Post-Traumatic Stress Disorder in the U.S. Military Arena: Social Action in the Name of Diagnosis, Treatment, and Disability Compensation by Michael P. Fisher DISSERTATION Submitted in partial satisfaction of the requirements for the degree of DOCTOR OF PHILOSOPHY in Sociology in the GRADUATE DIVISION of the UNIVERSITY OF CALIFORNIA, SAN FRANCISCO Copyright 2013 by Michael P. Fisher ii ACKNOWLEDGEMENTS This dissertation is a product of the generosity and support of numerous people. I am grateful for the inspiration, encouragement, and exceptional guidance I received from my committee: Janet K. Shim, Robert Newcomer, Adele E. Clarke, and Stephen Zavestoski. Each has shown me not only what it means to be a scholar but one who brings passion and excellence to everything they do. My committee chair, Janet, provided unwavering support and direction, always encouraging me to follow my intellectual interests. Her thoughtful and constructive feedback continually pushed my work to higher levels. Likewise, Janet’s intense dedication to my learning was evident in every email and phone conversation, even as I conducted my fieldwork 3,000 miles away. I am extremely fortunate to have had the opportunity to learn from such a caring, talented, and imaginative group of scholars. My work has also benefitted from the insights of other scholars I have been privileged to work with throughout my graduate studies. I am deeply appreciative of the support and guidance I received from colleagues at RAND and at the Department of Veterans Affairs. My gratitude also goes to Allan V. Horwitz, who served as a reader of my qualifying exam, and whose scholarship has inspired my own. I have been extremely fortunate to have had the unending support of family and friends throughout my graduate studies. I especially thank Chris Wold, Scott Fisher, Carl Menninger, Michael Petersen, and Lisa and Peggy Reid, each who in some way prompted me to turn my abstract vision of this dissertation into a reality. I also could not have accomplished this work without the support and friendship of my cohort, particularly iii Jamie Chang, Jennifer Nazareno, and Oliver Rollins. I am fortunate to have had such an inspiring, gifted, and fun group of colleagues while at UCSF. Finally, I am especially thankful for the veterans’ advocates, public officials, and researchers who openly shared their experiences and perspectives with me, and whose passion and devotion has motivated my work. Moreover, I dedicate this dissertation to the U.S. military service men, women, and families who have sacrificed their lives, health, or wellbeing in the line of duty. I am deeply grateful for all that you have given. Funding for this study was provided by the following sources, for which I am extremely appreciative: the Horowitz Foundation for Social Policy, the UCSF Anselm Strauss Fellowship, the UCSF Graduate Dean’s Health Science Fellowship, and the UCSF School of Nursing Andrews Fellowship. iv Post-Traumatic Stress Disorder in the U.S. Military Arena: Social Action in the Name of Diagnosis, Treatment, and Disability Compensation Michael P. Fisher ABSTRACT The U.S.-led wars in Afghanistan and Iraq have resulted in thousands of servicemembers and veterans diagnosed with PTSD or suffering from PTSD symptoms. As a result, PTSD has emerged as a salient social problem in the military context. This study is a social-historical qualitative study of war related PTSD during a decade of U.S- led war in Afghanistan and Iraq (2001-2012). Through in-depth interviews, participant observation, and extensive document analysis, I examine how public officials, veterans’ advocacy groups, and researchers working in the U.S. military context have constructed PTSD and the policies addressing it. I emphasize issues and policies concerning diagnosis, treatment, and disability compensation, which are significant loci of action for veterans’ advocates, public officials, and researchers. My findings first highlight that despite PTSD’s long-standing codification as a mental disorder, the diagnosis is a controversial one whose legitimacy is at times disputed, particularly in U.S. military contexts. These disputes manifest not in questions about whether PTSD exists, but in queries and statements about how many individuals are, or should be, diagnosed with PTSD; the struggle is over prevalence rates. Second, I argue that various cultural meanings associated with PTSD—particularly perceptions of its “true” prevalence, high economic cost, and negative impact on military manpower— have shaped PTSD policy. Specifically, economic and military manpower implications have compounded concerns about prevalence and led some public officials and v researchers to challenge the disorder’s clinical validity as well as its diagnostic tools, procedures, and systems, and to frame PTSD as a clinical state which is often induced or falsified because of the prospect of “secondary gains” such as VA benefits. Finally, I focus on the range of veterans’ advocate responses to and grievances about a lack of appropriate prevention, diagnosis, and treatment of PTSD. I argue that there exists a widespread channeling of veterans’ advocacy efforts into health and mental health issues and postulate that this biomedicalization of advocacy funnels otherwise radical activity into collective action focused on VA benefits. This research builds upon sociological scholarship, most notably theories of the social construction of mental illness and social movements in health. vi TABLE OF CONTENTS CHAPTER 1. INTRODUCTION ....................................................................................... 1 A Brief History of PTSD (Pre-2001) .............................................................................. 2 Research Problem and Study Aims ................................................................................ 5 Theoretically Situating PTSD Policy and Collective Action.......................................... 8 Constructing Mental Illness ........................................................................................ 9 Contesting Mental Illness ......................................................................................... 16 Compensating Psychological Damage ..................................................................... 21 Methods ........................................................................................................................ 23 Data Collection ......................................................................................................... 24 Data Analysis ............................................................................................................ 27 Dissertation Outline ...................................................................................................... 29 CHAPTER 2. THE U.S. MILITARY MENTAL HEALTH ARENA ............................. 32 A Brief Overview of Health Care and Benefits Organizations .................................... 32 A Brief History of Social Movement Organizations .................................................... 37 Conclusion .................................................................................................................... 40 CHAPTER 3. A CHRONICLE OF PTSD POLICY IN THE U.S. MILITARY.............. 41 Quietly Preparing for PTSD amidst Political Resistance (2001-2004) ........................ 42 Demanding Greater Responses to PTSD (2005-2006) ................................................. 47 Struggling to Transform Military Mental Health (2007-2012) .................................... 54 Personality Disorder and the Diagnostic Debate ..................................................... 58 Suicide in the Spotlight ............................................................................................. 62 Drugged and Deployed ............................................................................................. 63 vii The Resilience Resolution ......................................................................................... 65 Strained and Expanding Mental Health Care and Benefits Systems ........................ 67 Expanding Military Mental Health Research ........................................................... 71 Naming, Framing, and the DSM-5 ........................................................................... 74 Conclusion .................................................................................................................... 77 CHAPTER 4. PTSD AND THE POLITICS OF PREVALENCE ................................... 80 Perceiving Over-Diagnosis: Categorical and Behavioral ............................................. 81 Categorical Over-Diagnosis ..................................................................................... 82 Behavioral Over-Diagnosis ...................................................................................... 84 Compounding Concerns: Over-Diagnosis, Cost, and Military Manpower .............. 88 Perceiving Behavioral Under-Diagnosis: Stigmatization and Discrimination ............. 92 The Stigma Paradox .................................................................................................. 94 Perceiving Under-Diagnosis or Uncertainty: Screening ............................................... 97 Conclusion .................................................................................................................. 100 CHAPTER 5. VETERANS’ MENTAL HEALTH SOCIAL MOVEMENTS: A CONTINUUM OF CONCERNS, A CONTINUUM OF CAUSALITY.......................