Posttraumatic Stress Disorder: Issues and Controversies

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Is Posttraumatic Stress Disorder (PTSD) an illness that arises after horrific and life-threatening events? Or is it a label that medicalizes human suffering, and brings with it more problems than it solves?

Still a relatively new diagnosis, PTSD has changed our vocabulary and shaped our views on human coping and resilience. Yet almost every assumption upon which the diagnosis rests has come under question. In this volume, Gerald Rosen brings together leading international scholars in posttraumatic studies to consider the most contentious debates. Each chapter offers an analysis of the issues, reviews current research, and clarifies implications for the practicing clinician.

Posttraumatic Stress Disorder: Issues and Controversies is essential reading for all practitioners, researchers, and students who work in the field of trauma. Professionals in related health fields and the law will also find this book useful.

Posttraumatic Stress Disorder: Issues and Controversies Review

I'm a clinician with several decades' experience treating "complex" & "high-risk" clients, often with hospitalizations & prior treatment failures, most of whom have lived through "traumas". PTSD is the most common diagnosis on my caseload. Furthermore, I grew up with a father who was the last Marine of his platoon to be wounded or killed on Iwo Jima, and I was more-or-less raised by a next-door neighbor grandmother whose brothers were gassed in WWI, and whose father fought at Shiloh in the Civil War and was later multiply-wounded charging a Confederate battery. "PTSD" not only runs in my caseload, but also in my family.

This book, covering "issues and controversies" about PTSD, was written mostly by academic psychologists & psychiatrists - researchers & theorists, not clinicians. (Three authors are primarily clinical, one author is an historian, another an anthropologist.) Unsurprisingly, this book is not written mainly for clinicians.

Yet as a clinician, I call "PTSD: Issues & Controversies" "needed" for psychotherapists of all stripes. Why?

Here many PTSD controversies & issues highlight serious concerns I've had, as a practicing clinician, with the PTSD (and the DSM) "concept" or way of understanding . And other issues discussed make sense to me as a clinician, including those where I disagree with some interpretations.

Reviewing any book with a dozen chapters on diverse topics by different authors is difficult & dissatisfying. My approach will concentrate on only a few chapters, and touch on others.

McNally, a Harvard psychology professor and a member of DSM-IV's PTSD committee, writes a solid, experienced & thoughtful opening overview, "Conceptual Problems with the DSM-IV Criteria for Posttraumatic Stress Disorder". His approach is that of a theorist & researcher also concerned with clinical & social issues. As he states at the beginning, "Controversy has haunted the diagnosis of posttraumatic stress disorder (PTSD) ever since its appearance.... At the outset, psychiatrists opposed to the inclusion of the diagnosis in DSM-III argued that problems of trauma-exposed people were already covered by combinations of existing diagnoses... [including] concerns that PTSD was more of a political or social construct, rather than a medical disease discovered in nature."

Before the outcry, please know that McNally and the book's other authors are clear that there are situations that create real traumatizing in persons, and that these persons' sufferings are also real, should be recognized, and effective treatments (or treatment approaches) should be devised, tested & made available.

These first controversies, and some later ones, are at once both serious & silly. First, the serious. As a clinician who has worked with, lived with and/or listened to combat veterans from WWII, Viet Nam, the Gulf War and our current wars, and as a historian who has read accounts of reactions to combat in WWI, people's reactions to just this one type of trauma - combat, something everyone agrees can be traumatic - I know reactions differ, even differ significantly & confusingly from person to person, from generation to generation, from culture to culture, from war to war. What's traumatic to one person, often isn't to another. While we have many good ideas why this should be true, any experienced clinician knows that ultimately the reasons are complex and they will never be open to clear, precise or simple understandings.

This brings up serious issues: 1. What's the "nature" of trauma, and why is trauma so variable? 2. How accurate are PTSD's three symptom clusters? 3. How can we ensure that traumatized people are allowed to get recognition, support & `help'? 4. Given this high variability & uncertainty, how can we devise effective diagnoses & treatments?

McNally's analyses of these problems are good & well-presented. For example, drawing on the recent work of Cambridge-trained philosopher, Ian Hacking, McNally points out that trauma-reactions are, indeed, "mixed", that is both social/cultural & "found in nature". He's also clear that traumatizing isn't only in the "nature" of a separate "event" happening to a separate person, like a tree falling on a person and breaking a leg. Rather, trauma is something always mediated via a person's socially-influenced "cognitive appraisal".

Now the silly. Any non-dogmatic & experienced clinician knows that successful healing in psychotherapy has as much to do with incorporating a client's individuality, including individuality of circumstances, as the generality of diagnosis. Furthermore, as DSM has essentially one diagnosis that includes all trauma reactions, we're stuck with a label that often doesn't well fit the person in front of us. And trauma, depending on many factors, creates even more than the usual individual variability, particularly when there are complicating factors, as there almost always are. So we phutz, notice our clients & their needs, and make do. However, it's still good to have pragmatic clinical experience confirmed in careful academia.

I wish McNally was more challenging to the nature of DSM concepts, and I wish he was clearer about the underlying problems that create social pressures in the US where "medical" concepts are the only gateway for Americans to get recognition & help. But I suspect these limitations were due more to the space in the book & the limited scope of the article, and less to McNally's ability to analyze.

Bowman & Yehuda's "Risk Factors and the Adversity-Stress Model" focuses on enduring problems relating the intensity of the "stressor" or "trauma" to the person's response. Using examples, they say, "Not only do events vary in their meaning, so do the signs and symptoms of event-focused disorder." For example, they point out that, even in WWI, common British reactions or symptoms were significantly different in both specific presentation & type of symptom than were German reactions. They conclude, "...research demonstrates that PTSD is best understood as the periodic expression of long-standing dispositions that are often risk factors for both threatening exposure and subsequent dysfunctions. At the very least, pre-event risk factors that include enduring personality features and beliefs have been found to predict PTSD more reliably than event features."

True in one way. As the authors rightly point out, it's always vital to consider the person's individuality, not just what happened to them.

But. This can also be a way to bar the gate from getting recognition & help. And this bar has been raised in every war, including the current ones, from WWI to the present. This is often used to blame & disqualify persons, stating, for example, that the "cause" (singular) isn't the war, but "a pre-existing personality disorder". Which is also a lie. Research studies and overwhelming anecdotal data show, for example, that in many ways the cause of combat PTSD is always combat. Or perhaps more accurately, combat is always a serious & significant cause, without which combat PTSD wouldn't form. And as is stated elsewhere in this book, while some people are more likely to succumb to combat reactions, everyone ultimately can succumb. As my dad's lieutenant from Iwo Jima, a holder of the silver star, told me, "Everybody has his breaking point. I just didn't happen to find mine."

(In another chapter, Rosen, a practicing evaluator, though maybe not as much a clinician, based on his experience & extensive research, wisely points out that we, as therapists, really can't know for sure whether our clients truly present trauma symptoms or are malingering, faking it.)

Several chapters talk about problems with a special, distinct "trauma memory": "On the Uniqueness of Trauma Memories in PTSD" & "Memory, Trauma, and Dissociation". Memory & trauma, both individual & cultural, is a current hot topic, with studies ranging from the historical & anthropological to the neurological. These chapters contain many serious cautions for clinicians. And yet they also clearly lack experience with actual sufferers. No one who has been traumatized doubts that traumatic memories carry a punch lacking in other memories. And these are not "just memories", i.e., "just cognitions, thoughts". These memories come with a cluster of deeply felt-meanings, struggles & pain. Perhaps one of the silliest conclusions in the book is that trauma memories are no different than others based on neurology, and then to assume that the problem is that our current PTSD diagnosis highlights these memories, based on a movie-technique, called flashback.

Well, it just ain't true. For example, my father, who didn't see "flashback movies", at least to my knowledge, once commented on an experience in Iwo Jima, coming upon the mangled remains of a captured Marine. He never described this fully, nor did I push him. But he did say, "I guess that's one of the sights that has stayed with me."

The concluding chapter, by Bryant, a psychiatrist practicing with refugees from war-torn areas of the world, contains considerable wisdom about both symptoms presented & not presented, and the priorities of persons who have undergone horrible circumstances, priorities that we as clinicians need to respect. He also points out the cautions of applying western medical concepts to suffering, especially with persons from non-western cultures. As he says, "The fundamental relativity of human experience, even in extreme conditions, and the primacy of the subjective appraisal and social context, mean that there can be no such thing as a universal trauma response." Depending on how one defines "universal", this I find to be true. More importantly, he says, "For my part, I found that a diagnosis of PTSD in particular was poorly predictive of an individual's capacity to pay the psychological costs of what had happened, to function well despite hardship, and to keep going; nor was the diagnosis a reliable indicator of a need for psychological treatment."

In other words, we need a broader understanding of how we can help people who have experienced tragedy and how we recognize who, indeed, needs what kind of help. Rather than use PTSD alone as THE filter to see who needs help & what kinds, we need more diversity and, I strongly suspect, more humane sensitivity, based as much on our experience and our ability to listen and caringly, thoughtfully relate as to our ability to recall specific symptom lists with which to match the person.

My greatest concern is in the chapter on "Emerging Clinical Guidelines for Treatment". While there is some wisdom & useful caution here, too, on the kind of concept that DSM presents, there's definitely, from my experience and from more current research, too much confidence in the current Cognitive-Behavioral-Treatments fad, growing out of a notion of focusing exclusively on treatment.

For example, meta-analyses, that is, studies of research studies of psychotherapy, clearly show that the specific treatment offered is far less a factor in psychotherapy's success than, say, therapeutic alliance. (See The Heart and Soul of Change: Delivering What Works in Therapy, esp. 2nd edition. See my review.) Also a 2008 study, four years after this book's publication, showed that all valid psychotherapies for PTSD - not simply CBT - were equally effective. Further, other studies of experienced clinicians showed that in spite of CBT's academic & insurance popularity, few clinicians used the flagship treatment of "Progressive Exposure". As a clinician who regularly offers PE, this is no surprise. It doesn't work for most people, and they don't want it. This conclusion is more comprehensible given the challenges demonstrated in this book. It would have been especially nice, for the clinician, if these guidelines had included other therapies, and emphasized, say, "Empirically Supported Relationships" (See Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness to Patients. See my review.) and "Practice-Based Evidence" (See On Becoming a Better Therapist.) rather than only "Evidence-Based Treatment".

Which leads me to a request should there be a second edition. Include not only common factors, but also have broadly-based & experienced clinicians critique these chapters, to further prod the authors into better clinical relevance.

Still, I recommend that clinicians buy & read this book. As a clinician, I found important confirmations & challenges in almost every chapter. Several authors, including McNally and the historian, Ben Shephard, and the anthropologist, Allan Young, have written entire books which elaborate their essays here. But this is a good introduction. And through these introductions and the challenges they present, we psychotherapists can become better sensitized to PTSD issues, in us as practitioners and in our clients as persons suffering & deserving of the best help possible.

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