From Military to Civilian: Beyond Medicalization

​Those who follow veterans’ issues are aware of two overlapping explanations for difficult military-to-civilian transitions (MCT). The first is the well-advertised problem of chronic PTSD and other operational stress injuries (e.g., depression and anxiety problems) believed to affect up to one-third of those who leave the military. As others have argued, institutionalized military psychiatry defines veteran concerns as problems to be solved through medicalization (Shields et al., 2017; Howell, 2011; Caplan, 2011). This is reflected in broader research and public discourse on veterans, where the difficulties of transition have been primarily framed as health issues, and especially as mental health issues. Such a framing is problematic because it tends to not only medicalize, but also individualize and thus de-politicize the impacts of military service and military deployments. Medicalization emphasizes individual and technical solutions (i.e. all that is required are better treatments or programs) which admittedly can be helpful for many people. However, medicalized language does not acknowledge the purpose of militaries—war and training for war (military conditioning)— is largely absent from public discourse and policy on veterans’ transitions (Eichler & Bulmer, 2016).

When it comes to PTSD as a global explanation for veteran issues, there are a number of things which remain unanswered. Since its inception, observed symptoms were believed to reflect an underlying disease process. Thousands of studies conducted over nearly 40 years have attempted to identify brain anomalies to explain the wide range of seemingly unconnected mental struggles among soldiers and veterans. This ongoing research has been promising at points and contradictory and confounding at other times. But, missing from efforts to understand military trauma is context. By context, I mean mental conditioning within a value system that is necessarily rigid, perfectionistic, and demanding.

A second explanation has emerged focusing on the impacts of moral injuries arising from warzones. While the first (i.e., PTSD and OSIs) are deemed to be medical diagnoses, moral injury is considered to be a problem of compromised belief and value systems. Moral injuries are defined as reactions to perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations (Maguen & Litz, 2012). It was the subject of Jonathon Shay’s acclaimed book – Ulysses in America - focusing primarily on combat and the heat of battle which arguably are where the highest stakes are in play and where the potential to participate in or fail to stop terrible things from happening are ever-present. As noted by Nash et al. (2013), “Shay’s conception of morally injured veterans as victims of others’ wrongdoing mirrors views found elsewhere in the mental health and ethics literature regarding the central role in trauma of breaches in social moral contracts and damage to belief systems”. Our work with veterans certainly mirrors this observation. Namely, nearly every case of military PTSD is maintained by an unresolved moral dilemma; usually centering around betrayal across a broad range of operational contexts. In fact, Mobbs and Bonanno (2018) contend that moral injuries and transitional strain (e.g., loss of military identity) are the main sources of mental distress facing military veterans, not PTSD.

Loss of Relevance and Special Purpose
Soldiers don’t just espouse high moral codes – they live them, they embody them whether at home or deployed. They have to in order for these codes to become second-nature. The soldier who is tasked with protecting a convoy but refused the necessary equipment to do the job because of budgets and another who is sexually assaulted by a superior share a common reaction of betrayal. Don’t these qualify as assaults on moral codes? I think so. These types of events challenge the currently restricted notion of moral injury (as arising from warzones). In fact, the number one complaint among veterans medically released because of OSIs is a sense of betrayal by their chain of command and being thrown away by the system. Lingering reactions of helplessness, outrage, and shame certainly contribute to post-service mental health problems. Moral injury is not restricted to warzones. My point is that if soldiers are to be conditioned in high-minded moral codes, then breaching them in any context – in warzones or on home bases - can produce the same types and severity of psychological distress. I believe our current understanding of moral injury leaves out an important breeding ground for betrayal – the promise of specialness.

Embodied adaptations that make up military conditioning are accompanied by lessons in military superiority. Military conditioning is fostered within environments that hinge on pride and specialness—which soldiers must prove continually—that distinguish them from everyday people and from the people they were upon joining. Soldiers are trained to believe that they are valued members of a special group set apart from the broader society – the guardians and the protectors. This categorization of soldiers requires them to reject civilian values and their own civilian pre-service identities. This distinction between soldiers and their civilian counterparts cements a status of the military over civilian society (Whelan, 2017). To be relegated back to the status of being a ‘mere civvie’ often results in a lingering separation between veterans and their families and communities.

​We need to move beyond platitudes and stop telling soldiers they are special if we don’t mean it!

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