From the Editor: November/December 2010

I can still remember sitting in a workshop at the American Orthopsychiatric Association conference in Chicago in 1982 and feeling dumbstruck. The presenters were describing a then-new psychiatric diagnosis—post-traumatic stress disorder—that had debuted just two years earlier in the DSM-III. Of course, I’d read enough and seen enough movies to understand that “war is hell,” but a lucky lottery pick had kept me out of Vietnam, and, at the time, I didn’t know personally anyone who’d served there. As the presenters vividly connected the dots linking the horrors of combat and the widespread drug addiction, alcoholism, violence, homelessness, and suicide among thousands and thousands of Vietnam vets, the other therapists in the audience seemed as stunned and transfixed as I was. We could no longer ignore the reality that for far more soldiers than we could ever have imagined, the nightmare of the war continued to live on for years after the actual life-and-death experience of combat was over.

Now, three decades later, no area in the field of mental health has received more attention than PTSD and other reactions to traumatic events. Once invisible, it’s now so engrained in our cultural lexicon that it can even seem that it’s applied sometimes to everybody who’s ever had a bad day.

With all the great strides in the science, treatment, and public acceptance of PTSD in the past 30 years, you might think that the mental health field would be fully prepared to ensure the highest quality of care for those returning from combat in Iraq and Afghanistan as they struggle to get their lives back on track. But as Laurie Leitch and Elaine Miller-Karas write in this issue, the needs of these troops are not only “far more pervasive and widespread than many of us realize . . . [but] our mental healthcare establishment, both civilian and military, isn’t capable of handling this public healthcare crisis.” Leitch and Miller-Karas argue that conventional therapeutic approaches are often unsuited to military culture and are shunned by the soldiers they’re meant to help. In fact, so many thousands of troops and vets go untreated today that, despite all our new trauma methods, it seems we haven’t yet fully absorbed the lessons from the ordeal of our troops in Vietnam.

Elsewhere in this issue, Roy Clymer, formerly a staff psychologist at Walter Reed Army Hospital, writes with a fierce and eloquent sense of urgency that the development widely considered to be the most important advance in the trauma field—the coining of the PTSD diagnosis—has had a profoundly countertherapeutic consequence. From his perspective, much of PTSD treatment today, with its emphasis on technical methodology and neurobiological explanations, obscures the core of the experience we’ve too glibly labeled “traumatic”—the universal human struggle to face and live with the terrible existential experiences of war, death, and suffering. As he puts it, “The fundamental, universal human dilemma—how to cope with overwhelming feelings, come to terms with inherently opposing realities, find meaning in meaningless chaos—is turned into a ‘psychiatric disorder’ that can be ‘treated.'” The diagnosis of PTSD paradoxically exacerbates the problems of those so diagnosed, he contends. It “invites us to see others, and ourselves, as damaged, injured, or disabled,” and prevents us from taking responsibility for our lives and, ultimately, working to heal ourselves.

Whatever different viewpoints are represented in this issue, all the authors would agree on one thing: all in all, the “invention” of PTSD in 1980 brought about a revolution in the way the mental health system, and the public, thought about the impact of war on the soldiers charged with fighting it. But today, faced with hundreds of thousands of returning troops scarred by their service and straining the capacity of our mental health system, it appears that, however much we’ve learned in the past 30 years, the necessary revolution in our thinking about how best to help them is not yet complete.