Tuesday, July 17, 2012

On the reification of trauma

Trauma is a word borrowed from medicine where it means the damage caused to tissue by the application of energy, e.g, blunt force trauma is damaged cause by hitting a body with a blunt object such as a baseball bat.  This is a different kind of damage than that caused by, say, a bullet, though both are trauma.  Indeed, the nature of the damage can tell us something about the causative agent.  My objection to the diagnosis of PTSD is largely based on my objection to the idea of damage and it's inevitability implied by the concept of trauma.

The damage done by a bullet is pretty much (I say facetiously) independent of the person struck.  It depends almost entirely on the characteristics of the bullet: its caliber, velocity, trajectory, impact point, etc.  Two people hit the same way will generally suffer similar damage.  Yet this is clearly not true about the effects of combat (or other severe stressors) on people.  For example, at the grossest level, research shows that no matter how trauma is operationally defined (in a combat zone, shot at, wounded, etc.) most of the time most people "exposed" to "the trauma" don't develop PTSD.  Yet one frequently hears discussions about combat, of even just being in a war zone, as if it is inherently "traumatic" for virtually everyone.  I think this is an effect of what I see as the reification of the psychological concept of trauma.

The damage done by a bullet is a real, objective thing.  It can be seen, and cause and effect relationships are easily established.  Not so for psychological "trauma."  Exactly what is "damaged" by killing another person?  Or being terrified?  Or seeing a battle buddy killed?  Is any of these inherently damaging? And even if so, surely not the same "thing" is damaged in all three cases.  Would it be the same for different people "exposed" to each of these?  Indeed, could there ever be the same "exposure" for different people, even to the "same" event?

Consider two humvees on patrol when one is struck by a rocket propelled grenade that, let's say, kills one person in the first humvee.  Looking at each person's experience, it quickly becomes apparent that even though everyone there was at the same event, their "exposures" differ radically.  Indeed, every difference in situation, conduct, relationship, and history (and more) will make a substantial difference in what each experiences and must deal with.

Note first the huge difference in being in the first humvee or in the second.  Those in the first may well see their comrade die before their eyes, perhaps disappear "in a pink mist."  But even then, not necessarily.  Depending on where each is sitting and where they were looking and what they were doing, what they initially see could be quite different.  And the people in the second humvee will only hear of this later.

If the soldier didn't die immediately then who did what when can matter a great deal.  Did others provide first aid or not?  If not, why not?  In either case their may be intense feelings.  For example, the person who did provide aid my feel guilt when the victim dies.  And the person who didn't may feel ashamed for not doing so.

But these gross, obvious differences only begin to scratch the surface of all the differences that could make a difference.  Did someone have the job of being the lookout for ambushes?  Did everyone return fire or not?  Was this the first casualty each has seen?  Or the twentieth?  Was this someone's best friend?  Had they just had a fight?  Does someone else despise the deceased?  What experience has each had before the war with death?  With vulnerability?  What degree of loving support has each experienced in their life?  Etc, etc, and so forth.

Given all these potentially highly significant differences between the experiences of people, it is, I believe, completely erroneous to believe that the characteristics of the external event per se give us any useful information about its impact on the individual.  Yet every time someone talks about "the trauma" or the "exposure" this is, to some degree, what they are doing.

What I have said here will, no doubt, be obvious to many.  Yet it is, I believe, another way that the concept of "trauma" has coarsened and dimmed our understanding of what veterans must cope with following combat and thereby lessened the effectiveness of our efforts to assist them.

Roy Clymer

For the background and context for these remarks, please read my article on PTSD published in the Psychotherapy Networker which can be found here http://www.psychotherapynetworker.org/recentissues/1151-the-puzzle-of-ptsd or see a copy of it found on this blog titled "The Puzzle of PTSD."

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