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A most pronounced characteristic of the cases seen early in their illness is the profusion with which new symptoms appear and disappear. As time goes on, without treatment, a more stabilized syndrome crystallizes.

Those who have worked with combat veterans know that they are a group of patients who require a special degree of honesty and compassion. According to the US Census Bureau, there are 18.0 million veterans living in the United States, 17% of whom are women.2 In addition, at any given day, 1.4 million men and women serve on active duty, along with 718,000 civilian personnel. Another 1.1 million Americans serve in the 

. It is estimated that 7% of the US population has military experience, which is 

. Among post-9/11 veterans, 43% have a service-connected disability,

 perhaps related to the fact so few in modern society (less than 1%) serve in the all-volunteer military, requiring citizen-soldiers and their families to carry the burden.

Unfortunately, institutions charged with caring for veterans are often unhelpful. The Veteran’s Administration’s (VA) lack of transparency is a significant handicap for veterans and family members seeking treatment and explanations for their mental illnesses. Researchers, clinicians, and journalists are unable to find answers to important questions about the impact of war on veterans and their families. How many post-9/11 veterans have been diagnosed and/or treated for posttraumatic stress disorder (PTSD)? How many veterans have been diagnosed with any other mental health-related condition?

It is hard to say. The VA’s annual reports on Analysis of VA Health Care Utilization Among Operation Enduring Freedom (OEF), Operational Iraqi Freedom (OIF), and Operation New Dan (OND) Veterans, stopped being publicly available in 2016. Nevertheless, based on 2015 data, we can say that over a million post-9/11 veterans are using VA healthcare, and mental disorders are prevalent in this population (

 Aside from the fact the data are outdated, the data also captures only those veterans going to the VA. The VA does not keep track of those seeking counseling from the 360 veteran centers across the country

; nor those who seek help through the private sector; nor the largest subset of veterans and military personnel who suffer silently. Of course, there are multiple millions of family members and caregivers within the military population, those critical for the military veteran, are not covered for any services.

Differences in the Treatment of Military Versus Non-Military Populations

Psychiatric Casualties: How and Why the Military Ignores the Full Cost of War

 we were asked to opine on what clinicians should know about treating military populations (

read an introduction to Dr Russell and Dr Figley’s book 

.). First and foremost, while it is true that war changes everyone, it is also a great disservice to assume that most or all citizen-soldiers who served in the military and/or deployed to war zones, are fatally damaged goods. Going to war often signifies both the best and worst of times for veterans. Military populations offer fertile ground for studies on resilience and posttraumatic growth (PTG) among specialties within the service branches.

On the flip side, it is important not to view evidence of resilience or PTG as indicating an absence of mental or physical health-related problems. Another potential mistake is to assume that current or former military personnel must have suffered war trauma, and that is the primary or sole issue that leads them to seek mental health services. In reality, the all-voluntary military faces a wide-range of potential traumatic stressors that are inherent occupational hazards including combat, training accidents, transportation accidents, terrorist attacks, military sexual trauma, victims of crime, natural disasters, humanitarian relief missions, peace-keeping missions, along with other common stressors in the civilian sector (ie, domestic violence, childhood abuse, motor vehicle accidents, betrayal trauma, racial trauma, etc). The wise clinician is alert to the fact that even if a service member is a combat veteran, their distress will likely be a combination of factors, not just a product of combat experiences.

Next, clinicians should be sensitive to a host of risk factors and trauma-related conditions that are not entirely unique to military populations. Like police, federal and state law enforcement, and related professions, combat veterans, may deal with 1) the psychological impact of killing or seeing others killed; 2) having been wounded-in-the line of duty; 3) exposure to the presence of traumatic grief and complicated bereavement of fellow officers or from the death of a loved one, including one’s combat buddies; 4) moral injury from participating or witnessing killings, legal or otherwise; 5) intense survivor guilt, 6) co-occurring traumatic brain injury or phantom limb pain in amputees; 7) posttraumatic anger and sense of betrayal trauma; 8) handling of human remains; 9) being a prisoner-of-war by war enemy, drug cartel, or a political party; 10) chronic pain conditions; 11) opioid misuse; and 12) secondary trauma and compassion fatigue.

Similarly, war has taught us time and again that human beings have manifest traumatic stress injuries. These injuries cross a spectrum of possible conditions, and that diagnosis like PTSD represents only a sliver of possible afflictions.

 Historically, war or other traumatic stress injuries are often divided into 2 broad classifications: 1) neuropsychiatric conditions that consists of the culturally accepted diagnostic labels of the day such as PTSD, mood disorders, anxiety disorders, psychotic disorders, impulse control disorders, substance use disorders, neurocognitive disorders, eating disorders, sexual disorders, personality disorders, and others, and 2) medically unexplained physical symptoms (MUPS) which include chronic fatigue, headaches, chronic pain, atypical cardiac symptoms, idiopathic seizures, autoimmune conditions, and others.

In the 21st century, the Department of Veterans Affairs 

, “such as chronic pain and fatigue, are common in the general and military veteran populations” and that “Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM) and Irritable Bowel Syndrome (IBS) are among the most commonly diagnosed medically unexplained conditions.” However, there are far more potential MUPS diagnoses. These include noncardiac chest pain, pseudo seizures, multiple chemical sensitivity. Other studies on MUPS in the current war cohort indicate a high frequency of somatic complaints (

 Additionally, OEF/OIF veterans with and without a diagnosed mental health condition were treated in the VA for 222 types of MUPS.

As many clinicians are aware, somatic complaints are often considered a cultural idiom of distress.

 This is particularly true with military populations whereby stigma and fear of career reprisal can be so oppressive. The career-related stress makes it more likely to complain of headaches, back pain, and sleep problems as opposed to emotional symptoms.

Common Obstacles Military Populations Face to Receive Proper Mental Health Care

By far, the biggest obstacle that current and future military populations face regarding mental health care is the pattern of a sustained, self-inflicted mental health crises plaguing generations of Americans and society since World War I.

 These largely preventable catastrophes are caused primarily by chronic neglect and lack of accountability by the military and its government. Our most 

 noted 10 foundational lessons of war trauma identified by every military cohort since WWI. These lessons are essential to meeting the wartime mental health needs:

1) Recognizing that war inevitably causes large numbers of legitimate spectrum of war stress injury;

2) Adequate research, planning, and preparation are indispensable during both war and peace;

3) A large cadre of well-trained behavioral health specialists is compulsory during times of war and peace;

4) A holistic, public health approach to war stress injuries necessitates close collaboration with the private sector along with full mental health parity; 

5) Effective mental health services demand the empowered leadership of an independent, unified, organizational structure, a behavioral Health Corps, providing integrated, well-coordinated continuity of care equal to medical services;

6) Elimination of mental health stigma, barriers to care, and disparity should be a priority for leadership, as it directly affects individuals, families, and military readiness;

7) Ensure ready access to high-quality mental health services, including definitive care prior to military separation or discharge;

8) Families must receive adequate mental health and social support during and after military service;

9) Accurate, regular monitoring and reporting are crucial for timely, effective, management of mental health needs; and,

10) Robust dedicated mental health “lessons learned” policy and programs are integral to meeting present and future needs and prevent crises.

Despite being learned again at the end of every war, these lessons have not substantially improved veterans’ care. Perhaps the best evidence that little progress has been made comes from a Department of Defense (DOD) Task Force on Mental Health. In 2007 it identified

A single finding underpinning all others: The Military Health System lacks the fiscal resources and fully trained personal to fulfill its mission to support psychological health in PEACETIME or fulfill the enhanced requirements imposed during times of conflict (p. ES2).

The time for action is now. The human and financial costs of un-addressed problems will rise dramatically over time. Our nation learned this lesson, at a tragic cost, in the years following the Vietnam War. Fully investing in prevention, early intervention, and effective treatment are responsibilities incumbent upon us as we endeavor to fulfill our obligation to our military service members. 

This is a stirring plea for action, but the DOD offers no concrete proposal on where to start, or a sense of when we will know when it is enough. Without concrete proposals and ongoing commitment to investing in prevention, early intervention, and effective treatments, pleas like this one will remain empty.

Have we learned our lessons? More than 6 years into a shooting war, 99 urgent recommendations were made by the DOD task force, all reflecting neglect of the military’s well-documented centuries of “lessons learned.” The media, Congress, and Commander-in-Chiefs alike still have not met their responsibilities to investigate the reasons for gross negligence that harm countless members of the military population for this and future generations.

From our vantage point, the military is positioned in a unique leadership role within the broader society. It could inspire other leaders to step up, be accountable, and finally call for ending the stigma surrounding the mental health of its members. The question remains: why has the US government and its military refused to learn its war trauma lessons and what concrete actions are necessary to end the generational cycle of neglect and crises?

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service

is the Paul Henry Kurzweg, MD, Distinguished Chair in Disaster Mental Health at Tulane University and founder and director of the Tulane 

Those who served: America’s veterans from World War II to the War on Terror

. US Census Bureau, U.S. Department of Commerce. June 2020. Accessed September 15, 2021. 

Analysis of VA health care utilization among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans, from 1st Qtr FY 2002 through 3rd Qtr FY 2015

 (October 1, 2001—June 30, 2015). June 2015. Accessed September 15, 2021. 

5. Russell MC, Figley CR. Generational wartime behavioral health crises: Part one of a preliminary analysis. 

6. Hoge CW, Terhakopian A, Castro CA, et al. 

Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans.

Medical care needs of returning veterans with PTSD: their other burden.

Idioms of distress among trauma survivors: subtypes and clinical utility.

9. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: Part two of a preliminary analysis. 

10. Russell MC, Figley CR, Robertson KR. Investigating the psychiatric lessons of war and pattern of preventable wartime behavioral health crises

. Journal of Psychology and Behavioral Science

11. Arthur D, MacDermid S, Kiley K, et al. 

An achievable vision: report of the Department of Defense Task Force on Mental Health

. Department of Defense Task Force on Mental Health. Defense Health Board. June 2007. Accessed September 15, 2021. 

What psychiatric illnesses are most prevalent among veterans? And how can clinicians help them overcome obstacles to care?  

Treatment of Military Populations

Each moment of combat imposes a strain so great that men will break down in direct relation to the intensity and duration of their exposure. Thus, psychiatric casualties are as inevitable as gunshot and shrapnel wounds in warfare.

The psychiatric casualties of war may be inevitable, but the way the military responds to them is not. Since the 19th century, numerous books have been written on the history of war trauma, and they have included 

 Too often, however, the United States it seems like the military has failed to learn the lessons of the previous war. Veterans’ mental health has suffered in the process, resulting in a generational cycle of largely 

Why has the American military’s health care system refused to learn the fundamental lessons of wartime trauma, and how can the system be improved? Based on decades of research, writing, and our lived experiences as active-duty service members and mental health clinicians, we have taken up these questions in 

 We offer concrete solutions that, if enacted, could propel the military as a lead social change agent in eliminating harmful mental health stigma and disparities.

. I can trace my interest in war trauma back to the second grade, when I was living on the Camp Pendleton Marine Base in Oceanside, California. It was 1968, the height of the Tet Offensive in Vietnam. My father was a career enlisted Marine, a combat veteran of the Korean war and currently serving in the Vietnam war.

I have vivid memories of a steady stream of classmates whose names were called over the loudspeaker and instructed to go to the nurse’s office to be met with what we could only assume was traumatic news. The visibly anguished teachers had us keep our heads down on our desks while the nervous students gathered their personal effects; they were met at the door by an entourage composed of the vice principal, school nurse, and the base chaplain. We never saw those classmates and friends again.

When I embarked on my enlisted Marine career in 1979, I witnessed firsthand the residual effects of trauma associated with military service during war and peacetime. As a young lance corporal, I was hospitalized with a surgically-repaired broken jaw, and I serendipitously read David S. Viscott, MD’s 

 It resonated with my childhood experiences and ignited my dream of becoming a military psychologist.

In 1989, I ended my enlisted career in pursuit of a doctorate degree in clinical psychology at the Pacific Graduate School of Psychology (now Palo Alto University). For my dissertation I interviewed hundreds of combat veterans from World War II, the Korean War, and the Vietnam War.

 In 1992, I fulfilled my dream by restarting a career as a Navy clinical psychologist in the aftermath of the Persian Gulf War.

In 2003, I was deployed as head of neuropsychiatry for Fleet Hospital Eight in Bremerton, Washington, in support of the Iraq War invasion. It was then that I was awakened to the military’s failed mental health policies. My naval officer career was cut short due to my assuming the role of 

 Much of this story is documented in Tom Donahue’s film, 

Perhaps the most pivotal experience occurred after President Bush prematurely proclaimed “mission accomplished.” Near the same time the military’s highest ranking psychiatrist visited our field hospital and presented the outcomes of an innovative combat stress screening and reconditioning program.

 The admiral fatefully pronounced, “This is very exceptional work; however, unfortunately, it will all be forgotten and will need to be rediscovered by the next generation.”

After my military retirement in 2009, I embarked on a new career at Antioch University Seattle’s Doctor of Psychology (PsyD) program and established the Institute of WarStress Injury, Recovery, and Social Justice. Its mission is to end the pattern of mental health neglect and stigma associated with crises within and outside of military circles. The opportunity to collaborate with someone as esteemed as Charles Figley, PhD, the institute’s board chair, has been instrumental in paving the way to fulfill these high-vaulted goals. 

 represents our collective efforts to share a written history in the hopes of ending the harmful consequences of neglecting war trauma lessons. In doing so, we hope the military will take a lead role in transforming mental health care in this country.

Writing this book with Mark was an education. I do not recall the first time I corresponded with Mark, but I had heard of him for some time. He was already a hero among those most connected to veterans’ rights. Coming from a military family, he believed in and loved America and its military so deeply yet he was willing to risk everything to help veterans get better health care.

We wrote this book to identify what has gone wrong and to share a blueprint for correcting the harms we uncovered.

Mark’s journey from enlisted Marine to naval officer had enabled him to become the strongest voice for systemic improvement in behavioral health within the military. The bedrock values that emerged from our study are vital to all fighting forces: trust, confidence, and collective effort—despite the fear and fog of war.

We knew there would need to be at least one significant book to address the relevant research. There was so much to report—so many stories of hope and then disappointment. The deeper we dove into the files, the more consistent the larger story became. Soldiers are taught to fight, and even kill, but their system of care does too little to prepare them for combat, and too little to help them reflect on their experiences afterward. Too often, they have no answer to reasonable questions, such as “how will I be treated if I am injured and need help?”

Our primary goal is first to convince our colleagues and fellow researchers that the number of psychological and psychiatric casualties are staggering, despite the fact that they rarely register on a measuring device beyond paper-and-pencil tests.

Every war cohort since World War I has described 10 fundamental lessons of war trauma; these lessons seem to be routinely ignored and then need to be rediscovered.

 These lessons include 1) the need to provide comprehensive mental health services including definitive treatment for traumatic stress injuries prior to discharge from the military; and 2) the need to eliminate mental health stigma and barriers to care.

Neglecting war trauma lessons perpetuates a preventable generational cycle of mental health crises.

To manage the military’s dilemma of fulfilling the 2 often competing missions of fighting and winning wars with providing health protection to its forces, the military has relied upon 10 strategies that prevent it from advancing war trauma lessons.

 For instance, the military’s 100-year-old frontline psychiatry doctrine is primarily aimed at reducing both personnel attrition and the cost of mental-health-related disability pensions. However, we argue that this doctrine is ultimately quite harmful to the well-being of veterans and their families.

War is not a pleasant thing, but we can learn from it. For instance, lessons from combat medicine have helped advance emergency medical and mental health care. By synthesizing the lessons learned from the mental health impacts of war trauma, we may find a working model to transform mental health care in general and eliminate related stigma.

is a retired US Navy Commander and military clinical psychologist with more than 26 years of military service.

1. Appel JW, Beebe GW. Preventive psychiatry; an epidemiologic approach.

2. Russell MC, Figley CR. Generational wartime behavioral health crises: part one of a preliminary analysis.

3. Russell MC, Figley CR. Investigating recurrent generational wartime behavioral health crises: part two of a preliminary analysis.

6. Russell MC. Attentional focus and states-of-mind in post-traumatic stress disorder among

7. Zoroya G. Psychologist: Navy faces crisis. 

. January 17, 2007. Accessed July 14, 2021. 

8. Russell M. Mental health crisis in the Department of Defense: DoD Inspector General Hotline Investigation #98829 submitted by Commander Mark Russell, USN on 05JAN2006. Available upon request via Freedom of Information Act (FOIA) at Department of Defense; Office of Freedom of Information, 1155 Defense Pentagon; Washington, DC 20301-1155.

9. Russell M. The future of mental health care in the Department of Defense. Invited testimony before the Congressionally-mandated Department of Defense Task Force on Mental Health, on 19-20 October 2006, San Diego, CA.

Strangers at home: The Untold Story of American Military Mental Health

12. Russell M, Shoquist D, Chambers C. Effectively managing the psychological wounds of war. 

13. Glass AJ. Lessons learned. In: Glass AJ, Bernucci RJ, eds. 

Medical Department United States Army. Neuropsychiatry in World War II Volume I: Zone of Interior.

 Office of the Surgeon General, Department of the Army; 1966:735-759.

Between Flesh and Steel: A History of Military Medicine From the Middle Ages to the War in Afghanistan

A working model for eliminating stigma and transforming mental healthcare within the military.

Treating Psychiatric Combat Casualties

Addiction, while a mental health disorder in its own right, often covers deeper wounds. Treating addiction often requires a willingness to delve deep into a patient’s psyche and find the traumatic experiences that are motiving the substance abuse.

In this Mental Health Minute, Gray talks about her efforts to treat the traumas that often lurk behind addictions. She offers tips for building strong therapeutic alliances and recommends using eye movement desensitization and reprocessing to help patients with comorbid substance abuse disorders and trauma.

is a licensed therapist and recovery coach at Hand in Hand Counseling in Greenwich, CT.

The potential role of eye movement desensitization and reprocessing.

Treating Comorbid Substance Abuse and Trauma

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include

 Pillar of Salt: Gender, Memory and the Perils of Looking Back

Hard Knocks: Psychology and the Dynamics of Storytelling

Psychiatry, Politics, and PTSD: Breaking Down

 (Routledge, 2020). She has directed 6 feature films: 

Queens of Heart: Community Therapists in Drag

Mind Zone: Therapists Behind the Front Lines

Milk Men: The Life and Times of Dairy Farmers

Necessity: Oil, Water and Climate Resistance

. Dr Haaken has received numerous awards for her filmmaking, most recently the Lena Sharpe Persistence of Vision award at the 2019 Seattle International Film Festival.

 is a fascinating critical analysis of posttraumatic stress disorder (PTSD) as a diagnosis, the turbulent debates surrounding the role of trauma in psychiatry that led to its creation, and the institutional and sociopolitical functions it serves in a wide variety of settings such as the military, veterans’ affairs, war zones, refugee camps, and criminal justice system. I was impressed by the adeptness with which Dr Haaken tackles the ambiguity, uncertainty, and the internal contradictions present in the subject matter while resisting the temptation for simplistic answers. This interview delves into some of the broader conceptual and sociopolitical issues surrounding PTSD and psychiatric diagnoses discussed in the book.

: You wear many different hats (psychoanalytic clinician, critical psychologist, documentarian, and field researcher), which offers you a unique advantage in being able to approach psychiatry from a variety of different perspectives. Can you tell us more about your background and how that has influenced your critical inquiries?

: My first professional career was in psychiatric nursing, beginning in the early 1970s as a staff nurse in a treatment program for children, and later in medical training centers in California and Oregon. My nursing background was formative to my identity as a professional, even in the course of pursuing a PhD in clinical psychology. Nursing is a traditionally female job, but one that is very hands-on and close to bodily experienced suffering. I value that. As a clinician, I was influenced early on by the women’s movement and its rejection of a lot of the old diagnoses, with hysteria the prototypical example. I have always approached the diagnostic process as a form of storytelling that requires attentiveness to social contexts of mental suffering and to the language available for communicating distressed states. In addition to feminism, I was influenced by the radical psychiatry, critical psychiatry, and the antipsychiatry theories of the 1960s and 70s, all of which shared a critique of the medical model that underpins psychiatry.

When I joined the faculty at Portland State University, my research methods—grounded in critical theory, psychoanalytic-feminism, discourse analysis, and qualitative field research—were considered quite radical, although the department moved to incorporate more qualitative methods over time. I joined the faculty in the era when academic psychology was moving in a more applied direction. During the year that I joined the faculty, the animal lab (which took up an entire floor of our building) was in the process of shutting down. My department was migrating to field studies and taking up messy data and real-world problems that were central to my own program of research. My documentary films grew out of my field studies where initially I used cameras to capture more of the communicative language of participants than audio recordings permitted.

. What did you set out to do and where do you think you ended up in terms of your analysis?

: This new book extends a line of analysis pursued in 

Pillar of Salt: Gender, Memory, and the Perils of Looking Back

, a book that focuses on narrative aspects of psychiatry and how social movements shape diagnostic thinking. In the later decades of the 20th century, trauma disorders, from multiple personality disorder, dissociative identity disorder, to posttraumatic stress conditions, gained enormous currency in the mental health field. There were intensely heated debates over a widening array of symptoms thought to be disguised symptoms of trauma.

, I revisit some of those debates and the historical and cultural dynamics that shaped the way trauma models took hold late in the 20th century. With the rise of neoliberalism, and the push to marketize everything in sight and the dismantling of public services, the dramatic and morally charged accounts associated with trauma represented an effort to break through the high threshold for responding to more mundane forms of suffering. With PTSD narratives, I was interested in how this diagnosis migrated through this same era and how the scientific disputes over the diagnosis seemed to be symptomatic of a deeper problem in the field. I came to think of PTSD as a forensic diagnosis as it was used in settings where clinicians were enlisted in adjudicating the fates of individuals. There is some consensus that PTSD is a redemptive diagnosis in the sense that it assigns causality to an external force and does not implicate the sufferer. Many progressive clinicians embraced the expanded use of the diagnosis because it seemed to offer a form of sanctuary or protection from more damning labels. I was interested in what was excluded in the differential diagnostic process as clinicians were using this diagnosis, and particularly in the military and the Department of Veterans Affairs (VA), the courts, and other institutional settings.

: It was fascinating for me to read in your book about how the diagnosis of PTSD emerged from a union of research studies in stress and trauma, and how different the cultures of these traditions were. Stress research had adopted a very mechanical view of psychology, as you point out in your book: “People, like machines, are subject to breakdown under conditions that exceed their operational capacities.” While on the other hand, “To speak of psychic trauma is to position the problem within a moral community of responsibility as well… Whereas stress speaks to the machinery of mind, trauma evokes images of the ghosts in those machines” (p. 8-9).

 How do you think this tension has played out in subsequent research on PTSD?

: Early in my career, I was highly critical of machine metaphors, associating them with masculinist assumptions in science and dehumanizing modes of intervention. My own field of feminist psychoanalysis holds some affinity with the trauma models in their focus on storytelling, and the ghosts in the machine! Trauma therapists often speak of hauntings, which can be a meaningful way of representing the ineffable or elusive aspects of mental disturbances. But I do think it is a mistake to align metaphors too readily with conventional gender dichotomies, or good vs bad metaphors. The Yerkes-Dobson law, for example, developed by military psychologists during the First World War, is based on what could be described as a machine-model of stress and it remains the closest thing we have to a natural law in psychology. It still explains some aspects of the relationship between increased stress plotted against performance and breakdown. But military psychologists soon realized that the model failed to account for the complex dynamics and factors that mediate stress responses.

You also asked about how the tensions between stress research and trauma studies have played out over time. Until recently, stress has lost ground to the more mesmerizing stories associated with trauma. For a very long time, child sexual abuse, deserving of our attention as it is, has stirred far more public outrage and clinical interest than do the much bigger and prevalent problems of child poverty and neglect.

There have been a number of campaigns since the entry of PTSD into DSM III in 1980 to expand the diagnosis to include chronic or what came to be termed complex traumatic stress disorders. These campaigns failed in my opinion because PTSD has become such a marker of the societal boundary separating the deserving and the undeserving, good individuals who are victimized through no fault of their own from the willfully deviant, and complex trauma attempts to expand and redraw that boundary. PTSD retains its taxonomic legitimacy and forensic status by keeping the diagnosis pretty closely tied to a discrete event or set of events that depart from some demarcated expected realm of normal experience.

: Your critique is one that is sympathetic to the practicing clinicians, appreciative of the demands and the pressures under which they work, and the bureaucratic systems they are forced to navigate to help the patient in front of them. You write about “how practitioners were enlisting the PTSD category as a way of managing seemingly impossible clinical tasks – situations where they were negotiating various institutional, political, and psychological demands.” (p. 3).

Another example of this sort of dynamic that comes from your book is that of personality disorders. You discuss how prior to the official acceptance of PTSD as a diagnosis, military psychiatrists were pressured to diagnose traumatized veterans with personality disorders because the traumatic reactions could then be dismissed as deeply rooted character problems. You write, “Some of these troubles were indeed likely influenced by personality factors. But the political context made this avenue of exploration more of a tool for the military than a means of understanding the struggles of soldiers” (p. 9).

 The identification of maladaptive personality styles coming from an empathetic psychoanalytic clinician could be immensely psychotherapeutic in the right setting, but the same identification of personality dysfunctions in a different setting could be wielded as a weapon to silence, stigmatize, or discriminate. This suggests to me that the fundamental problem may really be these institutional, political, and psychological demands. Do you think that critical inquiry in psychiatry sometimes gets sidetracked by focusing too much on these diagnoses rather than on the institutional structures in which they are employed?

: Yes, I think the enormous investment of resources and campaigning to expand PTSD research has more to do with pressures on the field and professional marketing than it has to do with addressing the sources of mental suffering. One of the interesting boundaries that I take up in a chapter of the book is the line between PTSD and personality disorders. I trace the history of efforts to widen trauma diagnoses as a corrective to over-diagnosing personality disorders, including in the military. One of the reasons that psychiatric casualties were so low during the Vietnam War was that so many service members were dishonorably discharged under the character disorder labels. Doctors were seen by many veterans as complicit in the disciplining of rebellious soldiers through these diagnoses, just as they had during World War I. But PTSD depends very heavily on the concept of normalcy, the claim that this is a normal response to an abnormal situation. This leaves many other individuals and problems outside of the protective fold of the diagnosis.

: You write, “For those suffering harms more diffusely located in history or based on more systematic forms of violence or neglect, for example, polluted neighborhoods or poorly run schools, the diagnosis failed as a register of their claims” (p. 7).

 I do not know if any diagnosis can register these sorts of claims in a manner that is also adequate for clinical and scientific tasks. Perhaps our collective mistake is to think that we should look to diagnosis as a tool for the purpose of acknowledging systemic oppression?

: Yes, I do think that the over-expansion of DSM and its burgeoning taxonomy is part of the problem. But PTSD carries a unique history as a disorder in that it was specifically thought to be caused by societal conditions. Progressive clinicians largely embraced the category as a corrective to the systemic problem in psychiatry of over-pathologizing, as well as sexism and racism. Because the diagnosis carries a long history of morally charged campaigns, its expansion has had this inadvertent effect of reproducing some of the moralizing tendencies in psychiatry. PTSD was not simply discovered through some enlightened path of medical progress. It emerged as a kind of compromise formation (like an individual neurosis) at the frontlines where progressive clinicians used the tools of their profession to intervene in what are basically social problems.

The situational stress reactions of prior eras carried expectancies that normal individuals are able to move on quickly from disturbing events. For me, the question is not whether PTSD or any other diagnosis can adequately address societal forms of violence or oppression, but rather why these problems get so loaded onto this category and its exclusionary criteria. Proponents tend to focus on what PTSD includes and exposes in terms of societally produced suffering. I was interested in what this diagnosis tends to exclude.

: Your discussion of the antipsychiatry movement was quite interesting. You describe it as “a loose collection of intellectual and political projects focused on challenging the societal basis of psychiatric authority” (p. 10).

 You go on to comment with reference to Michel Foucault, PhD, “From a Foucauldian perspective, a critical psychiatry works to decenter the authority of psychiatric discourse by exposing its own historical contingencies” (p. 177).

 It seems to me that any framework that is utilized to deal with the realm of human distress, disability, and deviation will have historical contingencies and will be susceptible to having the societal basis of its authority challenged. Would you agree that even if the authority of psychiatric discourse is given to some other kind of discourse, an ongoing critique of a critical and Foucauldian nature would continue to be necessary?

: The legacy of Foucault in psychiatry and the social sciences most decisively includes rejection of master narratives of all sorts, whether in Marxism, psychoanalysis, psychology, or other human sciences. There is some recognition, written into ethical guidelines, that mental health professionals must attend to cultural differences and societal factors, and are required to recognize misuse of professional authority. These caveats are included in the preface to recent editions of the DSM. But the traditions of critique that I draw on require a more sustained and deeper engagement with both the ideological side of our professions, the ideas that take hold, and the material conditions of our work, which include things like how services are provided and paid for.

I also draw on critical traditions to recognize how social justice movements have profoundly shaped, even transformed, and how we think about boundaries between normal and abnormal, for example the issue of homosexuality. The APA was pushed by the gay rights movement to remove homosexuality in 1973 from DSM II. I also try to recover some of the ethos of the early antipsychiatry movement that has been marginalized in the mental health field; for example, the idea that patients suffering from delusions or hallucinations have something to say worth hearing.

: You acknowledge the influence of Peter Sedgwick on your views, referencing his contention that the antipsychiatry theorists often approach mental suffering from too much distance “rather than from the hard seat of the waiting room or the casualty department’s stretcher.”

 The impression I seem to get in this regard is that you are saying: yes, we need to problematize the role of psychiatric and psychological explanations with reference to what we consider to be abnormal, disordered, or dysfunctional, but we should not use this problematization to argue against the rights of individuals to have their distress and disability be registered and the right to receive adequate care within some framework of health or social welfare. Is this an accurate characterization?

: I do try to hold these complexities in mind and to draw out both the insights and blind spots of those early movements. This is a very interesting time we are living in now, and in many respects, a very hopeful one. After a long era of meager resources for public health agencies (the poor stepsister of medicine and private health insurance), public health and calls for investment in social welfare have gained enormous public support after this horrifying pandemic. The Black Lives Matter movement has pushed for a different vision of society than we have been fed over the past 50 years, particularly in the area of policing. There are calls around the country to move away from policing to a greater focus on crisis services and interventions outside of the criminal justice system. But I also think that a progressive vision of psychiatry requires more in terms of attitudes and thinking about patients suffering from mental illness. As mental health professionals, we should be working to build more receptive spaces in the community for individuals who may seem odd or who process reality differently.

: You write, “the obsessive tendency in psychiatry to ‘pin down’ PTSD within a stable, trans-historical taxonomy is itself symptomatic of the anxiety associated with this diagnosis” (p. 6).

 Subsequently you write regarding psychoanalysis, “psychoanalysis departs from medical psychiatry in widening the interpretive lens for diagnostic storytelling. It allows for ambiguity, for dynamic shifts in the meaning of events over time, and for the symbolic and metaphorical registers of symptoms” (p. 179).

 I can think of at least 2 sources of the sort of obsessive tendency that you describe, 1) the need for operationalization of constructs for the purposes of scientific inquiry, and 2) the categorical needs of the health care and legal system (such as, to reimburse or not to reimburse, to declare criminally sane or insane). Psychoanalysis has been able to allow for ambiguity, perhaps by distancing itself from these needs and restricting itself to a more clinical role. What do you think mental health systems can do differently to allow for the sort of ambiguity that you value?

: That is a fair critique of tendencies in clinical psychoanalysis—that its attentiveness to ambiguity and to the layers of meaning and the overdetermined aspects of mental life can feel like a luxury or privilege available to professionals who are remote from the hard decisions and demands of those living precarious lives. My book does include a critique of psychoanalytic interventions, noting that the diagnostic process for PTSD runs counter to many psychoanalytic principles. PTSD tends to focus on single causal factors, an emphasis that also runs counter to much of the scientific literature. But there also are rich traditions of social psychoanalysis and psychoanalytically informed community practices that I draw on.

Some of the problems you describe are bound up in the market economy and how deeply capitalist logic shapes medical training and its ledgers of value. I do think socializing mental health services and moving away from our dependency on private insurance and fees-for-service would be a good thing. Many of the storefront clinics that were part of the anti-psychiatry movement included treatment approaches that were quite nuanced in recognizing the complexity of patients and their problems. It was understood that individuals could be self-defeating and destructive, both victims and perpetrators. I also think there are some wonderful programs carried out in Vet centers and the VA by staff clinicians, programs that I describe in the book. The Hearing Voices movement is also an example of groups drawing on some of that same ethos and working outside of the medical model.

: At one point you comment, “Disorders can be both socially constructed… and at the same time valid ways of understanding mental functioning” (p. 13).

 I think that is an important point because there is a tendency to think that if something is socially constructed then it cannot be valid. Can you elaborate more on this?

: I am not anti-diagnosis, but I do generally view them as provisional and contingent on a community of shared meanings, rather than as entities readily objectified and operationalized through the tools of science. But diagnoses also hold currencies, both material and ideological, that are important to recognize. Much of my work focuses on the history of psychiatric diagnoses and forces that shape the migration of categories across some moral divide. I have also written about folk maladies such as codependence and love addiction, as well as syndromes bridging feminism and clinical research, such as the battered woman syndrome. PTSD grew out of the anti-war and feminist movements, and so it interested me as a category bridging social movements, popular culture, and DSM taxonomy. I like working at the messy borders between diagnostic categories. PTSD has this messy etymological and social history, with its collapsing of stress and trauma, present and past.

: One of my favorite sentences from your book is, “like many religious texts, the DSM is rife with contradictions. Practitioners bring their own interpretations of its arcane truths to the messy world of human experience” (p. 5).

 That is a rich analogy. I would add that like many religious texts, practitioners not only take it more or less literally, but also take it more or less seriously! (I have also observed how there is substantial disagreement when it comes to the philosophical foundations of the DSM, what sort of notion of mental disorder does it have, what it means by 

, and so on.) One of my dissatisfactions with a lot of popular critiques of the DSM is that they take the manual way too literally and way too seriously, perhaps because our system does too in some ways, but I feel any robust critique has to take into account these contradictions and the varying interpretations they provoke. Your thoughts?

: Yes, amen to that! After leaving the fundamentalist Christian fold of my youth when I entered adulthood, I developed a deep allergy to religious zeal, including in those fields where I hold allegiances and attachments. But the over-investment in the DSM seems more tied to its use in institutional settings and how decisions are made about patients’ lives when there is some consideration of mental states. There is a great deal at stake. Clinicians working with the courts, military, and in VA settings, including disability evaluations, are required to have considerable fluency in the DSM and its obsessive logic. Clinicians in private practice are required to enter a code on an insurance form, but can remain pretty agnostic about the taxonomy itself. They can bypass the disciplinary side of this manual.

In the last chapter of my book, I tell a story from interviews I carried out with both patients and clinicians at the Oregon State Hospital for my film, 

. One patient, sentenced to the state hospital for 20 years under the insanity plea, had killed his boss after falling from the roof on a construction site. He was diagnosed with a psychotic disorder, based on his preoccupation with numbers and codes. His psychiatrist, a compassionate clinician who frequently spoke on the patient’s behalf before the Psychiatric Security Review Board, was also preoccupied with numbers and codes. At hearings, he cited the canonical DSM criteria and the elaborate codes associated with Oregon Statutes in describing this case. I could not help but see the psychiatrist and patient as each registering some of the madness of the world they both inhabited, a psychiatric hospital that was also a prison. Of course, a crucial difference between the psychiatrist and the patient was in how many of their signifiers were legible to others. That difference decidedly favored the normalcy of the doctor.

: You comment in the book that the critique of the medical model in the 1960s was complemented by an embrace of alternative states of mind. There is an on-going revival of interest in the use of psychedelics, this time largely within a medical model, with PTSD being one of the conditions of interest. You discuss that the development of the therapeutic use of psychedelics invites us to revisit the work of Timothy Leary, PhD. What is your assessment of current investigations into the therapeutic use of psychedelics for PTSD and what insights do you think Leary has to offer?

: Campaigns to decriminalize psychedelics and other Schedule I drugs have been vital to the racial justice movement in the United States. In my own State of Oregon, a pair of ballot measures were passed last fall to decriminalize possession of small quantities of Schedule I drugs that have been a leading gateway into the criminal justice system. Many young people of color get arrested on minor drug charges. In my book, I take up some of the history of how drugs migrate across the good drug/bad drug boundary, often through the medical model. In the late 20th century, the trauma movement emerged as a site of rebellion against what many viewed as the excessive use of pharmaceuticals in the mental health field. Trauma required intensive, long-term listening. Perhaps inevitably, PTSD emerged as the modern-day poster condition in this new effort to bridge that divide, partly through its redemptive association with normalcy. It was interesting to me that a small group of multidisciplinary psychiatrists, founded in the 1980s to champion therapeutic use of psychedelics, moved quite quickly from the margins to the mainstream of public policy, if not to the mainstream of the field of psychiatry itself. It is a fascinating story that still unfolds—one that I would love to follow as a documentary filmmaker. There are many cultural dynamics operating here, including widespread interest in alternatives to the mind-numbing and anti-libidinal drugs so often dispensed by the medical profession.

I am glad you asked about Timothy Leary, whose legacy as icon of the 1960s often surfaces in campaigns to promote therapeutic use of psychedelics. In my book, I use this case of psychiatry’s recent romance with psychedelics to revisit the early research of Leary and his lesser known contributions to psychology and psychiatry. Through his studies on the use of psilocybin in group treatment settings in a prison outside of Boston, Leary advanced his theory of what he termed 

, with the former referring to the attitudes of practitioners, including to the drug itself, and the latter referring to the environmental context, including the aesthetic and social context of drug administration. Prisoners were provided psilocybin in special rooms with music and group support, and encouraged to set their own goals for self-development. Many of the current protocols for therapeutic use of psilocybin similarly involve long sessions with music of one’s choice, social support, and rituals, including some associated with Indigenous practices. The important insights that grew out of Leary’s work on these contextual influences on drug effects have had little influence on psychiatric administration of drugs in general, and they typically register as confound effects, although some of the focus on social support and aesthetics have been incorporated into protocols for therapeutic use of psychedelics, including here in Oregon.

If these protocols open larger questions about cultural practices and market forces in the mental health field, I think this could be a good thing. It will also be important to attend to how debates over the therapeutic use of psychedelics shape treatment options for patients suffering from major mental illness where clinical sets and settings—to borrow the phrase again from Leary – have been so impoverished.

: We have seen a lot of discussion around mental health over the past year, especially in the context of the COVID-19 pandemic. I think there is a certain unease in a lot of these popular discussions, where the desire to acknowledge the magnitude and prevalence of suffering coexists with concerns about medicalization of this suffering. Do you have any thoughts on how we as a society can have more meaningful conversations around mental health?

: The pandemic has indeed opened space for more meaningful conversations around mental health, particularly in the renewed focus on chronic stress as a public health and mental health problem. The internet is awash now with discussions of 

, and PTSD has emerged again as a signifier for shared suffering not born of individual failures or deficits. But I view much of this as a diagnostic containment strategy and a distraction from the real issues at hand. Dispensing diagnoses as an intervention in the pandemic is not very illuminating, even with PTSD as the site where societal sources of misery are narrowly acknowledged.

More than offering just a critique of the PTSD diagnosis, psychiatric diagnoses in general or the medical model, I hope my book contributes to self-reflection in the field about how the histories of our disciplines are embedded in larger societal histories, and on our roles in reproducing the very suffering we aim to control. Following psychiatry through military history was particularly instructive in bringing into bold relief the contradictory forces we face as clinicians in keeping individuals healthy in unhealthy places. It is not a conflict we can deliver ourselves from by simply refusing to be part of the system. Those in secure private practices can opt out, but many of us are part of institutions that offer less distance from how we are implicated in the difficult lives of others. But many of these institutional sites, where psychiatry is closest to the heartache and hard problems that exceed its reach, carry potential for greater creativity in a field that has suffered its own inhibiting obsessive conditions. That is why I am so delighted to be part of your Conversations in Critical Psychiatry. Thank you for inviting me!

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

Dr Aftab and Dr Haaken have no relevant financial disclosures or conflicts of interest.

Psychiatry, Politics and PTSD: Breaking Down

Psycho politics: Laing, Foucault, Goff man, Szasz, and the future

How should the sociopolitical nature of PTSD as a diagnosis inform our understanding of trauma?

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

“Trauma eventually affects everyone on the planet,” says Randall Bell, PhD, who has worked on disaster recovery around the globe. But after the disaster, it is time to figure out how to survive, and then thrive.

In this Mental Health Minute, Bell discusses his latest book, 

Post-Traumatic Thriving: The Art, Science, & Stories of Resilience

. Marshalling a combination of scientific studies and personal stories, he lays out a 3-stage journey from trauma to recovery.

holds a PhD in socioeconomics from the University of California, Los Angeles. He is the Chief Executive Officer of Landmark Research Group, LLC.

Is unresolved trauma the number one problem on planet earth? An economist with expertise in disaster-related distress makes the case. 

The Global Burden of Trauma

“There’s more to trauma than physicality,” Rachel Yehuda, PhD told attendees at the 2021 American Psychiatric Association (APA) Annual Meeting. “For decades we have been talking about how to integrate pharmacotherapy with psychotherapy. But we haven’t understood how to do it.” 

For patients with posttraumatic stress disorder (PTSD), one possibility is combining therapy and mind-altering drugs, like 3,4-methyl​enedioxy​methamphetamine (MDMA), panelists explained.

Mark Bates, PhD, former branch chief for Psychological Health Promotion in the Department of Defense’ Psychological Health Center of Excellence, presented findings from 6 phase 2 trials of combined MDMA and psychotherapy in the 

 The studies included 103 participants who had experienced treatment-resistant PTSD symptoms on average for more than 15 years.

Participants progressed through several types of sessions in all of the studies. First, participants and clinicians conducted an initial, 90-minute interview, preparing the participants for the MDMA-assisted sessions and discussing their PTSD. Then participants underwent 8-hour MDMA-assisted or placebo sessions. During this time, participants wore eyeshades and listened to music, and had the option of discussing their troubling experiences.

New research find altered states of consciousness may allow veterans and other patients with PTSD to face unspeakable experiences and find peace. 

Traumatic Stress Disorders

Treatment of Military Populations

Treating Psychiatric Combat Casualties

Treating Comorbid Substance Abuse and Trauma

Trauma and the Politics of Diagnosis: Janice Haaken, PhD

The Global Burden of Trauma

Looking to the Future of MDMA-Assisted Psychotherapy

Suffering a Common Fate

Teamwork and Trauma: a Conversation With Kasey Grewe, MD, and Niesha Voigt, MD

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Trauma Informed Care