Is post-traumatic stress disorder over-diagnosed ?
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http://www.scientificamerican.com/article.cfm?id=post-traumatic-stress-trap
Part one of two parts:
"Scientific American: Soldiers' Stress: What Doctors Get Wrong about PTSD:
A growing number of experts insist that the concept of post-traumatic stress disorder is itself disordered and that soldiers are suffering as a result.
Key Concepts
* The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.
* The flawed PTSD concept may mistake soldiers' natural process of adjustment to civilian life for dysfunction.
* Misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.":
In 2006, soon after returning from military service in Ramadi, Iraq, during the bloodiest period of the war, Captain Matt Stevens of the Vermont National Guard began to have a problem with PTSD, or post-traumatic stress disorder. Stevens's problem was not that he had PTSD. It was that he began to have doubts about PTSD: the condition was real enough, but as a diagnosis he saw it being wildly, even dangerously, overextended.
Stevens led the medics tending an armored brigade of 800 soldiers, and his team patched together GIs and Iraqi citizens almost every day. He saw horrific things. Once home, he said he had his share of "nights where I'd wake up and it would be clear I wasn't going to sleep again."
He was not surprised: "I would expect people to have nightmares for a while when they came back." But as he kept track of his unit in the U.S., he saw troops greeted by both a larger culture and a medical culture especially in the Veterans Administration (VA) that seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.
"Clinicians aren't separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems or who are just taking some time getting over it," Stevens says. He worries that many of these men and women are being pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.
Stevens, now a major and still on reserve duty while he works as a physician's assistant, is far from alone in worrying about the reach of PTSD. Over the past five years or so, a long-simmering academic debate over PTSD's conceptual basis and incidence has begun to boil over. It is now splitting the practice of trauma psychology and roiling military culture. Critiques originally raised by military historians and a few psychologists are now advanced by a broad array of experts indeed, giants of psychology, psychiatry and epidemiology. They include Columbia University's Robert L. Spitzer and Michael B. First, who oversaw the last two editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, former chair of Johns Hopkins University's psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard J. McNally, a leading authority in the dynamics of memory and trauma and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they assert, represent a faulty, outdated construct that has been badly overstretched so that it routinely mistakes depression, anxiety or even normal adjustment for a unique and especially stubborn ailment.
This quest to scale back the definition of PTSD and its application stands to affect the expenditure of billions of dollars, the diagnostic framework of psychiatry, the effectiveness of a huge treatment and disability infrastructure, and, most important, the mental health and future lives of hundreds of thousands of U.S. combat veterans and other PTSD patients. Standing in the way of reform is conventional wisdom, deep cultural resistance and foundational concepts of trauma psychology. Nevertheless, it is time, as Spitzer recently argued, to "save PTSD from itself."
Casting a Wide Net
The overdiagnosis of PTSD, critics say, shows in the numbers, starting with the seminal study of PTSD prevalence, the 1990 National Vietnam Veterans Readjustment Survey (NVVRS). The NVVRS covered more than 1,000 male Vietnam vets in 1988 and reported that 15.4 percent of them had PTSD at the time and that 31 percent had suffered it at some point since the war. That 31 percent has been the standard estimate of PTSD incidence among veterans ever since.
In 2006, however, Columbia epidemiologist Bruce P. Dohrenwend, hoping to resolve nagging questions about the study, reworked the numbers. When he had culled the poorly documented diagnoses, he found that the 1988 rate was 9 percent and the lifetime rate 18 percent.
McNally shares the general admiration for Dohrenwend's careful work. Soon after it was published, however, McNally asserted that Dohrenwend's numbers were still too high because he counted as PTSD cases those veterans with only mild, subdiagnostic symptoms, people rated as "generally functioning pretty well." If you included only those suffering "clinically significant impairment" the level generally required for diagnosis and insurance compensation in most mental illness the rates fell yet further, to 5.4 percent at the time of the survey and 11 percent lifetime. It was not one in three veterans who eventually developed PTSD, but one in nine and only one in 18 had it at any given time. The NVVRS, in other words, appears to have overstated PTSD rates in Vietnam vets by almost 300 percent.
"PTSD is a real thing, without a doubt," McNally says. "But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them."
The idea that PTSD is overdiagnosed seems to contradict reports of resistance in the military and the VA to recognizing PTSD denials of PTSD diagnoses and disability benefits, military clinicians discharging soldiers instead of treating them, and a disturbing increase in suicides among veterans of the Middle East wars. Yet the two trends are consistent. The VA's PTSD caseload has more than doubled since 2000, mostly because of newly diagnosed Vietnam veterans. The poor and erratic response to current soldiers and recent vets, with some being pulled quickly into PTSD treatments and others discouraged or denied, may be the panicked stumbling of an overloaded system.
Overhauling both the diagnosis and the VA's care system, critics say, will ensure better care for genuine PTSD patients as well as those being misdiagnosed. But the would-be reformers face fierce opposition. "This argument," McNally notes, "tends to really piss some people off." Veterans send him threatening e-mails. Colleagues accuse him of dishonoring veterans, dismissing suffering, discounting the costs of war. Dean G. Kilpatrick, a University of South Carolina traumatologist and former president of the Inter national Society for Traumatic Stress Studies (ISTSS), once essentially called McNally a liar.
A Problematic Diagnosis
The DSM-IV, the most recent edition (published in 1994), defines PTSD as the presence of three symptom clusters reexperiencing via nightmares or flashbacks; avoidance by numbing or withdrawal; and hyperarousal, evident in irritability, insomnia, aggression or poor concentration that arise in response to a life-threatening event [To see related sidebar please purchase the digital edition].
The construction of this definition is suspect. To start with, the link to a traumatic event, which makes PTSD almost unique among complex psychiatric diagnoses in being defined by an external cause, also makes it uniquely problematic, for the tie is really to the memory of an event. When PTSD was first added to the DSM-III in 1980, traumatic memories were considered reasonably faithful recordings of actual events. But as research since then has repeatedly shown, memory is spectacularly unreliable and malleable. We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit.
In one study by Washington University memory researcher Elizabeth F. Loftus, one out of four adults who were told they were lost in a shopping mall as children came to believe it. Some insisted the event happened even after the ruse was exposed. Subsequently, bounteous research has confirmed that such false memories are common [see "Creating False Memories," by Elizabeth F. Loftus; Scientific American, September 1997].
Soldiers enjoy no immunity from this tendency. A 1990s study at the New Haven, Conn., VA hospital asked 59 Gulf War veterans about their experiences a month after their return and again two years later. The researchers asked about 19 specific types of potentially traumatic events, such as witnessing deaths, losing friends and seeing people disfigured. Two years out, 70 percent of the veterans reported at least one traumatic event they had not mentioned a month after returning, and 24 percent reported at least three such events for the first time. And the veterans recounting the most "new memories" also reported the most PTSD symptoms.
To McNally, such results suggest that some veterans experiencing "late-onset" PTSD may be attributing symptoms of depression, anxiety or other subtle disorders to a memory that has been elaborated and given new significance or even unconsciously fabricated.
"This has nothing to do with gaming or working the system or consciously looking for sympathy," McNally says. "We all do this: we cast our lives in terms of narratives that help us understand them. A vet who's having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense."
To make the diagnosis of PTSD more rigorous, some have suggested that blood chemistry, brain imaging or other tests might be able to detect physiological signatures of the disorder. Some studies of stress hormones in groups of PTSD patients show differences from normal subjects, but the overlap between the normal and the PTSD groups is huge, making individual profiles useless for diagnostics. Brain imaging has similar limitations, with the abnormal dynamics in PTSD heavily overlapping those of depression and anxiety.
With memory unreliable and biological markers elusive, diagnosis depends on clinical symptoms. But as a study in 2007 starkly showed, the symptom profile for PTSD is as slippery as the would-be biomarkers. J. Alexander Bodkin, a psychiatrist at Harvard's McLean Hospital, screened 90 clinically depressed patients separately for PTSD symptoms and for trauma, then compared the results. First he and a colleague used a standardized screening interview to assess symptoms. Then two other PTSD diagnosticians, ignorant of the symptom reports, used another standard interview to see which patients had ever experienced trauma fitting DSM-IV criteria.
If PTSD arose from trauma, the patients with PTSD symptoms should have histories of trauma, and those with trauma should show more PTSD. It was not so. Although the symptom screens rated 70 of the 90 patients positive for PTSD, the trauma screens found only 54 who had suffered trauma: the diagnosed PTSD "cases" outnumbered those who had experienced traumatic events. Things got worse when Bodkin compared the diagnoses one on one. If PTSD required trauma, then the 54 trauma-exposed patients should account for most of the 70 PTSD-positive patients. But the PTSD-symptomatic patients were equally distributed among the trauma-positive and the trauma-negative groups. The PTSD rate had zero relation to the trauma rate. It was, Bodkin observed, "a scientifically unacceptable situation."
More practically, as McNally points out, "To give the best treatment, you have to have the right diagnosis."
The most effective treatment for patients whose symptoms arise from trauma is exposure-based cognitive-behavioral therapy (CBT), which concentrates on altering the response to a specific traumatic memory by repeated, controlled exposure to it. "And it works," McNally says. "If someone with genuine PTSD goes to the people who do this really well, they have a good chance of getting better." CBT for depression, in contrast, teaches the patient to recognize dysfunctional loops of thought and emotion and develop new responses to normal, present-day events. "If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT, you're going to miss the boat," McNally says. "You're going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events."
To complicate matters, recent studies showing that traumatic brain injuries from bomb blasts, common among soldiers in Iraq, produce symptoms almost indistinguishable from PTSD. One more overlapping symptom set.
"The overlap issue worries me tremendously," says Gerald M. Rosen, a University of Washington psychiatrist who has worked extensively with PTSD patients. "We have to ask how we got here. We have to ask ourselves, 'What do we gain by having this diagnosis?'"
Disabling Conditions
Rosen is thinking of clinicians when he asks about gain. But what does a veteran gain with a PTSD diagnosis? One would hope, of course, that it grants access to effective treatment and support. This is not happening. In civilian populations, two thirds of PTSD patients respond to treatment. But as psychologist Christopher Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, "In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own."
The reason, Frueh says, is the collision of the PTSD construct's vagaries with the VA's disability system, in which every benefit seems structured to discourage recovery.
End of part one.
Part one of two parts:
"Scientific American: Soldiers' Stress: What Doctors Get Wrong about PTSD:
A growing number of experts insist that the concept of post-traumatic stress disorder is itself disordered and that soldiers are suffering as a result.
Key Concepts
* The syndrome of post-traumatic stress disorder (PTSD) is under fire because its defining criteria are too broad, leading to rampant overdiagnosis.
* The flawed PTSD concept may mistake soldiers' natural process of adjustment to civilian life for dysfunction.
* Misdiagnosed soldiers receive the wrong treatments and risk becoming mired in a Veterans Administration system that encourages chronic disability.":
In 2006, soon after returning from military service in Ramadi, Iraq, during the bloodiest period of the war, Captain Matt Stevens of the Vermont National Guard began to have a problem with PTSD, or post-traumatic stress disorder. Stevens's problem was not that he had PTSD. It was that he began to have doubts about PTSD: the condition was real enough, but as a diagnosis he saw it being wildly, even dangerously, overextended.
Stevens led the medics tending an armored brigade of 800 soldiers, and his team patched together GIs and Iraqi citizens almost every day. He saw horrific things. Once home, he said he had his share of "nights where I'd wake up and it would be clear I wasn't going to sleep again."
He was not surprised: "I would expect people to have nightmares for a while when they came back." But as he kept track of his unit in the U.S., he saw troops greeted by both a larger culture and a medical culture especially in the Veterans Administration (VA) that seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.
"Clinicians aren't separating the few who really have PTSD from those who are experiencing things like depression or anxiety or social and reintegration problems or who are just taking some time getting over it," Stevens says. He worries that many of these men and women are being pulled into a treatment and disability regime that will mire them in a self-fulfilling vision of a brain rewired, a psyche permanently haunted.
Stevens, now a major and still on reserve duty while he works as a physician's assistant, is far from alone in worrying about the reach of PTSD. Over the past five years or so, a long-simmering academic debate over PTSD's conceptual basis and incidence has begun to boil over. It is now splitting the practice of trauma psychology and roiling military culture. Critiques originally raised by military historians and a few psychologists are now advanced by a broad array of experts indeed, giants of psychology, psychiatry and epidemiology. They include Columbia University's Robert L. Spitzer and Michael B. First, who oversaw the last two editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, the DSM-III and DSM-IV; Paul McHugh, former chair of Johns Hopkins University's psychiatry department; Michigan State University epidemiologist Naomi Breslau; and Harvard University psychologist Richard J. McNally, a leading authority in the dynamics of memory and trauma and perhaps the most forceful of the critics. The diagnostic criteria for PTSD, they assert, represent a faulty, outdated construct that has been badly overstretched so that it routinely mistakes depression, anxiety or even normal adjustment for a unique and especially stubborn ailment.
This quest to scale back the definition of PTSD and its application stands to affect the expenditure of billions of dollars, the diagnostic framework of psychiatry, the effectiveness of a huge treatment and disability infrastructure, and, most important, the mental health and future lives of hundreds of thousands of U.S. combat veterans and other PTSD patients. Standing in the way of reform is conventional wisdom, deep cultural resistance and foundational concepts of trauma psychology. Nevertheless, it is time, as Spitzer recently argued, to "save PTSD from itself."
Casting a Wide Net
The overdiagnosis of PTSD, critics say, shows in the numbers, starting with the seminal study of PTSD prevalence, the 1990 National Vietnam Veterans Readjustment Survey (NVVRS). The NVVRS covered more than 1,000 male Vietnam vets in 1988 and reported that 15.4 percent of them had PTSD at the time and that 31 percent had suffered it at some point since the war. That 31 percent has been the standard estimate of PTSD incidence among veterans ever since.
In 2006, however, Columbia epidemiologist Bruce P. Dohrenwend, hoping to resolve nagging questions about the study, reworked the numbers. When he had culled the poorly documented diagnoses, he found that the 1988 rate was 9 percent and the lifetime rate 18 percent.
McNally shares the general admiration for Dohrenwend's careful work. Soon after it was published, however, McNally asserted that Dohrenwend's numbers were still too high because he counted as PTSD cases those veterans with only mild, subdiagnostic symptoms, people rated as "generally functioning pretty well." If you included only those suffering "clinically significant impairment" the level generally required for diagnosis and insurance compensation in most mental illness the rates fell yet further, to 5.4 percent at the time of the survey and 11 percent lifetime. It was not one in three veterans who eventually developed PTSD, but one in nine and only one in 18 had it at any given time. The NVVRS, in other words, appears to have overstated PTSD rates in Vietnam vets by almost 300 percent.
"PTSD is a real thing, without a doubt," McNally says. "But as a diagnosis, PTSD has become so flabby and overstretched, so much a part of the culture, that we are almost certainly mistaking other problems for PTSD and thus mistreating them."
The idea that PTSD is overdiagnosed seems to contradict reports of resistance in the military and the VA to recognizing PTSD denials of PTSD diagnoses and disability benefits, military clinicians discharging soldiers instead of treating them, and a disturbing increase in suicides among veterans of the Middle East wars. Yet the two trends are consistent. The VA's PTSD caseload has more than doubled since 2000, mostly because of newly diagnosed Vietnam veterans. The poor and erratic response to current soldiers and recent vets, with some being pulled quickly into PTSD treatments and others discouraged or denied, may be the panicked stumbling of an overloaded system.
Overhauling both the diagnosis and the VA's care system, critics say, will ensure better care for genuine PTSD patients as well as those being misdiagnosed. But the would-be reformers face fierce opposition. "This argument," McNally notes, "tends to really piss some people off." Veterans send him threatening e-mails. Colleagues accuse him of dishonoring veterans, dismissing suffering, discounting the costs of war. Dean G. Kilpatrick, a University of South Carolina traumatologist and former president of the Inter national Society for Traumatic Stress Studies (ISTSS), once essentially called McNally a liar.
A Problematic Diagnosis
The DSM-IV, the most recent edition (published in 1994), defines PTSD as the presence of three symptom clusters reexperiencing via nightmares or flashbacks; avoidance by numbing or withdrawal; and hyperarousal, evident in irritability, insomnia, aggression or poor concentration that arise in response to a life-threatening event [To see related sidebar please purchase the digital edition].
The construction of this definition is suspect. To start with, the link to a traumatic event, which makes PTSD almost unique among complex psychiatric diagnoses in being defined by an external cause, also makes it uniquely problematic, for the tie is really to the memory of an event. When PTSD was first added to the DSM-III in 1980, traumatic memories were considered reasonably faithful recordings of actual events. But as research since then has repeatedly shown, memory is spectacularly unreliable and malleable. We routinely add or subtract people, details, settings and actions to and from our memories. We conflate, invent and edit.
In one study by Washington University memory researcher Elizabeth F. Loftus, one out of four adults who were told they were lost in a shopping mall as children came to believe it. Some insisted the event happened even after the ruse was exposed. Subsequently, bounteous research has confirmed that such false memories are common [see "Creating False Memories," by Elizabeth F. Loftus; Scientific American, September 1997].
Soldiers enjoy no immunity from this tendency. A 1990s study at the New Haven, Conn., VA hospital asked 59 Gulf War veterans about their experiences a month after their return and again two years later. The researchers asked about 19 specific types of potentially traumatic events, such as witnessing deaths, losing friends and seeing people disfigured. Two years out, 70 percent of the veterans reported at least one traumatic event they had not mentioned a month after returning, and 24 percent reported at least three such events for the first time. And the veterans recounting the most "new memories" also reported the most PTSD symptoms.
To McNally, such results suggest that some veterans experiencing "late-onset" PTSD may be attributing symptoms of depression, anxiety or other subtle disorders to a memory that has been elaborated and given new significance or even unconsciously fabricated.
"This has nothing to do with gaming or working the system or consciously looking for sympathy," McNally says. "We all do this: we cast our lives in terms of narratives that help us understand them. A vet who's having a difficult life may remember a trauma, which may or may not have actually traumatized him, and everything makes sense."
To make the diagnosis of PTSD more rigorous, some have suggested that blood chemistry, brain imaging or other tests might be able to detect physiological signatures of the disorder. Some studies of stress hormones in groups of PTSD patients show differences from normal subjects, but the overlap between the normal and the PTSD groups is huge, making individual profiles useless for diagnostics. Brain imaging has similar limitations, with the abnormal dynamics in PTSD heavily overlapping those of depression and anxiety.
With memory unreliable and biological markers elusive, diagnosis depends on clinical symptoms. But as a study in 2007 starkly showed, the symptom profile for PTSD is as slippery as the would-be biomarkers. J. Alexander Bodkin, a psychiatrist at Harvard's McLean Hospital, screened 90 clinically depressed patients separately for PTSD symptoms and for trauma, then compared the results. First he and a colleague used a standardized screening interview to assess symptoms. Then two other PTSD diagnosticians, ignorant of the symptom reports, used another standard interview to see which patients had ever experienced trauma fitting DSM-IV criteria.
If PTSD arose from trauma, the patients with PTSD symptoms should have histories of trauma, and those with trauma should show more PTSD. It was not so. Although the symptom screens rated 70 of the 90 patients positive for PTSD, the trauma screens found only 54 who had suffered trauma: the diagnosed PTSD "cases" outnumbered those who had experienced traumatic events. Things got worse when Bodkin compared the diagnoses one on one. If PTSD required trauma, then the 54 trauma-exposed patients should account for most of the 70 PTSD-positive patients. But the PTSD-symptomatic patients were equally distributed among the trauma-positive and the trauma-negative groups. The PTSD rate had zero relation to the trauma rate. It was, Bodkin observed, "a scientifically unacceptable situation."
More practically, as McNally points out, "To give the best treatment, you have to have the right diagnosis."
The most effective treatment for patients whose symptoms arise from trauma is exposure-based cognitive-behavioral therapy (CBT), which concentrates on altering the response to a specific traumatic memory by repeated, controlled exposure to it. "And it works," McNally says. "If someone with genuine PTSD goes to the people who do this really well, they have a good chance of getting better." CBT for depression, in contrast, teaches the patient to recognize dysfunctional loops of thought and emotion and develop new responses to normal, present-day events. "If a depressed person takes on a PTSD interpretation of their troubles and gets exposure-based CBT, you're going to miss the boat," McNally says. "You're going to spend your time chasing this memory down instead of dealing with the way the patient misinterprets present events."
To complicate matters, recent studies showing that traumatic brain injuries from bomb blasts, common among soldiers in Iraq, produce symptoms almost indistinguishable from PTSD. One more overlapping symptom set.
"The overlap issue worries me tremendously," says Gerald M. Rosen, a University of Washington psychiatrist who has worked extensively with PTSD patients. "We have to ask how we got here. We have to ask ourselves, 'What do we gain by having this diagnosis?'"
Disabling Conditions
Rosen is thinking of clinicians when he asks about gain. But what does a veteran gain with a PTSD diagnosis? One would hope, of course, that it grants access to effective treatment and support. This is not happening. In civilian populations, two thirds of PTSD patients respond to treatment. But as psychologist Christopher Frueh, who researched and treated PTSD for the VA from the early 1990s until 2006, notes, "In the two largest VA studies of combat veterans, neither showed a treatment effect. Vets getting PTSD treatment from the VA are no more likely to get better than they would on their own."
The reason, Frueh says, is the collision of the PTSD construct's vagaries with the VA's disability system, in which every benefit seems structured to discourage recovery.
End of part one.
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I'm sure that their are many members of the CF that are just tired of hearing about PTSD. If you need help just go get it. If you are over diagnosed so be it. It will all buff out in the end.
Tow Tripod
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The term has become a buzzword in the insurance industry - far too many claimants are saying they are suffering from PTSD as a result of a vehicle accident... :
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Greymatters said:The term has become a buzzword in the insurance industry - far too many claimants are saying they are suffering from PTSD as a result of a vehicle accident... :
Including Communications Operators who never even left their cubicles:
"DISPOSITION:
[38] The appeal is allowed.
[39] The worker is entitled to benefits for traumatic mental stress.
ie: For just hearing about trauma from civilian 911 callers and crews over the radio.
http://www.wsiat.on.ca/english/decisions/wsiatr/vol_84/1839_07.htm
"Cumulative effect:
Due to the nature of their occupation, some workers, over a period of time, may be exposed to multiple, sudden and unexpected traumatic events resulting from criminal acts, harassment, or horrific accidents. If a worker has an acute reaction to the most recent unexpected traumatic event, entitlement may be in order even if the worker may experience these traumatic events as part of the employment and was able to tolerate the past traumatic events. A final reaction to a series of sudden and traumatic events is considered to be the cumulative effect."
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Scientific American:
Part two of two parts:
"The first benefit is health care. PTSD is by far the easiest mental health diagnosis to have declared "service-connected," a designation that often means the difference between little or no care and broad, lasting health coverage. Service connection also makes a vet eligible for monthly disability payments of up to $3,000. That link may explain why most veterans getting PTSD treatment from the VA report worsening symptoms until they are designated 100 percent disabled at which point their use of VA mental health services drops by 82 percent. It may also help explain why, although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to more than $4 billion annually.
Perhaps most disastrously, these payments continue only if you are sick. For unlike a vet who has lost a leg, a vet with PTSD loses disability benefits as soon as he recovers or starts working. The entire system seems designed to encourage chronic disability. "In the several years I spent in VA PTSD clinics," Frueh says, "I can't think of a single PTSD patient who left treatment because he got better. But the problem is not the veterans. The problem is that the VA's disability system, which is 60 years old now, ignores all the intervening research we have on resilience, on the power of expectancy, and on the effects of incentives and disincentives. Sometimes I think they should just blow it up and start over." But with what?
Richard A. Bryant, an Australian PTSD researcher and clinician, suggests a disability system more like that in place Down Under. An Australian soldier injured in combat receives a lifelong "noneconomic" disability payment of $300 to $1,200 monthly. If the injury keeps him from working, he also gets an "incapacity" payment, as well as job training and help finding work. Finally a crucial feature he retains all these benefits for two years once he goes back to work. After that, incapacity payments taper to zero over five years. But noneconomic payments a kind of financial Purple Heart continue forever. And like all Australians, the soldier gets free lifetime health care. Australian vets come home to an utterly different support system from ours: theirs is a scaffold they can climb. Ours is a low-hanging "safety net" liable to trap anyone who falls in.
Two Ways to Carry a Rifle
When a soldier comes home, he must try to reconcile his war experience with the person he was beforehand and the society and family he returns to. He must engage in what psychologist Rachel Yehuda, who researches PTSD at the Bronx VA Hospital, calls "recontextualization" the process of integrating trauma into normal experience. It is what we all do, on various scales, when we suffer breakups, job losses or the deaths of loved ones. Initially the event seems an impossible aberration. Then slowly we accept the trauma as part of the complex context that is life.
Major Matt Stevens recognizes that this adjustment can take time. Even after two years at home, the war still occupies his dreams. Sometimes, for instance, he dreams that he is doing something completely normal while carrying his combat rifle: "One night I dreamt I was bird-watching with my wife. When we saw a bird, she would lift her binoculars, and I would lift my rifle and watch the bird through the scope. No thought of shooting it. Just how I looked at the birds."
It would be easy to read Stevens's dream as a symptom of PTSD, expressing fear, hypervigilance and avoidance. Yet it can also be seen as demonstrating his success in recontextualizing his experience: reconciling the man who once used a gun with the man who no longer does.
Saving PTSD from itself, Spitzer, McNally, Frueh and other critics say, will require a similar shift seeing most postcombat distress not as a disorder but as part of normal, if painful, healing. This turnaround will involve, for starters, revising the rubric for diagnosing PTSD currently under review for the new DSM-V due to be published in 2012 so it accounts for the unreliability of memory and better distinguishes depression, anxiety and phobia from true PTSD. Mental health evaluations need similar revisions so they can detect genuine cases without leading patients to impose trauma narratives on other mental health problems. Finally, Congress should replace the VA's disability system with an evidence-based approach that removes disincentives to recovery and even go the extra mile and give all combat veterans, injured or not, lifetime health care.
These changes will be hard to sell in a culture that resists any suggestion that PTSD is not a common, even inevitable, consequence of combat. Mistaking its horror for its prevalence, most people assume PTSD is epidemic, ignoring all evidence to the contrary.
The biggest longitudinal study of soldiers returning from Iraq, led by VA researcher Charles Milliken and published in 2007, seemed to confirm that we should expect a high incidence of PTSD. It surveyed combat troops immediately on return from deployment and again about six months later and found around 20 percent symptomatically "at risk" of PTSD. But of those reporting symptoms in the first survey, half had improved by the second survey, and many who first claimed few or no symptoms later reported serious symptoms. How many of the early "symptoms" were just normal adjustment? How many of the later symptoms were the imposition of a trauma narrative onto other problems?
Stevens, for one, is certain these screens are mistaking many going through normal adjustment as dangerously at risk of PTSD. Even he, though functioning fine at work and home and in society, scored positive in both surveys; he is, in other words, one of the 20 percent at risk. Finally, and weirdly, both screens missed about 75 percent of those who actually sought counseling a finding that raises further doubts about the evaluations' accuracy. Yet this study received prominent media coverage emphasizing that PTSD rates were probably being badly undercounted.
A few months later another study the first to track large numbers of soldiers through the wars in Iraq and Afghanistan provided a clearer and more consistent picture. Led by U.S. Navy researcher Tyler Smith and published in the British Medical Journal, the study monitored mental health and combat exposure in 50,000 U.S. soldiers from 2001 to 2006. The researchers took particular care to tie symptoms to types of combat exposure. Among some 12,000 troops who went to Iraq or Afghanistan, 4.3 percent developed diagnosis-level symptoms of PTSD. The rate ran about 8 percent in those with combat exposure and 2 percent in those not exposed.
These numbers are about a quarter of the rates Milliken found. But they are a close match to PTSD rates seen in British Iraq War vets and to rates McNally calculated for Vietnam veterans. The contrast to the Milliken study, along with the consistency with British rates and with McNally's NVVRS calculation, should have made the Smith study big news. Yet the media, the VA and the trauma psychology community almost completely ignored the study. "The silence," McNally wryly noted, "was deafening."
This silence may be merely a matter of good news going unremarked. Yet it supports McNally's contention that we have a cultural obsession with trauma. The selective attention also supports the assertion by military historian and PTSD critic Ben Shephard that American society itself gained something from the creation of the PTSD diagnosis in the late 1970s: a vision of war's costs that, by transforming warriors into victims, lets us declare our recognition of war's horror and absolves us for sending them for we were victimized, too, fooled into supporting a war we later regretted. We should recognize war's horror. We should feel the soldier's pain. But to impose on a distressed soldier the notion that his memories are inescapable, that he lacks the strength to incorporate his past into his future, is to highlight our moral sensitivity at the soldier's expense.
PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified and finally perhaps become the thing itself a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis."
"Richard McNally on PTSD rates in Vietnam Veterans":
http://www.youtube.com/watch?v=lomqzc8lHXk
"PROGRESS AND CONTROVERSY IN THE STUDY OF POSTTRAUMATIC STRESS DISORDER:
http://www.subjectpool.com/ed_teach/y4person/4_ant_bpd/McNally_AnnRev_%282003%29_PTSD.pdf
(sorry for the caps ).
Part two of two parts:
"The first benefit is health care. PTSD is by far the easiest mental health diagnosis to have declared "service-connected," a designation that often means the difference between little or no care and broad, lasting health coverage. Service connection also makes a vet eligible for monthly disability payments of up to $3,000. That link may explain why most veterans getting PTSD treatment from the VA report worsening symptoms until they are designated 100 percent disabled at which point their use of VA mental health services drops by 82 percent. It may also help explain why, although the risk of PTSD from a traumatic event drops as time passes, the number of Vietnam veterans applying for PTSD disability almost doubled between 1999 and 2004, driving total PTSD disability payments to more than $4 billion annually.
Perhaps most disastrously, these payments continue only if you are sick. For unlike a vet who has lost a leg, a vet with PTSD loses disability benefits as soon as he recovers or starts working. The entire system seems designed to encourage chronic disability. "In the several years I spent in VA PTSD clinics," Frueh says, "I can't think of a single PTSD patient who left treatment because he got better. But the problem is not the veterans. The problem is that the VA's disability system, which is 60 years old now, ignores all the intervening research we have on resilience, on the power of expectancy, and on the effects of incentives and disincentives. Sometimes I think they should just blow it up and start over." But with what?
Richard A. Bryant, an Australian PTSD researcher and clinician, suggests a disability system more like that in place Down Under. An Australian soldier injured in combat receives a lifelong "noneconomic" disability payment of $300 to $1,200 monthly. If the injury keeps him from working, he also gets an "incapacity" payment, as well as job training and help finding work. Finally a crucial feature he retains all these benefits for two years once he goes back to work. After that, incapacity payments taper to zero over five years. But noneconomic payments a kind of financial Purple Heart continue forever. And like all Australians, the soldier gets free lifetime health care. Australian vets come home to an utterly different support system from ours: theirs is a scaffold they can climb. Ours is a low-hanging "safety net" liable to trap anyone who falls in.
Two Ways to Carry a Rifle
When a soldier comes home, he must try to reconcile his war experience with the person he was beforehand and the society and family he returns to. He must engage in what psychologist Rachel Yehuda, who researches PTSD at the Bronx VA Hospital, calls "recontextualization" the process of integrating trauma into normal experience. It is what we all do, on various scales, when we suffer breakups, job losses or the deaths of loved ones. Initially the event seems an impossible aberration. Then slowly we accept the trauma as part of the complex context that is life.
Major Matt Stevens recognizes that this adjustment can take time. Even after two years at home, the war still occupies his dreams. Sometimes, for instance, he dreams that he is doing something completely normal while carrying his combat rifle: "One night I dreamt I was bird-watching with my wife. When we saw a bird, she would lift her binoculars, and I would lift my rifle and watch the bird through the scope. No thought of shooting it. Just how I looked at the birds."
It would be easy to read Stevens's dream as a symptom of PTSD, expressing fear, hypervigilance and avoidance. Yet it can also be seen as demonstrating his success in recontextualizing his experience: reconciling the man who once used a gun with the man who no longer does.
Saving PTSD from itself, Spitzer, McNally, Frueh and other critics say, will require a similar shift seeing most postcombat distress not as a disorder but as part of normal, if painful, healing. This turnaround will involve, for starters, revising the rubric for diagnosing PTSD currently under review for the new DSM-V due to be published in 2012 so it accounts for the unreliability of memory and better distinguishes depression, anxiety and phobia from true PTSD. Mental health evaluations need similar revisions so they can detect genuine cases without leading patients to impose trauma narratives on other mental health problems. Finally, Congress should replace the VA's disability system with an evidence-based approach that removes disincentives to recovery and even go the extra mile and give all combat veterans, injured or not, lifetime health care.
These changes will be hard to sell in a culture that resists any suggestion that PTSD is not a common, even inevitable, consequence of combat. Mistaking its horror for its prevalence, most people assume PTSD is epidemic, ignoring all evidence to the contrary.
The biggest longitudinal study of soldiers returning from Iraq, led by VA researcher Charles Milliken and published in 2007, seemed to confirm that we should expect a high incidence of PTSD. It surveyed combat troops immediately on return from deployment and again about six months later and found around 20 percent symptomatically "at risk" of PTSD. But of those reporting symptoms in the first survey, half had improved by the second survey, and many who first claimed few or no symptoms later reported serious symptoms. How many of the early "symptoms" were just normal adjustment? How many of the later symptoms were the imposition of a trauma narrative onto other problems?
Stevens, for one, is certain these screens are mistaking many going through normal adjustment as dangerously at risk of PTSD. Even he, though functioning fine at work and home and in society, scored positive in both surveys; he is, in other words, one of the 20 percent at risk. Finally, and weirdly, both screens missed about 75 percent of those who actually sought counseling a finding that raises further doubts about the evaluations' accuracy. Yet this study received prominent media coverage emphasizing that PTSD rates were probably being badly undercounted.
A few months later another study the first to track large numbers of soldiers through the wars in Iraq and Afghanistan provided a clearer and more consistent picture. Led by U.S. Navy researcher Tyler Smith and published in the British Medical Journal, the study monitored mental health and combat exposure in 50,000 U.S. soldiers from 2001 to 2006. The researchers took particular care to tie symptoms to types of combat exposure. Among some 12,000 troops who went to Iraq or Afghanistan, 4.3 percent developed diagnosis-level symptoms of PTSD. The rate ran about 8 percent in those with combat exposure and 2 percent in those not exposed.
These numbers are about a quarter of the rates Milliken found. But they are a close match to PTSD rates seen in British Iraq War vets and to rates McNally calculated for Vietnam veterans. The contrast to the Milliken study, along with the consistency with British rates and with McNally's NVVRS calculation, should have made the Smith study big news. Yet the media, the VA and the trauma psychology community almost completely ignored the study. "The silence," McNally wryly noted, "was deafening."
This silence may be merely a matter of good news going unremarked. Yet it supports McNally's contention that we have a cultural obsession with trauma. The selective attention also supports the assertion by military historian and PTSD critic Ben Shephard that American society itself gained something from the creation of the PTSD diagnosis in the late 1970s: a vision of war's costs that, by transforming warriors into victims, lets us declare our recognition of war's horror and absolves us for sending them for we were victimized, too, fooled into supporting a war we later regretted. We should recognize war's horror. We should feel the soldier's pain. But to impose on a distressed soldier the notion that his memories are inescapable, that he lacks the strength to incorporate his past into his future, is to highlight our moral sensitivity at the soldier's expense.
PTSD exists. Where it exists we must treat it. But our cultural obsession with PTSD has magnified and finally perhaps become the thing itself a prolonged failure to contextualize and accept our own collective aggression. It may be our own postwar neurosis."
"Richard McNally on PTSD rates in Vietnam Veterans":
http://www.youtube.com/watch?v=lomqzc8lHXk
"PROGRESS AND CONTROVERSY IN THE STUDY OF POSTTRAUMATIC STRESS DISORDER:
http://www.subjectpool.com/ed_teach/y4person/4_ant_bpd/McNally_AnnRev_%282003%29_PTSD.pdf
(sorry for the caps ).
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mariomike said:
mariomike:
Before I joined as a Medic I was a 911 Call Taker and Fire Dispatcher. And I can assure you that working that phone is not easy. I had 2 OSI's while working in the center. I don't have PTSD from it, but I saw people who did. They are the real the 1st responder. It's their job to take the call and either pass it on up the chain, or deal with the issue and dispatch the appropriate assets.
Sure 99.9% go smooth and simple, no worries. It's that other .1% that gets you. The call that doesn't quite go according to the textbook and SOP's that gets you. Your crew gets lost, there is COMM's equipment problems, the 911 data wasn't entered properly etc... Each one of these calls CAN be an OSI, and eventually the bank is full. Especially when you go home at night, watch the news and find out the outcome wasn't good.
Some people can handle it better than others , I'm not saying that each bad call WILL end with PTSD or an OSI. But it is still a possibility and those Call Takers/Dispatachers deserve to have it recoginzed and be compensated.
As for the topic at hand.
I think I agree with the American Doctor. Nightmares, trouble sleeping, adjustment issues etc are all a normal process of dealing with what occurred during a tour or with any Traumatic Event, and should be treated as such.
Not everyone will bounce back in a few weeks or months. Some might take a little longer to process and deal with it. They just need the opportunity and the tools to cope. Not everyone has the proper tools in the tool box, and need to go to Canadian Tire (ie MIR, CDU, Padre, SW etc...) to get them, and we are very willing to hand those tools out free of charge.
That's my 5 cents worth. I'm going to crawl back under my mushroom again.
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MedTech32 said:
Glad you are feeling better.
I know my old partner had a knack for triggering the occasional dispatcher ( EMD ) on-air meltdown . :evil:
All kidding aside, if you don't mind me asking, did you receive voluntary, or involuntary, Critical Incident Stress Debriefing ( CISD/CISM ), and if so, what was your opinion of it?
http://www.jems.com/news_and_articles/columns/Bledsoe/Killing_Vampires.html
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I 100% agree that the condition is legitimate, as well as that it is being over-diagnosed.
I 100% disagree with his statement that it is a favourite label to get sympathy instead of shun. Even though there are now far more programs to take care of it when the cases are legitimate, you're very rarely going to see people proudly waving an "I have PTSD" flag in battalion. A lot of people are understanding that some people need help and I don't think it's a pure stigma like it used to be, but to suggest that a person still wouldn't lose respect for it is false.
I 100% disagree with his statement that it is a favourite label to get sympathy instead of shun. Even though there are now far more programs to take care of it when the cases are legitimate, you're very rarely going to see people proudly waving an "I have PTSD" flag in battalion. A lot of people are understanding that some people need help and I don't think it's a pure stigma like it used to be, but to suggest that a person still wouldn't lose respect for it is false.
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mariomike said:
Hi Mike. As you are aware, I was in the same boat as MedTech32, albeit in the policing end of things.
When I left in '96, a CISD for a cubicle-dwelling communications operator was simply unheard of. That has since changed -at least in my old slice of paradise, but not before a lot of very good people either quit, completely lost it or were forced by their family doctor to take stress leave.
A little food for thought:
You've got a terrified woman, or a senior, or a little kid on the line and they're in deep doodoo. You've got your guys on the way but you have to keep your caller on the line to know what's happening.
Sometimes, the subject of their call gets to them before your guys do.
Then, what you get to do is sit there and listen to whatever happens to them. And there is not one sweet damn thing you can do to help them (but at least you never had to leave your cubicle).
I can tell you for a fact it is not healthy for you. And it does stay with you.
That may sound pretty lame here on a site populated by shooters, shootees, the people out in the weather, the folks who have seen it all firsthand, the folks who had to physically clean up after it, but the next time Metro Toronto or Peel Regional or some other
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Bass ackwards said:
They played one such tape at the 1978 CNE. Over, and over and... on the PA system for the public. You may recall that in June of that year an Air Canada DC-9 crashed at Pearson Airport killing 2 and injuring 105 passengers and crew. One single EMD pretty well ran that entire call. And it was textbook. He was cool as a cucumber his entire career, and I have the honour and pleasure of being dispatched by many more, just like him. Cool cucumbers they were! It helped to keep the guys working the streets cool too.
Here's a vintage LAPD tape Bass for your listening pleasure. Guaranteed to bring back some
Warning: This recording contains some terminology that was generally accepted at the time.:
http://harrymarnell.net/media/1965tape-3min20.mp3
And, for the fire dispatchers:
http://www.emergencyfans.com/sounds/1stctfir2.mp3
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Bass ackwards said:
..and that's an extremely good example of why one should never pre-judge what other occupations must go through.
Thanks for that.
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"Due to multiple disruptions and challenging work environments correctional officers often face high levels of stress, burnout, health problems, high turnover rates, low life expectancy and decreased quality of life. In fact, the National Institute of Corrections reports that after 20 years of service the life expectancy of a correctional officer is 58 (National Institute of Corrections, 2008)."
http://www.bradsmedalmounting.com/images/correxmpsvc.jpg
http://www.bradsmedalmounting.com/images/correxmpsvc.jpg
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Mike, re the vintage LAPD link you posted:
That's gotta be the start of the Watts riots in 1965, no?
I'll pass thanks, I gave at the office.
If Joseph Wambaugh is to be believed, the dispatchers (PSR's in LAPD terminology) were pretty much tear-choked as they tried to keep a handle on things during that riot.
As to the "cool as a cucumber" thing... I used to have that rep. The "smoking jacket voice" was what I got called. I thought it was awesome. Then one day, I - a studly young man in his late twenties- got called by one of the front desk clerks (a somewhat less than svelte woman in her late forties) who wanted to know when I was going to be working a certain channel because her mother always liked to put the scanner on when I was working that particular radio. Yikes!!!
Anyways, having hijacked this thread all to hell - sounding calm and serene and actually being that way are two totally different things.
We now return you to your regularly scheduled topic.
Edited to add a brief "thank you" to Bruce.
That's gotta be the start of the Watts riots in 1965, no?
I'll pass thanks, I gave at the office.
If Joseph Wambaugh is to be believed, the dispatchers (PSR's in LAPD terminology) were pretty much tear-choked as they tried to keep a handle on things during that riot.
As to the "cool as a cucumber" thing... I used to have that rep. The "smoking jacket voice" was what I got called. I thought it was awesome. Then one day, I - a studly young man in his late twenties- got called by one of the front desk clerks (a somewhat less than svelte woman in her late forties) who wanted to know when I was going to be working a certain channel because her mother always liked to put the scanner on when I was working that particular radio. Yikes!!!
Anyways, having hijacked this thread all to hell - sounding calm and serene and actually being that way are two totally different things.
We now return you to your regularly scheduled topic.
Edited to add a brief "thank you" to Bruce.
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Bass ackwards said:
Bass, here is the story of that historic recording:
http://harrymarnell.net/1965.htm
I have a collection of Joseph Wambaugh books. I watched the "New Centurions" on TV the other night. George C. Scott had a rather short retirement, didn't he?
Bass ackwards wrote:
"When I left in '96, a CISD for a cubicle-dwelling communications operator was simply unheard of. That has since changed -at least in my old slice of paradise, but not before a lot of very good people either quit, completely lost it or were forced by their family doctor to take stress leave."
I read in the Sun a few days ago that PTSD claims from subway motor wo/men are on the increase because of people committing suicide on the tracks. They must have increased since the "Luminous Veil" was installed on the Bloor Viaduct, a well known local suicide magnet. With nearly 500 suicides by 2003, the Viaduct ranked as the second most fatal standing structure in the world, after the Golden Gate Bridge in San Francisco. I don't think that figure includes the number of motorists the jumpers killed down below on the Don Valley Parkway. Since then, many potential suicides have chosen the TTC as "the better way", with predictable results on the stress levels of subway drivers.
In my Department, CISD started in 1984 when a full-time
http://www.torontoems.ca/main-site/service/peersupport.html
The moral support was nice, but the big financial win came in 2000. That is when the WSIB "Cumulative Mental Stress Policy" was written for the Emergency Services. What was once described as "burn out" was now paid by Comp. as a "Permanent Disability". It's sort of like "Cumulative Trauma Disorder" (CTD) aka "Repetitive strain injury" (RSI) from computers, in that it takes time to manifest itself.
The new Policy means if you are mentally stressed-out and they assign you to spend the rest of your career on the Island Ferry as a Deckhand or Ticket Collector, or elsewhere as an Arena-Pool Operator, Gardener, Meter Reader etc your Paramedic wage rate, along with the annual negotiated increases, will be maintained for the rest of your career. No more "red circling" of pay rate. Prior to that, otherwise able bodied Paramedics and EMD's re-classified to lower paying City jobs were forced to take $20/hr pay cuts. Either that, or quit to sell real estate. Unlike police and fire, EMS lacks a Prevention division for Modified Duty. Although, in recent years, there have been temporary placements in Community Medicine. EMD's are re-classified as Clerks.
Because of wage protection, Paramedic and EMD PTSD has become a huge financial burden for the City, because it's pretty well a mathematical certainly that over time they all will have "Cummulative" mental stress. As you say, some will accept and handle stress better than others. Some seem to thrive on the "adrenalin rush".
CISM came to a head on 11 Sept 2001. More than 9,000 grief and crisis counselors descended on New York City. The supply was far in excess of the demand.:
After a thorough review of the major studies conducted after 9/11/01, evaluating the efficacy of such interventions, the authors reported that, “Although psychological debriefing is widely used throughout the world to prevent PTSD, there is no convincing evidence that it does so. <snip> Some evidence suggests that it may impede natural recovery”
http://www.jpnonline.com/showFree.asp?rID=4906
Most of us from the Old School preferred to rely on each other, and we still do.
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What it seems to me, Mike, is that PTSD -or stress in general- is the "back injury" for the 21st century.
I'm long gone from the emergency services. I work in the industrial sector now -have for more than a decade. Good-paying union jobs.
What I hear lots of (and makes me want to become a suicide bomber) is big, healthy, able-bodied -and very lazy- men who get into a pissing contest with the foreman and say "f-it. I'll go on stress leave". And by golly they do just that. They go talk to their doctors and somehow manage to get a note.
All well and good, but for the poor bugger who really does have problems -like his predecessor who genuinely did hurt his back in days of yore- how do you separate the real from the contrived ?
No wonder there's a stigma attached.
I'm long gone from the emergency services. I work in the industrial sector now -have for more than a decade. Good-paying union jobs.
What I hear lots of (and makes me want to become a suicide bomber) is big, healthy, able-bodied -and very lazy- men who get into a pissing contest with the foreman and say "f-it. I'll go on stress leave". And by golly they do just that. They go talk to their doctors and somehow manage to get a note.
All well and good, but for the poor bugger who really does have problems -like his predecessor who genuinely did hurt his back in days of yore- how do you separate the real from the contrived ?
No wonder there's a stigma attached.
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Bass ackwards said:
You might have a point there, Bass.
I think I heard some brain specialist say that sometimes back pain may be psychosomatic. Or, perhaps I saw it on Doctor Phil.
[/quote]
I'm long gone from the emergency services. I work in the industrial sector now -have for more than a decade. Good-paying union jobs.
What I hear lots of (and makes me want to become a suicide bomber) is big, healthy, able-bodied -and very lazy- men who get into a pissing contest with the foreman and say "f-it. I'll go on stress leave". And by golly they do just that. They go talk to their doctors and somehow manage to get a note.
[/quote]
That's basically a one man Wildcat Strike. If they don't like the way the place is run, then go sell real estate or something.
I saw a lot of that too. But, never that blatant. The Stress Leave can never linked to a dispute with Management ( unless it is a Harassment complaint ), it must always be linked to a specific call. In the industrial sector, if they witnessed a co-worker killed in one of the machines they could likely get some time off. But, I've seen where guys dropped dead of "natural causes" on the job and the foreman didn't even slow the line down.
Even though it may well be a not so subtle protest against management, the employee just can't say that it is.
Those guys you mention are stupid. Sure, it looks like they are getting away with something, but they are not. Management has the right to manage. If these guys can't handle that, they can be fired using Progressive Discipline. It takes a while, but they
Don't be impressed by those a-holes. Never bite the hand that feeds you, I say.
WSIB is very clear on that subject: They will not cover stress caused by labour-management quarrels.
A lot of it has to do with Leadership. I mean some bosses will let you walk all over them, as long as you come to work. Other bosses are quite the opposite. Those a-holes you mention would never have had the balls to march into the office and start mouthing off if some of the hard ass people I worked for were sitting in the big chair! Being kind and gentle was not their specialty. They really knew how to crack the whip! hahaha And I remember them with great fondness because I respected them. I trusted them. Funny when you think back on it!
Re: 911 Dispatchers:
You may have read in the papers that two EMD's, two Paramedics, and one Supervisor were recently suspended. That call will be going to Inquest, and no doubt everyone's name will be published in the papers. We all go down with the same ship.
The Dispatchers are really the unsung heroes. We've had Air Traffic Controllers sit in "the fishbowl" and tell us that EMD is harder. Because rather than tracking planned trips, EMD's are constantly trying to organize chaos. And yes, I have listened to some of those "greatest hits" that you mentioned. The ones where babies were being born and people were dying. Screaming at the Dispatcher about why the ambulance a-holes were taking so long to get there. I know that I couldn't do that job.
[/quote]
All well and good, but for the poor bugger who really does have problems -like his predecessor who genuinely did hurt his back in days of yore- how do you separate the real from the contrived ?
No wonder there's a stigma attached.
[/quote]
I guess that's for the experts to decide.
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"I guess that's for the experts to decide."
Which brings us full circle to the title and topic of this discussion.
There does seem to be a "grief industry" as it is sometimes called. And God knows there's no lack of people willing to play the victim card every chance they get.
So are the experts erring too much on the side of caution ? Or are we as a society just getting wimpier ? (or, the flip side of that - more enlightened and compassionate).
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I haven't heard anything about those EMDs and paramedics getting suspended. Can you post a link or PM me ?
Which brings us full circle to the title and topic of this discussion.
There does seem to be a "grief industry" as it is sometimes called. And God knows there's no lack of people willing to play the victim card every chance they get.
So are the experts erring too much on the side of caution ? Or are we as a society just getting wimpier ? (or, the flip side of that - more enlightened and compassionate).
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I haven't heard anything about those EMDs and paramedics getting suspended. Can you post a link or PM me ?
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