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More bad news is that mental health professionals don't have the
answer. They can help, but their approach to understanding PTSD is far
too narrow. Many mental health professionals are rigidly bound by conventional medical definitions and practices. They can prescribe one or
more of the treatments that are available, but there are huge limitations
as to how effective these treatments are, and many assumptions inherent
in these treatments. Traditional mental health practices cannot fix the
broader issues of what PTSD means for combat veterans.

HOW MENTAL HEALTH PROFESSIONALS DEFINE PTSD

Mental health professionals rely on the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders (DSM for short) to make
a diagnosis of PTSD. If that diagnosis doesn't fit the client's symptoms,
then there are nearly 300 other diagnoses in the manual to choose from.
Although the American Psychiatric Association assembled the DSM, all
mental health professionals (i.e., psychiatrists, psychologists, clinical social
workers, psychiatric nurses, psychotherapists, and counselors) use the same DSM. (The distinctions between these different types of professionals will be addressed in a later chapter.)

The DSM manual (currently in its fourth edition) provides laundry
lists of all the symptoms found for each diagnosis, and the use of the manual creates the impression that mental disorders are well-defined conditions that everyone agrees on and understands in the same way. Mental
health professionals memorize the specific criteria of the most common
disorders, or refer to the DSM menu to find just the right one(s), in order
to inform their patients of their diagnosis, often after less than an hour
meeting with them.

Realities of the DSM Definition of PTSD

Although patients frequently ask mental health professionals to tell them if
they're "normal," we aren't in the business of "normal," because we don't
know how to define what normal looks like, and people generally don't
come to us unless there's something bothering them. Plus, if we work in the
civilian sector, insurance companies generally won't pay us when we use the
DSM label for normal-"No Diagnosis on Axis I or II" ("Axis I" includes all
diagnoses that you can acquire, including PTSD; "Axis II" includes personality disorders, which are usually lifelong). That means that virtually no one
walks out of our offices "normal"; everyone can expect to be blessed by one
or more of the diagnoses contained in the DSM.

Most people (including many mental health professionals) don't realize that the diagnoses contained in the DSM were essentially created by
committees of doctors sitting around conference tables. They are best
guesses regarding which groups of symptoms should be considered discrete disorders, based on the doctors' clinical experience treating patients
with mental health problems and their interpretation of published studies.
Many of the diagnoses, including PTSD, have been shown to have a strong
biological basis and have stood the test of time; however, the science of
how these diagnoses are validated and how useful they are in deciding how
to help someone remains very complex and subject to considerable error.

Although the medical establishment considers mental disorders in
the same way that other medical illnesses are considered, these conditions are not like tuberculosis or pneumonia, where the offending bacteria
obtained from an ill patient can be grown in a petri dish, observed under
a microscope, or found in a blood test. We don't have any definitive means
of making a mental disorder diagnosis other than what patients tell us
about their symptoms, which we compare with the lists of symptoms in the
Diagnostic and Statistical Manual of Mental Disorders.

This is not to knock the DSM, or any of the brilliant men and women
who created it; it's just to recognize that the manual is designed merely
as a way for mental health professionals to communicate with each other
regarding the various types of problems patients present with. If a medical
doctor refers a patient suspected of having "PTSD," "major depression,"
and "traits of a personality disorder" to a psychiatrist, all of the medical
professionals perceive this in a similar way, and this common language is
used to direct treatment. The use of a diagnosis with an agreed-upon definition helps us to feel more confident about what we're doing, including
which treatment we think will be most effective.

However, one major problem is that the various disorders outlined
in DSM overlap extensively with each other. They are not distinct conditions, like bacterial infections. They blur together, and it has been proven
through carefully conducted studies that different mental health professionals will frequently diagnose different disorders when they interview
the same patient. This fact is very important to consider when we start to
talk more about how effective current treatments are.

All that aside, PTSD seems relatively straightforward for mental health
professionals to diagnose, and it's unique among other DSM disorders in
that it's clearly tied to one or more traumatic event. To diagnose PTSD,
we ask the client about the nature of the trauma and the symptoms. If the
trauma led to the development of the requisite number and type of symptoms lasting for at least one month, then we can conclude that the person
has a diagnosis of PTSD. Warriors frequently look at the list of symptoms
and say, "Yep, that's me." Family members also look at the list of symptoms
and say, "Yep, that's John (or Jane)." When a combat veteran tries to get
help for war-related reactions that are interfering in some way with life, the
mental health professional will gladly oblige them with the diagnosis. The veteran might also be diagnosed with one of many disorders that frequently
go hand in hand with PTSD symptoms: depression, panic disorder, generalized anxiety disorder, alcohol or substance use disorder, and maybe a personality disorder (e.g., antisocial, borderline, or "not otherwise specified").

However, the DSM approach to figuring out the problem doesn't
really help the warrior understand what's going on, or why he or she got
blessed with this condition while many fellow unit members seemed to be
spared; nor does it necessarily help in figuring out the best course of treatment, if treatment is even indicated. When it comes to combat-as well as
professions like law enforcement, emergency medicine, and firefighting,
where exposure to trauma and danger is part of the job-the whole concept of normal and abnormal gets thrown out the window.

Although trauma-related reactions were recognized well before 1980,
PTSD was first proposed as a diagnosis in 1980 in the third edition of the
DSM (DSM-III), as a way to help mental health professionals communicate between themselves and with their clients concerning the collection
of symptoms that seemed to be associated with life-threatening traumatic
events. Part of the impetus for creating the definition of PTSD was the
generation of veterans from Vietnam, as well as the history of conditions
described after previous wars, such as shell shock. It took a number of
years after the Vietnam War to recognize that thousands of veterans were
suffering serious postwar reactions for which they were not being treated
or compensated.

After publication of the DSM-III, there was intense debate regarding
whether or not PTSD should be considered a legitimate disorder, since
many of the reactions are expected after serious traumatic events. The
definition changed somewhat between the third and fourth editions of
the DSM, and there is continued debate regarding whether the definition
is either too restrictive or too liberal in defining what should be considered abnormal reactions to trauma, and what level of functioning should
be considered impaired. Another committee is working to come tip with
revised criteria for the fifth edition of DSM, scheduled for release in 2012.

Although the PTSD definition in DSM is considered to encompass warrelated reactions, it's based largely on single episodes of trauma in civilian settings where the person is a victim of assault, rape, an accident, or a natural disaster. This is very different than the experiences of warriors who are
trained to encounter trauma as part of their profession (and individuals who
work in other dangerous professions like law enforcement or firefighting).

PTSD is a paradox. For medical professionals it's simply defined by
the specific set of symptoms and impairment. However, every "symptom" included in the definition can also reflect normal responses to lifethreatening events or the normal way the body responds to extreme stress.
Reactions that mental health professionals label "PTSD" may be entirely
expected for warriors who have trained and prepared themselves to deal
with serious traumatic events. Warriors speak a different language than
mental health professionals when it comes to their reactions to war.

Perceptions Matter

Why is this important? The answer has to do with your perception of yourself as a warrior. If you view yourself (or your warrior loved one) as having
a disorder according to what a professional (or society) says, rather than
someone experiencing expected reactions from combat, it affects how you
feel and think about yourself or your loved one. A negative perception
of yourself actually affects your body chemistry. Perceptions (usually considered in the realm of psychology) involve nerve functions that connect
with virtually all organ systems in the body. The mind and body are not
separate. Many therapies focus on helping to correct negative perceptions
through a process called "cognitive reframing." Having a positive view
of yourself is an essential starting place toward navigating the reactions
resulting from combat experiences.

A positive view is one that acknowledges mental health problems as
part of the normal human experience and not a personal failure of character; it recognizes that you have control only over the things that you have
control over (which is much less than you might think), and that every
human makes mistakes. A positive view acknowledges that perfection is
unachievable; it means accepting that you did the very best you could,
even if you feel (or wish) that you could have (or should have) done something differently, which would have resulted in a better outcome.

Mental health professionals can contribute to the stigma of mental illness through the perception that most everyone coming into their office
has something wrong with them. A therapist's role isn't typically one of a
minister or coach, but rather that of an educated professional entrusted to
make the correct diagnosis so that the right treatment can be prescribed.
This perspective sets up an expectation that this person is the judge of
what's normal or abnormal, rather than an ally helping the client navigate
their own way through serious life difficulties. Some therapists fool themselves into thinking they know what the best treatment is for each individual sitting in front of them. Good therapists understand that they don't
know what's best for their client, and set the stage by helping to normalize
the experience of the client by saying something like, "I don't see how you
could have done anything differently at the time," or "How did you have
the strength to respond in that way?"

The bottom line, coming from an insider in the profession, is that
if you've read this far, you're probably "normal." Everyone who has ever
deployed to a war zone is changed by his or her experiences; it would
be abnormal not to be. Some reactions may seriously interfere with your
life, but that doesn't mean there's something wrong with you as a person.
There are things that you'll identify and want to change, but, more important, the journey of readjusting after combat is one of learning to live with
your experiences, and of integrating them into who you are without blaming yourself for what happened or what you did or didn't do. It's a process
of developing an understanding of how you react to situations now in a
way that's different from how you reacted before you became a warrior.

DEFINING "NORMAL" VS. "ABNORMAL"