14 November 2011

The Vets Are Alright (The Rest of Us Are the Problem)

This post is cross posted over at the wonderful Gunpowder & Lead blog. They're the same post.

As I read through recent stories about military veterans one thing has crystallized for me: the relentless focus on injuries, PTSD, TBI and the soldier's and veteran's general distress.

Based solely on the media's portrayal of returning soldiers and veterans one would believe them all to be fragile individuals whose lives may shatter at the slightest additional trauma. However, the vast majority of soldiers return healthy and capable, even if they are forever changed by their experience serving. That is to say, we seem to live in a world where the afflictions of soldiers are covered in the media like airplane crashes, rather than car accidents:
Page-one coverage of airplane accidents was sixty times greater than reporting on HIV/AIDs; fifteen hundred times greater than auto hazards; and six thousand times greater than cancer, the second leading killer in America after heart disease.
To be sure, PTSD, TBI, amputations, automobile accidents, plane crashes, and cancer deaths are all very real and very tragic but it's long past due that we consider the consequences of our relentless focus on the those afflicted by war because they are real as well.

While the media's predilection for rare and extraordinary stories has been well documented what's more important than the coverage itself is the nature of the coverage. For example: this October 2010 Washington Post article, Traumatic brain injury leaves an often-invisible, life-altering wound. This article is typical for its genre, coming in at nearly 3,000 words, yet devoting only a few sentences to any sort of wider context. We are told the raw number of diagnoses of TBI since 2000, then given another, larger, number from a RAND corporation study. Completely missing is any sense of scale. Do those 180,000 (or is it 300,000?) soldiers represent 1%, 10%, or 90% of individuals at-risk for TBI?

In a 1996 paper Shanto Iyengar, the Chandler professor of Communication at Stanford University, examined how television news influenced viewers' attributions of responsibility for political issues and concluded:
By reducing complex issues to the level of anecdotal cases, episodic framing leads viewers to attributions that shield society and government from responsibility. Confronted with a parade of news stories describing particular instances of national issues, viewers come to focus on the particular individuals or groups depicted in the news rather than historical, social, political, or other such structural factors.
This relentless focus on anecdotal, emotional cases that have been stripped of their context is immensely damaging in two different, yet synergistic ways.

The first has to do with people's inability to accurately assess likelihood and frequency. As Jason Daly recently wrote in Discover:
Even if a risk has an objectively measurable probability—like the chances of dying in a fire, which are 1 in 1,177—people will assess the risk subjectively […]. If you have been watching news coverage of wildfires in Texas nonstop, chances are you will assess the risk of dying in a fire higher than will someone who has been floating in a pool all day.
The actual name for what Daly is writing about is the availability heuristic (though it is often referred to as the availability bias), which states simply that people tend to estimate prevalences and occurrences based on how easily they can bring an example to mind.

Which brings us to news stories like those I linked above, because of their focus on wounded and damaged veterans they make these depictions available. None of these pieces are a problem in and of themselves, but taken together they form our predominant characterization of returned veterans. Moreover, the particular way in which they disseminate this information tends towards the anecdotal and emotional. In a study of the same effect at work in the reporting of automobile accidents using newspaper reports from 1999-2002 Monica Rosales and Lorann Stallones found:
Injury related events are more likely to be covered when they seem to be out of the ordinary, rare, or dramatic. This may lead to presenting such stories as isolated events (episodic), not as a public health concern. This type of reporting may provide the public with an inaccurate perception by overestimating infrequent causes of mortality and underestimating frequent causes.
The second effect of our national obsession with wounded veterans is more subtle. As Ethan Watters recently wrote in the New York Times, speaking of ADHD, rather than PTSD:
What the history of psychiatry tells us is this: Mental illnesses are not spread evenly among populations over time but come and go as unique and deeply complicated combinations of culture and biology. Which symptoms we collectively see as legitimate determines how we individually express internal feelings and unease. Psychiatric historians suggest that every generation has a “symptom pool,” behaviors by which individuals can communicate their distress.
While Watters was writing specifically about ADHD, his point applies equally well to PTSD. With so much of our culture shaped by a frenzied media, it's imperative that we recognize feedback loops like this. As the anecdotes become ever more heart wrenching we will only widen and deepen the pool of symptoms by which individuals may express their distress. Clinical psychologist Vaughan Bell recently found this interaction of cultural symptom pools and PTSD writing about PTSD among demobilized guerrillas in Colombia:
While working on a project to rehabilitate ex-members of illegal armed groups, [Dr Ricardo de la Espriella] noticed a striking absence of post-traumatic stress disorder in his patients, despite them having experienced extreme violence both as combatants and civilians. Many had taken part in massacres and selective assassinations, and many had lost companions to equally brutal treatment. There were high levels of substance abuse, aggression and social problems, but virtually none showed signs of anxiety. Intrigued, de la Espriella decided to investigate more closely and carefully interviewed the ex-paramilitary patients again, using the Clinician Administered PTSD Scale, which asks specific and detailed questions about post-trauma symptoms. After this more detailed examination, more than half could be diagnosed with the disorder.

The reason for why none of these symptoms presented in day-to-day life seemed to lie in paramilitary subculture. While aggression and drug abuse are tolerated, anxiety is taboo to the point where members showing signs of anxiety can be killed by their compatriots for being ‘weak’. This brutal emotional environment shapes the men to neither show nor spontaneously report any form of fear or nervousness.
The crucial point here is the feedback between wider cultural views and the individuals who suffer from psychiatric disorders. To be clear this feedback is not an issue of accepting or denying whether these disorders exist. As pointed out by both Dr. Richard McNally:
PTSD is a real thing, without a doubt. But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them.
and Ethan Watters:
The really mind-bending fact — the one that Americans can rarely seem to grasp — is that just because these disorders are culturally shaped does not make them necessarily less real.
At a time when, "Veterans who left military service in the past decade have an unemployment rate of 11.7 percent, well above the overall jobless rate of 9.1 percent" it's high time we begin asking ourselves uncomfortable questions about the dark side of our fixation with injured veterans and their struggles.

Greg Jaffe recently penned a piece in the Washington Post with the headline, "Troops feel more pity than respect." In the NYT retired Army linguist Kristina Shevory wrote of her peacetime service:
[T]here’s a growing sense that I’m not a full veteran. I didn’t suffer hundreds of mortar attacks. I didn’t roll over an I.E.D. on patrol in a Humvee. I didn’t watch a buddy step on a land mine and turn into "pink mist."
We have already reached a point in our cultural characterization of soldiers that they are beginning to profess their own discomfort and insecurity with it. Unfortunately, these views aren't the canary in the coal mine warning of impending trouble, they are the collapsed mine shaft.

With our relentless focus on emotionally titillating stories of soldiers and veterans who suffer tragedy, whether they are redeemed by the end or not, we perpetuate a binary view of soldiers: They are either the epitome of professionalism and sacrifice, or they are tragic and broken. Moreover each story serves to deepen the symptom pool, dragging distressed soldiers closer to calamity by forcing them deeper—towards more extreme behaviors—in order to communicate their anguish as the shallower depths become more anodyne.

These effects don't influence any individual's conscious views or judgements. There is no tipping point to this. It is the gradual accretion of dozens upon dozens of newspaper stories and nightly news segments which ever so gradually steer us toward an ever more dangerous simplification of the men and women who have, and do, wear our country's uniform.

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