commit ourselves to the ongoing labor of love, as Veterans Affairs psychologist Dr. David Collier calls it, of taking what steps we can to understand and support veterans, helping them truly come home from war.

[1] See Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press for more about this subject.
[2] Robert L. Whitaker. (2010). Anatomy of an Epidemic. New York: Crown.
[3] In Chapter 6 of Caplan (2011), I offer detailed guidelines for interviewing veterans, as well as suggestions for dealing with some common problems that can arise in these interviews.

War-Traumatized People: What to Call Them, How to Help Them

Just posted @ http://www.psychologytoday.com/blog/s...


Created May 10 2011 - 9:45am
©Copyright 2011 Paula J. Caplan All rights reserved


Controversies about those traumatized by serving in combat

When we think "ill" or worse, "mentally ill" we think two destructive things. First, there is a professional [who is] handling that, so I need not act. Second, they are unlike healthy me, but if I get near I may catch it. This is obviously awful, too.
- Jude McGee

This essay grows out of responses readers sent to my two previous ones here about people traumatized by war: "What is a Healthy Response to War?" and "Why NOT Call War Trauma a Mental Illness?"

In response to those two essays, some readers posted comments publicly on the Psychology Today website, and several friends and colleagues who sent private emails pursued these topics and raised important, related ones. If you have not read those posted on this website, I urge you to do so before finishing this essay.


Q: What to call war-traumatized people?
A: How about calling them "war-traumatized people"?

In response to the concern I expressed about harm that we do to war veterans (and often to other traumatized people) by construing the traumatic effects as mental illness, two people said that they had been relieved to receive a label. It is true that we must acknowledge the potentially positive effects of putting in words what a person is experiencing as overwhelming, fragmenting, and bewildering. It can help initially to be told, "You have Post-traumatic Stress Disorder" (PTSD) or "Major Depressive Disorder," for instance, because the labels are neat, the number of words is few, and most people (mistakenly) believe that once a professional has diagnosed them, that professional will know how to make them feel better.

In my play, WAR&THERAPY, the woman veteran asks to be labeled with PTSD, and the therapist replies: "Yes, because that sounds clean and clinical. For one moment you'll feel relief. But after that, it will bring you nothing but harm, keep you thinking you should be over it by now."

One reader said that every word in the term "Post-traumatic Stress Disorder" applied to her. But my point is that it does not tell others what she has been through in the way that such terms as "war trauma" or "rape trauma" would.

One reader presented the Catch-22 that, whereas being labeled mentally ill can add to veterans' burdens, not to name their suffering can leave them "feeling crazy." There is a third option, however, and that is to name it as accurately as possible, in everyday language, such as: "This person was traumatized by being in combat and now is plagued by fear and guilt."


To label or not to label?

Someone with the username Sebastian said in a comment on this site that he finds "all this talk about stigma and labels" annoying. He thinks that people should just ignore what others say about them, because "99% of stigma is all in your head," and anyone who is unable to ignore that has a weak sense of self. As Anonymous replied, however, it is hard to be told that it's easy to ignore psychiatric labels when they have been used to deprive you of your freedom and your rights. Anonymous described having been detained without charge or trial, then forcibly drugged. And Anonymous asked, "Is it my weak sense of self that means I'm now labeled and defined as incompetent and have my every word and action second-guessed and run through a filter of received prejudice? .... I could never be elected to high office, I know I could never get security clearance and work for example in the intelligence agencies." I urge readers to read the rest of Anonymous's comment, which was posted May 5, 2011, at 12:01 p.m. It will break your heart, but it shows the realities of the lives of many because they have been so categorized. And psychdiagnosis.net includes 53 stories of people whose lives were ruined in various ways by psychiatric diagnosis.

To read such first-person stories should alarm us all the more, given that the research simply does not show that labels help therapists help their patients (in fact, it often gets in the way) and given that a vast array of kinds of harm have come to people just because they have received virtually any psychiatric diagnosis, no matter how mild the label might seem. (Please see the two essays mentioned above and the references cited therein.)

For every person who has told me that they were relieved to get a label, far more have told me either that getting a label hurt and did not help or that they were relieved at first and expected it would help but were disappointed to learn that it did not.

If you receive such a label and are fortunate, the fact that you have the label may lead some people to take your suffering more seriously - i.e., "John/Jane is not just complaining but is experiencing severe emotional pain." But since labeling does not improve treatment or prognosis, how about if we take it seriously when a person tells us they have been through hell and are still suffering...without having to declare them mentally disordered? And isn't that all the more important when the kind or severity of the trauma (such as being in combat, being sexually abused as a child, being held hostage) is such that most of us would react as the sufferer is reacting? Surely we do not want to withhold from people in emotional pain our care, compassion, respect, and help unless they agree to be labeled mentally ill.

War veterans who have told me they were relieved to be diagnosed with PTSD have invariably explained that that was because it seemed that someone was finally listening to them and was telling them that they were not unique. Right. Not unique but nevertheless mentally ill. I would not want anyone I cared about who had been through war to be told that their sleepless nights, their grief, their fear, and their moral conflicts and existential crises were signs that they were mentally ill. As I have asked before, if those kinds of reactions to war are evidence of illness, what exactly would we call healthy reactions? [1]

Some readers pointed out that diagnostic labels are important, because without them, patients have to pay for therapy out of their own pockets. I lived in Canada for nearly two decades, at the end of which I believed even more fervently than before that people deserve help when they are suffering and that professional help should be covered by insurance. Since some therapists are helpful, and there are sometimes reasons that a person wants to talk with a therapist rather than anyone else, that insurance coverage is extremely important. Until we can change our system so that payments are based on helping people with the problems they describe rather than relying on unscientifically-derived psychiatric categories, many people will want to be psychiatrically labeled so their insurance will pay for their therapy. All the more reason, then, to make sure to put in place protections of those rights that the diagnosed often lose, and all the more reason to make sure we tell war veterans and other traumatized people that, even though they have been labeled mentally ill, we really do not believe they are. This comes with a sigh that such machinations are necessary now and for the foreseeable future.

I am glad that some who wrote to me found helpful therapists, and I do not doubt their reports. But I wish to raise the question of whether the people who helped them could have done so without labeling them mentally ill. It is possible to say, "I see that you are suffering, it's understandable in light of what you have been through, and I will try to help you" without saying, "And this makes you mentally ill." In fact, those who write the psychiatric diagnostic manual have said repeatedly and publicly that they have not even been able to come up with satisfactory definitions of mental disorder. [2] This makes it all the more troubling to watch the rush to assign the labels.

The fact that therapists have helped some people is wonderful for them but does not mean that all or most therapists could have helped, and it does not mean that what their therapists did could only have been done by therapists. In fact, the finest therapists I know have told me that they believe that compassionate, intelligent people who are not trained therapists can do what they do. Indeed, research has shown that social support, including but not limited to self-help groups, is remarkably effective. And virtually everyone who tells me that therapists helped them also describe having been helped by other caring people and/or groups besides therapists.

I used to have a psychotherapy practice, and I was surprised that every time a patient told me I had done something helpful, something they were sure no one else could possibly have done, it was either nothing that I had learned in my training but only what would have been done by any caring, respectful person who thought carefully about what the speaker said, or it was something I had learned but that could fairly easily be taught to other therapists and non-therapists.

Does it help to talk with someone who has either been there literally (e.g., in Vietnam or Afghanistan) or been in similar situations (e.g., repeatedly molested by a close family member)? It certainly can. But so can talking with people who are willing to listen carefully and respectfully and to learn what it has been like for the speakers. It is one thing to say that some therapists are really helpful but another thing to say that no one but a therapist could help that much, and for humane and political reasons, it is important to demystify therapy and therapists. And to talk to a friend or other caring person, one does need to be slotted into a category of mental disorder.

I responded to one reader: "I am happy for you that you had a therapist who was right for you and smart and caring and effective. Part of what scares me is that, although there are wonderful people...working with survivors of the worst kinds of trauma, there are also therapists I have known who were so voyeuristic, self-absorbed, [or] slapdash in dealing with people they had diagnosed with [serious psychiatric labels] that ... since the people who seek help from those identified as trauma experts are already so vulnerable, it is scary to think of recommending they see even a 'trauma expert'...unless they can get to someone [who is proven to be good]." The problematic therapists may represent only a fraction of those who are out there, but the sad fact is that one cannot assume, when desperately needing help and support, that the therapist into whose office one walks will be both helpful and safe.

It is sad that even some of the therapists one would think would be most likely to help those traumatized by war can do great damage. One of the veterans I interviewed for my book [3] told me that the therapist he saw at a VA Hospital said the vet could tell him anything about the war, and he would listen. But when the veteran told him a story that, while harrowing, was hardly rare as war stories go, the therapist cut him off, saying, "Please stop." The veteran was so shaken to learn that he could not even tell his story to someone paid to help and paid to specialize in working with war-traumatized individuals that he wandered around for hours in the parking lot, too disoriented and devastated to be able to locate his car.

I need to repeat here: Some therapists are wonderfully helpful. I hope it is clear by now that that I have never even questioned that. But with the enormous numbers of military and non-military therapists across the United States and based in combat zones, the fact remains that hundreds of thousands of veterans are homeless, jobless, addicted to drugs or alcohol, violent (whether suicidal or otherwise), or serving time in prison because whatever is being done to help them has not been enough.

It is time to stop expecting that therapists can fix all the carnage of war, with or without therapy and with or without medication.

In Part 2 of this essay, I will address further the question of what else can be done to help those suffering from war and other kinds of trauma.

[1] Paula J. Caplan. (2011). When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans. Cambridge, MA: MIT Press.
[2] Paula J. Caplan. (1995). They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Addison-Wesley.
[3] Caplan, 2011.

War-Traumatized People: What to Call Them, How to Help Them (Part 1)

Just posted @ http://www.psychologytoday.com/blog/s...


Created May 10 2011 - 9:45am
©Copyright 2011 Paula J. Caplan All rights reserved


Controversies about those traumatized by serving in combat

When we think "ill" or worse, "mentally ill" we think two destructive things. First, there is a professional [who is] handling that, so I need not act. Second, they are unlike healthy me, but if I get near I may catch it. This is obviously awful, too.
- Jude McGee

This essay grows out of responses readers sent to my two previous ones here about people traumatized by war: "What is a Healthy Response to War?" and "Why NOT Call War Trauma a Mental Illness?"

In response to those two essays, some readers posted comments publicly on the Psychology Today website, and several friends and colleagues who sent private emails pursued these topics and raised important, related ones. If you have not read those posted on this website, I urge you to do so before finishing this essay.


Q: What to call war-traumatized people?
A: How about calling them "war-traumatized people"?

In response to the concern I expressed about harm that we do to war veterans (and often to other traumatized people) by construing the traumatic effects as mental illness, two people said that they had been relieved to receive a label. It is true that we must acknowledge the potentially positive effects of putting in words what a person is experiencing as overwhelming, fragmenting, and bewildering. It can help initially to be told, "You have Post-traumatic Stress Disorder" (PTSD) or "Major Depressive Disorder," for instance, because the labels are neat, the number of words is few, and most people (mistakenly) believe that once a professional has diagnosed them, that professional will know how to make them feel better.

In my play, WAR&THERAPY, the woman veteran asks to be labeled with PTSD, and the therapist replies: "Yes, because that sounds clean and clinical. For one moment you'll feel relief. But after that, it will bring you nothing but harm, keep you thinking you should be over it by now."

One reader said that every word in the term "Post-traumatic Stress Disorder" applied to her. But my point is that it does not tell others what she has been through in the way that such terms as "war trauma" or "rape trauma" would.

One reader presented the Catch-22 that, whereas being labeled mentally ill can add to veterans' burdens, not to name their suffering can leave them "feeling crazy." There is a third option, however, and that is to name it as accurately as possible, in everyday language, such as: "This person was traumatized by being in combat and now is plagued by fear and guilt."


To label or not to label?

Someone with the username Sebastian said in a comment on this site that he finds "all this talk about stigma and labels" annoying. He thinks that people should just ignore what others say about them, because "99% of stigma is all in your head," and anyone who is unable to ignore that has a weak sense of self. As Anonymous replied, however, it is hard to be told that it's easy to ignore psychiatric labels when they have been used to deprive you of your freedom and your rights. Anonymous described having been detained without charge or trial, then forcibly drugged. And Anonymous asked, "Is it my weak sense of self that means I'm now labeled and defined as incompetent and have my every word and action second-guessed and run through a filter of received prejudice? .... I could never be elected to high office, I know I could never get security clearance and work for example in the intelligence agencies." I urge readers to read the rest of Anonymous's comment, which was posted May 5, 2011, at 12:01 p.m. It will break your heart, but it shows the realities of the lives of many because they have been so categorized. And psychdiagnosis.net includes 53 stories of people whose lives were ruined in various ways by psychiatric diagnosis.

To read such first-person stories should alarm us all the more, given that the research simply does not show that labels help therapists help their patients (in fact, it often gets in the way) and given that a vast array of kinds of harm have come to people just because they have received virtually any psychiatric diagnosis, no matter how mild the label might seem. (Please see the two essays mentioned above and the references cited therein.)

For every person who has told me that they were relieved to get a label, far more have told me either that getting a label hurt and did not help or that they were relieved at first and expected it would help but were disappointed to learn that it did not.

If you receive such a label and are fortunate, the fact that you have the label may lead some people to take your suffering more seriously - i.e., "John/Jane is not just complaining but is experiencing severe emotional pain." But since labeling does not improve treatment or prognosis, how about if we take it seriously when a person tells us they have been through hell and are still suffering...without having to declare them mentally disordered? And isn't that all the more important when the kind or severity of the trauma (such as being in combat, being sexually abused as a child, being held hostage) is such that most of us would react as the sufferer is reacting? Surely we do not want to withhold from people in emotional pain our care, compassion, respect, and help unless they agree to be labeled mentally ill.

War veterans who have told me they were relieved to be diagnosed with PTSD have invariably explained that that was because it seemed that someone was finally listening to them and was telling them that they were not unique. Right. Not unique but nevertheless mentally ill. I would not want anyone I cared about who had been through war to be told that their sleepless nights, their grief, their fear, and their moral conflicts and existential crises were signs that they were mentally ill. As I have asked before, if those kinds of reactions to war are evidence of illness, what exactly would we call healthy reactions?

Some readers pointed out that diagnostic labels are important, because without them, patients have to pay for therapy out of their own pockets. I lived in Canada for nearly two decades, at the end of which I believed even more fervently than before that people deserve help when they are suffering and that professional help should be covered by insurance. Since some therapists are helpful, and there are sometimes reasons that a person wants to talk with a therapist rather than anyone else, that insurance coverage is extremely important. Until we can change our system so that payments are based on helping people with the problems they describe rather than relying on unscientifically-derived psychiatric categories, many people will want to be psychiatrically labeled so their insurance will pay for their therapy. All the more reason, then, to make sure to put in place protections of those rights that the diagnosed often lose, and all the more reason to make sure we tell war veterans and other traumatized people that, even though they have been labeled mentally ill, we really do not believe they are. This comes with a sigh that such machinations are necessary now and for the foreseeable future.

I am glad that some who wrote to me found helpful therapists, and I do not doubt their reports. But I wish to raise the question of whether the people who helped them could have done so without labeling them mentally ill. It is possible to say, "I see that you are suffering, it's understandable in light of what you have been through, and I will try to help you" without saying, "And this makes you mentally ill." In fact, those who write the psychiatric diagnostic manual have said repeatedly and publicly that they have not even been able to come up with satisfactory definitions of mental disorder. [2] This makes it all the more troubling to watch the rush to assign the labels.

The fact that therapists have helped some people is wonderful for them but does not mean that all or most therapists could have helped, and it does not mean that what their therapists did could only have been done by therapists. In fact, the finest therapists I know have told me that they believe that compassionate, intelligent people who are not trained therapists can do what they do. Indeed, research has shown that social support, including but not limited to self-help groups, is remarkably effective. And both of the women to whom I have been referring also described having been helped by other caring people and/or groups besides therapists.

I used to have a psychotherapy practice, and I was surprised that every time a patient told me I had done something helpful, something they were sure no one else could possibly have done, it was either nothing that I had learned in my training but only what would have been done by any caring, respectful person who thought carefully about what the speaker said, or it was something I had learned but that could fairly easily be taught to other therapists and non-therapists.

Does it help to talk with someone who has either been there literally (e.g., in Vietnam or Afghanistan) or been in similar situations (e.g., repeatedly molested by a close family member)? It certainly can. But so can talking with people who are willing to listen carefully and respectfully and to learn what it has been like for the speakers. It is one thing to say that some therapists are really helpful but another thing to say that no one but a therapist could help that much, and for humane and political reasons, it is important to demystify therapy and therapists. And to talk to a friend or other caring person, one does need to be slotted into a category of mental disorder.

I responded to one reader: "I am happy for you that you had a therapist who was right for you and smart and caring and effective. Part of what scares me is that, although there are wonderful people...working with survivors of the worst kinds of trauma, there are also therapists I have known who were so voyeuristic, self-absorbed, [or] slapdash in dealing with people they had diagnosed with [serious psychiatric labels] that ... since the people who seek help from those identified as trauma experts are already so vulnerable, it is scary to think of recommending they see even a 'trauma expert'...unless they can get to someone [who is proven to be good]." The problematic therapists may represent only a fraction of those who are out there, but the sad fact is that one cannot assume, when desperately needing help and support, that the therapist into whose office one walks will be both helpful and safe.

It is sad that even some of the therapists one would think would be most likely to help those traumatized by war can do great damage. One of the veterans I interviewed for my book [1] told me that the therapist he saw at a VA Hospital said the vet could tell him anything about the war, and he would listen. But when the veteran told him a story that, while harrowing, was hardly rare as war stories go, the therapist cut him off, saying, "Please stop." The veteran was so shaken to learn that he could not even tell his story to someone paid to help and paid to specialize in working with war-traumatized individuals that he wandered around for hours in the parking lot, too disoriented and devastated to be able to locate his car.

I need to repeat here: Some therapists are wonderfully helpful. I hope it is clear by now that that I have never even questioned that. But with the enormous numbers of military and non-military therapists across the United States and based in combat zones, the fact remains that hundreds of thousands of veterans are homeless, jobless, addicted to drugs or alcohol, violent (whether suicidal or otherwise), or serving time in prison because whatever is being done to help them has not been enough.

It is time to stop expecting that therapists can fix all the carnage of war, with or without therapy and with or without medication.

In Part 2 of this essay, I will address further the question of what else can be done to help those suffering from war and other kinds of trauma.

Beyond the Flowers and Cards, Mother's Day's Original Meaning

Just posted at http://www.psychologytoday.com/blog/s...


Created May 7 2011 - 6:29pm ©Copyright 2011 Paula J. Caplan All rights reserved


The role of war and peace in the origin of Mother's Day in the United States

May we step aside from the intense media focus on the apparent death of bin Laden to take note that hundreds of thousands of American women will spend this Mother's Day worrying about their children who are in the military in Iraq, Afghanistan, and other parts of the world, where they could lose their lives in one of our wars?


One of the prime movers for creation of a Mother's Day in the United States was Julia Ward Howe, whose "Mother's Day Proclamation" was inspired by the devastation of the American Civil War and the Franco-Prussian War. In it, Howe called for mothers to grieve for those who had died and then to work for peace. Her proclamation is well worth reading slowly and with care. It is here below, and in light of what she says, I wish you and yours not only a happy but also a pensive Mother's Day. May we take her words as inspiration to act, to work for peace.

Mother's Day Proclamation

by Julia Ward Howe

Arise, then, women of this day!
Arise, all women who have hearts,
Whether our baptism be of water or of tears!
Say firmly:
"We will not have great questions decided by irrelevant agencies,
Our husbands will not come to us, reeking with carnage, for caresses and applause.
Our sons shall not be taken from us to unlearn
All that we have been able to teach them of charity, mercy and patience.
We, the women of one country, will be too tender of those of another country
To allow our sons to be trained to injure theirs."
From the bosom of the devastated Earth a voice goes up with our own.
It says: "Disarm! Disarm! The sword of murder is not the balance of justice."
Blood does not wipe out dishonor, nor violence indicate possession.
As men have often forsaken the plough and the anvil at the summons of war,
Let women now leave all that may be left of home for a great and earnest day of counsel.
Let them meet first, as women, to bewail and commemorate the dead.
Let them solemnly take counsel with each other as to the means
Whereby the great human family can live in peace,
Each bearing after his own time the sacred impress, not of Caesar,
But of God.
In the name of womanhood and humanity, I earnestly ask
That a general congress of women without limit of nationality
May be appointed and held at someplace deemed most convenient
And at the earliest period consistent with its objects,
To promote the alliance of the different nationalities,
The amicable settlement of international questions,
The great and general interests of peace.