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The (de)construction of a psychiatric diagnosis: PTSD

among former guerrilla and paramilitary soldiers in
Colombia
a b a
R. de la Espriella , E. Sweetnam Pingel & J.V. Falla
a
Departamento de Psiquiatría y Salud Mental, Hospital Universitario de San Ignacio ,
Pontificia Universidad Javeriana , Carrera 7 No. 40-62 Piso 8, Bogotá, Colombia
b
Department of Health Behavior Health Education , University of Michigan School of
Public Health , 1415 Washington Heights, SPH 1 Room 3718, Ann Arbor, MI, 48109-2029,
USA
Published online: 17 May 2010.

To cite this article: R. de la Espriella , E. Sweetnam Pingel & J.V. Falla (2010) The (de)construction of a psychiatric
diagnosis: PTSD among former guerrilla and paramilitary soldiers in Colombia, Global Public Health: An International
Journal for Research, Policy and Practice, 5:3, 221-232, DOI: 10.1080/17441691003709430

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 Global Public Health
Vol. 5, No. 3, May 2010, 221
232

The (de)construction of a psychiatric diagnosis: PTSD among former

guerrilla and paramilitary soldiers in Colombia
R. de la Espriellaa*, E. Sweetnam Pingelb and J.V. Fallaa
a
Departamento de Psiquiatrı́a y Salud Mental, Hospital Universitario de San Ignacio, Pontificia
Universidad Javeriana, Carrera 7 No. 40-62 Piso 8, Bogotá, Colombia; bDepartment of Health
Behavior Health Education, University of Michigan School of Public Health, 1415 Washington
Heights, SPH 1 Room 3718, Ann Arbor, MI 48109-2029, USA
(Received 10 March 2009; final version received 4 February 2010)
Downloaded by [New York University] at 05:37 21 May 2015

The demobilisation of guerrillas and paramilitaries in Colombia, also known as

irregular armed groups, has raised the question among mental health profes-
sionals as to whether ex-combatants who have had repeated exposure to stressful
events might meet the requirements for posttraumatic stress disorder (PTSD).
Upon arrival at a psychiatric clinic in Bogotá, 76 patients were evaluated by a
group of mental health professionals with experience in this diagnosis. Contrary
to clinicians’ expectations, there was a conspicuous lack of PTSD among this
population. Subsequently, the clinical team administered the Clinician Adminis-
tered PTSD Scale with 21 of these patients; PTSD was found in 57% of the men.
The authors consider various arguments that might explain this discrepancy.
Differences between the clinical presentation of PTSD among the ex-combatants
and the classic descriptions contained in the DSM-IV-TR may be explained by
organisational characteristics of the irregular armed groups. Further research is
necessary which focuses on the mental health of populations in the context of
political violence, such as those encountered in Colombia.
Keywords: PTSD; political violence; reinsertion programmes; diagnostics;
Colombia

Introduction
In July 2007, the Colombian High Council for Reinsertion (ACR) approved the
entrance of 76 men into a drug rehabilitation programme at Nuestra Señora de la
Paz Clinic in Bogotá, Colombia. These men had recently been members of either a
guerrilla or paramilitary group, and had been directly involved in brutal combat
scenarios. Each of the men had demobilised, declaring before the ACR their crimes
and their intentions to remain civilians. Upon their arrival at the Nuestra Señora de
la Paz Clinic, clinicians (including two of the authors) expected to see clear signs of
posttraumatic stress disorder (PTSD), given the trauma to which these men had
likely been exposed. The clinical team was surprised to find, however, that few
symptoms listed in the Diagnostic and Statistical Manual manifested themselves
among these men. This led them to administer a second diagnostic instrument, the
Clinician Administered PTSD Scale (CAPS), the results of which showed clear signs

*Corresponding author. Email: rdelae@gmail.com

ISSN 1744-1692 print/ISSN 1744-1706 online
# 2010 Taylor & Francis
DOI: 10.1080/17441691003709430
http://www.informaworld.com
 222 R. de la Espriella et al.

of PTSD. By using a grounded theory approach to analysing the narratives

contained within the CAPS interview, this paper seeks to explore the circumstances
that led to this diagnostic discrepancy, as well as to make use of these cases as an
opportunity to reflect on the meaning of a PTSD diagnosis, both from a clinical and
a cultural standpoint.

Background
In contrast to many other nations in the Latin American region, Colombia has never
had a harsh, sustained military dictatorship, or an economy so bogged down that
one step up seemed insurmountable. Yet, citizens of the world would agree that
Colombia has experienced an inordinate amount of strife for at least the past half
century, characterised by astonishing violence and the lack of state security. The
violence has persisted for generations, as conditions of reparation and justice have
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yet to be attained.
Young Colombian men comprise the majority of those engaged in the struggle, as
either guerrillas or paramilitaries. On one hand, they have been murderers of the
worst sort; on the other, they are also the primary victims in these confrontations.
Colombia suffers from one of the highest homicide rates in the world. For many
years, homicide has been the leading cause of death among men aged 15
44, either
for political violence or drug trafficking (Medecins Sans Frontieres 2006).
Political violence has clearly had a long history in Colombia. In the past 30 years,
several presidential administrations, including those of Barco, Samper and Pastrana,
have tried to nurture a peace process and stimulate reconciliation of the two sides
(Behar 1985, Alape 1993, CISP 1999). This process has included both peace talks
between the government and the irregular armed groups, as they are commonly
known, and the demobilisation programmes, in which paramilitaries and guerrillas
are offered the option of reintegration into civilian life. All too often, however,
demobilised men have returned to the rebel lifestyle and newly formed armed groups
(Alape 1993, Pax Christi 2007). Since the election of President Álvaro Uribe in 2002,
the Colombian Government has continued the demobilisation process, with a larger
emphasis on the paramilitary groups and minor guerrilla groups (Pax Christi 2007).
The demobilisation effort is being led by the High Council for Reinsertion
(ACR), which has delineated several priorities, including the monitoring of mental
health for the population in question. The demobilised individuals reap legal benefits
in this process, such as absence of legal judgement for acts committed in combat
once they give full confessions and promise to cease all illegal activity. The
reinsertion of these men into civil life necessitates attention to the diverse pathologies
present in the population, especially in the area of mental health. As a result of the
high rate of drug addiction among ex-combatants, programmes have been created
that specifically address this issue. In addition to these programmes, ex-combatants
entering the system are often screened for PTSD.
In examining trauma in the Colombian context, Hernandez (2002) highlights the
concept of social trauma, which consists of ‘injurious historical and societal
dynamics maintained in a mediated interaction between the individual and society’.
While individuals do experience social trauma, ‘it is more appropriate to speak of it
as the product of inhuman relationships’ that thereby affects groups of people, as
opposed to the isolated individual. We find the attention to both personal and
 Global Public Health 223

collective aspects of trauma quite salient to our later discussion of the traumatic
experiences of Colombian ex-combatants.
According to Baca (2005), the German neurologist Hermann Oppenheim used
the concept of traumatic neurosis at the end of the nineteenth century, describing
patients he had evaluated who had suffered traumatic events. Jacob Mendes Da
Costa was the first physician to study a group of veterans who were experiencing
heart palpitations, pain in the diaphragm, migraines and vertigo. In 1871, he named
the condition ‘soldier’s heart’, though it was also called Da Costa’s syndrome
(Turakhia et al. 2008). Similar conditions have been diagnosed as ‘neurocirculatory
asthenia’, ‘combat neurosis’, ‘WWII stress’ and ‘Vietnam Syndrome’, among other
names. The condition became notorious among veterans of the Vietnam War and
prevalence reached 50% in cases of prisoners of war and survivors of concentration
camps (Yehuda and MacFarlane 1995, Bobes Garcı́a et al. 2000, Mueser et al. 2004,
Baca 2005). The National Vietnam Veterans Readjustment Study found that 31% of
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veterans had experienced PTSD at some point in their life; 15% presented symptoms
at the time of the evaluation (Kulka et al. 1990).
Certain factors are thought to increase the possibility of developing clinical
symptoms, factors such as genetics, history of child abuse, personality disorder, prior
traumas, lack of social support and history of previous psychological problems
(Yehuda and MacFarlane 1995). Interestingly, the occurrence of a traumatic event is
not sufficient to develop PTSD, a fact that has vexed researchers and clinicians alike.
Some argue that PTSD verges on the status of a ‘pseudocondition’, a socially
constructed amalgam of anxiety and depressive neuroses all too often employed,
along with the notion of trauma, to the slightest tumble of the emotional EKG
(Summerfield 1999, 2001).
Bearing this body of literature in mind, we set forth to analyse transcripts from a
series of interviews with the demobilised population, identifying emergent themes
that spoke to the central question we wish to answer in this paper: why did the results
of one diagnostic instrument differ so markedly from another? While immersing
ourselves in the diagnostic interviews and the reflexive process entailed therein, we
also began to consider the larger implications for PTSD diagnostics generally.

Methods
Nuestra Señora de la Paz is a large psychiatric clinic in a major Colombian city. Its
drug addiction programme for demobilised men began in the second half of 2007
with 76 men. Preparations to receive these men were given special attention within
the clinic, owing to the delicate nature of the programme. A separate space for the
men was annexed within the clinic, although some interaction did occur with
patients from other areas. The programme lasted 10 months.
The professional team assembled for the programme consisted of a psychiatrist, a
psychologist, a social worker, an occupational therapist, a nurse, and other auxiliary
personnel from the infirmary. Aside from the focus on drug dependence, the
objective of the programme was the diagnosis and management of psychiatric
conditions, ultimately facilitating the re-entrance of participants into civil life.
The age distribution of the 76 men in treatment ranged from 18 to 46 years, with
a mean of 27.9 years. A low level of education was the norm among the men. Six of
the patients were illiterate, 16 possessed an incomplete primary education, 17 only
 224 R. de la Espriella et al.

completed primary education, and 28 had an incomplete secondary education. One

patient had studied at a trade school and another had a professional career. Of the
patients, 62% were indigent prior to entering the institution. In terms of marital
status, 66% of patients were single at the time of the study; 5% were separated; 28%
were in a documented civil union and no data were available for 1%.
The patients originated from different parts of Colombia, with the greatest
number coming from the department of Antioquia (whose capital city is Medellı́n)
and the city of Bogotá. Combined, these two areas contain about 25% of the
population of Colombia. In accordance with the aforementioned emphasis of
President Uribe on the demobilisation of paramilitaries, 72% of patients are former
members of these right-wing groups; 13% were guerrillas and 3% were part of both
groups. No data were available for 12%.
Given that the programme focused on mental health issues, principally that of
addiction to narcotics, the team measured substance use among the original 76
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participants. Tobacco use was found to be more than 80% and alcohol more than
90%. The illicit substance most often consumed was marijuana at over 80%, followed
by cocaine/crack at over 70%. Upon being asked about consumption prior to
demobilisation, 71% of the participants admitted to having consumed psychoactive
substances. Only 6% reported not having consumed substances prior to demobilisa-
tion, whereas 14% claimed non-habitual use.
Considering the intense combat violence to which the men entering the
reinsertion programme at Nuestra Señora de la Paz Clinic were exposed, the clinical
team held the initial assumption that PTSD, as described in the DSM-IV-TR (2000),
would be present in this population. Despite this expectation, we found that patients
were not exhibiting the symptoms of PTSD, such as responding to past trauma with
‘intense fear, helplessness and horror’. On the contrary, most of the men initially
seemed indifferent to the atrocities witnessed and committed. Rebellious and
oppositional behaviour regularly manifested itself, complicating the treatment of
both individuals and the group as a whole. From the beginning, participants told
stories about their engagement in massacres, assassinations and violent acts without
showing a trace of modesty, regret or remorse. Instead, many of the men strove to
exhibit strength and confidence. We therefore raised the question, ‘What are the
characteristics of these individuals that seem to protect them from acquiring PTSD?’
We contrasted this apparent absence of PTSD with previous clinical encounters
with military men at the clinic, in which the symptoms were present in nearly all
cases. Episodes of anxiety, flashbacks and memory disorders were widespread.
Having witnessed PTSD among members of the regularised armed forces, we
logically pondered its absence in this newly arrived group, despite the fact that the
two shared similar combat experiences and sociodemographic characteristics.
The clinical team made the decision to utilise a second instrument, the CAPS, in
addition to the DSM-IV-TR criteria, in order to confirm the absence of PTSD in the
patient population. The 30-item CAPS scale is considered the gold standard in the
assessment of PTSD (Blake et al. 1995). We administered a Spanish version, which
despite not having been validated specifically in a Colombian population, has been
shown to possess excellent diagnostic capabilities in comparison to other psycho-
metric instruments such as the CGI-G, TOP-8, DTS and TQ (Bobes et al. 2000,
Crespo and Gómez 2003). The CAPS has demonstrated a Cronbach alpha of 0.94.
 Global Public Health 225

Interview questions are asked of the individual in reference to three traumatic

stressors, which may be determined from the Life Events Checklist (LEC). The
questions correspond to the DSM-IV-TR criteria for PTSD. A numerical score is
determined by the number of indicators experienced, as well as their frequency and
intensity (Blake et al. 1995). This process recognises existent PTSD or evidence of its
presence earlier in life. It also detects the gravity of the disorder, any feelings of guilt
about acts committed or avoided, survivor guilt, personal detachment and whether
the patient exhibits a lack of consciousness about his or her surroundings (Blake
et al. 1995).
In the first stage of the programme, we evaluated 76 men. Upon our decision to
administer the CAPS, however, the number of available participants had been greatly
reduced. A variety of factors contributed to this reduction in number, including
hospitalisation for physical ailments, abandonment of the programme, exclusion for
disciplinary sanctions and release upon demonstration of freedom from drug
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dependence. Patients exhibiting psychotic or cognitive conditions that would make

an interview impractical were also excluded. Ultimately, 21 patients gave informed
consent to be interviewed using the structured CAPS interview guide.
Upon completion, the interviews were transcribed; all identifying data, including
city of origin and proper names, were changed. The CAPS interviews exhibited
positive signs of PTSD in 12 cases (57.14%) and of those 12, four were also positive
for posttraumatic stress earlier in life. While initially performing their daily activities
in the drug treatment programme, these men had not exhibited symptoms sufficient
to meet the DSM-IV-TR criteria for PTSD. Upon being questioned directly about
their combat experiences, however, trauma narratives began to emerge. At this point,
we changed course and acknowledged the presence of PTSD in this population. This
change in diagnosis forced us to wonder why symptoms that were not initially
apparent surfaced in the individual interviews.
After having used the CAPS interviews to simply detect the presence of PTSD,
we returned to them to search for answers to our concerns surrounding the differing
outcomes of the available diagnostic instruments. We therefore began the process of
thematic analysis using Strauss and Corbin’s grounded theory approach (Corbin and
Strauss 2007). The clinical team used an open coding process in poring over the
interviews a second time and identified recurring themes in the narratives of the men,
which seemed central to their experiences and socialisation while members of the
irregular armed groups. The interviews were then coded, according to the themes
identified and, subsequently, analysed in relation to our question regarding the
differential diagnosis.

Results
Of the 15 major themes that emerged from the narratives of the former combatants,
five were particularly salient in providing an explanation for the initial absence of
PTSD symptoms among this population: loyalty, mistrust, strength, isolation and
obedience to the organisational hierarchy. Nearly all of the stressful events described
by the 21 CAPS participants occurred either prior to or while being a member of
the irregular armed group. Such events included participation in massacres and the
assassinations of family members. Many participants recounted more than three
events, surpassing the number suggested by the CAPS. In addition, we relied on a
 226 R. de la Espriella et al.

solid body of scholarly publications devoted to the topic of irregular armed groups in
Colombia in order to provide the context for our analysis of the men’s narratives. In
giving an account of this analysis, we used the italicised words to emphasise the five
predominant themes previously listed.
Guerrillas, as much as paramilitaries, lead a type of military career, with various
phases, including recruitment, instruction, adaptation and a veteran’s phase
(Goffman 1961, Adelantado 2004). In the enactment of each phase, the men in
our programme defined their identity through the organisation
obedience to the
hierarchy. Distinctions can be made between guerrillas and paramilitaries, and yet
general patterns emerge in the organisational structures of these groups. We believe
that in examining this structure, and the lived experiences of the men while part of it,
we are able to achieve a greater understanding of the rules that govern the emotional
responses of the ex-combatants.
The recruitment phase for the guerrilla and paramilitary groups generally
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occurred in two predictable locations: small towns and the marginal zones of a
city (Meertens and Segura 1997, Gutiérrez and Gallo 2000, Pineda and Otero 2004).
Gathering places for individuals consuming illegal drugs were especially favoured as
recruitment sites. In this phase, recruits who showed signs of weakness (a dimension
of strength) or tried to evade service (loyalty) were sometimes assassinated.
The instruction phase varies in length depending on the group, but is usually
anywhere from 2 months to 2 years. In paramilitary groups, the men are given a gun
soon after recruitment and trained in military combat. During the instruction phase,
the importance of not placing trust in others is reinforced (mistrust), as is the tenet
that one must not show weakness (strength), lest they risk being killed. Initiates must
engage in tests or special tasks that demonstrate trustworthiness (obedience to the
hierarchy) and loyalty in front of superiors.
A gradual approach to familiarising oneself with death occurs during the
adaptation phase (strength). The men routinely participate in assassinations and
the manipulation of cadavers. The recruits are organised into ‘cleaning squads’, ‘elite
teams’, ‘extortion squads’ and those responsible for ‘settling accounts’. Often times,
the men must kill others who ‘aren’t working out’; this task can include the
quartering of the bodies (obedience to the hierarchy). Many of the men defended such
actions, maintaining, ‘It’s either me or them’.
Rising through the ranks of the hierarchy is the ultimate goal. At no point is a
soldier exempt from participating in acts of violence, even as a veteran. Veteran
status does accord one more power within the organisation and may be reached
through enduring demonstration of loyalty and an absence of weakness.
The strictly hierarchical structure of the irregular armed groups emphasises
control over the exercise and expression of sexuality. According to men in the
guerrilla groups, a set of rules dictated which days members could have sexual
relations. Furthermore, systematic abortions were forced on pregnant women within
the group. Among the paramilitaries, whose membership is exclusively male, sex is
limited to vacation periods and usually with commercial sex workers. Only the
commandants are allowed to have stable and enduring relationships. As for
homosexual expression, it is expressly forbidden in both types of armed groups.
The experience of isolation and loneliness was central in the men’s narratives.
Such feelings were as much a result of physical separation as from the difficulty of
placing any trust in others. Along with many other Colombians, these men have been
 Global Public Health 227

displaced by the violence within their own borders. Links to their family and region
of origin signify danger, as return would mean putting their own lives at risk as well
as those of their family members (isolation). The men alluded to the notion that
loyalties within the irregular armed groups often organised themselves around region
of origin. In a country where travel within national borders has been greatly
restricted by decades of violence, regional identities remain strong. By choosing to
demobilise, these men have effectively been cut off from their home communities.
Many of these rural areas in Colombia have had a long history of conflicts
involving the civil population, with guerrilla and paramilitary groups claiming
specific territories and thus sharply dividing the country. Everyone must have loyalty
to one group or the other; neutrality can rarely be maintained. Families are often
dragged into situations where family members are kidnapped or assassinated by
these groups. As one former paramilitary recounted, ‘One hundred of us arrived at a
little country hamlet and we overtook it, killing everyone and burning everything
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that belonged to the guerrillas. We killed all of the guerrilla soldiers in front of the
people in order to teach them a lesson. As we were leaving, the guerrillas ambushed
us and killed 50 of my fellow soldiers and mined the fields. I was enraged and so we
returned and punished the people for not having warned us’. The patients related
stories of family rupture that in some cases involved several generations. Traumatic
childhood events further illustrated a history of isolation. According to one patient,
‘When I was six years old, my mother put us on a bus, my four year old brother and
me. I realised she had abandoned us when we reached another town . . . the police
took us to the the Colombian Institute for Family Well-Being (ICBF). They began to
look for a family for us, but I didn’t manage well and instead began working at age
seven. The police told me that someone was going to adopt us and they took me to a
family, but I escaped, I didn’t want to stay with any family, and so I walked all
around and lived in the street’.
A clear feeling of belonging and camaraderie does not exist in the irregular
armed group. Unlike a military organisation sanctioned by the state, where the
company or squadron is recognised for loyalty and unity, the assassination of fellow
members ultimately promotes mistrust, paranoia and isolation. Among these ex-
combatants, no true loyalty is possible within the group, or outside of it. Some of the
men did express, however, the notion that they felt a sense of disorientation after
having demobilised. ‘It was hard for me to leave the organisation, I was already well
known, had control, had respect and fear, when I left I lost everything and that hurts,
I regret having demobilised’.
From the time that they were admitted to the irregular armed group, any
psychiatric manifestations had to be hidden, as showing signs of anxiety or
depression could result in one’s own death (isolation and mistrust). Mental health
treatment, therefore, necessitated a change in paradigm for these men. In this new
setting, participants had to verbalise symptoms as well as peacefully tolerate others.
Acts such as leaving behind one’s gun or learning to be accepted by others without
fear were, therefore, emotionally demanding. Getting more in touch with spirituality
as well as participation in religious events made a marked difference in the group in
terms of their ability to respond to therapy.
In our analysis of these five themes, a very clear picture emerged as to the lack of
initial PTSD symptoms among this population. Within the irregular armed groups,
the consequences of any lack of strength, loyalty or obedience can be summarised as
 228 R. de la Espriella et al.

involving torture and/or death. Despite the emphasis on loyalty, however, a great
deal of mistrust exists on the part of the combatant and he thus experiences an
incredible sense of isolation. The result of this type of socialisation within these
groups is the intentional suppression of the symptoms of PTSD. Yet, given the open-
ended nature of the interviews, and perhaps the fact that they occurred later in the
therapeutic process, they provided an opening for these men to begin to share their
experiences.

Discussion
In the administration of the CAPS interviews, the professionals were able to immerse
themselves in the narratives of these men: their experiences, beliefs, values and
attitudes. In so doing, they came to understand the perceptions of the men towards
the armed organisations, their own treatment at the Clinic, their family and
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themselves (Arroyo Bragas and Valladares Tayupanta 2002, Pineda 2003). This
immersion, as well as the daily interactions with the former combatants that
occurred during the ten-month period, led the authors to reflect deeply on the
experience of trauma and the makings of a PTSD diagnosis.
A diagnosis is useful in that it can serve as a catalyst for change in a systemic
model. The diagnosis is a working hypothesis, which may or may not be ‘true’ and
which is refutable, according to the Popperian approach to science. Far more
important, however, than this notion of a ‘true’ diagnosis, which essentialises an
underlying, unrevealed condition, is the meaning that a diagnosis has for a patient.
In both its symbolic and functional aspects, a diagnosis may be considered useful if it
helps in a patient’s therapeutic process. The initial diagnostic impression was not one
that pointed to PTSD, but the CAPS interviews forced us to confront the notion that
signs of psychological trauma might assume new shapes among this population and
that they might, therefore, be well served by this diagnosis and its ensuing
therapeutic treatment.
A central point we wish to make is that diagnoses often reflect moral categories,
forcing us to additionally consider the biases that the observer introduces. In any
attempt at explanation of this diagnosis, the contribution of various aspects of the
clinical context must also be duly examined. Many images and stereotypes exist
about the members of irregular armed groups in Colombia, owing to the violence in
combat, to which much of the civilian population has been witness. A prejudicial
attitude towards the ex-combatants would, therefore, likely be encountered in any
professional therapy team (Cecchin 1996, Garda 1998).
The clinical team initially assumed a defensive stance against these violent men
known to have committed multiple murders. The explanation most often given for
the absence of PTSD was that these men were antisocial and thus incapable of
remorse. Furthermore, in the beginning of the programme, the men did not exhibit a
critical element contained in the first criterion of the DSM-IV-TR (2000) definition
of PTSD: the emotional response of fear, helplessness and horror towards the
traumatic event(s).
The sentiment of disapproval towards this population was most evident among
administrative personnel. Direct care personnel may have been better prepared, as
they were accustomed to working with the mentally ill, another heavily ostracised
population. Concerns over possible psychological distress among the staff, as has
 Global Public Health 229

been described among persons who have been privy to accounts of extreme violence,
such as judges and priests, encouraged certain precautions. We approached the
CAPS interviews only after extensive training, labouring to ensure the well-being of
those involved with the care of the ex-combatants.
In the first stages of the programme, we saw an increase in ‘code greens’, the
alarm that is sounded in cases of patient agitation. Some personnel recounted stories
of violence that had taken place during these ‘code green’ incidents; later interviews
with others present did not corroborate such events. These examples illustrate the
dangerous and violent ex-combatant as imagined by much of the staff. Such
incidents and perceptions waned over time.
Our thematic analysis of the CAPS interviews allowed us as clinicians to question
our initial assumption that PTSD was not present in this population. In the course of
this reflexive process, we were able to be self-critical not only in terms of our tacit
approval of the diagnostic criteria, constructed within a social context, but also in
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our own biases in approaching the patient population.

By forcing us to be open to alternate manifestations of the symptoms of PTSD,
as well as aware of cultural and clinical bias, the reflexive process allowed for a
reinterpretation of this clinical scenario in which we find that this condition is indeed
present among ex-combatants in the paramilitary/guerrilla conflict. Furthermore,
these men may be particularly vulnerable as a result of the prolonged nature of the
conflict, a circumstance similar to that of the Vietnam War. The initial failure to
diagnose these men with PTSD, as well as any discussion of the trauma suffered,
must be understood in the context of this particular struggle and its immeasurable
effects on Colombian society as a whole. Membership in the irregular armed groups
exposed these men to events that undoubtedly generated an enormous amount of
psychological stress. Their lives were nearly always at risk and they often witnessed
acts that threatened the lives of others. In addition, the patients themselves
perpetrated acts of cruelty and violence upon innocent people. Despite having
committed such acts, however, it is evident that these men were still vulnerable to the
effects of a variety of traumatic experiences.
As we mentioned earlier, in order for treatment to be effective, the men had to
embrace emotional and physical lifestyle changes. For example, the masking of
symptoms was vital while a member of either the guerrilla or paramilitary
organisation; in the psychiatric hospital, it is necessary to express and reflect upon
emotions. If an individual cannot trust anyone and sees enemies around every corner
while in the irregular armed group, then we may contrast this environment with that
of the institution, where trusting and collaborative relationships are essential. In the
irregular armed groups, the consumption of substances is permitted and even
encouraged; in the Clinic, we strive to manage drug dependence, not to mention
setting weapons aside and controlling violent outbursts (see Table 1).
It has been argued in the literature that PTSD may be utilised as a strategic
diagnosis to garner resources, support and compensation (Summerfield 2001). The
authors acknowledge the truth in this assertion, yet we would maintain that ample
evidence of trauma exists in this particular population. In addition, we propose that
susceptibility to PTSD may be increased in these men by virtue of the fact that they
not only witnessed violent acts, but were often responsible for them as well. We must
concur, however, that the linguistic characterisation of PTSD is misplaced
(Hernandez 2002). Noting the prevalence of childhood trauma in this population,
 230 R. de la Espriella et al.
Table 1. Comparison of the principles of the irregular armed group to those of the
psychiatric clinic.

In the group In the institution

Masking of symptoms Expressing symptoms

Isolation and mistrust Working in a group
Substance abuse Sobriety
Guns Unarmed
Violence Living together peacefully

it would be impossible to pinpoint a lone event in the lives of these men that is the
source of their trauma. The issue of causation is equally pertinent: was childhood
trauma the cause of their decision to join an irregular armed group? Is it possible
that men who chose to demobilise suffered more or less trauma than those who
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remain in the group? The measurement tools currently at our disposal are
insufficient to answer these questions. According to Hernandez (2002), ‘Uncertainty
remains about how to conceptualise trauma and its long-term effect after exposure
of whole generations to mass atrocity and the destruction of their social and cultural
worlds’. Furthermore, the suffix ‘disorder’ is an obvious misnomer, as a diagnosis of
PTSD seeks to normalise a psychological response to intense trauma (Hernandez
2002).

Conclusions
The experience of PTSD is enacted among men who have demobilised from irregular
armed groups in Colombia. In the present sample, PTSD was shown to exist in more
than half of the cases (57.14%), but was not diagnosed initially. The demobilised men
have learned not to display symptoms of anxiety, depression or psychosis as a
survival strategy within the armed group and outside of it. Meanwhile, the clinical
personnel exhibited bias that limited their view of the emotional responses of the
men, condemned as morally evil by society.
The diagnostic criteria of the DSM-IV-TR (2000) were not entirely applicable in
the Colombian context. If we agree that the diagnosis of PTSD has undergone
transformation in its definition and clinical criteria, we find that the current criteria
seem insufficient to describe symptoms that must be understood in the complex
sociopolitical context of Colombia. Utilising a constructionist approach, we argue
that a diagnosis may be enacted differently among various actors and observers. The
realm of understanding must be amplified in order to include transcultural
manifestations of this disorder.
A frequent criticism of psychiatry has been the medicalisation and pathologisa-
tion of diverse conditions. While this appraisal is hardly unfair, we must also
consider the occasionally beneficial function of the diagnosis as well. An acknowl-
edgement of the trauma suffered by these men is a step towards reconciliation, if not
absolution. In recognising the suffering of the Other, the search for this diagnosis is
an effort to reabsorb the former combatants into Colombian society as a whole.
Interestingly, at the conclusion of the programme, the clinical staff had started
referring to the participants as ‘good people’ and ‘big kids’. The men were now
 Global Public Health 231

included as those perceived to be victims of the country’s political violence. The

suffering and blame is thus transferred from the site of the individual to that of the
collective national identity. By denying the presence of PTSD, we deny these men
available treatment that will ease the process of their reinsertion into Colombian
society.
Ultimately, more research must be conducted exploring the theme of violence. By
deepening our understanding of men who have been part of irregular armed groups,
we may see them not only as victimisers, but also as victims. The men who
participated in this study are victims of their experiences and conditions of
vulnerability. Those who have engaged in the Colombian armed conflict often
have difficulty constructing a self-image that is positive, creative and free, even once
the reinsertion process has begun.
We must further explore the particular clinical aspects of persons who have
participated in irregular armed groups, recognising clinical variations and associated
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factors that modify the diagnosis. It is necessary to keep in mind that the DSM is a
useful tool, but it is insufficient to capture the complexity of the clinical variations of
PTSD, which may be shaped by the sociocultural context. According to Von Foerster
(1992), in expanding our view, we achieve ‘binocular vision’ of the condition and
avoid the blind spots. By working through the issues presented by the social
reinsertion of demobilised guerrillas and paramilitaries in Colombia, we can avoid
their re-marginalisation as a result of an untreated diagnosis.
The importance of managing these cases, while maintaining the security of the
personnel who work with and research the phenomenon of violence, cannot be
overemphasised. Not only must their physical safety be ensured, but they must also
be protected from the emotional damage potentially wrought in hearing stories of
extreme violence.
The present study shows that belonging to irregular armed groups can be an
attractive option for men with histories of isolation, abandonment and poverty.
These groups provide them with a feeling of belonging, an image of strength and
power through violence. We therefore must address the structural conditions of
poverty in Colombia that ensure social marginalisation. Until this time, the
reinsertion programs will continue to be a stopgap measure for a phenomenon
that ultimately must be confronted at its root.

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