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Trauma as Disease and Trauma as History

© John H Ehrenreich, 2002

In the wake of the events of September 11, psychological “traumatization” became a household word. Newspapers and magazines, television and radio shows carried stories on the psychological effects of terrible events, on symptoms parents might expect to see in their children and in themselves, on advice as to how to deal with trauma. Mental health workers –psychiatrists, psychologists, social workers, marital and family counselors --- rushed to provide information and services to the public. For some, especially those living in and around New York City, this meant direct involvement in providing disaster services to rescue workers, to victims, and to victims’ families. Others, all over the country, wrote articles for local newspapers made presentations at local schools, provided “debriefing” sessions for local employers, and responded to their own on-going patients’ increased levels of fear and anxiety.

As mental health workers rushed to respond to the psychological effects of an act of politically-inspired terrorism, the content of their response was shaped by the extensive knowledge and experience gained over the last two decades in treating victims of a variety of kinds of traumatic events, including veterans of combat in Vietnam, rape victims, survivors of motor vehicle accidents, survivors of childhood physical and sexual abuse, victims of natural disasters, refugees from ethnopolitical warfare, and rescue workers responding to airline crashes. Two different models of traumatization shaped their responses: traumatization as mental disorder (the “psychiatric” or “biomedical” model) and traumatization as “normal” response to extreme events (e.g., the “disaster response network” model). This article will suggest that a third model, the “psychosocial”  model, although less explicitly articulated, is also beginning to shape contemporary understandings of trauma, and will seek to explore some of the tensions between these alternate conceptualizations of trauma and discuss some of their implications for future responses to trauma.

The Three Traditions of Trauma Response

            Responses to catastrophic events, whether experienced by individuals or by large groups of people simultaneously, have been conceptualized in several ways. (For the sake of clarity, these will be treated as distinct traditions, although, in fact, they overlap extensively).

The biomedical (psychiatric) model

Most familiar to most mental health workers is what might be called the “biomedical” conceptualization: At risk of oversimplification, this holds that, in the wake of horrendous events, many people develop a long term mental disorder. Although presaged in early twentieth century notions of “shell shock” or “combat neurosis,” it was not until the 1980 publication of the DSM-III (American Psychiatric Association, 1980) that it was formally introduced to the psychiatric and psychological community as “Post Traumatic Stress Disorder.” In subsequent editions of the DSM, the precise criteria for PTSD were modified and a new category to describe short term responses to traumatic stress, “Acute Stress Disorder,” was added, but the broad conceptualization of PTSD has remained unchanged.

The essential feature of PTSD, as defined by the DSM-IV (American Psychiatric Association, 2000) is the development of characteristic symptoms (reexperiencing, avoidance or numbing, hyper arousal) following exposure to an extreme traumatic stressor. Other symptoms that may follow exposure to an extreme stressor, such as painful guilt feelings, dissociative symptoms, impaired relationships with others, and impaired affect modulation, and other psychiatric disorders, such as Depression, Substance-Related Disorders, and Generalized Anxiety Disorder, are described as associated or co-morbid phenomena. Having defined PTSD, the door is opened to studies of the epidemiology of the disorder (including cross-cultural studies), pre-disposing conditions (e.g., pre-morbid personality patterns, genetic factors, the nature of the traumatic event, itself), and underlying biological and psychological mechanisms. Various approaches to treatment (e.g., medication, prolonged exposure to environments containing cues that remind the victim of their experience, cognitive behavioral techniques to facilitate recall and reintegration of traumatic memories) can be assessed in terms of their effectiveness in reducing the component symptoms of PTSD.

The establishment of PTSD as a formal diagnosis was, in many respects, a highly progressive step. As Herman (1991, p. 116) pointed out, “the tendency to blame the victim has strongly influenced the direction of psychological inquiry.” Researchers and clinicians sought explanations of perpetrators crimes in the behavior of the victim. Rape victims had “asked for it;” war veterans’ shell shock was due to preexisting personality defects or moral weakness; battered women were “masochistic.” The establishment of PTSD as a diagnosis explicitly linked the symptoms of the sufferer to a history of horrendous experiences. This resituated the sufferer, as victim rather than as co-creator of his or her own suffering, and simultaneously alerted mental health clinicians to explore possible traumatic causes of the component symptoms of PTSD.

A number of writers (e.g., Herman, 1991) have pointed out that the DSM notion of PTSD is based on the responses of victims of circumscribed traumatic events (e.g., motor vehicle accidents, relatively short periods of military combat, natural disaster, rape). In survivors of more extreme and/or prolonged and/or repeated traumatization (e.g., sustained childhood sexual abuse, confinement in a concentration camps, torture), the symptom patterns observed are more complex. Alterations in affect regulation, transient dissociative episodes, alterations in self-perception, alterations in relations with others, and alterations in systems of meaning, such as loss of religious faith, are common. Conceptualizing these as “associated” symptoms or “co-morbid” disorders fails to capture the totality of the symptom pattern.

Herman proposed that this constellation be given a distinct DSM categorization, as “complex post traumatic stress disorder.” As with the original establishment of PTSD as a formal diagnostic category, she argued, establishment of the new diagnosis would re-make the connection between the patient’s present symptoms and the traumatic experience and would help prevent mislabeling victims in pejorative ways (e.g., as having a “personality disorder”). In addition, linking a specific diagnosis to the experience of extreme, repeated, and prolonged traumatization would help clinicians distinguish between the distinctive anxiety, phobias, panic, depression, and somatic symptoms of survivors and “ordinary” anxiety, phobias, panic, depression, and somatic symptoms. It also suggests the centrality of therapeutic goals such as reestablishing connection with others, and reempowering the self. With this addition, responses to trauma would be understood “as a spectrum of conditions rather than as a single disorder,” ranging from “a brief stress reaction that gets better by itself and never qualifies for a diagnosis, to classic or simple post-traumatic stress disorder, to the complex syndrome of prolonged, repeated trauma” (119). Herman’s proposed “new diagnosis” was not accepted by the preparers of the 2000 (DSM-IV) edition. For present purposes, however, it should be noted that even Herman’s expanded notion of post traumatic reactions understands the “symptoms” of the victims as evidence of a “disorder.”

The Disaster Response Model

A second, rather different approach to understanding the effects of horrendous events comes from the disaster response literature. The disaster response model is conventionally seen as rooted in three traditions: the “crisis intervention” model stemming from, among other sources, Lindemann’s (1946) account of the Coconut Grove nightclub fire in Boston; sociological studies of natural disasters such as the 1972 Buffalo Creek, West Virginia floods (Erikson,     ),  and the literature on stress and coping (e.g., Lazarus, and Folkmann, 1984).

In this model, the symptoms of traumatization are understood, in their inception, at least, as “normal” responses to extreme stress.  “Hyperarousal” represents a heightened sensitivity to potentially threatening events; “numbing” an emotional shutting down to avoid being overwhelmed. A normal sequence of responses to horrendous events can then be described. Very immediately after the traumatic event, there may be a period in which victims appeared dazed, confused, apathetic, numb, or alternatively, hyperaroused or anxious. Once the immediate crisis has stabilized, a wide variety of post traumatic symptoms may appear, including grief, depression, anxiety, feelings of helplessness, suspiciousness, sleep disturbances, irritability, restlessness, moodiness, difficulties concentrating, somatic complaints, intrusive thoughts, problems in interpersonal functioning, to name but a few (to which no response or delayed response might be added).

For most survivors, these symptoms gradually fade, but in a not insignificant minority, they persist. When they do so, they may (or may not) meet the patterns of PTSD or of an “abnormal bereavement” syndrome or of “post-traumatic depression” or of generalized anxiety disorder or, in non-Western cultures, they may take the form of what the DSM calls a “culture bound syndrome” such as susto (Latin America), ataques de nervios  (Caribbean, Latin America) dhat (India), or latah (South Pacific, Southeast Asia).  PTSD and the other post traumatic syndromes are thus understood as aberrations, failures to resolve normally resolvable responses.

This shifts the burden of intervention from treatment to prevention: Can we, through some set of interventions, prevent the progression from “normal” responses to disaster to “abnormal” responses? A number of approaches to early intervention have been proposed. They have a number of underlying principles in common. As elaborated by Ehrenreich (2001), these principles include:

  1. The “hierarchy of needs:” Physical safety and material security are prerequisites for people to regain a stable mental state. For this reason, the mental well-being of rescue and relief workers, which is essential in enabling these workers to meet the basic needs of victims, and a psychologically appropriate organization of shelters, family aid centers, and the like are very high priorities, even from the perspective of direct victims of the disaster.
  2. The presumption that powerful emotional responses to horrendous events are normal, not a sign of mental illness or weakness: Individuals have natural healing processes. The central task of intervention is to elicit, facilitate, and support these healing processes. Interventions may focus on reducing psychological arousal and anxiety, restoring social support systems, and helping victims regain a sense of control.
  3. The kinds of preventive responses that are helpful change over time: Immediately after a disaster, services for rescue and relief workers and providing direct, concrete relief for victims are essential. Mental health services for primary victims (except for “psychological first aid” for those whose emotional responses prevent them from cooperating in obtaining their basic needs) are less critical and, indeed, cognitively complex interventions may be useless. Later on, aggressive outreach services may be called for. Focus on identification of those at risk for more lasting adverse psychological effects and on interventions to reduce the risk become central.
  4. Direct interventions with individuals also have an underlying logic: People need to make sense of their experience, and talking, drawing, making music, or engaging in spiritual exercises may assist them in this. They need to feel empowered, to regain a sense of control over their life and fate. They need to be reassured that their responses are normal, not signs of “going crazy.” They need to reestablish systems of social support. And they need to reconnect to their communities.
  5. Not everyone or every group has the same needs. Interventions of all sorts must take culture into account. Groups such as women, children, the elderly, and those with physical, mental, or emotional disabilities may have special needs.     

In many respects, the disaster response model appears to have been the dominant model presented by the mass media and embraced by many mental health practitioners in the days following September 11. One issue that emerged, however, the efficacy of early intervention in preventing PTSD, underlines the difference between the medical model and the disaster response model. Shortly after September 11, several eminent PTSD researchers ( Foa et al, 2001) raised questions about the use of “debriefing” and its variants as an early intervention. Debriefing” (or, more formally, “critical incident stress debriefing”) is a procedure developed by Mitchell (1983) and his associates as part of a larger program of interventions to deal with the traumatic stress predictably encountered by emergency workers such as policemen and emergency medical technicians. The core of the procedure consists of structured group discussions of the traumatic experience and of people’s reaction to it. It allows people to share powerfully charged feelings of anger, helplessness, or fear in a way that helps defuse them. It reduces isolation. It helps people create a narrative of their own experience.

Research as to its effectiveness has been equivocal, however (see Raphael and Wilson, 2000). For example, in several studies, although disaster victims offered debriefing had no better outcome in terms of reduction in the component symptoms of PTSD, yet majorities of those who had undergone debriefing described it as having been helpful (Rose & Bisson, 1998).  Although a wealth of methodological issues bedevil the research, part of the disparity may lie in the question of “helpful for what?” From the medical model perspective, prevention of PTSD or reduction in existing symptoms of PTSD (re-experiencing, numbing and avoidance, hyperarousal) is the appropriate criterion. From this perspective, debriefing and its variants may be ineffective. From the disaster response model perspective, the ability of victims to function or to tolerate their distress or to be free from such not easily measurable symptoms as “spiritual emptiness” may be more appropriate criteria and the conclusions may be very different.

The Psychosocial Model        

The biomedical model and the disaster response model take the individual response to horrific events as their starting point. Social processes are not entirely ignored, of course. The role of social supports in preventing PTSD and the impact of community disruption in prolonging and exacerbating the adverse effects of disaster are well known. But the core argument of both models is that traumatic events represent an adaptive challenge for individuals, which they may or may not be able to meet.  A third approach to understanding the impact of horrendous events, less clearly articulated in the American context, takes social experience and shared history as starting points. Traumatic events happen not to isolated, abstract individuals but to individuals who are part of a particular community in a particular society and who live at a particular historical time. 

Just as the shift from the accepted biomedical approach (PTSD) to “complex PTSD” is tied to a shift from a focus on circumscribed experiences of trauma to a focus on more sustained or repeated traumatic events, the shift to the psychosocial viewpoint is facilitated by a shift to a focus on some of the characteristic forms of traumatization of the late twentieth/ early twenty-first century: ethnopolitical violence, civil war, massive brutalization of civilians, and terrorism. (The shift is, in fact, from traumatic events that are experienced individually to those that are essentially social in their impact). The events of 9/11 fit well.

To start with, from this perspective, the response to terrible events that we call “PTSD” is itself seen as situated historically and politically. PTSD is usually described as if it is an essential and universal response of human beings to traumatic events. In fact, Bracken (1998) has argued, PTSD has not simply always existed, waiting to be “discovered” by psychiatry. It emerged over the last hundred years or so, not as a discovery, but as “something created by psychiatry at a particular historical and cultural moment” (p 39; emphasis added).

“The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented, and by the various interests, institutions, and moral arguments that mobilized these efforts and resources (Young, 1995, p. 5).

The Western concept of PTSD, Bracken, continues, is based on a strongly approach to human life in which the intrapsychic world is seen as primary and society is seen as simply a collection of separate individuals. In much of the world, however, the self is seen as consensual, sociocentrically oriented, defined more by relationships and specific social situations than by private consciousness (Kleinman, 1987). To perceive response to trauma as individual (or social responses as simply the sum of individual responses) is to minimize local traditions of illness, the social creation of meaning, healing rituals, and social sources of resilience. The social and cultural contexts in which people experience and (hopefully) recover from traumatic events are ignored. To situate individual recovery from trauma in social context rather than as an individual task explicitly links it to such issues as social reintegration and reconstruction in  the wake of war or natural disaster, bringing perpetrators of violence against individuals and communities to justice, and promoting social reconciliation between previously antagonistic groups. 

            Judith Herman’s (1992) seminal book, Trauma and Recovery situated the growing understanding of psychological trauma in all its manifestations in the United States, historically. Herman noted that both witnesses to violence and, especially, perpetrators of violence have a strong interest in “forgetting” what happened.

To hold traumatic reality in consciousness requires a social context that affirms and protects the victim and that joins victim and witness in a common alliance. For the individual victim, this social context is created by relationships with friends, lovers, and family. For the larger society, the social context is created by political movements that give voice to the disempowered… The systematic study of psychological trauma therefore depends on the support of a political movement. (p. 9).

In fact, she pointed out, the body of knowledge about the psychological effects of violence has been periodically forgotten and rediscovered. She attributed the rediscovery of trauma in the 1970s (which culminated in the introduction of PTSD as a diagnostic category in DSM-III in 1980) to two political movements: The movement against the war in Vietnam (and especially of Viet vets themselves) “made it possible to recognize psychological trauma as a lasting and inevitable legacy of war” (p. 27).  Almost simultaneously, the women’s liberation movement rediscovered the psychological consequences of rape, and then of spousal abuse and sexual abuse of children. And by the early 1980s, “[it became] clear that the psychological syndrome seen in survivors of rape, domestic battery, and incest was essentially the same as the syndrome seen in survivors of war” (32)

Situating much of what we call “traumatization” in horrific events created by and, to some extent, controllable by people  - rape, war, child abuse, torture – reconceptualizes treatment, much as did Bracken’s and Young’s historical situating of PTSD. Self help groups, “consciousness raising” groups, community organizing and political activity aimed at changing social mores (with respect, for instance, to date rape or wife battering) move to center stage, ahead of “treatment” of the (individually conceptualized) victim.

The Current Status of the Study of Psychological Trauma

Herman’s analysis of the social roots of modern concern with psychological trauma led her to a final question: Might these insights be lost again? “At the moment,” she wrote, in 1992, “the study of psychological trauma seems to be firmly established as a legitimate field of inquiry… [E]ach month brings forth the publication of new books, new research findings, new discussions in the public media… But history teaches us that this knowledge could also disappear. Without the context of a political movement, it has never been possible to advance the study of psychological trauma” (p. 32).

To anyone who has recently attended a psychological conference or who reads even casually in the current psychological, psychiatric, and social work literature or who follows the mass media treatments of traumatization in the wake of 9/11, Herman’s concern may seem foolish. Although the political movements that forced the understanding of psychological traumatization into public awareness may have faded, PTSD is enshrined in the DSM. Each month still “brings forth the publication of new books, new research findings, new discussions in the public media.” There is certainly little danger of the idea of trauma being “lost” again, in a literal sense. Yet the discussion above of the three models of psychological traumatization suggests a more subtle version of Herman’s concern: Might research on trauma and its dissemination continue at a rapid pace yet Herman’s core insight, that “the study of psychological trauma is an inherently political enterprise because it calls attention to the experience of oppressed people” (Herman, 1997, p. 237) be forgotten?

            Two observations may be relevant: Over the last two decades, the trauma field has become “professionalized.”  It has spawned its own professional societies (e.g., the International Society for Traumatic Stress Studies), several graduate training programs, a “consensus statement on early intervention in the wake of mass violence (Ritchie, 2001), a set of “Standards for International Trauma Training Programs” (ISTSS, 2001), and demands that early intervention be based on “evidence based programs” (Bisson, 2001).   Research has proliferated: Entering “PTSD” as the keyword for a PsychInfo search generates references to no less than 2658 articles and 76 books for the years 1995-2001 alone! The concept of “psychological traumatization” has been extended to populations far removed from the combat veterans and rape victims of the 1980s – to victims of motor vehicle accidents, recipients of grave medical diagnoses, surgery “survivors.”

            At the same time, the validity of the biomedical model and even of the disastger response model of response to traumatic events has come under severe challenge. A growing number of clinicians have become concerned with designing programs to help relieve psychological trauma in less developed countries struggling with the residues of war and poverty. In these contexts (e.g., Rwanda, Bosnia, East Timor), issues of ongoing ethnic violence, concrete needs for jobs and health care and housing, social reintegration and reconciliation may dwarf “emotional” issues. Although “traumatization” may be widespread, symptom presentations rarely resemble (or are limited to) PTSD or even “complex PTSD). More commonly, traumatized individuals seek help for somatic symptoms or marital conflict or dissociative symptoms, while local observers perceive the primary consequences of traumatization to be increased levels of minor interpersonal conflict, widespread apathy, increased drug and alcohol use, marital breakdown, and violence directed at women and at children. Yet, despite the exposure of the majority of the population in some countries to traumatic events, most people remain able to function and “life goes on.”

Still other clinicians have found themselves treating refugees from political violence now living in the United States. Here, too, issues of powerlessness, of bodily representations of emotional and physical suffering, of the cross-cultural “meaning” of symptoms, of transgenerational transmission of the psychological effects of trauma may seem more relevant than the DSM criteria or “manualized,” “empirically validated” treatments for PTSD.

            The simultaneous professionalization of the “trauma world” and challenges to the core concepts on which it is based may have a number of negative consequences for the field as a whole.

  • As professional trauma scholars lose sight of the political dimension of trauma, the risk of their conflating very different phenomena, each worthy of study in its own right, grows. When motor vehicle accident victim and rape victim, hurricane survivor and civil war survivor are equated because both have “flashbacks,” the essential nature of the experiences of each may be lost.
  • An overly narrowly focus on PTSD symptoms may lead to missing the impact of trauma -- even individual trauma — on the community. For instance, a recent study found that more than eight per cent of substance abuse disorder in the United States, eight per cent of current divorce or separation, and twenty-one per cent of current spouse or partner abuse were attributable to combat exposure of U.S. men, either directly or mediated by the development of PTSD (Prigerson, Maciejewski, &Rosenheck, 2001).
  • Conversely, one of the great puzzles of trauma studies is why some people develop PTSD after exposure to a traumatic experience, while others, exposed to the same events, do not. This could be called the issue of “resilience” in the face of trauma.  From the standpoint of studying PTSD in individuals, this can only be explained in terms of differences in genetic makeup, personality, coping mechanisms, social support, and similar variables. Yet the ability of millions of people in poorer countries to function, despite histories of extreme traumatization, suggests that social and cultural processes may play a key role in creating resilience.

Although mutual isolation of these two poles of trauma-related activity from each other may impoverish each, in the real world, they actually compete. Money for PTSD research is plentiful, driven, no doubt, by the high lifetime prevalence rates of PTSD. Money for community mental health programs for victims of domestic violence or for long term treatment of impoverished victims of torture abroad is harder to come by, and funds for training programs to help deal with the consequences of psychological traumatization in the developing countries is not even on the radar screen. “PTSD” has triumphed, yet the victims of traumatization, in the broader sense, are once again divided into the deserving and the undeserving. To the extent that the “professionalization” of trauma has ignored the experience of oppressed people – of the victims of ethnic cleansing, of mass rape, of torture, of “disappearances” – the study of trauma has been truncated and the central insights of an earlier generation of trauma scholars has been lost.

Explanations for this shift in trauma studies are not hard to find. The social movements that engendered the rediscovery of trauma have, in large measure, subsided or turned their interests to promoting the advancement of individuals rather than transforming society. After the seventies, the American political pendulum swung away from the idea that the government had a central role to play in resolving social issues and funds for community mental health programs declined. On a world scale, the end of the Cold War and the decline in movements for social justice, along with the corruption and the repeated failures to promote economic development led to a precipitous decline in foreign aid and to “donor fatigue.”  At home, intense competition for a diminished pool of mental health care dollars (exacerbated by the spread of managed care) led to intense competition among the mental health professions; science, rational systems of diagnosis, and monopolies over “empirically validated” treatments became tools in this struggle.

Yet at the same time, “globalization” and the spread of free market capitalism have helped trigger massive immigration. The end of Cold War rivalries removed a brake on ethnopolitical warfare. Widespread global unrest, whatever its causes, has produced a public familiar with ethnic cleansing, mass atrocity, the breakdown of the distinction between combatant and civilian, the rise of mass rape as an instrument of war. One consequence has been a growing human rights consciousness. And, with the events of September 11 has come the realization that America, too, is part of that world in which mass atrocities occur. Both poles of the contemporary understanding of trauma have been strengthened.

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