For a while, he floated along in a stupor, on multiple medications for depression and anxiety, relentlessly calling Veterans Affairs Canada. He applied to be classified as a ptsd sufferer, which would allow him to collect a disability pension, but he was rejected. He appealed and was reassessed, and then his appeal was rejected, too. In 2008, he arrived at the Carewest Operational Stress Injury clinic in Calgary, where he was given a preliminary diagnosis of chronic ptsd. Another year later, he appealed successfully to Veterans Affairs. To qualify for his pension, he had endured five assessments in eight years, despite having what seemed like a clear and obvious case. By then, the source of the original trauma was at least ten years old. Why had it taken so long? John speculated to me that military physicians were reluctant to issue a ptsd diagnosis because it would cost the military money. But the answers reach deeper than that, into the history of the disorder and the complications of diagnosis.

sychologists have been trying to understand how trauma affects human beings at least since Sigmund Freud and Joseph Breuer’s work in the late nineteenth century, and to understand how war trauma in particular affects soldiers at least since the First World War. Beginning almost immediately in 1914, soldiers were being sent back from the trenches with afflictions such as amnesia, aphasia, blindness, and deafness. Some walked with elaborate, unnatural gaits; some could not sleep, trembled all over, gibbered incessantly, or cowered in the fetal position. In film footage shot at the Netley Hospital near Southampton, England, in 1917, researchers captured a very thin man dressed only in his underwear strutting across the room, stooped halfway over, his rear end thrust out, his arms mechanically flapping, his whole body twitching and jerking. For the British High Command, such exhibitions were symptoms of mass malingering and cowardice — signs, perhaps, of the corruption of the British character brought on by the years of relative affluence and leisure that preceded the war. But the numbers were too great and the conditions too bizarre to completely ignore, so psychiatrists and neurologists were hastily commandeered, hospitals were set up, and the field of military psychiatry was born.

Spanning the twentieth century’s two world wars, brilliant and sometimes eccentric figures — Charles Myers, W. H. R. Rivers, Thomas Salmon, John Rickman, Roy Grinker, and Moses Kaufman, among others — made significant strides in identifying, describing, and attempting to treat what was alternately called shell shock, war neurosis, battle fatigue, post–Vietnam syndrome, and finally, by the late 1970s, post-traumatic stress disorder. The early pioneers sought physiological causes for the disorder, but ultimately concluded that it was irreducibly psychological. By the end of the Second World War, they had identified its primary symptoms: intense anxiety, hyper-vigilance, flashbacks and nightmares, emotional numbness, volatility. They had also arrived at the rough outlines of appropriate and effective treatment: a period of rest, relaxation, and safety; therapy to bring the traumatic experience to consciousness and emotional acceptance; and, when possible, reintegration of patients with their units.

There remained, though, the sense among military people that most psychiatric casualties were malingerers and cowards, and a fear that the promise of pensions for psychically wounded veterans would create an incentive to mimic psychiatric problems. This perception began to change only after the Vietnam War. Early in the conflict, American psychiatric casualties were at a historic low, with most soldiers being swiftly returned to their units. But as the war unfolded, the incidence of psychiatric problems — or at least the perception of such incidence — among soldiers nine months or more after their tours of duty rose dramatically.

Amid an atmosphere of deepening hostility to the bloodshed abroad, organizations like Vietnam Veterans Against the War and sympathetic psychiatrists like Chaim Shatan and Robert Jay Lifton began pushing for recognition of post-Vietnam syndrome. In 1980, the American Psychiatric Association responded to the pressure, adding post-traumatic stress disorder to the third edition of its Diagnostic and Statistical Manual of Mental Disorders. This in turn placed pressure on militaries and governments to begin acknowledging and addressing ptsd as a legitimate, common illness.

The diagnostic criteria have evolved in the current manual, dsm-iv, to include an intense negative emotional reaction and persistent avoidance of the traumatic event, or any other association with it; flashbacks; nightmares; emotional numbing; hyper-arousal; and hyper-vigilance. These symptoms must last for at least a month; otherwise, one is diagnosed with acute stress disorder. And they are neutral as to the source of the trauma — that is, they do not speak to specifically military origins.

Harvard Medical School professor Judith L. Herman crafted an elegant description of the universal roots of ptsd in her 1992 book, Trauma and Recovery. “Psychological trauma is an affliction of the powerless,” she wrote. “At the moment of trauma, the victim is rendered helpless by overwhelming force... Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning.” The presence of a discernible traumatic event should, in theory, make ptsd simple to diagnose. One psychiatrist I spoke with suggested that it should actually be one of the easiest conditions in the dsm to identify. But diagnosis can be complicated by other factors: a history of conditions like depression and addiction, or traumas unrelated to military service. (This may have been the case for John, for example.) Unlike most physical war injuries, ptsd is intimately intertwined with a person’s psychological history.

Diagnosis might one day become easier, thanks to ongoing research into ptsd’s neurological causes and indicators, and to advances in neuro-imaging. Dr. Ruth Lanius, a professor of psychiatry at the University of Western Ontario and one of the leading researchers in the field, says volume loss in the hippocampus, a region of the brain associated with the creation of new memories, may help explain why ptsd sufferers re-experience aspects of the trauma through flashbacks, dreams, and bodily sensations. The amygdala, the brain centre connected with emotions, appears to have been affected in people with ptsd as well. In healthy people, measurable fight-or-flight responses are triggered by threatening circumstances, and they dissipate at a predictable rate once the threat is gone. In those with ptsd, the fear switch is permanently on, or “disregulated,” meaning they are in a continuous state of hyper-arousal. Sufferers also experience a general disconnection between the emotional function of the amygdala and the executive functions of the frontal cortex, the region of the brain responsible for rational planning and assessment of reality.

These neurological advances could eventually also lead to better, more focused treatments for ptsd, but that remains for the future. In the meantime, the Canadian military has been working to improve its prevention and treatment measures: the steps it has taken over the past few years to overhaul its mental health system look like a direct response to André Marin’s original criticisms. In all likelihood, soldiers returning from recent tours in Afghanistan will not face the same challenges John and Dave did, and those who come home with signs of psychological trauma will be far less likely to go untreated. This has been a system-wide effort, but much of it has been driven by one particularly motivated soldier, Lieutenant-Colonel Stéphane Grenier.

met Grenier on a February morning at Le Moulin de Provence café in Byward Market in Ottawa. Now well into his forties, he is a wiry, animated man with a shaved head and wire-rimmed glasses. Grenier served under Roméo Dallaire in Rwanda, and since then has been deployed in Cambodia, Lebanon, Haiti, and most recently Afghanistan. He is an intense, focused, and driven man, and though he enjoys lengthy conversations (“I’m a Frenchy — I love to talk!”), he obviously had little patience for idleness. “I told our media people, ‘I won’t let him interview me if it’s for less than an hour,’” he said a few moments after walking into the café. “I wanted to know that you are serious.” The press officer assigned to sit in with us already looked exhausted.

“When we came back from Rwanda,” Grenier said, “General Dallaire said, ‘Let’s record what happened to us.’ So I made an internal video called Witness the Evil, where General Dallaire first came out about his struggles with ptsd.” He recounted a bit of his own story for me. “When I first came back from Rwanda, I was a mess,” he said. “From 1995 to 1998, I was a mess. I would smell dead bodies out of nowhere. I would wander around in a trance without any memory of it. I came into the hospital one day after contemplating suicide, and I wondered, ‘What is wrong with me? I have a wife, children...’”

He was already frustrated by the military’s mental health system, which was, he said, “too linear” and too disconnected from the experience of being a soldier. Previously, those who could bring themselves to acknowledge that they were having problems would be shifted from their units into a medical system with professionals who did not share their experiences, and whom they did not trust. The disconnect between soldiers and medical caregivers was an ongoing problem. Grenier became uncharacteristically sarcastic when speaking about the kinds of advice mental health educators used to give. “They would say, ‘Make sure you relax, get enough sleep, eat properly, exercise every day, stay in touch with your friends.’ But how are you supposed to do that when you’re in a ditch outside the wire?”

His breakthrough moment came when his superior officer took him aside and told him, “Stéphane, you’re not the guy I heard about.” This, he told me, “gave me permission to seek help. The day I did that was the day I started to recover. And when I did that, I thought, ‘Holy shit, what if this was general?’” Meaning, what if every struggling soldier had someone he trusted and respected take him aside and say, “Hey, you haven’t been yourself. Maybe you need to go get some help”?

In 2001, Grenier launched the Operational Stress Injury Social Support (osiss) program, which today includes some forty support counsellors — twenty Canadian Forces veterans who were once diagnosed with ptsd, and twenty family members of ptsd sufferers. “Operational stress injury” is a phrase Grenier coined to bypass the stigma associated with “post-traumatic stress disorder,” a term most soldiers despise, because it implies that they have a disease rather than a kind of wound. One of the counsellors’ most important roles, he told me, is to “pound the jungle drums and find people in the hurt locker”; another is to provide an easy segue into treatment — to give soldiers permission to get help.

“Early on, we didn’t have expertise in deployment mental health issues,” says Lieutenant-Colonel Rakesh Jetly. Dr. Jetly is a psychiatrist who, like Grenier, was deployed in Rwanda and has, in his current role as adviser to the Mental Health Directorate in Ottawa, twice spent time working at the base hospital in Kandahar. “In Rwanda, we didn’t have people there, and then we didn’t have any set program of how to help people post-deployment.” Now, Jetly says, the Canadian Forces’ approach to mental health is comprehensive. “It starts at the recruit level; they need to think of it in the same way as physical fitness,” he told me. “Right off, we talk about coping and stress. The idea is that individuals have to take care of themselves, and also to start being responsible for others.”

Among the military’s new initiatives is the Joint Speakers Bureau, launched by Grenier after he returned from Afghanistan in 2007. The jsb teaches deploying soldiers, and especially leaders, how to detect and address operational stress injuries. These education programs began just last fall, and so will only impact the late stages of Canada’s mission in Afghanistan, but they will be an important part of future deployments. In addition to the jsb sessions, soldiers received the Road to Mental Readiness manual, part of a program developed with input from the US Navy seals. The guide contains tips on techniques for controlling stress, such as tactical breathing, and outlines the resources available to them in the field. Once in theatre, a full team is in place — not only peers and superior officers, but also chaplains, med-techs, medical officers, and a full mental health support team. If a soldier needs to be sent home, a psychiatrist can get on the phone and make the appropriate appointments in advance.

The Canadian Forces have also changed their reintegration practices. Notably, they have introduced a five-day decompression stay at a resort en route back to Canada, in keeping with the common belief that soldiers coming home from the Second World War reintegrated more quickly and successfully into civilian life than those who served in Vietnam, partly due to different methods of transport. The long journey by ship from Europe or the Pacific allowed for a slow period of readjustment, whereas the flight from Saigon was jarring. Jetly recalls for me how disorienting his return from Kigali was: “One day, I was sleeping in a stadium across from dead bodies; the next day, I was back in Ottawa.”