There’s a long and interesting article in today’s Independent, highlighting the remarkable finding that US soldiers are much more likely than British ones to suffer post traumatic stress disorder (PTSD) – by a massive 30% to 4%. The article’s American author, Ethan Watters, suggests that the difference is cultural. His analysis turns out to be more of a critique of US ways in ignorance of British ones – but the core idea, that mental illness can be driven by society’s attitudes is an interesting and disturbing one. Disturbing because it suggests that the modern fashion for exploring victimhood is making suffering worse than it needs to be.
Mr Watters says that the original diagnosis of PTSD was developed by anti-war professionals in the Vietnam era, and motivated by the wish to show the harmfulness of violence and war. Because people increasingly expected to suffer illness after experiencing trauma, like combat experience, they duly did. PTSD was pretty much unknown before Vietnam (and it’s not the same as shell-shock and other manifestations of mental illness resulting from combat experience noted in earlier wars). Of course there is not much evidence of PTSD in earlier wars because nobody was looking for it. Also, I might add, survival rates are much higher these days. Mr Watters then goes on to develop the idea that illness is exacerbated by the emptiness of modern culture, which deprives victims of moral support.
This is all very well as a narrative, and I think there is something in it. But I don’t think this explains why so many fewer British veterans suffer PTSD. Mr Watters suggests that the British are much more sceptical about PTSD , and have a stronger belief in natural resilience. That does not sound like the modern Britain that I know and love, where victim culture appears rampant and, I suspect, more politically accepted than in the US. And besides, we are much less religious than Americans, so surely the desolation of modern culture should be much more prevalent? The difference between the two countries is much more likely to be around the way their respective armies work. British veterans are more likely to suffer from alcohol abuse or depression, incidentally.
But the idea remains that a focus on victimhood and traumatization, which can verge on celebration sometimes, is very unhelpful. We should celebrate resilience. Most people have it within their own resources to recover from trauma, and many can be strengthened by it; we need to acknowledge this, rather than undermine the confidence of those do not, in fact, need outside support.
Thanks for the thoughtful post about my article. Mostly my point was that different cultures predispose people to different symptoms after bad events. But I think it is also true to say that different cultures suggest different thresholds for what is unbearable. As many people have pointed out (including Summerfield as mentioned in the article) that line seems to be on the move in the West in general. We are encouraged to see a growing number of life events as likely to make us sick. I doubt the UK is ahead of America in this regard. In this one way at least, we are still the world leader.
An interesting effect observed after 9/11: A victim support group who got together and talked to each other about their experiences would get more anxious by the end of the session, whereas if the group sat together in silence, they would experience relief.
My understanding of the process of recovery from trauma (I have trained in a method of trauma therapy called Somatic Experiencing) is that it makes a great deal of difference how the sufferer talks to himself and others about his experience.
The british unwillingness to talk, and their knack of being silently supportive, may well be helping them more than the belief in ‘talking things through’ beloved of therapists and maybe more popular in America. However, the sufferings of soldiers caused by war take many forms, and I don’t think we should be too quick to think the british soldiers are coming back happy and healthy.
If talking is to be done, the curative forms are spiritual and meaning-making. The trauma has probably given the sufferer a papable sense of death, and this is healed by ‘coming to terms with death’, rather than getting back to a state were death doesn’t seem real. ‘Back to normal’ is not an option, the way forward is to become ‘deeper than normal’.
Victor Frankl, the psychologist and concentration camp survivor, developed a therapy around the premise that man needs meaning more than anything else. I believe a lack of a sense of meaning can be behind many forms of suffering – depression, drug/alcohol problems, PTSD and more.
The soldiers of today come back to a home that is as careless as it ever was. What they need for recovery is to see the rest of us taking life seriously. Really worrying about the how to help in the Middle East, really thinking about our priorities for making the world a better place. Even taking some principled action on climate change might help. Life is a serious business, these ‘victims’ know it, we have a lot to learn from them.
Are there any other institutional incentives or variances between the US and UK that might explain some of the difference? Are US and UK military medical practitioners trained the same way? Working to the same guidelines? Working in the same administrative system (obviously not) or community of practice that guides diagnoses one way or another?
Put more bluntly, the diagnosis of PTSD in the US military / veterans affairs system might (through its link to combat service) mean that future counselling and associated costs are all fully paid for. A more general diagnosis of depression might not. UK veterans have the NHS to fall back on outside the military health system. US veterans do not.
That’s an interesting point Zee. That might well explain why depression gets a higher diagnosis in UK veterans. I think the overall reporting of mental health problems is still quite a lot lower for UK veterans. But there might be a reticence for UK veterans to report mental health problems even when they do have symptoms. The NHS is not great at dealing with mental health issues – though I think there are veterans’ charities that are increasingly getting involved through the military’s own support systems.
One point that I think everyone is missing here is the fact that US military units have seen far more combat than equivalent UK units in the post 9/11 era. Have UK units been involved in major casualty-producing engagements as in Fallujah and Najaf in 2004, Ramadi in 2005 and Sadr City in 2oo6-7 and Doura in 2007, as US units have? (I was embedded with American units at all of those places as a reporter). The answer is no. Unfortunately, the US style of warfare today simply produces more casualties per capita than the UK.
Further, US military units deploy longer, more often and tend to be sent to deadlier regions than UK units (think Basrah vs. Fallujah). Within PTSD research, there is something known as the “dose-response curve” that says the more trauma you are exposed to, the more likely you are to develop PTSD. This is part of what we’re seeing here with the 4%/30% differential (though the US PTSD rate is closer to 15% from what I’ve seen.) Sure, culture plays a huge role in PTSD diagnosis, but so do events on the ground, something mental health professionals are apt to overlook.
Thank you Dave. This is an interesting observation. It may be less true of Afghanistan than Iraq, as for a period at least British personnel were exposed extreme combat situations through some rather questionable tactical decisions, and the country had a very high body count for some years. But it does go back to the idea that it may be more related to the way the armies work than cultural differences between the nations.