By Richard J. McNally
Harvard University Press, 420 pp., $35
In the 1890s, affluent Viennese families sent their daughters to Sigmund Freud to treat mysterious problems such as sleepwalking, paralysis, and fits of coughing. Freud took these afflictions to be stigmata of sexual experiences long submerged in the unconscious, and using hypnosis he tried to awaken the memories and release the painful childhood secrets. But it is unclear whether Freud actually cured any of these women. Scholars debate whether he even extracted more than a handful of stories of sexual abuse. By 1897, Freud began to doubt that repressed childhood traumas were the source of all adult hysteria and neuroses. "It has slowly been dawning on me in the last few months. I no longer believe my Neurotica," he wrote to his colleague Wilhelm Fliess. "It is impossible to distinguish between truths and (emotionally charged) fiction."
About a century later the search for buried secrets resumed in full force, and with devastating consequences. Unlike Freud, some overzealous twentieth-century therapists had remarkable success in "finding" memories. Not only did they uncover stories of parental violation, they also found tales of blood-soaked satanic worship, cannibalism, and alien abduction. Heartache ensued as hundreds of families were ruptured by groundless accusations of the sexual abuse of children; caretakers were cross-examined in courtrooms and even imprisoned, based solely on their young charges' fantastic tales of mistreatment. Patients were tragically misled about the source of their unhappiness, while the therapeutic profession was staggered by its self-inflicted wounds.
At least one good thing is coming out of these infamous disasters: a more refined body of scientific research on memory. Richard McNally has brought together data from hundreds of published studies on memory and has provided a thoroughly masterful synthesis. His book is precisely written, tightly organized, and argued in a highly persuasive, non-polemical fashion. "Until the mid '90s, debates about trauma and memory were hampered by vitriolic accusations issuing from both sides and by the scarcity of clinically relevant scientific data," McNally writes. "Now, an outpouring of research has clarified many of the most contentious issues." Can survivors put trauma completely out of their minds? Do the workings of memory differ for traumatic events? How does emotional stress affect memory? How do shame and guilt magnify the traumatic potential of an event? These are just a handful of the important questions that McNally systematically tackles.
One of the most critical--and overlooked--questions that McNally addresses is disarmingly simple: what counts as trauma? Some traumatologists believe that a trauma should be defined as whatever traumatizes a person. McNally rejects this circular approach. True, a person might feel "traumatized" by, say, a minor car accident--but to say that a fender-bender counts as trauma alongside such horrors as concentration camps, rape, or the Bataan Death March is to dilute the concept to the point of meaninglessness. McNally defines a traumatic event as one that is unexpectedly life-threatening or horrifying or both--as properties of the event itself rather than as a reflection of the subjective response to it. "The more we broaden the category of traumatic stressors," he asserts, "the less credibly we can assign causal significance to a given stressor itself and the more weight we must place on personal vulnerability factors."
The conclusion of McNally's research, and of the research of others, is that memories of horrible experiences are rarely, if ever, repressed--that is, exiled from consciousness without the victim knowing it and actively kept out of her awareness. On the contrary, those who endure shocking ordeals almost always remember them, even if they choose not to think about them or desperately wish to forget them. Moreover, therapists and memory researchers have been too lax about trying to distinguish reluctance to disclose dreadful experiences or failure to think about them from a true inability to remember the events. McNally's book reminds us how much popular psychological wisdom still needs to be unlearned--by the public, by the media, by judges, and, not least, by many mental health professionals. This correction has been a long time coming, because the notions that we bury memories of intolerable events, that those memories are accurate when unearthed, and that they hold the key to understanding our current distress, are axioms of the Freudian legacy that is inscribed on our culture.
While it would be wrong to say that latent memories are always untrue, accepting them at face value is terribly dangerous. Scientific evidence, as well as clinical and forensic experience, tells us that the accuracy of a memory cannot be judged by how vivid it is or how emotionally compelling it feels. Without independent verification, plausible-sounding recollections embellished or wholly produced by one's own imagination or at the suggestion of another are virtually impossible to distinguish from accurate ones. In the end, it becomes clear that the psychological "truths" we seek--the tidy causal explanations for why we feel, think, and act as we do--are unknowable, because we are influenced by so many variables of which we are genuinely unaware.
Enter the methods of cognitive psychology. McNally employs them to help resolve the ongoing controversy by enabling scientists to test hypotheses about how people may either forget events or falsely come to believe that they have been traumatized. The importance of his book is plainly owed to its scientific authority; but McNally is an astute cultural observer as well, and he installs the memory debate and the consideration of trauma--how it is defined, how it affects victims--in an illuminating social framework. It would be unfortunate if Remembering Trauma were judged by its cover--that is, as a work only on the urgent but somewhat fashionable subject of repressed memories. Its scope is much larger. McNally takes seriously the oft-cited remark of Judith Lewis Herman that "without the context of a political movement, it has never been possible to advance the study of psychological trauma." There is some truth here, McNally agrees, but we must remember that just as campaigns against domestic violence, child abuse, and even the Vietnam war have advanced our understanding of victims, those same movements have at other times exploited and even manufactured victims for political ends.
This essentially political tension casts a large shadow over the field of traumatology. And when scientific data are perceived as clashing with efforts on behalf of victims, there have been ugly scenes. The cognitive psychologist Elizabeth Loftus has been vilified for publishing groundbreaking data on the malleability of memory. As a sought-after expert witness in repressed memory cases, she has been accused of sympathizing with child molesters. A few years ago the literary scholar Elaine Showalter received death threats for her book Hystories, a study of modern epidemics of hysteria such as multiple personality disorder. In July 1999, Congress unanimously passed House Resolution 107, which "condemns and denounces" three psychologists, Bruce Rind, Philip Tromovitch, and Robert Bauserman, for a "severely flawed" study, and the Senate then approved it unanimously. The psychologists' offense was publishing an empirical paper in the prestigious journal Psychological Bulletin concluding that child sex abuse does not inevitably lead to lasting psychological harm. McNally presents new evidence showing that the psychologists' conclusion--which was by no means an irresponsible reading of the data they examined--might not hold up, but he is fierce about protecting their scientific freedom.
Now McNally, too, risks excommunication from the Church of Traumatology, for the charge of blaming the victim. For he presents evidence showing that emotional breakdown after a tragedy is the exception, not the rule. It occurs because some individuals are simply more susceptible than others to developing psychiatric disorders following a crisis. This will not please the psychobabblers and the melodramatists and the daytime-television bookers; but McNally is unfazed. "Ultimately the best form of advocacy," he writes, "is pursuing the truth about trauma wherever it may lead."
One contentious issue to which the data lead McNally is the extent to which certain psychological conditions are invented rather than discovered. That people try desperately to make sense of their feelings--that they initiate an "effort at meaning," as the British psychologist Frederic C. Bartlett calls it--is poignantly brought home by McNally's experience recruiting subjects by means of an advertisement in a newspaper for a study on memory of childhood sexual abuse. Over the course of a few days he had three eerily similar interviews with young women who wanted to be subjects in the study. When McNally asked them about details of the abuse, none could recount any. He then asked them sympathetically why they responded to an ad seeking sexual abuse survivors if they had no knowledge of actually being abused, and the women replied that they had many problems they could not explain--chronic sadness, too much drinking, feeling tense around older men, and so on. According to McNally, "The source of their problem remained mysterious . . . until they realized that they must have been sexually abused but repressed the memory of the abuse."
But while their suffering was formidable--and McNally never loses sight of this--the mystery was not. After all, many patients end up deciding what is wrong with them based upon the so-called illness narratives that the media and the faddish therapists endorse. Consider multiple personality disorder (MPD), one of the most dramatic outcomes of an "effort at meaning" combined with zealous therapy. Psychiatrists disagree whether MPD occurs spontaneously in nature as a consequence of childhood trauma, but even skeptics believe that it is genuine in that the patient is typically not faking her condition. The psychiatrist Paul McHugh, one of the first to publicly question the MPD explosion, believes that MPD is produced in the therapist's laboratory, "promoted by suggestion and maintained by clinical attention, social consequences, and group loyalties." The American Psychiatric Association removed MPD from its nomenclature in 1994 (but replaced it with a controversial condition called "dissociative identity disorder," which is basically the same as MPD). The general consensus today is that if there truly are individuals who--spontaneously, without suggestion--forget their identity for discrete periods, and "lose" time, and are inhabited and controlled by another self during that absence, they are exceedingly rare.
The best evidence that MPD can be invented is the skyrocketing of its prevalence following the release in 1977 of the film Sybil, the true story of a woman who supposedly had sixteen discrete personalities. Prior to the movie, there were between 50 and 200 recorded cases of documented multiple personality disorder. By the 1990s, estimates climbed as high as 20,000 to 40,000. The story of Sybil provided the prototypic narrative: a young child subject to systematic and extraordinary cruelty by a parent is literally shattered by the abuse and vacates herself during the ordeal, thus creating other identities ("alters") to protect the main personality from overwhelming terror.
In a disturbing postscript to the Sybil phenomenon, Herbert Spiegel, a wellregarded expert in hypnosis at Columbia University who had once treated her, revealed that Sybil was a product of her more than ten years of therapy with Cornelia Wilbur. In an interview in 1997, Spiegel called Sybil a "grand hysteric"; she was without question deeply troubled, but she did not have MPD. Instead, she was suggested into it. Not only was she extremely hypnotizable, Spiegel emphasized, but she had read The Three Faces of Eve, thus acquiring a model for multiplicity. Moreover, her psychiatrist seemed to encourage her to create alters. During her sessions with Spiegel, Sybil asked him if he wanted her to switch personalities, "to be Helen." Who is Helen? he asked. "Well, when I'm with Dr. Wilbur she wants me to be Helen . . . that's a name Dr. Wilbur gave me for this feeling," Sybil replied. In a letter to Wilbur, Sybil remarked that "I do not have any multiple personalities. I don't even have a 'double' to help me out. I am all of them. I have been essentially lying in my pretense of them."
Skeptics such as Spiegel hold that MPD is essentially a manifestation of hysteria--that is, a symbolic expression of psychological distress driven by unconscious conflict. Perhaps, metaphorically speaking, it is a way to express forbidden aspects of the self. Feminists are drawn to this interpretation. Gloria Steinem glorifies MPD as a way for women to use secondary personalities to exercise creative forces that patriarchy has suppressed in the primary self. This liberationist interpretation is silly and dangerous, because it helps people to justify an indulgence in dysfunctional behavior.
The irony, of course, is that a liberationist reading of such symptoms may have once reasonably applied to Freud's hysterical female patients. Several of them went on to play meaningful roles in first-wave feminism in Europe. Perhaps it is not so far-fetched to interpret their hysterical symptoms, such as loss of voice, as a protest turned inward. It certainly makes sense that feminists would have a stake in validating the accuracy of recovered memories and in the idea that women, once mistreated, remain forever scarred by it. "Not until the women's liberation movement of the seventies," writes Judith Lewis Herman, "was it recognized that the most common post-traumatic disorders are not those of men in war but of women in civilian life," referring to rape victims, battered women, and sexually abused female children. "The study of trauma in sexual and domestic life becomes legitimate only in a context that challenges the subordination of women and children," Herman insists.
By contrast, which responsible mental health expert would talk about the study of diseases such as schizophrenia, bipolar illness, or major depression "only" being legitimate against a backdrop of victim politics? Which responsible clinician would interpret those diseases as mere idioms of distress? None, of course. Core symptoms of severe mental illness (delusions, hallucinations, manic energy, numbness, and so on) are believed to be direct manifestations of abnormal neurochemistry and brain function, not inchoate misery molded into diagnostic shapes by suggestion, reward, or the emotional gratifications of the sick role. Generally, though by no means always, illnesses such as schizophrenia have a predictable course and response to treatment. Patients who are psychotic or profoundly depressed do not get better when the insurance money runs out, or when there is reason to evade responsibility--two circumstances that Spiegel has observed routinely in MPD cases. Nor are white women of North America disproportionately affected, as they are by MPD.
Granted, there may well be a biological substrate in MPD patients. Sybil was highly hypnotizable and may have inherited a biological predisposition to dissociate--to lose her sense of time and self--under intense stress. When a person with such a predisposition also suffers great inner turmoil, she could easily, and unconsciously, latch onto an attractive illness narrative and transform her distress into a recognized mental disorder. Such a psychic strategy--which may be imbibed from the media and from self-help books--directs which sensations she should pay attention to and which she should ignore. Therapists contribute to the process by declaring some sensations more important than others, a practice based solely on hunch rather than on evidence that doing so brings greater comfort or understanding (in which case focusing on particular symptoms and not others would indeed be justified). In this way, therapists and patients may unwittingly negotiate a "mental disease."
How victims remember trauma is one of the most divisive issues facing psychology today. McNally comes down on the side of clinicians and researchers who believe that victims typically remember their adversities extremely well. On the other side are psychiatrists such as Judith Lewis Herman, who concluded in 1992 in Trauma and Recovery that "the ordinary response to atrocities is to banish them from consciousness." Once banished, however, the memory does not fade away. Herman thinks that the memory burrows into the mind like a deep abscess, releasing toxins that cause all manner of psychic and physical disarray. The job of the therapist is to draw memory to the surface, even if at first, as Herman writes, "the patient may not have full recall of the traumatic history and may initially deny such a history, even with careful, direct questioning." Psychoanalyst Alice Miller, the author of The Drama of the Gifted Child, contends that many women are unaware of "brutal" abuse that they suffered in childhood and thus "their illusion of a good childhood can be maintained with ease." Herman and Miller are perhaps the most influential psychotherapists writing on trauma today. Their highly readable and often poignant books are classics in the fields of traumatology; but they are not empirically rigorous.
Then there is Memory, Trauma Treatment, and the Law, another popular book used in forensic cases, which was published in 1998. This tome is by psychotherapist Daniel Brown, attorney Alan W. Scheflin, and psychotherapist D. Corydon Hammond. (Hammond recently lectured his students at the University of Utah that myriad cults in this country are masterminded by a Jewish doctor named Greenbaum who once sympathized with the Nazis. He believes that these cults engage in pornography, heroin distribution, and international arms smuggling.) The text treats satanic ritual abuse as if it were an actual and serious problem, and instructs that "memory for infant trauma is encoded accurately and indelibly," and encourages the use of hypnosis for memory retrieval.
McNally addresses the issues that Herman, Miller, and Hammond and company raise by noting the similarities and the differences between memories for traumatic events and everyday ones. Again and again, the data show that all recollections change over time. The first lesson, then, is that the mind's eye does not operate like a video recorder. Memory is a spectacularly fallible instrument. The perception of events, their storage in the mind as memories, their retrieval: these are all processes subject to misperception, decay, and imperfect reconstruction. No mechanism has yet been found that protects memories from fading. We fit bits and fragments of recollections together in ways that make sense to us in the fullness of our current circumstances. We are always angling the prism of memory. In fact, psychotherapy is a grand, guided exercise in such inwardly expedient adjustment: sometimes the results are rewarding and illuminating (even if less than historically accurate), at other times they are grievously misleading.
Consider the plasticity of memory. Elizabeth Loftus has conducted several important studies of memory manipulation. Her findings have been widely replicated. In one experiment, Loftus showed college-student subjects a film clip of a two-car crash. She asked half of them about seeing broken glass after the cars "hit" each other and the other half about broken glass after the cars "smashed into" each other. While no broken glass was depicted anywhere in the film, subjects who were asked about the "smash," but not the "hit," were much more likely to report having seen it. Loftus calls this post-event suggestion. In a second type of experiment, memories were injected outright. The best known of this genre is Loftus's lost-in-the-mall study. She told subjects that she had learned from relatives that when they were five years old, they were lost in a shopping mall, rescued by a shopper, and reunited with their family. Unknown to the subjects, Loftus contacted the relatives before relating the made-up vignette. Not only was Loftus able to convince one-quarter of the subjects that they had experienced the event, some even added embellishing details to the "memory."
Using similar techniques, other researchers have successfully implanted dramatic childhood memories such as near-drowning, animal attacks, and injuries inflicted by other children. Thus the story creates the memory, rather than vice versa. Even outlandish fantasies can be deeply held. McNally's research team at Harvard University found that when subjects who claimed to remember being abducted by aliens are read scripts of abduction (based on details that they gave the researchers), they manifest increases in physiological indices of emotion, such as heart rate and skin conductance (sweating on the palm of the hand), that are larger than those registered by Vietnam veterans diagnosed with post-traumatic stress disorder who hear scripts of their combat traumas.
Does this mean that the phenomenon of repression is merely psychological folklore? Or that no long-forgotten knowledge and images recovered during the course of psychotherapy or otherwise can ever be true? No, McNally says. It is a potential hypothesis, but it remains to be proven. What we do know, McNally makes clear, is that the data are rock solid in establishing that memory is highly malleable, and that without corroboration we cannot infer from the vividness or the intensity of a memory that an event is historically true. As it stands, McNally correctly states, the burden of proof that the "ordinary response" to horror is its expulsion from awareness remains with those who believe it is so.
How to get to the bottom of this? McNally systematically sets out the minimum standards that studies should meet in order to confirm that repression occurs. The basic plan would entail gathering a pool of subjects who were involved as children in a well-documented traumatic situation. Then, years later, they would be interviewed to see how many had no recollection at all of the event. Finding such a pool would take work, but the task is not impossible. Once the pool was divided into those subjects who remembered and those who did not, researchers would need to exclude from the latter group those who had any of four possible reasons for failing to recall the event.
The first reason for exclusion is that the subject was less than three or four years old when the trauma occurred. This cutoff minimizes the chance that failure to remember was due to natural childhood amnesia, which wipes out events that took place when the subject was very young. The second disqualification is that the subject should not have suffered head injury, malnutrition, brain diseases, or severe sleep deprivation, because these conditions interfere with memory acquisition and retrieval. The third is that the subject has some obvious reason to deny continuous knowledge of the abuse. (There is the matter of the law itself: in some states, only lawsuits involving "repressed" memories can be filed; if someone has always remembered being abused, the statutes of limitations typically prevent him from seeking justice.) And the fourth reason is that the subject simply forgot. A forgotten event is one that is brought to awareness relatively easily with prompting, and is quickly recognized ("oh, yes") as having once transpired. This is much more likely to happen in the case of an event that was not perceived as traumatic at the time it took place. Not uncommonly, men and women who were fondled as children report that while they found the experience confusing or upsetting at the time, it was not terrifying or life-threatening (the properties of a true trauma). Thus, they chose to put it out of their mind, and did so successfully.
McNally could not find a single study or case report that met all of these standards. In fact, in study after study--of Holocaust survivors, of accident victims, of the children of the Chowchilla bus kidnapping, of torture victims--the subjects do not complain about forgetting; if anything, some are still tormented by their memories. Several studies said to support repression actually involved victims who sustained head injuries as part of the traumatic event they could not later recall. To be sure, even if a study meeting all four of McNally's requirements failed to identify any repressors, this would not tell us that the phenomenon never occurred in nature. After all, if something occurs rarely (say, less than one in one thousand times), most research samples will miss it. But at least we could reject as radically off the mark estimates made by repression enthusiasts that one-third to one-half of all incest victims are unaware of their mistreatment.
'Contemporary debates about trauma--how it is defined, how it is remembered, how it affects victims--have been shot through with politics since the Vietnam War," McNally tells us. Indeed, it was Vietnam that gave us the diagnosis of post-traumatic stress disorder (PTSD). The condition is marked by the intense re-experiencing of a horrific, often life-threatening event in the form of relentless nightmares or unbidden waking images. Crippling anxiety and phobias are also common.
To be sure, after a tragedy most people feel emotionally devastated, agitated, or even numb; but after a few weeks their reactions fade, leaving a residue of painful reminiscences and sadness. When symptoms last more than a month, however, the individual may have PTSD. Generally, between 10 percent and 30 percent of those who confront harrowing, cataclysmic experiences develop PTSD. (About one-third of the survivors directly in the path of the bomb in Oklahoma City developed it.) One plausible theory is that PTSD represents a biologically programmed fear reaction that, for reasons not fully understood, does not subside once the fear-producing situation is removed. The unabated fear reaction yields symptoms of re-experiencing, anxiety, and phobias.
The story of PTSD starts with the Vietnam veteran. In the late 1960s, a band of self-described antiwar psychiatrists--spearheaded by Robert Jay Lifton, who was well known for his work on the psychological damage wrought by Hiroshima--formulated a new diagnostic concept to describe the psychological wounds that the veteran sustained in the war. In 1972 they proposed "Post-Vietnam Syndrome," a disorder marked by "growing apathy, cynicism, alienation, depression, mistrust, and expectation of betrayal as well as an inability to concentrate, insomnia, nightmares, restlessness, uprootedness, and impatience with almost any job or course of study." Typically, the symptoms did not emerge until months or years after the veterans returned home.
The efforts of Lifton and his group would shape the dramatic image of the Vietnam veteran as the kind of "walking time bomb" immortalized in films such as Taxi Driver and Rambo. In the summer of 1972, the New York Times ran a front-page story on Post-Vietnam Syndrome. Titled "Postwar Shock Is Found to Beset Veterans Returning From the War in Vietnam," the article, by Jon Nordheimer, alleged that 50 percent of all Vietnam veterans--not just combat veterans--needed "professional help to readjust." The story contained phrases like "psychiatric casualty," "emotionally disturbed," "mental breakdowns," and "men with damaged brains." According to the sociologist Jerry Lembcke, a Vietnam veteran, "the story provided no data to support the image of dysfunctional veterans that it spun; what it did provide was a mode of discourse within which America's memory of the war and the veterans' coming home experience would be constructed."
This mode of discourse set the Vietnam veteran apart from soldiers that came before him. "The suggestion or outright assertion $(was that$) Vietnam veterans have been unique in American history for their psychiatric problems," writes the historian Eric T. Dean Jr. in Shook over Hell--PostTraumatic Stress, Vietnam, and the Civil War. Civil War soldiers also succumbed to mental breakdown, but because their war is portrayed as a righteous crusade to end slavery, it elicits images of heroes and prompts battle re-enactments. Only an unjust conflict such as Vietnam, Dean argues, could prepare the cultural imagination to accept the idea of soldiers as psychiatric victims, tragic misfits, and tormented losers. As the image of the psychologically injured veteran took root in the national conscience, the psychiatric profession debated the wisdom of giving him his own diagnosis.
In 1980, the American Psychiatric Association adopted post-traumatic stress disorder as an official diagnosis. (In that same year MPD was entered into the formal lexicon.) More generic than Post-Vietnam Syndrome, a diagnosis of PTSD was applicable to those who suffered other kinds of traumatizing conditions, such as natural disasters, accidents, or rape. Prior to the introduction of PTSD, there were other designations for traumatic reactions--in World War I and World War II, combat reactions were called shell shock or battle fatigue--but otherwise well-adjusted individuals were believed to be at small risk of suffering more than a transient stress reaction once they were removed from the front. Originally, prolonged dysfunction following a terrifying experience was believed to reflect underlying genetic or psychological vulnerability; the feared stimulus itself, such as combat, was deemed little more than a precipitating factor.
The diagnosis of PTSD changed all this. According to the British psychiatrist Derek Summerfield, PTSD "was meant to shift the focus of attention from the details of a soldier's background and psyche to the fundamentally traumatogenic nature of war." No longer were prolonged traumatic reactions viewed as a reflection of constitutional vulnerability; they became instead a natural process of adaptation to extreme stress. A traumatic event was thus defined as one that would cause significant distress to anyone anywhere. The influence of individual differences shaping response to crisis gave way to the profound impact of The Trauma, with its leveling effect on all human response.
Today, more than two decades after PTSD was ratified as a formal diagnosis, psychiatrists recognize that perfectly healthy people can indeed develop the condition following catastrophic shock. The risk of this happening, however, is considerably greater for those with pre-event psychological vulnerabilities, such as mental illness, personality disorders, and conduct problems as children. Not only do temperament and intelligence influence an individual's response to extreme events, they may well play a part in whether individuals become exposed to those events in the first place. People who are sensation-seeking, impulsive, or poor at predicting the consequences of their actions are more likely to get in harm's way. Intelligence has been shown to be a protective factor. (After all, general cognitive competence reflects in part the ability to evaluate new information and experiences and to adapt.) McNally emphasizes the relevance of pre-trauma traits, even though doing so can be deemed politically incorrect. As one traumatologist writes in The International Handbook of Human Response to Trauma, pointing out the issue of vulnerability to PTSD "potentially invalidates the experience of survivors, or worse, blames them for their legitimate reactions to those events."
So PTSD represents both a legitimate mental condition and a cultural artifact of the Vietnam era. It was partly intended to validate the suffering of veterans, but the irony is that nobody knows how many Vietnam veterans were actually affected. A government-mandated study on PTSD in Vietnam veterans found in 1988 that half of the approximately three million in-country veterans suffered either PTSD or a less severe form ("partial PTSD") at some point in the decade since returning from war. But this seems implausible: if only 15 percent of all troops were exposed to combat, it seems odd that 50 percent suffered symptoms of war trauma. Moreover, other military data reveal that during the years of most intense fighting, psychiatric casualties numbered twelve troops per thousand, or a little more than 1 percent.
Other factors may have inflated the number of Vietnam veterans believed to be afflicted. Take the undeniable economic allure of disability benefits distributed by the Veterans Administration. Today, a veteran disabled by PTSD can collect up to about $2,000 to $3,000 per month tax-free. Though well intended, the V.A. benefit system offers perverse financial incentive for veterans to remain ill. The effect of pensions was noted as early as World War I. "As men got better, the thought of losing their allowance would cause their ... symptoms to return or new ones to appear," wrote one British psychotherapist in the early 1920s.
Settling into the role of Vietnam veteran with PTSD is not always an economic affair, of course. When the V.A. hospitals created PTSD wards in the 1980s, the therapeutic culture cast combat exposure as the root of all postwar anguish. In the service of PTSD treatment, many well-meaning clinicians diverted veterans' attention from their immediate responsibilities toward sharing war stories in group therapy. "Anyone expressing skepticism about the validity of PTSD as a psychiatric condition--on the ground, say, that it became a catchall category for people with long-standing disorders of temperament and behavior who were sometimes seeking to shelter themselves from responsibility--was dismissed as hostile to veterans or ignorant of the mental effects of fearful experiences," observed Paul McHugh, the former chairman of psychiatry at Johns Hopkins University.
Psychiatrists have long recognized the complicated relationship of disabled veterans to the V.A. For some, the agency represents a kind of hostile dependency in which the veteran blames the government for his crippling war stress but craves the caretaking and resources its facilities can offer. For others, the hospital is a meeting place where they can socialize with fellow veterans and re-experience the camaraderie and sense of purpose they felt as young soldiers. For some of these men, military service was the most meaningful period of their lives. Conditions were hospitable, then, for an unsuspecting collusion between a troubled middle-aged veteran who perhaps had only minor complaints of nightmares or occasional disturbing thoughts of Vietnam and his therapist. Both have been trained by their culture into thinking that he had PTSD. The appeal to the veteran was obvious: the diagnosis bolstered his image as a wounded warrior, and helped him to make sense of his failures, and allowed him to attach meaning to pervasive feelings of demoralization, apathy, or irritability. From a clinical standpoint, though, clinicians were distracted from the patients' main problems by a preoccupation with dramatic symptoms. Finally, a growing number of researchers, McNally among them, worry that the well-documented problem of symptom exaggeration by patients may well undermine the validity of much of the research on combat stress.
In a recent book on psychiatrists and the military, the British war historian Ben Shephard observed that Vietnam, as the inspiration for the diagnosis of PTSD, "helped to create a new consciousness of trauma in Western society." It is a consciousness that presumes psychological fragility in the face of shocking adversity. A decade ago, for example, the Red Cross was sending only about three counselors to hurricane disaster sites, and now it deploys between one hundred and three hundred. After September 11, the trauma industry was out in full force. According to one estimate, nine thousand purveyors of therapy raced to lower Manhattan advocating intervention for any person even remotely connected to the tragedy.
Hospital and clinic directors in New York City braced themselves for epic caseloads of patients with post-traumatic stress. In the horror of the moment, their frantic preparations made sense; but the flood of patients did not come. This is not surprising. Most people are resilient. They prefer to cope--they can cope--on their own and in the embrace of their families, their communities, and their religion. Yet soothing and strengthening oneself, without expert help, is increasingly regarded as an anachronism, like setting one's own broken bone. The notion that a potent stress could pose an ennobling challenge to the human spirit, rather than a destructive threat to its integrity, is more and more foreign to the way Americans now live.
"Does everyone who goes through trauma need a therapist?" asked a skeptical reporter in USA Today. The answer seems to be yes. New York state mental health authorities estimated that about 1.5 million people, or one in five city residents, would need counseling after the attacks (though only 120,000 showed up for FEMA-funded services as of June 2002). That summer, city-based charities along with the Red Cross announced combined grants of up to almost $500 million over five years to "address the enduring problem of psychic damage--grief, stress, trauma--after September 11."
McNally, too, is impatient with the profession's tendency to medicalize normal human reaction to catastrophe, to play fast and loose with the attribution of mental illness. As just one example, he points to a study in The New England Journal of Medicine in which researchers questioned a random sample of Americans within mere days after September 11. The researchers found that 90 percent of those polled said they had at least one "symptom" (sleeplessness, trouble concentrating, feeling "very upset" when reminded of the attack, disturbing memories or dreams, feeling irritable). Forty-four percent said they had been "extremely" bothered by at least one of these problems. While these were normal initial reactions, the researchers described this subgroup as having "substantial symptoms of stress," and improbably warned that "clinicians should anticipate that even people far from the attacks will have traumarelated symptoms."
Such alarmist directives fuel the anxious hiring of crisis counselors, a practice that should be seriously reconsidered. Fortunately, last year the National Institute of Mental Health and the World Health Organization criticized the intrusive activities of practitioners who call themselves "debriefers." They are trained to get victims to express their feelings about the event--to cry and to re-live it as vividly as they can. Such emoting can rub some people raw, going against the grain of their natural adaptive instinct to distance themselves emotionally. A recent review of debriefing in The Lancet revealed that some victims actually recover from stress more slowly or feel worse after receiving the intervention compared to those who did not get it; at best, the intervention makes no measurable difference. Moreover, knee-jerk promotion of trauma therapy weakens people's trust in their own capacities. Appealing to an "expert" on anguish deprives one of the experience of having struggled to master one's tribulations by means of one's own inner resources.
For the most part, those surveyed about their mental health after September 11 were not direct victims. They were not at the World Trade Center scrambling for their lives. Yet even when people do suffer horrible events so directly, it is not inevitable that they are clinically traumatized. McNally describes studies documenting the resilience of political prisoners who have been tortured and of civilians who escaped genocide. Yet the psychological agendas intrude in these cases, too, in the form of the refugee mental health movement. "Almost everyone in Kosovo will consider her- or himself traumatized," warns the mental health literature from CARE International. The same has been said of Rwandans, Cambodians, and Bosnians by other agencies such as UNICEF, the U.N. High Commission on Refugees, CARE, and the U.S. Office of Refugee Resettlement.
As a consequence of these ominous but unexamined assumptions, millions of dollars have been spent on clinics dispensing Western-style psychotherapy in the furthest reaches of the globe (Iraq is likely to be next), even though program evaluations reveal that actual use of specialized psychological help is typically very low. In fact, numerous reports indicate that even refugees who have been victims of hideous atrocities are often more apt to blame their anguish on the effects of forced migration and resettlement than on violence in their homeland. They typically shun therapy, which is, after all, a highly culture-bound activity; but they eagerly welcome efforts aimed at relieving their loneliness, and their anxiety about economic survival, and their loss of occupation. It is no surprise that critics of the refugee mental health movement, such as the British psychiatrist Derek Summerfield, bemoan the urgency to diagnose PTSD. He attributes this to a consequentialist ethic that leads us to judge the malignancy of an act by the degree of harm that it produces. This consequentialist calculus permeates the trauma field, McNally notes, and he cautions emphatically against confusing harmfulness with wrongfulness.
Finally, McNally worries about the legal implications of defining trauma down, and the consequent trivializing of truly disabling post-traumatic reactions. In employment litigation, women who claimed PTSD from being sexually harassed have successfully sued or settled for large awards. Others have won settlements for being "traumatized" by hostile work environments. In her harassment suit against President Clinton, Paula Jones claimed PTSD from their encounter. Clinton ended up settling with Jones, while the entire country was in turn traumatized by the spectacle.
The Boston Globe reported last fall that three local therapists are campaigning for recognition of a new diagnosis: post-traumatic slavery disorder. Apparently, drug abuse, broken families, crime, and low educational attainment in segments of the black community can be directly linked to the trauma of slavery, and "black people as a whole are suffering from PTSD"--an abuse-excuse appeal for reparations if ever there was one. Satirists could barely contain themselves, proposing, among other new diagnoses, "post-traumatic birth disorder," defined as being "brought on by the pain, insensitivity, embarrassment, and forced relocation that the victims had to endure as a result of the birth process, not to mention the indignity and violence associated with that first spanking."
None of us is likely to remember that first spanking, but memory generally serves us well. It provides the core of our identities and the substance of our autobiographies. It is the foundation for cognition. But memory is exceedingly subject to distortion. For the most part, our reconstructions are good enough for everyday life; but in the legal arena, inexact recall can literally be a matter of life and death. In the current sex abuse scandals in the Catholic Church, the vast bulk of accusations have been made by adults who always recalled their violation, but amid the clear-cut cases of abuse there is the considerable danger that a stream of false accusations is likely to emerge as new "victims" are influenced by media coverage or by suggestive therapy.
McNally's book prepares us for that possibility, and more generally for the peril of another kind of abuse: memory abuse. Remembering Trauma is a powerful counterweight to a literature that has often ranged from sloppy to ill-informed to overwrought, and to a field that is too often susceptible to the promptings of politics and culture. McNally has produced a work of exemplary scholarship that should begin to free our conceptions of trauma from the grip of many contemporary illusions. If it accomplishes this, it will be a grand achievement far beyond its field.
Sally Satel, M.D., the W. H. Brady Jr. Fellow at AEI, is the author of PC, M.D.--How Political Correctness is Corrupting Medicine (Basic Books) and coauthor of the forthcoming One Nation Under Therapy (St. Martin's Press).
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