Last night, the ABC aired a Four Corners episode, “The war within“, dealing with the issue of Post Traumatic Stress Disorder (PTSD) affecting current serving personnel in the ADF.
Like many similar productions from the US and UK, the episode featured the confronting and moving narratives of soldiers and their families struggling to deal with the effects of traumatic stress. The main thrust of the report, that the ADF has been manifestly inadequate in its duty of care to traumatised military servicemen and women, was dissipated by the incapacity of the reporting journalist, Nick McKenzie, to graduate his allegations beyond innuendo or allusion.
The “Dunt Inquiry” into the suicides of veterans and mental health care in the ADF has not yet been released for public discussion. The testimony of those interviewed in the Four Corners episode all indicate that there is not enough done about PTSD in the ADF.
The story of PTSD is one of soldiers and politics. The disorder was constructed in the 1970s as a means of depicting the plight of aggrieved US veterans of the Vietnam War.
In Australia, the shameful treatment of Vietnam veterans was symbolically atoned with the “Welcome Home Parade” in 1987. With the reconciliation between Australian society and the Vietnam veteran community, the conversation of the Vietnam War shifted from politics to medicine.
The Department of Veterans’ Affairs (DVA) became the generous benefactor of mental health services to veterans and their families, both in procuring the best the private health system had to offer and the provision of counselling to veterans and their families.
Whilst no-one disputes the genuine suffering of these men and women, such a process came at a cost.
The original studies of Vietnam veterans indicated that about 15% had developed PTSD. These findings have since been disputed in the scientific literature, with some researchers claiming that veterans and their advocates overstated the problems.
Regardless, the overall impression from the literature is that PTSD is far less common amongst those exposed to traumatic stress, when compared to depression, alcohol and drug abuse and anxiety.
PTSD is distinguished by the fact that a traumatic event is necessary for its onset. The other disorders can be argued to be related to factors other than trauma and therefore not the responsibility of the ADF or DVA.
Under the DVA’s “Statements of Principles”, there is no time limit as to when PTSD can develop in a veteran for it to be accepted as a service related condition. This has, understandably, lead to an explosion of PTSD diagnoses among the veteran population.
Because social institutions have orientated their response to trauma around the model of PTSD, questions of public policy and just allocation of resources have been resolved in ways that disadvantage many.
Whilst soldiers encounter horrific experiences and develop a particular pattern of distress, the vast burden of trauma in the community is borne by the survivors of violence perpetrated in families and institutions.
Society has embraced the reality of war, but continues to avoid confronting that of the s-xual abuse of children or the brutalisation of women. Instead of PTSD, such survivors are diagnosed “personality disordered” (the modern incarnation of the misogyny of 19th Century “Hysteria”) leading to experiences of rejection and marginalisation.
It is curious to note that, anecdotally, many US Iraq War Veterans are having their claims for compensation for war-related psychiatric disorder rejected by the US Veterans’ Administration, which argues that many of these men and women have personality disorders or bipolar disorder. These conditions are not considered war-related and their claims are rejected. The wrong label puts you in the wrong category, despite the fact that all that is post-traumatic is not PTSD.
The other issue identified in last night’s Four Corners episode was Professor Dunt’s contention that it is “probable that most Australian veterans with PTSD, are not getting best practice treatment for early onset cases.” This opens up a problematic discussion about what the term “best practice” means.
Veteran PTSD, presumably due to its high profile and the resources dedicated to it, has attracted many with academic or entrepreneurial ambitions to the field. Many health service providers have been drawn to the care of trauma survivors, each proffering their own form of therapy — “CBT”, “DBT”, “EMDR”, “ACT” and so on.
Because briefer psychological treatments, like CBT (Cognitive Behavioural Therapy) are easier to research (and more cost-constrained) they have come to dominate the evidence base of “best practice” and their advocates are profoundly influential in policy formulation.
Such treatments may provide some relief to some patients, but the vast majority of survivors of overwhelming trauma, require a long-term therapeutic relationship, which is responsive to different developments in their lives. It is highly debatable whether such a caring relationship can be developed within the context of the organisation that was responsible for the original trauma.
The other issue is the controversy that surrounds the process of “debriefing” — the process of counseling survivors of traumatic events. The balance of opinion is that such interventions do not prevent development of psychiatric disorder and that the routine imposition of debriefing in the aftermath of trauma should cease. This was one of the grounds upon which a class action by a group of UK veterans against the Ministry of Defence failed in 2004.
Sending people off to war necessitates a moral obligation to provide for the psychological injuries that result from traumatic experiences. This has never been an issue of debate.
The most important questions are those that emerge from under the obscuring shadow cast by the construct of PTSD.
Michael Robertson was the clinical director of a veterans’ mental health programme on the Mid-North Coast of NSW from 2000-2005. His PhD examined the ethical dilemmas raised by PTSD.