stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
The problem comes
when we have to deal
with the invisible
wounds of war,
the wounds from
psychological trauma,
from fatigue, from loss
and grief, and even
from moral injury
of having to deal
with the ambiguous,
difficult, and untenable
situations into which
we place our young
men and women when
we send them to war.
The treatment of
these unseen, invisible
wounds is difficult.
the portrayal of a serial killer described as having schizophrenia brought on by his
PTSD. Who wrote that! In this day and age, when we understand so much more
about mental disorders, a writer carries on this wild old Vietnam veteran stigma of
the crazy Rambo who is going to go out and kill everybody.
I think that what happens internally is most important. Charles Hoge and others
have alluded to the relationship of the individual and how she perceives herself
within the culture. What is her identity as a member of a larger group and does her
perception of having something that we define as mental illness make her separate
from her larger perceived group As a former Marine, I like to use the example of
Marines because they are so clear and distinct in many ways. What makes a Marine
a Marine If you take a kid who is 18 years old, shave his head and put him in the
right uniform is he a Marine No. It is not until he has gone through boot camp
and had that collection of shared experiences, taken on values, taken on particular
attitudes, and taken on a certain level of training that he becomes a Marine. It is not
just Marines. It is the same with soldiers, sailors, airmen, Coast Guardsmen, police
officers, fire fighters and disaster workers. You become that person. You incorporate
that training as part of your identity. You take on the warrior code and you incorporate
that external set of cultural norms and external experiences into your identity.
When a warrior is wounded, we have warrior transition units, wounded warrior
barracks, wounded warrior regiments in the Marine Corps, and Safe Harbor in the
Navy. These are places where wounded warriors go to recover and they wear their
stigma of physical injury with pride. Their amputated limbs or the scars that they
have from the numerous surgeries are worn proudly as badges of honor.
The problem comes when we have to deal with the invisible wounds of war,
the wounds from psychological trauma, from fatigue, from loss and grief, and even
from moral injury of having to deal with the ambiguous, difficult, and untenable
situations into which we place our young men and women when we send them to
war. The treatment of these unseen, invisible wounds is difficult. While it may not
require great physical pain, numerous surgeries, or refitting prostheses on amputated
limbs, it demands dealing with the questions, “Who am I now Where do I belong
What have I become Has this turned me into somebody who is no longer a warrior
Am I now a member of some other group” In the mind of the warrior, that
other group may include that guy who is living in the park homeless. “Am I going
to become that burned out guy who is hopelessly cynical and going to numerous
self-help groups Am I no longer a warrior Am I no longer a proud, fit, active,
engaged, fired up, strong young man or woman Am I now a wounded, damaged
person What have I become”
Regarding PTSD, there are many tasks in treatment and most require integrating
the experience of what happened to the Marine in war into her current identity. The
treatment often requires a certain level of “mature intimacy,” a term I have borrowed
from Bessel van der Kolk’s book about traumatic stress. Successful treatment requires
the capacity to bear pain in the presence of another human being. Together, patients
and therapists must confront the conflicts, ambiguities, inconsistencies, and difficult
issues, and tolerate them while going through this process of recovery—to look at
them openly, honestly, and drop that “image armor” of a warrior long enough to
address those deeper issues requires that you become vulnerable.
As I have implied, vulnerability is the antithesis of the warrior ethos. As a warrior
you rarely want to talk about vulnerability. You only talk about that in terms
of infantry tactics and addressing vulnerabilities to the security and protection of