Culture does matter! A British response to David Morris’ article in the ‘New Yorker’

By Stefan Schilling
Best Defense guest therapist

In a recent issue of the New Yorker, David J. Morris published an insightful article on Post Traumatic Stress Disorder (PTSD) with the title "How Much Does Culture Matter for P.T.S.D.?" Morris looks at a crucial aspect of PTSD that seems to be forgotten in the debate about why U.S. soldiers and Marines appear to suffer at higher rates than other NATO member countries — namely the role of culture.

While agreeing that culture is in fact a relevant factor in determining the differences in PTSD rates (specifically between the United States and the Britain), his main arguments — 1.) combat intensity, and 2.) British attitudes towards seeking help — are not sufficient to explain the issue. In fact national healthcare culture and influence of military organizational culture are more likely to explain this issue, as will be shown below. Morris’s claim that Americans saw more fighting in Iraq than British in Basra is uncontested, at least for the first few years after the invasion. But when taking Afghanistan into account, it becomes obvious that the British troops in Helmand saw very fierce fighting, IED attacks at unprecedented scales, and high casualty rates — all attesting to the intensity of combat in the southern Afghan province — however, without a subsequent increase in PTSD rates, which have been relatively stable for the last 10 years at 4 percent. Further, the British "stiff upper lip," which leads soldiers to suck it up and arguably drown their sorrow by self-medicating with alcohol, is allegedly evident in the high alcohol misuse rates among British troops of about 22 percent. While, according to studies, it is certainly evident that British troops are drinking more than their American counterparts, and this has been linked to having had a combat role, the latter leads only to a temporary increase shortly after deployment, returning to "normal" levels in due course. More importantly, though, the rates of alcohol misuse are associated with low rank, younger age, being single, or having a parent with a drinking or drug problem. Considering that most British troops are recruited from predominantly broken families, and with some 15 percent of women and 27 percent of men in the general population drinking more than the weekly recommended levels, binge drinking being invented in Britain, it is no surprise that these troops are more likely to drink. Further, it has been shown that alcohol is used in the British military as a group binding catalyst.

Morris’s analysis, and that of many of many contemporaries, is missing two very fundamental characteristics of cultural influence on PTSD rates: PTSD rates are first influenced by military organizational culture, and secondly by access of veterans to healthcare.

Morris based his claim, as most commentators do, on Hoge’s 2004 study of troops from the 82nd Airborne, 3rd Infantry Division and 1st Marine Expeditionary Unit who were deployed to Iraq in early 2003 and 2004, which claims combat intensity is primarily responsible for PTSD rates. However, the troops in 2003-04 and later were not only subject to intense fighting, but also to factors very visible to readers of this blog: poor leadership and preparation, inadequate equipment, and misproportioned troops.

Many authors, Tom Ricks being one of them, have attested to the ill preparation and training, as well as inadequate tactical and operational approaches employed during the initial years of the Iraq war. John Nagl put it perhaps most eloquently in the foreword of FM 3-24: "The American Army of 2003 was organized, designed, trained, and equipped to defeat another conventional army; indeed, it had no peer in that arena. It was, however, unprepared for an enemy who understood that it could not hope to defeat the U.S. Army on a conventional battlefield, and who therefore chose to wage war against America from the shadows."

Anyone who has ever been unprepared for his job, had a horrible boss, feared losing his position, or possessed knowledge that the company’s new customer support concept is doomed to fail knows what a detrimental effect such a work environment can have on your psyche and emotional well-being.

If part of your job, however, is driving around in unarmored Humvees in the middle of a sprawling urban city while receiving small arms fire, RPGs, mortars, and being threatened by IEDs, then feeling unsupported by your leadership or the military chain of command is not only frustrating, but life-threatening. Knowing fully well that the amount of troops deployed, the training you received, and the equipment you have been issued is not adequate for pacifying a city the size of Fallujah or a country the size of Iraq has immediate repercussions on the level of frustration, anger, and fear a soldier can endure.

Epidemiological research on PTSD has shown that factors such as the amount of support troops receive (evident in the equipment, pre-deployment training, support for families during deployment and post-deployment support, etc.), the leadership they are blessed with or have to endure, the level of control they have over their own job, the cohesiveness and camaraderie within the primary fighting group have significant effect on PTSD symptom reporting in combat troops. All these factors, from support by the military chain of command, unit morale, group cohesion, identity, leadership or job strain are influenced by the prevalent military culture. So the way military organizations choose to train, staff, lead, and equip their troops has direct effects on their resiliency to deal with stress. The recent discussion on why junior officers choose to leave the Marines and the Army, which clearly attested to a leadership crisis in the two branches, is just another side of this coin.

However, this is far from being news. Studies conducted in World War II like S.L.A. Marshall’s Men Against Fire, or Stouffer’s The American Soldier, as well as the Shils and Janowitz study on the Wehrmacht, which are still taught at staff colleges, have all hinted at connections between such military-inherent factors and mental disorders.

While the above explanation focuses on military-inherent cultural characteristics, the second explanation for high rates of PTSD in U.S. soldiers and Marines is influenced by national healthcare culture. With PTSD, as Morris quotes Jonathan Shay: "mimic[ing] virtually any condition in psychiatry" the diagnosis is highly subjective. What sets most of these diagnoses apart from PTSD is the latter focus on an etiological event — in which a person "experienced, witnessed, or was confronted with an event where there was the threat of or actual death or serious injury." The event may also have involved a "threat to the person’s physical well-being or the physical well-being of another person" (DSM IV 309.81). Hardly anyone deployed in a combat zone has not — to some degree — experienced such a situation. To make matters worse, paradoxically, some symptoms of the disorder actually might have beneficial effects in the combat zone. Hyper vigilance, for example, in civilian life a symptom of PTSD, is in combat a survival instinct — 360 degree awareness. Hoge calls this part of being a warrior. Obsessive Compulsive Disorder, like PTSD, an anxiety disorder which often co-occurs, is characterized by repetitive behaviors to alleviate anxiety. Emphasis on constant checking and rechecking of gear and punishment for failing to pack correctly might very well condition some troops for such behaviors, but intuitively knowing where your gear is when the stress of combat takes over makes the difference between life and death in battle.

With such subjective diagnoses, why aren’t more non-U.S. soldiers diagnosed with PTSD? Perhaps, because they do not have to be! The major non-military difference between troop contributing nations in Afghanistan is that, with the exception of the United States, every other country has some form of national healthcare system or national mandatory insurance system. Soldiers and their families from Britain, Germany, Denmark, or Canada to just name a few, will always receive healthcare, no matter what their financial or employment status, irrespective of their veteran status. U.S. soldiers just do not have this luxury. Yes, Veterans Affairs offers a solution, but only for five years after separation from active military service, irrespective of sustained service-connected injuries or illnesses. The hassle to gain access to the VA, attested to in the claims backlogs which have made news in recent months and eligibility disputes, make access to VA healthcare a hurdle for many veterans, reservists, and National Guard troops, especially those dealing with some form of mental disorder. So it is no surprise that according to the U.S. Census Bureau one in 10 veterans under the age of 65 is uninsured, an unrivaled disregard of a nation’s veterans. A diagnosis of PTSD, or for that matter a mild traumatic brain injury can be a way to secure or expedite much-needed healthcare. After all, healthcare provided by the VA is arguably among the best in the country and has been recognized as excellent in Senate testimonies.

A recent RAND study showed that many reservists use unemployment compensation for ex-servicemembers as a means to deal with voluntary or involuntary job loss after deployment. Why is it so far-fetched to presume then, that veterans, of whom most are probably really experiencing some symptoms of PTSD as a result of their service, seek VA healthcare to aid in their transition to normal civilian life?

It becomes evident that other variables seem to be influencing PTSD rates apart from combat exposure or simply a "stiff upper lip." The above-mentioned arguments suggest that PTSD seems in fact to be influenced by factors more integral to the military organization and its culture, as well as different national approaches to healthcare access, and thus show that, indeed, culture does play a highly important role in explaining PTSD rates.

Stefan Schilling is a Ph.D. student at the Institute of Psychiatry and the Defence Studies Department of King’s College London, studying and comparing Post-Traumatic Stress Disorder in Germany, Britain, and the U.S. Military. He is also working as research officer at KCL’s Defence Studies Department, based at the Joint Services Command and Staff College (JSCSC) of the British Defence Academy.