In the early 19th century Samuel Butler wrote a quasi-utopian
novel called Erewhon. It was startlingly prescient. Those
who committed crimes were considered to be ill. Those who were ill
were considered guilty of a crime. Society objected to facing the
pains of others. In the following century Aldous Huxley expanded
the same envelop in Brave New World. Joy was the order of
the day; unhappiness was unacceptable self-indulgence. Depression,
feelings of unworthiness, and similarly common strains were
unnecessary, rendered so by pills Huxley called soma. (Sex
was for fun exclusively and procreation was a crime; babies were
made in the laboratory — that’s why God made petri dishes and
test-tubes.)
Butler and Huxley would not be at all shocked by the current
contretemps over what should go into the next edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM), the proximate cause being the proposed inclusion of
bereavement as a disorder. The DSM is a guidebook for psychiatrists
and psychologists, akin to the user’s manual that comes with your
appliances and vehicles, that standardizes the human psyche and
renders it susceptible to tinkering along suggested lines. Equally
important (well, maybe more so), it determines what tinkering will
be covered by insurance. Ah ha!
Put baldly, the more tinkering is suggested in the DSM, the more
money there is to be made by those who purport to plumb the human
mind. (“And how did that make you feel, Shirley?”) It surely is
true that being listened to can be therapeutic. But if listening
required professional attainments, bartenders would have to be
board-certified.
According to a January 25 New York Times article
addressing the issue, depression as defined by the current DSM does
not include bereavement (i.e. what one feels when a loved one
dies). The community is divided over whether it should. The dispute
comes down to whether it is inappropriate to be unhappy when, say,
your child dies. Some in the profession appear to feel this is
“normal,” while others feel that it is a pathology that should be
treated, no doubt with a little help from Medicaid.
Feeling bad about a death is not the only potential DSM
inclusion on the table. Other favorites are “binge eating disorder”
(can “binge drinking” be far behind?), and “premenstrual dysphoric
disorder” (what are comediennes to do when PMS “jokes” aren’t funny
anymore?). It is statistically verifiable that once a behavioral
condition, however transitory, is labeled a “disorder” the number
of people diagnosed with the “disorder” goes zooming up the charts.
Suddenly tens of thousands of people who formerly were reduced to
having to pull up their socks and get on with their lives can now
lie back on the couch and indulge a “disorder” they didn’t
previously know they had. That is very gratifying for some
personalities and very lucrative for the person who “diagnosed”
their disorder.
If all this were restricted to low-lit rooms, couches, boxes of
Kleenex, and someone murmuring “Hmmm, and did your uncle remove his
hand when he realized you were uncomfortable?” it would all be
relatively harmless quackery.
But it doesn’t stop with the session on the couch. The
pharmaceutical industry gets into the act as well. There are pills
(soma?) to be popped, such as those, e.g. Paxil, Prozac,
Zoloft, implicated in the suicides of people, chiefly those of a
youthful age, being “treated” for various adolescent angsts. These
episodes may match up with the high number of American soldiers
committing suicide.
The unhappy (and largely unexamined) fact is that the military
does not have a sufficient number of troops to fight the protracted
wars now slowly grinding to an inconclusive halt (and so has to
keep re-using the troops it has), and it does not have enough
doctors to treat those who are dealing with the consequences. So,
in order to get the stressed trooper back up on his or her feet and
into the fight, out comes the pill bottle. The result, as I
personally confronted during my brief tenure as Deputy
Undersecretary of Defense for Wounded Warrior Care and Transition
Policy, is soldiers too addled to assemble a simple sentence.
Which brings us to another revision to the DSM to be prayed for,
this one not an addition but a deletion. The DSM currently
characterizes Post-Traumatic Stress as a “Disorder.” U.S. military
medical personnel confronting a soldier’s reaction to trauma,
usually manifested as some greater or lesser degree of stress,
commonly seize on the DSM definition in addressing the reaction.
This produces one or a combination of the following results,
sometimes depending on whether the soldier means to stay in the
service or leave it:
The soldier who intends to make a career of the military is
loath to have a “disorder” on his or her (inexpungible) military
record. The military culture is one that penalizes anyone suspected
of emotional weakness. The military is trying to change this, with
little success. Commanders may urge people to report themselves if
they are experiencing symptoms of stress, promising there will be
no penalty, no stigma, attaching to those who ask for help. By and
large, soldiers do not trust the leadership, at least on this
point. Accordingly, soldiers who need help are likely to resist
seeking it.
The soldier who intends to leave the military is equally
reluctant for his or her medical record to have the pejorative term
“disorder” permanently inscribed as they try to find employment in
the civilian job market. For some professions, e.g. law
enforcement, the associated stigma can be an absolute bar to
employment.
Post-Traumatic Stress is a condition associated with warfare for
as long wars have been fought. It is freighted with euphemisms that
can be found in accounts of conflict going back to the
Iliad, but there is little more understanding of how to
manage it today than there was when Achilles slew Hector, despite
mountains of monographs, studies, and theoretical therapies. The
one conclusion that clearly can be drawn is that reaction to trauma
differs from one person to the next and is not susceptible to the
kind of standardization implied in the Diagnostic and
Statistical Manual of Mental Disorders.
Whatever becomes of “bereavement” as an accouterment to
depression in the next edition of the DSM, the term “Disorder” must
be detached from Post-Traumatic Stress if our military personnel
are to have a fair shot at surviving the consequences of their hard
service to our nation.
