Erin Finley, a medical anthropologist whose research focuses on post-traumatic stress disorder, recently published her groundbreaking book, Fields of Combat: Understanding PTSD among Veterans of Iraq and Afghanistan.
Erin studied anthropology with me at Emory University, and also holds a masters of public health from Emory. Erin has made herself into one of most consistent contributors to neuroanthropology, including posts on Neuroanthropology.net, great participation in our conferences, and now a chapter for our forthcoming volume The Encultured Brain: An Introduction to Neuroanthropology.
Erin is presently a health research scientist at the Veterans Evidence Based Research Dissemination and Implementation Center and adjunct assistant professor in the Division of Clinical Epidemiology at the University of Texas Health Science Center in San Antonio, Texas.
I was truly excited to hear about her first book, and interviewed Erin about her work through email. She gave a great interview about her research, what anthropology shows us about PTSD, and how to make a difference with this difficult problem.
After the interview, I link to reviews of Fields of Combat, her recent NPR interview on her book, and her previous posts on PTSD.
Erin Finley & Fields of Combat Interview
Lende: So, Erin, tell me about your new book.
Finley: Fields of Combat is about U.S. veterans’ experiences of the wars in Iraq and Afghanistan, and what it is like for those who come home and develop post-traumatic stress disorder (PTSD). The book is really built around veterans’ own stories of combat and its psychological aftermath.
But Fields of Combat then goes on to put those experiences into social and cultural perspective, examining the history of PTSD, military and Department of Veterans’ Affairs (VA) responses to PTSD, and how veterans negotiate complex and often contradictory cultural messages around PTSD in making decisions about treatment-seeking and recovery. The goal is to put PTSD into context for a wider audience.
Lende: Can you give me an example from the book of how you put PTSD into context?
Finley: One example of how the book puts PTSD into context is by examining a revolution that has been ongoing over the past several years in the PTSD treatment provided by the VA.
For many years, much of what was widely understood about PTSD – our cultural ideas about PTSD – was influenced by the fact that the clinical and research communities had not yet developed the scientific knowledge to understand what causes PTSD, how it works within the body and the mind, and how best to treat it. As a result, PTSD was thought of as a chronic and disabling illness for which there was no cure.
Now that has changed. We have very good treatments available for PTSD, and the VA has worked to make those treatments available at facilities all over the country. Even so, many Veterans simply aren’t aware that it is possible to recover from PTSD and so may remain hesitant to reach out for help. By understanding how our cultural messages around PTSD have been shaped by its historical legacy, it becomes easier to understand much of the stigma surrounding the illness and the day-to-day impact this has on Veterans’ coping and treatment-seeking behaviors.
Lende: Tell me some more about your field work, and how that has helped you understand PTSD and how veterans cope.
Finley: My fieldwork was an incredible experience. I settled on San Antonio, Texas as a research site because the city has such a large population of veterans and active duty service members. Ultimately, the fieldwork ended up providing a good example of how the breadth of anthropological methods can allow for insights that are multi-faceted enough to reflect the real world.
My methods included semi-structured interviews and structured surveys conducted with a variety of veterans, including males and females from all branches of services, veterans of Vietnam and the first Gulf War as well of Iraq and Afghanistan, and veterans who had been diagnosed with PTSD as well as those who had made a very smooth transition back into civilian life.
I also had the opportunity to interview family members and clinicians and community service providers working with active duty service members and veterans, and to engage in participant observation at events throughout the San Antonio area. In a certain sense, I was trying to create an ethnography of combat PTSD in San Antonio at a particular moment in time, and so relied on a lot of the classic ethnographic methods to pull it all together.
The end result was a portrait of PTSD that was kaleidoscopic and complex, and which revealed that there is no one way of viewing or experiencing post-traumatic stress. The task then became how to convey that complexity to the reader, and the best way seemed to be to let veterans and other participants speak for themselves as much as possible.
Lende: Can you give me an example of how veterans’ voices helped cut through the complexity and show post-traumatic stress in a new light? How does letting veterans and other participants speak for themselves add to our understanding?
Finley: One of the things that doesn’t get a lot of attention in most of the research on PTSD, and which really stands out in veterans’ stories, is the importance of grief. So many veterans describe feeling incredible grief over buddies who were killed in combat, relationships that may have fallen apart during deployment, or even post-deployment changes in themselves or in their lives that they are unhappy about.
In particular, listening to veterans talk about the way that they mourn their friends was very eye-opening, because although that kind of bereavement received a lot of attention in World War II-era accounts of combat stress, it has fallen out of the realm of what most people think about with regards to PTSD. Listening to veterans speak about their concerns in an unstructured way can help to show where the usual symptom checklist fails to provide a full account of their experience.
Lende: You’ve written posts before for Neuroanthropology, and are contributing a chapter to our edited volume The Encultured Brain. Can you tell readers a bit about how you use neuroanthropology, and why it is important to your work?
Finley: Neuroanthropology offers an extremely useful set of tools for thinking through some of the questions raised by PTSD, particularly when examined from a cross-cultural perspective. PTSD is – like any mental illness – an experience that is often felt to be physical and emotional and mental all at the same time. This makes it a particularly meaningful site at which to challenge body-mind dualism and probe how the internal and external environments intersect.
For example, a traumatic event is something that happens in the external environment, but that event is perceived by the individual in ways that may be shaped by culture, life history, genetics, physiology, and cognitive processes. In the wake of trauma, neuroscience provides one window onto the responses that may begin to unfold within the individual, while psychology, anthropology, and the social sciences provide another. Taken together, they allow us to develop a much richer understanding of how a pathological response to trauma may come about, and what steps might be taken to move that response in a more positive, adaptive direction.
Lende: That last part of your answer – of steps that might be taken – highlight the applied dimensions of your research. What are some of the steps you think should be taken about PTSD? And how can anthropology play a role in doing that?
Finley: There are two steps in particular that we should take, both of which require a shift in the cultural messages circulating around what PTSD is and what it means.
The first step requires shifting the cultural dialogue around PTSD, which for many years has been largely negative. PTSD has developed a reputation for being chronic and disabling, in part because for many years we simply didn’t have the knowledge base required to treat it effectively. Now that we have solid evidence for the effectiveness of treatments like Prolonged Exposure Therapy and Cognitive Processing Therapy, it is important to begin shifting the messages around PTSD to reflect the fact that it need not be a lifelong illness.
We would never expect someone who has been through a trauma to be the same afterwards as he or she was beforehand – just as we would never expect that anyone who has been through any experience of great suffering would remain unchanged – but with proper treatment, someone with PTSD can look toward much-improved quality of life and even full recovery within a relatively short period of time.
The second step requires shifting the way that many of us think about people living with PTSD, who still encounter the stigma of being thought cowardly or weak. It’s sort of bizarrely ironic when you think about it, given that individuals with PTSD are those who have been through some of the most extreme and horrifying circumstances in human life – and have survived.
Far from being weak, they have often proven themselves to be heroes, to be truly extraordinary people. The more we recognize the strength of trauma survivors and provide them with the kinds of treatment and support that make the most of that strength, the more likely we are to see positive coping and care-seeking and real recovery for the majority of those affected.
Anthropology, of course, is a very effective tool in identifying these kinds of cultural messages and tracing their impact on how people experience events, make decisions, and take action. It can be a vital partner in public education and other efforts to improve PTSD care in the years to come.
Lende: Thanks for this great interview, Erin. Best of luck with your book – it deserves a wide audience!
Finley: Thanks so much, Daniel!
Fields of Combat – The Book
Cornell University Press site for Fields of Combat: Understanding PTSD among Veterans of Iraq and Afghanistan.
Both heartbreaking and hopeful, Fields of Combat tells the story of how American veterans and their families navigate the return home. Following a group of veterans and their their personal stories of war, trauma, and recovery, Erin P. Finley illustrates the devastating impact PTSD can have on veterans and their families. Finley sensitively explores issues of substance abuse, failed relationships, domestic violence, and even suicide and also challenges popular ideas of PTSD as incurable and permanently debilitating.
Publisher’s Weekly posted this short review of Fields of Combat:
With 120,000 soldiers diagnosed with post-traumatic stress disorder since the beginning of the Iraq war in 2003, the tales of our returning troops demand the nation’s attention, argues Finley, a medical anthropologist with the Department of Veterans’ Affairs in Texas. Not surprisingly, the symptoms of PTSD have changed little since the Civil War–restlessness, nightmares, aggression, hyper-vigilance. Yet the diagnosis was officially recognized as a disability only 30 years ago. Treatment, while it has evolved, remains mired in conflict over best practices and mistrust between vets and civilian clinicians.
Though Finley relies on 20 months’ worth of fieldwork, it’s the experiences of four soldiers that stand out in heartbreaking relief: O’Neil, whose wife was shocked to discover he carried grenades in his pocket while serving as a medic; Marine Tony Sandoval, who can barely complete a full sentence about the horrors he saw; soldier Jesse Caldera, who is haunted by fears he killed a child; and Derek Johnson, who lost a leg but, unlike many veterans, was able to reconnect with his wife. Finley declares there is great hope for the soldiers struggling to build a life worth living.
In June, Erin Finley appeared on NPR’s Talk of the Nation – For Soldiers With PTSD, A Profound Daily Struggle.
The radio interview first features Dexter Pitts, a veteran who suffered injuries in Iraq and developed PTSD and is now a police officer in Louisville, Kentucky. Erin Finley comes in around 7:45. After a few difficulties getting her on a mike, the interview really digs in around 9:20 and goes until about 14:30. Clinical psychologist Craig Bryan then speaks briefly, and Erin and Craig and host Neal Conan then continue on talking and responding to callers for the rest of the 38 minute show.
The NPR report also features a nice excerpt from Erin’s book (find it at the bottom of the post). Here is just a taste of it:
In Derek’s story, there was no crisis, no single event that forced him into treatment, no immediate danger to himself or his family. Instead, there was a long, slow series of events that made it clear he had a problem, one that was not going away and one that could get in the way of fulfilling his plans for himself and his obligations to his family. This necessitated action.
For more from Erin, you can read her previous posts on Neuroanthropology.net:
PTSD comes about as the result of an individual’s attempt to learn to avoid danger out in the world. Therefore, when a trauma occurs, the circumstances surrounding that trauma are imprinted on the memory in such a way that those circumstances become associated with high levels of physiological arousal and anxiety – an evolutionary mechanism intended to help the individual avoid similar dangers in future.
As a result, individuals with PTSD are likely to avoid what are called ‘triggers,’ sensory reminders of circumstances in which they experienced a threat. Because these people experience the traumatic memories and their associated triggers with intense anxiety, they avoid rather than processing and integrating them. Thus it is thought, under this model, to be the avoidance of painful memories that results in their uncontrolled intrusion into dreaming and waking life.
But what this model doesn’t explicitly account for is the determination of what memories are experienced as so horrifying, so disturbing, and so unmanageable that they can drive an individual to continually push them out of mind rather than working through them in the normal way. And it is here – it seems to me – that we can begin to appreciate the cultural place of meaning amidst the biocultural interactions at work in the acquisition of long-term PTSD.
We do know – when it comes to Post-Traumatic Stress Disorder (PTSD) – that narrative matters. As I wrote in an earlier post, the most effective therapies yet proven for reducing PTSD symptoms are the exposure therapies, particularly Prolonged Exposure (PE) therapy. These therapies are more effective for reducing the full range of PTSD symptoms than any pharmaceutical yet identified. And the crux of these therapies rests on telling the story of the trauma, sometimes over and over again. This simple practice, this process of speaking, has been reliably demonstrated to result in an improvement of PTSD symptoms for many patients.
But for all its clinical benefit, this extraordinary observation tells us very little about the mechanisms of psychic healing after trauma. Instead, it points to a growing body of evidence that suggests it is not just narrative that matters in PTSD, but, more intriguingly, that it is the type of narrative that matters.