Back from War

What do we know about the mental health of returning soldiers?

This piece is a response to Alison Howell’s LRC article “Afghanistan’s Price,” which appeared in the November 2011 issue.

A recent LRC essay by Dr. Alison Howell demonstrates a lack of historical insight too frequently seen in today’s universities. Although she invokes history at the end of her article, she does so in a token way that does not demonstrate what has been learned from rigorous scholarship.

The problem of the return of soldiers to civilian life is not a new one. Since the end of the Napoleonic wars (if not before) we have data on veterans. Many solutions were tried to help their sufferings. Pensions, albeit more or less discretionary, were, like today, considered too low. Hospices for indigent soldiers became state affairs in late 18th century on the model of the Invalides in Paris (a project started in 1670). The press reported numerous suicides of veterans in the late 18th and early 19th centuries, perhaps because it was easier to gather details on them than on more obscure but unhappy survivors. Almost no psychiatric care was offered except asylums. The process of issuing honours and awards was democratized about the same time that political reforms gained impetus in Europe in the 19th century, a form of recognition that was thought helpful in alleviating the difficulties of soldiers coming back home. Overall health care improved for soldiers during the second half of the 19th century largely due to unfavourable press coverage of sanitary problems during the Crimean and American Civil wars. The first social welfare measures became available to a limited extent in most western countries, first in the form of indemnities for work-related injuries. By the time the First World War broke out the situation of veterans was as follows: partial financial support for the invalids, obligatory proof required of inability to earn a living because of disability, institutionalization of the most problematic cases, almost no mental help outside asylums and a tendency among veterans not to seek whatever help was available.

Demobilization was slow and haphazard in 1919—in short, a near disaster. More pensions than ever before were distributed but they were still insufficient. More progressive psychological help became available but on a limited scale. The balance sheet was not very positive. This is borne out in archival documentation, which is replete with calls for help from veterans, their families and their friends.1 Generally what was sought was a job for the veteran, not the least because the economic situation of the early and late 1920s and of course the Depression during the 1930s made employment rare. Even with the preferential hiring of veterans within the public service, the job market could not accommodate the sheer number of returning soldiers, which exceeded 600,000 men.

Treatments of injured veterans were just beginning to become available in the mid 1930s when another war loomed ahead. Building on the experience of the past world war, several very conscious decisions were made that would improve decisively the care of veterans: better recognition of psychiatric casualties. numerous conversion programs to civilian life, basic education for the less educated or re-education for those unfortunate enough to be handicapped and, last but not least, quick demobilization with fairly generous premiums. While these decisions contributed to fewer problems in the post–Second World War period, the main reason there were fewer problems in 1945 than in 1919 was something totally out of the hands of the Department of Veterans Affairs. Contrary to 1919, the economic perspective of Canada in 1945 was extremely positive and employment was readily available. The same was true following the Korean War in 1953. If there is one lesson to be learned from the past it is this: the availability of employment is a key factor in the successful reintegration of the veteran into society and this, unfortunately, depends on cyclical economics that cannot be predicted.2

Availability of jobs is important. The process of asking for a job and being helped is also meaningful. At the time soldiers and veterans were seen with sympathy. In the 1920s, sympathy could take the form of job offers because everybody knew that a job was the condition of survival and health at a time when there were almost no social security programs to speak of. It is different today. Veterans now have access to health care and are on average in a better financial position that their predecessors. But sympathy is still in order. What form does it take today? Ending all intervention in war zones? This is the implicit argument in Howell’s article: mental health is a function of combat and only combat (or seeing atrocities). I think that there is no proof that her argument is right. Indeed the things I know about the past do not warrant her opinion.

There are a number of other lessons to be gleaned from the past, many at odds with those suggested by Howell. Quick treatment of mental breakdowns – meaning hours or days after the “injury” – was crucial. (However, this was accompanied by the concomitant problem of detecting mental injuries.) The best treatment was rest outside the combat zone but not too far from the battlefield, because an important aspect of a successful treatment was the quick return of the individual to the parent unit, although not necessarily in the same job. For example, many infantrymen became “pioneers,” or engineers/labourers in a special company of their regiment. In many cases the return to the “normality”—the routine—of war was as important as the rest cure itself. In difficult cases rest was induced by sedatives—the first pharmaceutical-based treatments that would be followed by more complex drug treatments beginning in the second half of the 1950s. Severely traumatized soldiers were not returned to the front. Of the latter group, the luckiest were sent back to depots and given administrative duties; but many were “boarded” (more on this later) and demobilized. Often the medical boarding process was more traumatizing to the soldier than the mental injury. In some soldier files we can even get the impression that too much concern or attention was sometimes more deleterious to mental health than less.

Treatments for combat stress and its consequences are described at length in the Canadian medical history of the Second World War. In Battle Exhaustion: Soldiers and Psychiatrists in the Canadian Army, 1939–1945, in 1990 at a moment when post-traumatic stress disorder was known to specialists but not to the general public, Bill McAndrew and Terry Copp wrote:

The experience of battle exhaustion by itself was unlikely to have long-term consequences for the individual. The acute “breakdown” that occurred in combat was quickly relieved by removing the soldier from danger. Such individuals might well react similarly under comparable stressful situations but otherwise they were unlikely to be affected. Post-traumatic stress syndrome was not more likely to occur among battle exhaustion cases than among other veterans, possibly because the battle exhaustion casualty had not continued to repress his fears.

I think that this conclusion does apply today with qualification, because the context has changed: then, veterans were not singled out as psychological time bombs. Perhaps the development of acute mental health problems was less likely in a society that accepted returning soldiers without singling them as a problematic group.

Contrary to what we can infer from Howell’s article, suicides were mostly of the same nature as in the civilian world: broken hearts and schizophrenic conditions for the youngest, and for the oldest insoluble financial problems, marital problems, alcohol problems and the expectation of a difficult life after the return to peace. As in the civilian population, older individuals committed suicide more frequently than younger.

When you read files of Second World War soldiers who committed suicide, it is striking that so few seem related to actual combat or horrors of war or scenes of poverty or the liberation of death camps. I write “seem” because I have read only about 60 such files out of a possibility of around 300 suicides committed by Canadian Army personnel. Research demands time and resources and the results are not guaranteed. It is my belief that I may not find what fits my political preference, and that would be fine. Far preferable that traumatism or harsh discipline or injustice or incompetence of higher army leadership should explain a high proportion of mental troubles, depressions and anxiety crisis. That would mean that removing men from war situations or not participating in any war at all would move us towards a better society with fewer psychological problems and suicides. My early results—and I admit that they are fragmentary but I sincerely think that they will be vindicated in the end—do not point to such an idyllic future.3 Most suicides (probably more than 80 percent) are the result of personal problems not peculiar to soldiers except maybe the fact of being far away for long periods or being estranged from family and friends.

Official computations give 120 suicides for the army and the RCAF in Canada and 154 overseas. The rates peak in 1940–42, a hint that most suicides were committed by soldiers not having been exposed to combat.4 The 60 suicides I found up to now are almost all of soldiers who never went farther than the United Kingdom. Several soldiers committed suicide in 1944–45 because they were expecting an employment crisis. That crisis did not happen but they could not have known. A few even took their lives because they became discouraged when they learned that Japan had surrendered, depriving them of an opportunity to fight in the Pacific. Suicides for medically related conditions following a bad experience or a catastrophic injury happened but they were relatively rare, certainly under a total of 20 for the years 1944, 1945, 1946 and the first six months of 1947 (my data stop there). These are very low numbers for an armed force composed of over 1.1 million men and women who soldiered for almost six years. Unfortunately some suicides are related to treatment or cessation of treatment because at that time psychiatric care was more difficult to get outside the army, as it is today. There was a huge problem with diagnosis and maybe five to ten suicides are linked to too rapid a diagnosis of schizophrenia, still called in some 1940–41 files “dementia praecox” (new medical labelling by itself clearly did nothing to improve patient treatment or conditions) or insufficient mental stability. The measure of mental stability became standard in the middle of war with the famous “M revised” test. An unstable soldier would be either moved to different employment within the ranks or would be discharged after a medical board (three doctors plus at least one report from a specialist, usually a psychiatrist). This ended regular pay, frequently the first good pay that the man had ever received. Because most soldiers were diverting some of their pay to their wife or their parents, it meant that after discharge they were vulnerable to notions of failure since they were no longer able to provide for their loved ones.

We will not be sure until more research is done, but I think that we will find the same pattern for Afghan veterans: no more suicides in the armed forces than in the Canadian population, most of them linked to personal problems and a majority committed by soldiers who never saw combat. I believe that in the long term the suicide rate has reached a low and will probably not vary much if the general conditions offered to soldiers and veterans are as good as they are today. Indeed, there are so few suicides and our army is so tiny that the Canadian Forces Expert Panel on Suicide Prevention considers it statistically irrelevant to review the evolution year by year. That is why incidents are grouped into five-year periods: 56 suicides from 1995 to 1999, 50 from 2000 to 2004, and 49 from 2005 to 2009 (the first contingent deployed in Afghanistan was in February 2002). The rates are respectively 20, 19 and 18 per 100,000. These rates seem to point to a slow reduction in suicides. They are below the suicide rates for Canadian men in general (only men are considered here because few women are involved), which are between 20 and 28 per 100,000 for men aged 20 to 64 years from 1995 to 2009.5

From an epidemiological point of view suicide is not an issue in the Canadian Forces of today. This is not unexpected. A slow decline in suicides is an evolution that corresponds to the historical trend in almost all population of soldiers since the 1840s, a fact that was noticed by Émile Durkheim (the great patriarch of suicide studies) and many doctors and social scientists before 1900.

When the statistics above were first published there were either ignored or criticized for being incomplete.6 So Statistics Canada was tasked with the difficult mission of researching the deaths of military personnel over the previous decades, for personnel who stayed in the Forces and personnel that were released. It was published in May 2011. To my knowledge it is the only reliable study of the kind.7 It investigated the deaths of 3,969 out of 188,161 soldiers enrolled between 1972 and 2006. Three periods were considered: 1972 to 1986, 1987 to 1996, and 1997 to 2006. Statistics Canada experts consider that the risk factor for suicide is statistically significant only in the first period: 1.63, compared to 0.94 and 1.26, a ratio of one meaning the same mortality as in the Canadian population.8 (It is not clear why the ratio for the last period is not considered statistically significant.) If we accept the wisdom of Statistics Canada’s scientists, then one could see that the highest risk factor coincides with the Trudeau years, when relations between the Canadian Forces and the government reached a low. More seriously, the deployment frequency (only traditional peacekeeping during the first period) of shrinking armed forces and the stress associated with long and frequent separation from family are the first relevant factors to be investigated.

The perception that the government cares and that public opinion is not unfavourable might also be hypotheses to be tested. Again I am not far from considering sympathy, or world affective style if you prefer, as a working hypothesis.9 Being bold I would even add a last shocking hypothesis: Canadian soldiers, now having the sense that they are making a difference in a troubled area of the world, have a better perception of themselves, which is a crucial factor when one observes the mental health of any population. As I have explained in my remarks on Second World War cases, I have good reason to doubt a too-direct link between combat stress and suicide rates. We should be very cautious in interpreting statistics. As I write they certainly do not prove Howell’s thesis. I doubt they will ever.

Perceptions are paramount when the foundation of mental health is shaken. We are dealing with several different ones here: the perceptions of professionals evaluating the soldier/veteran, the perception of the institution (colleagues and ex-buddies at the parent unit first), those of family and friends, those in the public sphere, including the publically expressed expertise of intellectuals, and, finally, those of the patients themselves. Since it is these last that must be cared for and since by definition they are the most problematic to change, we also have to work with families, friends, the institution and the professionals to have some healing effect. But a treating psychiatrist has almost no chance of influencing public opinion.

Progress has been slow. One may even argue that progress has stopped, and that maybe we are going backward with PTSD. As a diagnosis its record is mixed.10 Its introduction has been well documented by researchers such as Richard Rechtman (chief psychiatrist at a French hospital and anthropologist), Wilbur G. Scott (an American sociologist), Ben Shephard (a British historian), Derek Summerfield (a British psychiatrist), Allan Young (a Canadian anthropologist specialized in the social study of medicine), to name only a few. Summerfield and Young are the most adamant critics of PTSD.11 They speak of an “invention” in the mid 1970s to answer a social demand from Vietnam veterans, a demand that was canonized by “opportunistic” personages such as Chaim Shatan, Robert J. Lifton and Mardi J. Horowitz. These individuals invented a new medical condition for soldiers and civilians traumatized after a catastrophic event, not necessarily a war, though war was central in their argument to amend the diagnosis protocol for psychiatric illnesses in The Diagnostic and Statistical Manual of Mental Disorders.

To make a long story short, symptoms previously associated with conditions formerly described as shell shock, war neurosis, battle exhaustion or post-Vietnam syndrome were combined with symptoms of anxiety crises caused by incarceration in a concentration or a death camp or by an earthquake, and so on, and designated “post-traumatic stress disorder” in the 1980 revision of The Diagnostic and Statistical Manual of Mental Disorders (DSM-III).12 It is clear that, to quote a critic less radical than Young and Summerfield, “the challenge was to find a definition that would protect victims from suspicion, responsibility or accusation. The only way to achieve this was in fact ideological, by claiming that the event was the only aetiology, but to assert this, the event had to create the same pathology in almost anyone.”13 The key concern was to remove the suspicion of simulation from psychiatric literature, that kind of suspicion having been the main reason to limit psychiatric treatment in the Great War and, to a lesser extent, at the beginning of the Second World War. But therapists may have some difficulty treating an ideological illness. The biggest danger is that instead of taking into consideration the patient’s personality and his or her overall mental condition, they reduce the causes to only one: the traumatic event. Nonetheless Rechtman concludes that PTSD could be saved as a medical category because it clearly removes the blame from the patient.

Personally I am not convinced that PTSD is a useful medical category if only for this reason: despite the fact that PTSD was introduced to replace the war neurosis of DSM-II, most frequently the medications prescribed are cocktails of tranquillizers and antidepressants, and more of the latter that the former. Antipsychotics are also used but not as frequently as other drugs.14 If we place the recent evolution in a long term perspective we have reason to be concerned: artificially inducing sleep was part of the cure developed during the Second World War, but one can argue that that was in part because psychiatrists were rare in the army (one per army corps, so about one for 50,000 troops!). Now that we have more and more psychologists and psychiatrists, we seem to rely on more sophisticated medications with results that are not always good.15 Would that be because our society prefers labelling to listening?16 Are drugs and psychotherapy adequate answers to what seems to be more a moral or political debate, to frame the question as Rechtman does?17 Is it too far-fetched to conclude from that short survey of treatments that rest is paramount, with time to forget and social acceptance? Would I be cynical by calling this sympathy? It seems to me that to politicize a mental disorder, real but probably mislabelled, would do nothing to cure those affected, and might even cause them harm, because the perception of having waged a useless war, of having been a sort of accomplice in NATO massacres, of being pariahs of an otherwise non-violent Canada is not helpful. There is way too much politics involved here to be assured that mental health is the priority.

Howell acknowledges that public support for the army or lack of it is important, giving the example of the United States in Vietnam.18 But she refrains from telling us that one of the lessons that the Americans learned in the 1970s is that the process of decompression, or “de-operation” if you prefer, is critical. U.S. military physicians and psychologists discovered that the incidence of mental disorders grew in direct proportion to the speed at which soldiers returned home, and that it was better to ship men by boat from the theatre of operation (as during the two world wars and Korea) than to fly them home. The Canadian Forces have a similar decompression stop (Guam for a time, then Cyprus) of four to six days between the war zone and home. The de-stressing process is accomplished in unit or with a group of comrades-in-arms, because comrades are the first helpers even before the family. But there is a complicating factor influencing contemporary decompression: better electronic communications—such as instantly transmitted letters from home—may interfere with the de-stressing process in ways difficult to investigate at this moment.

Howell faults the Department of National Defence for having programs aimed at combat readiness. Of all we know it is far better for most men to be reintroduced in their “normal” environment as soon as possible. In that sense being “mission-focused” is not necessarily a hindrance to healing and could even be a benefit. She also faults DND for manipulating wives, and faults the department on courses given on the management of stress. She faults both DND and Veterans Affairs so many times—indeed always—to the point where the blame becomes suspect. How can these two departments be so incompetent knowing what they know, from the past, from their own experience and from the shared experience of other armies? Would it not simply be better if the incidence of mental problems increase to a point where the army is simply never deployed in war zones?

That question has to be asked because it appears to be the real point of Howell’s essay. If we stopped war making, she implies, “Canada the good” (her expression, including the quotation marks) would then be back on the radar screen of our politicians. And as in the good old days, Canada would engage only in peaceful missions.

But here is my question: is there a direct relation between “killer missions” and mental health? Howell stresses emphatically that the mental health of soldiers returning from Afghanistan is a catastrophe because they witnessed numerous civilians being killed by NATO forces, and because the poverty of the country was so distressing that mental “catastrophizing” was not an unreasonable response. But Afghanistan is not unique in this respect. It should be obvious to any reader that many peacekeeping missions, especially in the former Yugoslavia, Africa and Haiti, were conducted in equally difficult environments where atrocities were all too common. What should also be obvious is that most if not all missions in these areas of the world were failures.

There is a circumstance absent in Afghanistan but pervasive in peacekeeping missions: the powerlessness to act to save lives of local populations. It is true that in Afghanistan most attempts to intervene were plagued by our difficulty to understand the tribal nature of Afghan society and our reliance on heavy weapons and electronic intelligence; but, and I know this will not please some members of the Canadian intelligentsia, firing a weapon on whom one thinks are killers may have relieved some sense of powerlessness—an impossibility in traditional peacekeeping missions. So if civilian casualties and the witnessing of horrors are linked to mental health, and I think they are, then there should be a high rate of depression, psychosis and suicide among veterans coming back from pure peacekeeping missions. We do not have statistics going back far enough (to the late 1950s) to confirm this hypothesis, but the data we have from the mid 1970s to the mid 2000s (see above) seem to point out that the stress of peacekeeping is as bad if not worse than the stress of combat. One needs only to read Roméo Dallaire’s Shake Hands with the Devil: The Failure of Humanity in Rwanda.

I will go further. Looking back to the 1800s I would suggest that “demobilization for peace” could produce equal or higher rates of suicide and mental disorder and family problems than keeping the army ready for its manifest purpose: fighting. There is, and I know this will be another unpleasant revelation, a small portion of the population that believes that sometimes you have to kill to defend things that seems vital, and that these individuals like to congregate in a group called “the army” with other people having similar beliefs. But will these people become mentally unbalanced because of their war-fighting experience at a rate “within the range of 5 percent to 20 percent, with some [U.S.] studies suggesting a rate of upward 60 percent,” to quote Howell?

For those who are not yet convinced of the kind of politically correct science we are exposed to in Howell’s essay, let us now turn our attention to the last two paragraphs. She sees for our time a “continued push to remobilization,” at a time when the Libyan operation is finished and the Afghan one is in the process of being wound down. Instead, she writes, we should start thinking what it means to demobilize not the soldiers but Canadian society. “Only then,” she writes, “can we confront our collective amnesia and take seriously the possibility that we can demilitarize our foreign policy, and ourselves.” I think that a war as persistently discussed in the media as the Afghan war has been is far from being a symptom of collective amnesia. Returning to peacekeeping might be a commendable change in our foreign policy, but it is not a sure way of improving the mental health of troops and veterans. “Good” politics does not by the sheer virtue of the values professed lead to better remedies for mental problems.

All this is not to say that war does not cause health problems. It does. But the incidence of these problems is not as critical as received wisdom would have us believe. Mental health depends on several factors that are and are not linked to traumatic events. To deduce that the event “Afghan war” causes an increase in mental health problems is simplistic and might even be false. To infer from a single event that there will be more problems is not a scientific statement, and to correlate foreign policy with mental health is a rather audacious jump in reasoning. Above all I disagree with the use of mental health problems to justify political posturing.


  1. For letters of 1914–18 veterans or their close relations and the responses of powerful personages, see the correspondence files in the Currie Papers at Library and Archives Canada.  

  2. Veterans’ joblessness seems to be a problem among the young leaving the U.S. Army after a few years of adventures. See Sheila Dewan’s “As Wars Ends Young Return to Scant Jobs: From Front Line to the Unemployment Line,” in the December 18, 2011, issue of <em>The New York Times</em>. The version available online at <http:> is incomplete and somewhat misleading. </http:> 

  3. I described my research in an article in the fall 2010 issue of the <em>Bulletin d’histoire politique</em> and gave preliminary results before the Centre de recherche et d’intervention sur le suicide et l’euthanasie (CRISE), a research centre at Université du Québec in Montreal, in April 2011.  

  4. Army and RCAF statistics were published in the <em>Official History of the Canadian Medical Services 1939–1945, Volume Two: Clinical Subjects</em>, edited by W.R. Feasby (Queen’s Printer, 1953). The Royal Canadian Navy did not submit separate suicide statistics to Feasby. Rates for 1940–42 are 14, 12 and 13, and under 10 for the rest of the war. This is too low because, as always with suicide statistics, military and non-military, there is underreporting. As underreporting is probably higher for civilians, most studies are slightly biased against the military. One reason to look in personal files is to remedy this problem of underreporting. See a similar methodology using coroners’ files in John Weaver’s <em>A Sadly Troubled History: The Meanings of Suicide in the Modern Age</em> (McGill-Queen’s University Press, 2009).  

  5. These figures come from Annex C of the 2010 <em>Report of the Canadian Forces Expert Panel on Suicide Prevention</em>; they were updated in June 2011 “Backgrounder: Suicide in the Canadian Forces,” <www.forces.gc.ca>. With regard to lower suicide rates in the Canadian Forces than in the general public, I infer from my own research that the factors are psychological screening at enrollment, financial security, better physical and mental fitness on average, better health care, stronger family ties, more developed sense of being part of a community, and exciting and fulfilling missions instead of nine-to-five work. </www.forces.gc.ca> 

  6. It would be rather disturbing to think that these statistical reports were dismissed because they were not proving that the war in Afghanistan caused a sharp increase in mental problems.  

  7. One follow-up study of soldiers who had suffered battle exhaustion was undertaken in 1950 but it is considered unreliable (see Copp and McAndrew’s <em>Battle Exhaustion</em>).  

  8. See Statistics Canada’s “Canadian Forces Cancer and Mortality Study: Causes of Death,” May 2011, table 6 and box 3 at <www.statcan.gc.ca>. </www.statcan.gc.ca> 

  9. I borrow the term “world affective style” from Bernard Granger and Jean Naudin, French psychiatrists who used it in <em>La schizophrénie</em> (Le Cavalier bleu, 2006).  

  10. See chapter 2 of the World Health Organization’s World Health Report 2001 at <www.who.int>, which states: “The specific diagnosis of PTSD has been questioned as being culture-specific [from and for Westerners] and also as being made too often. Indeed, PTSD has been called a diagnostic category that has been invented based on socio-political needs.” </www.who.int> 

  11. See Summerfield’s “The Invention of Post-Traumatic Disorder and the Social Usefulness of a Psychiatric Category,” in the January 2001 issue of the <em>British Medical Journal</em>, available at <www.bmj.com>. Young is the author of <em>The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder</em> (Princeton University Press, 1995). </www.bmj.com> 

  12. See Scott’s “PTSD in DSM-III: A Case in the Politics of Diagnosis and Disease” in the August 1990 issue of <em>Social Problems</em>, available at <www.voteview.com>, and Shephard’s <em>A War of Nerves: Soldiers and Psychiatrists 1914–1994</em> (Jonathan Cape, 2000). </www.voteview.com> 

  13. See Rechtman’s 2004 “The Rebirth of PTSD: The Rise of a New Paradigm in Psychiatry” in <em>Social Psychiatry and Psychiatric Epidemiology</em>, available at <www.springerlink.com>. Emphasis added. </www.springerlink.com> 

  14. A list of drugs available at <en.wikipedia.org>. The popular <em>Merck Manual Online</em>, available at <www.merckmanuals.com>, divides the treatment of PTSD patients into psychotherapy and drug therapy, with the accent on psychotherapy. But for the drug treatment, Merck’s first suggestion is antidepressants, then mood stabilizers. The symptoms listed (nightmares, flashbacks, prostration) resemble those we used to hear about for the First World War shell shock cases. The list of causes of PTSD in 2004 printed home pocket edition of the <em>Merck Manual</em> goes from experiences of war to “being in a small boat after a near drowning accident.” </www.merckmanuals.com></en.wikipedia.org> 

  15. On the links between diagnoses, drugs and medical lobbies, see “The Illusions of Psychiatry,” a two-part essay by Marcia Angell published on June 23, 2011, in the <em>New York Review of Books</em>, available at <www.nybooks.com> and <www.nybooks.com>, and the responses, published on August 18 at <www.nybooks.com>. </www.nybooks.com></www.nybooks.com></www.nybooks.com> 

  16. To quote Scott in “PTSD in DSM-III”: “Privately, psychiatrists may practice the art of medicine by doing what they think best for their patients. Professionally, however, they must conform to current scientific consensus or run the risk of being labeled ‘quacks.’ When a formal diagnosis is required, they must use the most recent DSM in order to state officially whether or not someone is sick. Two types of error thus may result in the application of these official diagnoses: well persons may be diagnosed as sick, and diseased one may be misclassified or considered healthy.”  

  17. Trials on groups of persons showing PTSD symptoms are underway using “interpersonal psychotherapy,” “exposure therapy” (in which the therapist encourages the patient to face memories) and “relaxation therapy.” See current studies at the Columbia University Medical Centre listed at <www.columbiatrauma.org>. </www.columbiatrauma.org> 

  18. I cannot resist quoting Shephard’s conclusion on PTSD: “The new public mood of acceptance, symbolised by ‘Vietnam Veterans Week’ in 1979, when President Carter told a gathering of some 200 of them in the White House that ‘the nation had not done enough to respect, to honour, to recognise and to reward their special heroism,’ the unveiling of the Vietnam Wall in Washington and the ‘surge of patriotic feeling’ generated by the Iran Hostage Crisis in 1981 all seemed to set the seal on the process of healing.” I would not go as far as to call for more patriotism, but, as I have repeatedly said, sympathy might be the best remedy to some mental health problems. And I emphasize this: sympathy for armed forces members is not the same as a gentler foreign policy.