Radical Civility

Cross-posted from Blog Them Out of the Stone Age

Does the “red badge of courage” — Stephen Crane’s famous phrase for a wound suffered in battle — have to be literally red?

Maybe. Maybe not.

Today’s London Daily Telegraph has an article that states, somewhat misleadingly, Traumatized US Soldiers to Get Purple Hearts.

Actually, as the article makes clear, that’s far from certain. The idea is on the table. Whether it will become reality is another matter.

American soldiers who suffer post traumatic stress disorder would be awarded Purple Heart medals, usually given to those who are wounded in action, under a controversial plan being actively considered by the Pentagon.

Nine decades after soldiers were executed for “cowardice” brought on by what was then called shellshock during the First World War, veterans of Iraq and Afghanistan may be the first to have their mental injuries treated the same as battlefield wounds.

US Defence Secretary Robert Gates has urged Pentagon advisers responsible for battlefield awards to study the proposal after Army psychologists said widening the criteria for a Purple Heart would increase the acceptance of soldiers suffering from PTSD, and persuade more to seek help for their problems.

Pentagon figures show that 40,000 troops have been diagnosed with post traumatic stress since 2003 but it is classified as an illness not an injury, making it ineligible for a Purple Heart under current rules.

Officials say one in eight combat troops in Iraq and one in six of those in Afghanistan are taking prescription antidepressants like Prozac or sleeping pills.

John Fortunato, a military psychologist at Fort Bliss, Texas first suggested Purple Hearts for PTSD last month. “These guys have paid at least as high a price as anybody with a traumatic brain injury, as anybody with shrapnel wound,” he said.

Mr Gates immediately proclaimed it an “interesting idea” that needed to be looked into.” But the plan has sparked a fierce and impassioned debate among the US military, with a flurry of comments in the pages and on the websites of publications like Stars and Stripes and the Army Times.

Ray Kimball, an Army major who helped found the Iraq and Afghanistan Veterans of America support group, is a strong supporter. He believes the move would have “huge impacts on the perception of mental health issues in both the Armed Forces and society as a whole”.

He said: “PTSD is a combat wound. We already treat it as such for the purposes of medical evacuation, readiness for combat, and post-service disability assessments. So let’s take it one step further.”

But an anonymous Army intelligence officer told Army Times: “It’s an insult to those who have suffered real injury on the battlefield.”

“An insult to those who have suffered real injury”? That’s strong stuff, and might be dismissed as a fringe opinion. Unfortunately, it isn’t.

Maj. Ray Kimball, the proposal supporter quoted above, is a founding member of Iraq and Afghanistan Veterans of America. He has written about this issue on the IAVA Blog and in a piece that appeared last month in Military.com:

PTSD is a combat wound - we already treat it as such for the purposes of medical evacuation, readiness for combat, and post-service disability assessments. So let’s take it one step further - make anyone with a diagnosed manifestation of PTSD that in any way impairs function eligible for the Purple Heart.

The current criteria in existence for the Purple Heart would not have to be changed - nowhere do those criteria specify severity of wound, or how the wound was physically inflicted. They only require that the servicemember be wounded or killed in action - in fact, the criteria spend far more time spelling out which “actions” qualify than in addressing the character of wounds. Nor would this action debase or cheapen the Purple Heart - in fact, the award has already evolved significantly from its original establishment in 1782 as a Badge of Military Merit. Whether the change was including wounds wrought by terrorist acts or allowing awards for friendly fire, the changes each addressed an overlooked aspect of the wound that needed to be honored by the nation.

PTSD has remained a hidden wound for too long. DoD’s new campaign is a huge leap in the right direction of erasing the stigma of this affliction, and properly recognizing this hidden wound with the Purple Heart is the next logical step.

Kimball went on to invite comment on the Military.com Discussion Board. He got it — most of it sharply critical and even contemptuous of the very idea that soldiers with PTSD should get the Purple Heart.

The objections, generally speaking, are emotionally charged and have a knee-jerk quality that I’ve often seen in connection with civilian psychiatric disorders. The not so subtle message is that physical illnesses and injuries are “real,” whereas psychological illnesses and injuries are not, but are instead attempts to throw the cloak of illness / injury over what are “really” defects of character. This, in turn, testifies to the persistence of the idea of the mind/ body split. In scientific and medical circles the idea of such a split was exploded decades ago, but it remains firmly embedded in everyday, “common sense” perception.

One reason for this is the denial of what is otherwise a highly disquieting thought: that physical changes — specifically biochemical changes — affect the functioning of the brain and therefore, it is supposed, of one’s basic identity. To admit this connection is to admit the possibility that it can happen to anyone, and I suspect the most vociferous opponents of awarding the Purple Heart to soldiers with PTSD are, at bottom, more fearful of this possibility than most.

Cross-posted from Blog Them Out of the Stone Age

The current Time magazine features a cover story entitled “A Medicated Army,” discussing the practice of prescribing antidepressants and antianxiety meds to soldiers in combat environments:

For the first time in history, a sizable and growing number of U.S. combat troops are taking daily doses of antidepressants to calm nerves strained by repeated and lengthy tours in Iraq and Afghanistan. The medicines are intended not only to help troops keep their cool but also to enable the already strapped Army to preserve its most precious resource: soldiers on the front lines. Data contained in the Army’s fifth Mental Health Advisory Team report indicate that, according to an anonymous survey of U.S. troops taken last fall, about 12% of combat troops in Iraq and 17% of those in Afghanistan are taking prescription antidepressants or sleeping pills to help them cope. Escalating violence in Afghanistan and the more isolated mission have driven troops to rely more on medication there than in Iraq, military officials say.

As many readers know, I have bipolar disorder, and consequently have a long acquaintance with many of the meds being prescribed. At the moment, for instance, I take Lamictal on a daily basis and clonazepam (the generic equivalent of klonopin) as needed. The former operates as an antidepressant. It has mood stabilizing properties that make it a reasonably good prophylactic against mania — in fact I’ve had no trouble with incipient “highs” since I began taking Lamictal about two years ago. The latter is a mood stabilizer and anti-anxiety med. The biochemical manifestations of bipolar disorder are more complex than most people suppose. I have had days when I felt neither up nor down, but had such an insistent sense of generalized anxiety that I had to cancel class because I felt too light-headed to responsibly drive down to campus. Once I grasped its beneficial properties, clonazepam has done a lot to alleviate that problem. I also take the generic form of Ambien on a fairly regular basis in order to make sure I get a good night’s rest. Regular sleep — what’s known as “good sleep hygiene” — is a bedrock element in managing the illness.

The situation of a college professor in the midwest is obviously dissimilar from that of a combat soldier in Iraq or Afghanistan, but I think my experience can contribute a degree of insight. To begin with, I think it’s important to regard the meds as simply a tool to assist with the overall task of maintaining good health. There’s a tendency for those who take them to regard them as a sort of query against their character: that if they were somehow stronger they wouldn’t need to take the meds. That leads to problems. First, it reduces self-confidence and self-esteem. Second, it often creates a state of partial denial in which a person may take the med, but does not acquaint himself closely with the medication’s properties. He may not follow the guidelines for taking the med responsibly and when he feels better may quit taking the meds entirely. (Medication noncompliance is the single biggest problem among those with bipolar disorder.)

Third, there can be a tendency to regard the meds as shouldering the whole burden of managing the problem, whereas I have found it helpful to take an active role in managing the disorder rather than just passively taking the pills. I monitor myself for symptoms, even subtle ones that no one around me would recognize. I try to exercise on a regular basis. I make use of as many other tools as I can gather to help with the job: a psychiatrist, a therapist, and also the support of friends. There’s too much tendency to let fears of the stigma prevent a person from letting others know about one’s situation. But I’ve found that for every jerk there are many people who welcome the opportunity to be of assistance.

Finally, I have made a personal commitment to be public about having bipolar disorder. In each course I teach, I find a topic that lends itself to disclosure that I have the illness (in the U.S. history survey, for instance, the work of 19th century reformer Dorothea Dix provides a good opportunity). In a class of 200 students, statistically two students have been or will be diagnosed with bipolar disorder. I have never yet disclosed the illness and not received subsequent contact from a student who has the same diagnosis. They express appreciation for my candor and particularly a sense of relief in realizing that they are not alone, and that someone they regard as highly functional can have the disorder and lead a reasonably normal life. I often wind up meeting with them to discuss the illness and how best to manage it. Students usually have a lot of concerns: What will their life be like? what degree of stigma will they face? Frequently they do not yet have in place a good support system for managing the disorder. I recently spoke with a student who has no psychiatrist and therapist; her prescriptions are written by a general practitioner. I’ve been able to assist with referrals to good psychiatrists and therapists within her health care network.

How does this relate to military personnel who take psychotropic meds? First, I wonder how many officers and NCOs self-disclose that they are taking the same meds. If they keep this info away from their soldiers, they send a double message: overtly it’s OK for you to take these meds, but tacitly it’s really not because I wouldn’t be caught dead letting you know that I take them myself. It would require real moral courage, but an officer willing to talk matter of factly about taking these meds, and at the same time functioning effectively as an officer, would serve as a powerful role model. (I find that’s the role I often play with my students.) Such an officer’s example could not only reassure the soldiers who take the meds, but would also help shift the military culture toward one in which other soldiers would find it easier to trust and support their comrades in arms.

Second, I think it’s important to de-mystify these drugs as much as possible, so that the fact of taking them does not, in its own way, add to the issues that soldiers must face. To repeat, taking a med to assist with a problem is not a confession of weakness or bad character. On the contrary, it takes strength and maturity to face up to a problem squarely and do what it takes to accomplish the mission — whether that mission is to maintain one’s health as a civilian or one’s effectiveness as a soldier.

Third (and as a corollary), I have found it useful to apply, metaphorically, the warrior ethos to the task of managing the illness. I conceptualize bipolar disorder as an enemy that will never cease in its efforts to destroy me — either outright or by destroying my quality of life — and that consequently I have to work conscientiously and intelligently to keep it in check. I’ve found that my military training and my familiarity with strategic studies have come into play, in various, sometimes unexpected ways, to help me do this.

It would be wrong to create a sunny picture. Even in my safe suburban life, the task of managing bipolar disorder requires a lot of vigilance and is not without its setbacks. For obvious reasons the problem is compounded for those in combat zones, and the last thing I would ever want to suggest is some sort of situational equivalence. At the end of the day, shorter tours of duty and regular rotation into safe areas (such as they are) is a better solution to the problem. But until then, if the Army is going to pursue what I regard as a sensible 21st century policy — to treat issues of depression, stress and anxiety as problems to be solved rather than defects to be scorned — then it needs to shift the military culture to conform with the policy. I hope these insights from my own situation, however modest, may be of some help.