Trauma, Ethics and the Political Beyond PTSD

The Dislocations of the Real

G. Bistoen

• Publisher: Palgrave Macmillan
• Year: 2016
• ISBN:
  9781137500854
• Topic: Psychology
• Subtopic: Personality in Psychology
• Index: Psychology

The contemporary psychiatric approach to trauma, encapsulated in the diagnostic category of PTSD, has been criticized for its neglect of the political dimensions involved in the etiology and treatment of trauma. By means of a philosophical and psychoanalytical analysis, the depoliticizing potential of the biomedical approach is tied to a more general 'ethical crisis' in post-traditional societies. Via the work of Lacan, Žižek and Badiou on the act and the event, this book constructs a conceptual framework that revives the ethical and political dimensions of trauma recovery.

Part I

The Biomedical Approach to Trauma and the Ethics of Human Rights

1

Individualization, Decontextualization and Depoliticization in the Biomedical PTSD-Approach to Trauma

The feminist trauma theorist Judith Herman was amongst the first to insist, in Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political Terror (1997), on the necessity of a political movement alongside the practices of studying and treating psychological trauma. She argues that ‘advances in the field occur only when they are supported by a political movement powerful enough to legitimate an alliance between investigators and patients and to counteract the ordinary social processes of silencing and denial’ (p. 9). In this sense, Trauma and Recovery is itself a political book: it starts from the controversial thesis that mechanisms on the social and individual level work together to deny or repress the truth of trauma, which is rendered literally unspeakable. The intriguing thesis put forward in Trauma and Recovery is that the process of healing from trauma is essentially embedded in a wider sociopolitical framework that must always be taken into account.

However, psychological trauma research in general has not picked up the claim that recovery from trauma necessarily entails a political dimension. The eclipse of the politics of trauma recovery is reflected in the ubiquitous use of various treatment programs that focus on the intrapsychic processing of the traumatic experience without taking the sociopolitical context into consideration. Indeed, it has been argued in recent years that the dominant Western framework for thinking trauma recovery, epitomized in the psychiatric construct of Post-Traumatic Stress Disorder (PTSD), risks robbing the traumatized of their political agency rather than securing a place for it (Craps, 2013). This claim is related to a more general critique targeting the tendency in the disciplines of clinical psychology and psychiatry to render invisible the ‘true’ external/social causes of human suffering. Western notions of psychopathology, heavily influenced by and embedded in a long-standing biomedical tradition, identify the individual as the locus for therapeutic intervention, rather than the social conditions associated with various forms of distress (McKinney, 2007; Pupavac, 2004; Summerfield, 1997). Additionally, the basic psychotherapeutic stance, in the wake of Sigmund Freud’s discovery of the talking cure, is to be wary of patients’ attempts to externalize the causes of their suffering, as this enables them to avoid confronting the manner in which they are subjectively implicated in the problems they experience. As such, the individualizing, internalizing and decontextualizing trend captured in the notions of ‘medicalization’ and ‘psychologization’ forms an antonymic pair with the called-for (re)politicization of various forms of human misery. When applied to PTSD, this tension-generating dichotomy becomes ever more pressing, since this particular type of psychopathology is regarded as primarily externally determined on the one hand (Rosen & Lilienfeld, 2008), while simultaneously treated as an intrapsychic disorder on the other (Young, 1995). Although it is acknowledged that in some cases the sociopolitical environment causes the subjective distress, ‘contextual considerations seldom fit into formal trauma-and-recovery paradigms’ (Montiel, 2000, p. 96). In what follows, I intend to show that these difficulties (the focus on the individual, the neglect of cultural and contextual factors, and a general disinterest in engaging with the social conditions that caused distress) derive from the biomedical approach that dominates the way we think about trauma.

The political dimension of trauma recovery is most salient in contexts of collective disruptive events that cause pain, loss and suffering, such as natural disasters, armed conflicts, state-organized terror, civil war, and so on. Note that the attention given to trauma in these contexts is a rather recent phenomenon within the humanitarian sector. There was no mention of it in manuals of refugee health as recently as the early 1980s; the psychotherapeutic turn in humanitarian aid is often situated only in the early 1990s. For instance, Doctors without Borders first deployed psychiatrists and psychologists in December 1988, in the aftermath of the earthquake in Armenia (De Vos, 2012, p. 102). After this first intervention, mental health became one of the organization’s primary goals. However, throughout this book it will become clear that even in contexts of individual trauma, the use of medical technologies to address this type of suffering imposes a framework that obscures the political and ethical sides of trauma, which, in line with Herman’s (1997) main assertion, are nevertheless always present.

How, then, was trauma ‘discovered’ as an international humanitarian issue? This is not a gratuitous question, as it entails a declarative act that not only recognizes but also establishes the fact that war-affected populations are at risk of being traumatized en masse. Evident as it may seem, how do we know that war and natural catastrophes cause traumatic pathology that needs to be addressed with Western psychological technologies? The importation of trauma programs in the 1990s did not follow the affected populations’ expressed demand for this kind of help. Vanessa Pupavac (2004) argues that the imperative for international psychosocial programs lay in sociocultural ‘developments within donor countries and debates in their humanitarian sectors over the efficacy of traditional aid responses’ (p. 491). She points out that it was the benefactor who identified the need for trauma projects in these settings, based on our supposedly universally applicable, scientific understanding of trauma itself, which obviously raises moral questions about who has the power to define the problem: whose norms, knowledge and priorities guide the offers of assistance? As Jan De Vos (2012, p. 104) remarks, it did not take long for critics to suggest that trauma psychiatry was a covert form of neocolonialism, due to its tacit imposition of Western cultural norms. Those who defended the idea of trauma responded to this accusation by claiming that they were simply busying themselves with universal realities (De Vos, 2012, p. 104). Sound scientific and evidence-based research concerning PTSD was claimed to transcend cultural and anthropological differences (for example, de Vries, 1998). The scientific status of PTSD thus serves to safeguard the purported neutrality of the interventions predicated on this model; the question regarding PTSD’s empirical status, along with its claims to universality, therefore has a political side to it. The biomedical approach to illness and distress cannot be uncoupled from the debates concerning the political dimension of trauma interventions.

The third edition of the DSM, which appeared in 1980, was developed in line with the central tenets of the biomedical framework. Significantly, this was the edition in which PTSD was first included as a distinct psychiatric diagnosis. The so-called ‘biomedical turn’ in psychiatric diagnostics was part of a strategy to enhance the scientific image of psychiatry, which had been heavily discredited in the 1960s and 1970s by a series of ‘anti-psychiatric’ experiments (Kirk & Kutchins, 1992; Vanheule, 2014). In the next section, I will discuss some of the core beliefs on which this model is predicated.

1 The biomedical model

In The Rise of Causal Concepts of Disease (2003), K. Codell Carter describes how in the 19th century the idea took root that diseases are best understood by means of causes that are ‘natural (they depend on forces of nature as opposed to the willful transgression of moral or social norms), universal (the same cause is common to every instance of a given disease), and necessary (the disease does not occur in absence of its cause)’ (p. 1). In the early 19th century, individual diseases were defined by a pattern of prominent signs and symptoms, and every disease was believed to have a range of remote and proximate causes: each instance of a disease was claimed to be caused by a series of conditions particular to the case in question. The question was ‘why does this person get the mumps?’ as opposed to ‘what causes the mumps?’ The idea that there would be one universal, necessary and sufficient cause that explains every episode of a single disease was simply unthinkable. The only way this could be conceived was by defining diseases in terms of their causes rather than in terms of symptoms. This powerful evolution in medical thinking, which put etiology center stage, constitutes an attempt to transform medicine in order to fit scientific requirements. In medicine, this goal could be accomplished because the etiological agents (bacteria, viruses, genetic mutations) could themselves be identified and objectively distinguished from each other. The greatest advantage of such an approach is that it makes possible consistent and uniform strategies of intervention that target these specific causes (in both prevention and treatment).

Within the field of psychopathology, the attempt to define disorders as nosological entities will always be associated with the name of Emil Kraepelin (1856–1926). In analogy with the medical model, this German psychiatrist thought of mental disorders as natural disease entities with an independent existence. Mary Boyle (2002) rightly identifies the Platonic roots of such a stance: reality is considered to be universal and unchanging, while perceptions are always relative and imperfect. This position leads to ‘ontological theories of disease’ that pose ‘the existence of natural and unvarying disease entities, separable from the person, and whose presentation [is] uniform across sufferers’ (Boyle, 2002, p. 9). Each disease entity is thought of as a discrete and separate unit, defined by its own distinctive cause, symptoms, course and outcome. Kraepelin sought to find the essence of every mental disorder, a defining trait that is both necessary and sufficient to make the diagnosis, an intrinsic or underlying quality that causes an entirety of other, more superficial characteristics (Ellis, 2001).

However, whereas Kraepelin initially believed that every distinct mental disorder would eventually be explained by a specific genetic mutation or a specific neurobiological marker, in line with the etiological standpoint described by Carter (2003), over a hundred years of research has failed to identify such an unequivocal sign for a single psychiatric diagnostic category (Dehue, 2008; Kupfer, First & Regier, 2002; Vanheule, 2014). Etiology in the field of mental problems has been found to be complex and multidimensional: research indicates a variety of risk factors on different levels, such as genetic, molecular, neuronal, psychological, social and cultural factors (Lemaire, 2014). The absence of two-way pathognomic signs or symptoms, that is, of indicators that are both necessary and sufficient to diagnose a specific disorder, poses great difficulties for psychiatry’s scientific status.

In absence of such findings regarding etiology or pathophysiology, mental disorders have been defined by a number of nonspecific signs and symptoms that appear to correlate on more than chance level. The (forced) choice to remain agnostic with regard to etiology, in favor of a description of the readily observable surface phenomena, was the major intervention that marked the much-discussed break of DSM-III with its predecessors.¹ The explicit goal of this move was to augment the reliability of psychiatric diagnostics (Kirk & Kutchins, 1992). The downside of this approach was that mental disorders became defined on the basis of shaky symptom constellations, which, by themselves, offer little information as to the validity of the proposed categories (Boyle, 2002). Despite these limitations, there is a tendency to reify the mental disorders in the DSM: the labels are often used as if they refer to underlying natural disease entities that cause the clinical tableau in a straightforward fashion, whereas in fact they simply represent the name given to a particular cluster of symptoms (Hyman, 2010).

1.1 Mental disorders as natural kinds

Ontological psychiatric theories assume that the forms of mental disorder found in the West are basically the same as those found elsewhere: their nature is not significantly modified by social and cultural influences stemming from either the patient’s or the researcher’s context. Theory is believed to be external to the facts under observation, in the sense that the basic data of psychiatric research (that is, symptoms and syndromes) ‘exist prior to and independent of psychiatric theory’ (Bracken, Giller & Summerfield, 1995, p. 1075). Western psychiatric diagnoses are frequently taken to be ‘natural kinds’ that exist independently of any cultural determination. This is nicely illustrated by the inclusion of a ‘Glossary of culture-bound syndromes’ in appendix I of the DSM-IV-TR (American Psychiatric Association [APA], 2000, pp. 897–905).² The explicit reference to a limited set of culturally determined afflictions retroactively confers the status of ‘cultural independency’ on everything that went before. Psychiatry and clinical psychology assume that the deductive-nomological scientific method makes possible the delineation of the universal aspects of mental illnesses, in independence from subjective values, ethnic or social bias and so on (Bracken, 2002). Knowledge about these data, generated through the implementation of established scientific methodologies, is regarded as neutral, value-free and universal.

Do the mental disorders described in the DSM capture a reality that exists independently of the classification system itself? Is the order imposed by the DSM upon the multiform variety of clinical symptoms something artificial and culturally dependent, or does it reflect an order which was always already there, inscribed in nature? The preoccupation with establishing a classification that describes natural kinds in part derives from practical considerations: if the ideal of ‘carving nature at its joints’ were achieved, clinical intervention would become a lot easier. In analogy with physical medicine, psychological problems could then be approached as individual cases of a limited range of already established psychiatric disorders, which would allow predictions as to the (generic) cause of the disorder and the most efficient course of treatment. In other words: the idea of natural kinds allows for a generalization of the produced knowledge concerning etiology and treatment.

When applied specifically to trauma, the described assumptions suggest that PTSD has a universal and timeless character, which translates into claims such as: it has been around from the earliest times; people in the stone age suffered from PTSD just as people from the 21st century do; people across the globe react with more or less the same symptoms when faced with adversity, generated through a quasi-identical pathophysiological mechanism; and so on. The assertion that PTSD reflects a universal human response to distress suggests that it is possible to predict the impact of war, violence and disaster on Western and non-Western people alike. Moreover, it supports the idea that there exist universally applicable medical technologies to address this form of suffering. It is important to emphasize that the cornerstone of these presuppositions is the scientific method through which psychiatric knowledge is gathered: this method is believed to guarantee the latter’s accuracy and validity. Before we delve into a discussion of whether or not PTSD meets the scientific standards that warrant its inference as a medical syndrome, I will briefly discuss two more assumptions of the psychiatric trauma approach that lead to a few undesirable consequences: its assumption of a universal subject and its cognitive framework.

1.2 The universal subject and its vulnerability

At its core, psychiatry is very much determined by Cartesian dualism, the idea that the inner and outer worlds are ontologically separated from each other (Bracken, 2002). The res cogitans, the substance of our minds with the capacity for thought, is believed to exist in isolation from the external world, although it is not without a relationship to this world. Trauma psychiatry presupposes the existence of some kind of inborn universal human subject that is affected by distressing experiences in more or less the same way across different times and places. This human subject is not considered an effect of the social, political or cultural context in which it is embedded: it is fundamentally a priori, isolated and autonomous. As such, the similarity between people from different cultures is emphasized, whilst difference and diversity are downplayed. Furthermore, it is immediately clear that the main trait of this universal human subject is its vulnerability: the individual inhabitants of violent crises are seen as fundamentally at risk of traumatization, and part of the impetus for psychosocial humanitarian work is the desire to prevent or attenuate the impact of horrific events on the fragile human mind. This will prove important for the discussion of the ethical stance associated with PTSD in the next chapter.

1.3 Cognitive theory

Contemporary understandings of psychopathology are highly influenced by cognitive psychology, which views mental problems as the result of dysfunctional beliefs or faulty information processing (Bracken, 2002; Brewin & Holmes, 2003). Cognitive theory approaches the human mind as an information processing system. It uses the computer as the privileged metaphor to illuminate our mental processes. Within this theoretical framework, mental ‘schemata’, ‘cognitive scripts’ or ‘unconscious schemas’ (that is, the software running on the computers) are believed to organize our sensory experience in a ‘theory-driven’ way, a process that generates a meaningful and orderly world (Janoff-Bulman, 1992). In other words, according to this view, meaning is produced within individual minds, it is dependent on the person-specific schemas and their interaction with the outer world. In these schemata, our deepest convictions and most fundamental assumptions about the world are condensed (Janoff-Bulman, 1992). Through these structures, raw experience is ordered into coherent meaning. Mental schemata help the person to understand the world and to orientate him or herself in it.

It is through this cognitive lens that traumatic experience is generally understood within contemporary (psychological) theories: trauma occurs when something happens that contradicts our most fundamental assumptions about the world (Ehlers & Clark, 2000). For instance, that the world is just and good; that the world is meaningful; that we have a degree of control over what happens to us in an ‘action–outcome contingency’; that good things happen to good people; and so on (Janoff-Bulman, 1992). The central idea is that a traumatic event offers ‘information’ that cannot be reconciled with the pre-existent schemata: the conflict between the inner beliefs and the reality of the trauma generates tension and distress. In other words, the traumatic event cannot be assimilated into the existent schemata; its processing is blocked. The iconic symptoms of re-experiencing the event (in nightmares and flashbacks) are comprehended as a series of belated attempts to finish the obstructed processing of the event. This ‘completion tendency’, which is reminiscent ...

Table of contents

• Cover
• Title
• Introduction
• Part I  The Biomedical Approach to Trauma and the Ethics of Human Rights
• Part II  The Dislocations of the Real
• Notes
• References
• Index