Psychiatry, Politics and PTSD

Breaking Down

Janice Haaken

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9780367819385
• eBook ISBN: 9781000094091
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Integrating critical and feminist psychology, psychiatry, and psychoanalysis, this text offers a distinct perspective of posttraumatic stress disorder (PTSD) as a clinical and social phenomenon.

The book draws upon interviews carried out in field settings to examine the true individual and social costs of being diagnosed with PTSD. The author examines how social contexts and social movements shape diagnostic thinking about mental trauma and how the PTSD diagnosis emerged as a symptom of a crisis in psychiatry over demands to recognize the social and political origins of mental suffering. Chapters explore case examples from a range of settings, such as military and veterans' affairs clinics, war zones and refugee camps, psychosomatic medicine, the criminal justice system, and more.

Providing a new way of thinking about PTSD and an alternative to both critics and defenders of the diagnosis, this text will be useful for scholars and practitioners in psychiatry, psychology, psychoanalysis, public health policy as well as, sociology, social work, gender studies, and the law.

Chapter 1

Listening to Distressing Stories

How people integrate a terrible experience into their sense of self is a complex process. My own mother taught me as a young girl that it is better to be killed if you are raped. In her Christian worldview, it was better to die in purity than to live in sexual defilement. The women’s movement of the 1970s organized to resist both rape and the stigma of rape—the idea that survivors were morally contaminated or “damaged goods.” Yet filing charges against perpetrators through the courts often requires establishing damages or personal injury—a legal process that makes it difficult to prosecute an injustice without establishing that one has been psychologically impaired by the experience.

As a feminist and psychoanalytic clinician, I listen for these cultural echoes in how women talk about experiences of sexual assault. I recall a woman who came to see me years ago with a fairly common concern of women in their 30s. She wanted to get pregnant and have a child but was struggling with a reluctant and emotionally distant boyfriend. He seemed to have commitment issues. He had recently ushered her through a tour of the house he had purchased without her having seen the place. Additional signs pointed to poor prospects with this man: He was content with their weekly rituals of take-out dinners followed by tepid sex; he had no interest in having a child (although vaguely open to the possibility down the road); and an old girlfriend served as his general life advisor. Over the first six months of therapy, we explored her history of intimate relationships and what she experienced as her own disturbing lack of sexual desire, in palpable contrast to her growing longing for a baby. In one session, my patient described being a victim of rape several years prior. She had been working as a stripper at a local club and a customer followed her home. The man had crawled through her bathroom window, ripped off her skirt and raped her on the floor, then fled through the front door. She called 911 and the police arrived and took her report. She had no memory of the rapist’s face, only recollections of the sickening smell of beer and the weight of his sweaty body on her frame and his penis jamming inside her. A police report was filed but my patient chose not to pursue the investigation.

As she described the events of that night, her account of the rape was bound up in her experience of working at the club. She had played over and over in her mind the sequence of events. As a pole dancer, there were rules for touching, and she did exercise control over customers. But there was always this uneasiness she felt driving home, wondering if something like this might happen. Shortly after the rape, she quit her job at the club and moved in with her parents, neither of whom knew she worked as a dancer. As we spoke about the rape, I was aware of her searching my face and looking for signs of disapproval. Would I place her in the same line-up of morally suspect victims to which the police seemed so ready to assign her in their questioning? Would I share the imagined reproaches of her parents? This rape did have a profound and lasting effect on my patient. Her suffering was heightened, however, by the disdainful attitude of the police and her aching aloneness at the time. In subtle ways, she had structured her daily activity to minimize situations that might remind her of the hideous residue of this man. Over the course of her therapy, the rape became part of her larger life-narrative.

PTSD treatments center on emotionally processing a memory—the Criterion A of the diagnosis thought to be the cause of the disorder. The question of whether my patient met the criteria for PTSD was not at issue in her therapy since her initial diagnosis of depression—dysthymic disorder—still described her symptoms. And she had not applied for victims’ benefits through the state—a program that covers counseling and can require establishing a diagnosis of PTSD. A paradox of PTSD treatment, however, revolves around its tendency to reproduce a dynamic where the abuser remains at the center of the stage. Bessel van der Kolk (2015), for example, cautions that

if a person does not remember, he is likely to act out: he reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.

(p. 183)

In this chapter, I show how the process of acting out—of unconsciously converting a conflict into modes of containing the conflict—applies as much to the clinician as it does to the patient.

All diagnoses carry the subjective judgments of the clinicians that assign them. They are shaped by countertransference reactions—responses to the patient based on associations with psychologically meaningful experiences in the therapist’s own past. Just as the patient engages in transference reactions, so too does the therapist. But these judgments are mediated both by the professional culture that guides clinical thinking as well as through the dynamics of the therapist’s personal history. In addition, as psychoanalyst Lynne Layton (2015) explains, clinical interpretations include unconscious identifications with the dominant culture and its ruling ideologies. One of those ideologies centers on over-investment in the power of the “talking cure” itself—the belief that emotional suffering is largely an individual problem requiring individual interventions. For clinicians working in institutional settings, whether state hospitals, the courts, schools, Veterans Administration, or the active military, the constraints on their own therapeutic powers and the range of individual choices available to their clients are palpably present. My interest has been to understand how clinicians in these settings use the PTSD diagnosis to manage those constraints.

Clinical Storytelling

The DSM-5 (American Psychiatric Association, 2013) comments in its introduction that “we have come to recognize that the boundaries between disorders are more porous than originally perceived” (p. 6). The job of the clinician is to discern a picture within those porous boundaries. And although the diagnoses are partly based on statistical analysis of aggregate data, the practitioner sees one person at a time and hears one story at a time. In using the manual as a guide, practitioners must turn from the distressed person before them to the 950-page manual on the shelf and leaf through the hundreds of options available for classification. For clinicians seeking to determine if the symptoms map onto the PTSD criteria, the ideal prototype is the person who presents with a story of a life-threatening recent event and reports how this event continues to preoccupy the person and interfere with functioning. As Richard McNally (2009) concludes in distilling the clinical essence of PTSD, the memory of the traumatic event is the “heart of the diagnosis” (p. 599).

In some institutional settings, PTSD signifies more of an attitude toward a patient than a diagnostic procedure. Most patients at the state hospital where I carried out interviews have histories of significant trauma, much of which is documented in charts filled with heartbreaking stories. But the daily reality is that the patients are prisoners confined to this institution because they have committed serious crimes. Conflict over their own dual roles as therapists and prison guards repeatedly arose in the course of making Guilty Except for Insanity (Haaken, 2013), a film about patients entering the Oregon State Hospital (OSH) through the insanity defense. In one scene in the film, staff are demonstrating how to administer five-point restraints in a way that conforms to legal and ethical standards. A high rate of using physical restraints on patients is an indicator of a poorly run psychiatric hospital. Staff at OSH took considerable pride in keeping rates of restraints low, even though staff defended the use of the practice with violent patients. In the film scene, four staff members surrounded the gurney to demonstrate how the restraints work. In the course of the scene, one of the nurses commented that “often patients come into the hospital with PTSD issues so you want to be respectful of their boundaries and the potential for triggering past trauma in holding them down. It can feel like an assault.” She was part of a group at the hospital pushing for more trauma-based care—an approach that acknowledges how the institution and treatments administered can be traumatic for some patients.

In this demonstration of restraints, PTSD was invoked as a reminder that patients bring into the hospital histories not of their own making. This diagnostic lens provided a humanizing view of the resistive patient. Although admitted under the insanity plea, these patients were also viewed as victims of a mental illness. The evaluation process centers on determining whether the person is able to conform their behavior to the requirements of the law and whether a “mental disease or defect” impairs this capacity. By reminding co-workers that “this person may have PTSD issues,” the staff member introduces a caveat. Restraints are acknowledged as potentially traumatizing. At the same time, the conflict over the harmful effects of restraints is externalized. The trauma is represented as an effect of the patient’s past rather than as embedded in institutional practices. Further, invoking PTSD introduces a form of institutional splitting—avoidance of anxiety by keeping separate the two elements of a conflict, in this case the trauma produced through the restraints and the trauma that patients bring through their histories. The conflict associated with restraints is managed through separating patients into those vulnerable by way of their PTSD histories and those who are not vulnerable and thus evoke less concern.

Much like staff at the OSH, clinicians in the Veterans Affairs system are located at a site where they face conflicting pressures to both recognize the effects of warfare and bring these effects under control. Clinicians I interviewed in the course of my field work were keenly aware of their roles in managing a growing mental health crisis related to over a decade of ongoing and open-ended warfare. Therapists were under pressure to treat and prevent PTSD and other mental health disorders, while also maintaining the fighting forces (J. Sardo, personal communication, June 8, 2011; Russell, Schaubel, & Figley, 2018). Furthermore, the US Department of Defense and the VA system have emerged as primary sites for destigmatizing mental health problems, particularly through campaigns focused on recognizing symptoms of PTSD.

Diagnostic Disputes

This book situates PTSD in the context of a crisis in psychiatry over its responsibility to intervene in socially produced suffering. Although the mental health field encompasses a wide range of disciplines and applied practices, the American Psychiatry Association, as author of the DSM, holds the leading role in developing a taxonomy of mental disorders. The anti-psychiatry movement of the 1960s and 1970s, along with the feminist and anti-war movements, took aim at psychiatry for its failure to address societal factors in the development of clinical syndromes and its collusion in the very problems that the profession claims to alleviate. In advancing this critique, British psychiatrist David Cooper (2001), an early leader in the anti-psychiatry movement, describes the treatment of people hospitalized “with what is called a ‘schizophrenic breakdown’ ” and how psychiatry as a profession is “co-operating in the systematic invalidation of a wide category of persons” (p. xi). This early critique centered on the position of psychiatric hospitals in the institutional control over behaviors cast as deviant. But as the PTSD diagnosis gained official recognition, it became symptomatic of a wider crisis in psychiatry over its role in the social management of suffering. Part of this crisis centered on challenges to culturally hegemonic notions of normalcy, and of the role of psychiatry in codifying differences between variations along a continuum of normalcy and behaviors that cross some threshold into mental pathology.

The PTSD movement generated adherents in the late 20th century through its insistence that normal people can appear quite mentally disturbed when confronted with extreme situations (Herman, 1992; Litz et al., 2009). The question of what constitutes “normal experience” has generated considerable ongoing debate, however, in the wake of PTSD’s entry into the DSM (Brewin, Lanius, Novac, Schnyder, & Galea, 2009; Malik & Beutler, 2002). The diagnosis presupposed a circumscribed event that departed from some idyllic conception of normal life. The initial model was also based on exposure to events bound in time and place. Critics pointed out the class and race premises of the diagnoses and posed further questions: Is living in a violent household a normal experience? What about homeless people or those living under police-state conditions in cities or asylum seekers along the US/Mexico border? Who defines departures from normalcy? And what about military forms of PTSD where soldiers are serving multiple deployments over many years? Even in the PTSD prototypes of war and rape, the diagnosis tended to focus on a dramatic story based on a single event.

PTSD stands alone in the DSM as a disorder defined by its cause. It developed as part of a campaign initiated by anti-war clinicians and veterans’ groups to address the long-term consequences of warfare. Yet the question of etiology—how to identify the cause of a disorder—remains one of the more elusive controversies in the field of psychiatry (Brewin, Andrews, & Valentine, 2000; Brunner, 2000; Davidson & Foa, 1993; Hurst, 1917; Kinzie & Goetz, 1996). Although uncertainties over causality underlie the entire system of psychiatric classification, PTSD became a lightning rod in the late 20th and early 21st centuries for this seemingly intransigent problem. Humans gather up a vast array of formative experiences over time that shape the clinical picture. Indeed, the push in the PTSD field to develop procedures for identifying Criterion A—the “index trauma”—proceeded out of step with the larger trend in psychiatry toward recognizing multiple etiological factors. Research on genetics points to a complex web of determinants that contribute to mental disorders, and to the hundreds of genes that may play a role. The genome project fell short of expectations in the 1990s in clarifying these muddy etiological waters (Koenen, 2007; Yehuda, 2006). As DSM Work Group members Robert Spitzer and Michael First (2005) confess in summarizing the work of the fourth edition of the manual:

Little progress has been made toward understanding the pathophysiological processes and etiology of mental disorders. If anything, the research has shown the situation is even more complex than initially imagined, and we believe not enough is known to structure the classification of psychiatric disorders according to etiology.

(p. 1898)

This proclamation attests to the limits of psychiatry’s claims of direct parallels between mental and physical illness as well. There are no consistent biological markers or tests for most mental disorders (Kleinman, 2012; Yehuda, 2006). The disorders are based on groupings of behavioral indicators, many of which would not be considered pathological in a different cultural or historical context (Good, Good, Hyde, & Pinto, 2008; Kleinman, 2011). In a sense, all mental disorders are syndromes—a term that admits to limited knowledge concerning underlying etiology of observed signs and symptoms. Even the term disorder, which replaced the less clinical term reactions in the first versions of the DSM manual, signifies the murky linguistic terrain of psychiatry. Disorders are not diseases in the medical sense, but they do point to deviations from normalcy. Since mental health professionals differ widely in the theories o...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• 1 Listening to Distressing Stories
• 2 Trauma and Troubled Personalities
• 3 Psychic Trauma and the Body
• 4 Distressing and Disabling Conditions
• 5 Suffering Together: Group Responses to Trauma
• Conclusion
• Index