From Shell Shock to PTSD: How Far Have We Really Come? by Kellen Kurschinski

Guest Blog from Kellen Kurschinksi

The recent deaths of four Canadian soldiers as the result of alleged suicides has raised more troubling questions about the impact of Post-Traumatic Stress Disorder [PTSD] on personnel and veterans of the Canadian Forces. Whether the effects of trauma were an ultimate or proximate factor in the decision of these men to take their own lives is not yet known but the tragedies have nevertheless cast a light on the challenges that soldiers struggling with personal grief and mental illness face on a daily basis. What we do know is that PTSD is the most significant medical and personnel issue facing veterans’ authorities in Canada today. Indeed, one recent report suggests that up to 6000 active duty soldiers may develop symptoms of PTSD over the next several years, an overwhelming prospect for a veterans’ health care system that is already stretched beyond its means and is facing ongoing cuts to services.

Canada’s problems are not unique. The Americans and British are contending with similar, and some would argue, more grave challenges. Nor is PTSD a necessarily ‘new’ phenomenon. Trauma, in its broadest sense, is an intrinsic outcome of exposure to scenarios involving the experience or threat of violence (including sexual violence), catastrophic injury, or death to oneself or others. In the context of war, trauma has been recognized as a medical condition since at least the 17th century. During the American Civil War, army physicians referred to it vaguely as ‘nostalgia’, a depressed, melancholy-like state afflicting soldiers who had experienced (or were about to experience) the strain of combat. The watershed moment in modern clinical understandings of war trauma came during the First World War, as army physicians and the burgeoning psychiatric community grappled with a myriad of traumatic conditions that emerged on and off the battlefield, the most common of which were ‘shell shock’ and ‘neurasthenia’. The fundamental question facing physicians and veterans’ authorities was whether these disorders were acquired during service or an innate defect in the patient. The former were curable to varying degrees and in certain cases merited pensioning. The latter category, which included men who came forward after discharge claiming to be suffering from symptoms of traumatic illness, were more easily dismissed as hysterics, or worse, malingerers.

For nearly a century, ‘attributability’ has been the underlying question guiding pension policy in Canada. In other words, the decision to grant compensation is based on the degree to which an individual’s disability is caused or exacerbated by military service. Just ‘who’ is eligible, the level of compensation for varying conditions, and the appraisal of what constitutes a disability has changed substantially over the course of the last century, but the premise remains the same.

Nonetheless, the notion that many veterans suffering from mental trauma did so because of predisposition, rather than the strains of military service, continued to linger within army medicine throughout the Second World War and well into the postwar period. These long-held assumptions were finally cast aside in 1980, when in response to mounting pressure from Vietnam War veterans and radical psychiatrists, the American Psychological Association formally acknowledged PTSD in the its Diagnostic and Statistic Manual of Mental Disorders (DSM-III). Since then, the criteria and scope of PTSD have evolved, but historically speaking, the 1980 decision was a major turning point because it affirmed mental trauma as an acquired condition, rather than a psychological or personal defect. In doing so, it presented the opportunity for thousands of veterans to lay claim to compensation for alleged pain, suffering, and economic loss they had experienced as a result of their service.

For a disabled veteran, a pension is an important source of stability, irrespective of the nature of their condition. Financial hardship only worsens the stressors that trigger the acute symptoms of PTSD. This is an uncomfortable state of affairs for veterans authorities: while they have been willing to accept that many veterans with PTSD are not curable in the traditional sense, the difference between a ‘treatable’ (or perhaps ‘adaptable’) veteran living with PTSD and those who face extreme difficulty is nearly impossible to predict. In every case, the essential material, community, and medical supports need to be accessible and robust enough to withstand the highs and lows of their illness.

Veterans Affairs Canada has and will continue to play a vital role in providing and guiding veterans to these much need resources. It will also have to face difficult questions on a number of its existing policies for compensating the disabled.

Under the New Veterans Charter, the Canadian government introduced a lump-sum payment system called the ‘Disability Award’ to compensate veterans for injuries or illnesses incurred or aggravated while on active duty. Veterans have vehemently criticized the system for providing inadequate support and comparatively meager levels of compensation compared to the traditional monthly pension they received.

Such an approach – interestingly at the request of veterans themselves – was taken in an amendment to the Pension Act in 1920. Though less sweeping than the latest revisions to the Charter, the 1920 amendment granted First World War veterans with a 5 to 14 per cent disability the opportunity to take a similar lump-sum gratuity in lieu of future pension payments. Within 18 months, nearly one-third of all disability pensioners (over 20,000 veterans) opted for the gratuities of $300 or $600 dollars depending on the severity of their condition. Perhaps as many as 3000 of these were men suffering from ‘nervous disorders’ – an category of conditions based on official medical nomenclature which commonly served as a euphemism for war trauma.

Government officials thought they had done these veterans a service by lining their pockets and sending them out into civilian life with a substantial nest-egg, compared to the paltry compensation of $2.50 or $5.00 a month under the Pension Act. These awards, in a strikingly similar rationalization to the current ‘Disability Award’ offered under the New Veterans Charter, would help better facilitate their re-establishment and compel soldiers to focus on overcoming their disabilities. To pension authorities, it was also an ideal way of reigning in government spending in the aftermath of the war.

The amendment proved to be a catastrophic failure. By the end of the 1920s, droves of veterans who had experienced difficulty reintegrating into society or witnessed deterioration in their health began pressuring veterans’ authorities to reevaluate and reinstate their disability pensions. The economic hardships of the Great Depression exacerbated the situation further, leading to a number of substantial amendments in the Pension Act. Included was a provision that allowed veterans to reapply to have their pensions reinstated. Chaos ensued. Between 1929-33 some 56,000 applications were submitted to Canadian pension authorities: only 12,000 new awards were ultimately granted, while about 10,000 veterans who had commuted their pensions under the 1920 amendments were reinstated. The system experienced a crippling backlog, forcing some veterans to wait over a year to have their claim processed. Few veterans suffering from traumatic conditions were able to convince pension authorities that their condition had continued to plague them – only about 1000 new applicants were ultimately accepted.

If PTSD, with its uncertain trajectory and its diverse constellation of symptoms and triggers is to be the leading medical dilemma facing veterans authorities in the coming years, then some hard lessons should be taken from the experience of Canada’s experience in the aftermath of the First World War. Certainly, the context, scale, and social interpretation of disability differ dramatically between then and present day, but from a policy perspective, there are parallels that deserve further exploration. If the same rationalization was used to ‘prop up’ veterans and facilitate their re-establishment in the 1920s, is there wisdom in following a similar path today? If we consider for a moment that the medical meanings, patient experience, and popular acceptance of PTSD is historically and culturally contingent, then how should policymakers plan and prepare for these epistemological shifts? Does providing a disabled veteran with ongoing access to financial compensation for pain, suffering, and economic loss impede the successful return to civilian life, or is there evidence in the history of the veterans’ experience to suggest that these approaches imbued within the modern welfare state have continuing merit? Perhaps most importantly, if the state’s role is to diminish – and there are many signs indicating it will – what effect will this have on popular attitudes towards PTSD, the frequency of its diagnosis, and social and material support available to those who suffer from it?