Psychiatric colonialism,PTSD and the Western psychiatric diagnostic tradition . . . is one man’s food another man’s poison?

Introduction

Stress related disorders are important on many levels: traumatic events can irreversibly change lives, damage careers and relationships and cause immense suffering not only to individuals but also to those around them. Diagnosis of distress carries very many meanings. Diagnoses help us understand epidemiological data, and burden of disease as well as the need for appropriate resources. A diagnosis can also be used in the courts to secure compensation and pensions awarded on becoming a ‘case’ with a diagnosis, and that diagnosis is almost always Post-Traumatic Stress Disorder (PTSD). In the developing world aid agencies and NGO’s are attracted to trauma and disaster where (mostly) western led mental health teams will seek to diagnose PTSD, and apply western developed therapies on diverse cultures, often via translation, each with its own perspectives of suffering and the response to trauma. This paper questions the PTSD diagnosis and argues that a failure to consider Biopsychosocial and cultural dimensions of the patient and applying western therapies in foreign lands, is inappropriate, may be ineffective and may at worst do more harm than good. One size doesn’t necessarily fit all, and although well intentioned, training programmes for non-mental health professionals such as the WHO’s MHGap, which uses a reductionistic diagnostic model based firmly upon the International Classification of Disease (ICD) and is firmly rooted in the Western psychiatric tradition and merely serves to extend its hegemony and arguably doesn’t necessarily serve the people it is meant to help.

The classification and diagnostic criteria of stress related disorders is problematic even in our own back yard (Dittmann & Dilling, 1990) The PTSD diagnosis in ICD10 (F43.1 post-traumatic stress disorder) leaves little wriggle room for manoeuvre and is unforgiving of anyone not fitting its strict diagnostic criteria. This matters because the PTSD diagnosis is also the principal way to get your condition acknowledged in social terms, to receive psychological therapy, as well as compensation, benefits and practical support. But if your condition does not qualify for this diagnosis, the alternatives are poor.

The F43.0 acute stress reaction is a transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days, which off-cause is wrong when the condition persists after months.

Another alternative is either F43.2 adjustment disorder which is a temporary condition expected to disappear in some months’ time and is a product of life’s normal stressors, for example, divorces and other social disturbances and should subside in 6–9 months, which also makes this diagnosis unattractive or the F43.9 reaction to severe stress, unspecified, lacks any definition whatsoever (Dittmann & Dilling, 1990; Galatzer-Levy & Bryant, 2013).

Since the therapist, psychologist, or psychiatrist is left with almost no alternative than to resort to the PTSD diagnosis to give a patient legitimacy, it may be a poor representation of the symptoms described and just because an individual doesn’t meet PTSD diagnostic criteria, doesn’t mean they haven’t been mentally scarred by traumatic events.

The end result is that the criteria for PTSD diagnosis are twisted and bent to suit the goal, or just simply ignored, so the diagnosis is used for many occasions where the incident is not life-threatening (A-criteria) or lack the symptoms and creates a situation aptly described by Maslow . . . ‘If the only tool you have is a hammer, all you look at looks like nails’ (Maslow, 1966).

So why have we created a diagnostic system that is so unequipped to deal with a range of symptomology following traumatic events, and offers little alternative to a diagnosis sets narrow, rigid criteria and demands exposure to real or perceived events of life-threatening severity (Dittmann & Dilling, 1990).

The origin of the diagnosis PTSD

Although first described in the American DSM-III in 1982 in the wake of the Vietnam War, PTSD as the epitome of psychological trauma, has, through the eye of faith, a long and venerable history. Symptoms arising from war trauma are described in Homer’s Iliad, Herodotus and Shakespeare as well as contemporaneous descriptions from the American Civil War onwards. (Horwitz, 2015). The German psychiatrist Ganser described in a condition which later was eponymously known as Ganser psychosis, describing symptoms of derealisation and dissociative behaviour (Andersen et al., 2001).

In WW1 non-physical symptoms resulting in functional impairment and disability became known as shellshock (as initially believed to result from the percussive effect of shellfire on the brain) and a number of rather distinct syndromes were described in the literature of the time including movement disorders, paralyses, blindness, amnesias and aphonia. Acceptance of Shellshock as a legitimate reason to be excused the battlefield and be medically evacuated was a slow and at times grudging process and many cases were looked upon as cowardice and treated accordingly (Jones et al., 2007; Rae, 2007; Gersons, 1992).

In World War II the symptoms of psychological trauma were acknowledged and dealt with more sympathetically, but the full impact of traumatic events was not really acknowledged before the Vietnam war. It was in the light of the clear suffering of mainly US Vietnam Veterans supported by other pressure groups such as the feminist movement and Holocaust survivors that the PTSD diagnosis was spawned, as much out of political expediency as phenomenological exactitude, in order to give legitimacy to the suffering of service Veterans, now clearly visible to the wider population in media and in the movie house (Weissman, 2012).

However, the point about this truncated and oversimplified history, is that it is not a history of PTSD, although it has been used as such by some to give legitimacy and credibility to the diagnosis. Rather, like the use of the PTSD diagnosis itself, the historical accounts themselves have been embellished, twisted and distorted to fit the PTSD diagnosis when in reality, all we can safely conclude from history is that war trauma causes mental scars and long-term disability presenting in disparate ways and varying with time, place and individual circumstance. Some of these symptoms may indeed be PTSD, but in adopting the narrow, reductionist PTSD diagnostic criterion, we have unwittingly excluded many who do not suffer from PTSD, yet who remain severely psychologically damaged and in need of support. We should be much more inclusive of the range of psychopathology following traumatic events and think in terms of Post Traumatic Disorders (PTD’s), of which PTSD is one particular manifestation (Bryant, 2019; Deahl et al., 2001)

The convergence and eagerness of institutions and therapists to treat

After traumatic events, both natural and manmade there is an overwhelming wish to ‘do something’ for victims (NICE, 2018). The incentive is driven by a number of factors and engenders a ‘one size fits all’ approach which fails to address the differences between individual and collective, as well as single incident versus multiple trauma. The trauma response following a motor vehicle accident and a tsunami will be very different and any therapy must take account of the context.

The organisations, often NGO’s, helping and giving psychological treatment has a clear economic benefit from doing so. Even within the military, mental health professionals are keen to demonstrate their usefulness. Individual therapists also have also an economic benefit, and of course a wish to show empathy and compassion for victims. Governments and politicians likewise, are want demonstrate action and recognition of the victim’s plight. The result of this is an Army of well-meaning mental health professionals offering psychological therapy immediately after a traumatic event which, is neither necessarily beneficial nor helpful.

The understanding and classical view of PTSD and treatment is in this situation can be completely forgotten and no questions asked whether an intervention is beneficial or not, or indeed, might even do harm. Instead, a panoply of therapies sits in the armoury, deployed regardless of presenting symptoms, be it supportive counselling, EMDR, cognitive-behaviour therapy (CBT), NLP or MPT (Morgenstein, 2021). The rush to help and be seen to do something can become problematic if interventions are deployed without any consideration of what is beneficial for the individual and what is often a unique symptom profile which may or may not include PTSD.

Whither the biopsychosocial approach?

Like all mental disorders, the ICD-11 diagnosis of PTSD follows the western psychiatric tradition, reductionist and operationalized, how relevant or appropriate is it therefore to impose this western diagnostic straightjacket on other cultures with different value systems and wildly different resources and access to mental health care? PTSD is a particularly problematic exemplar. Following conflict or natural disaster, western NGO’s and aid agencies inevitably intervene, looking at suffering through the western diagnostic lens, diagnosing PTSD, thus demonstrating a need for therapy and treatment (further justifying their presence), with limited available resources to meet this need and, if western psychological interventions of whatever sort, actually help, they will only ever be available to the few raising ethical questions of fairness and discrimination, as well as the economic issue of whether the resources would be better deployed providing safety, warmth, food and shelter to victims. Moreover, for the few who achieve access to therapy, this is often short term and incomplete and by the time the next disaster strikes and the ‘Aid circus’ moves on leaving victims (who have now become patients) bereft of care, or subject to the vagaries of (generally inadequate) (Dubey, 2015; NICE, 2018).

Meeting the demand . . . mind the (MH)Gap

Acknowledging and responding to the shortage of mental health professionals in many parts of the developing world, WHO have developed a training package to bridge the gap between demand and capacity that exists in many parts of the developing world. Mental Health Gap (or MHGap) is designed to equip non-mental-health professionals to assess, diagnose and treat a broad range of mental disorders likely to be encountered in community settings (Keynejad et al., 2021).

Although laudable in principle, MHGap potentially compounds the problems raised by the PTSD diagnosis. Across the board, the mental disorders addressed by the MHGap program are again based upon ICD diagnoses, looking at mental distress through the prism of the western psychiatric tradition paying little attention to local culture, traditions or values and inadvertently diagnosing patients with conditions, frequently alien to a particular culture and demanding treatments that are either unavailable or for which local resources are simply inadequate. NGO’s provide treatments themselves, but, as in disaster or conflict situations, the intervention is short term and incomplete by the end of the NGO ‘mission’. Moreover, even when a therapeutic intervention is provided, this is often delivered by multiple practitioners as staff, mostly employed in the field on short term contracts, rotate and complete their ‘mission’ denying the hapless patient any possibility of continuity or care, a crucial ingredient of any psychotherapy.

Whether MHGap is helpful in diverse cultural contexts remains to be seen, though it certainly ticks the box ‘need to be doing something’ (Wessely & Deahl, 2003).

We question the wisdom of imposing the western psychiatry and classification on diverse cultures, be it PTSD, or ICD-10 imposed by a western intervention program such as MHGap (which is also part of the global mental health agenda). It was somewhat bizarre working in Central Asia to make frequent diagnoses of major depressive disorder when, no word for depression actually existed in the host language or as stated in this reference (Okasha & Dawla, 1992). Likewise, a prescription for psychological intervention was often met with bemused confusion in a culture where emotional distress was managed within the family or by local traditional healers. Imposing western psychiatric ideology in these situations risks therapeutic failure, for as Jerome Frank famously once remarked, it is not the specific therapy that matters, so much as patient and therapist ‘buying into’ an agreed Therapeutic framework, be it dynamic, behavioural, or whatever (Frank, 1980).

Moreover, imposing a western therapeutic paradigm risks undermining longstanding cultural beliefs, traditions and practices that help define the identity of a society and the individuals place within it (Okasha & Dawla, 1992).

Beside the problem of cultural diversity there are also changes in western society, with a shift from individual to the societal and a sense that society should shoulder responsibility for helping those in psychological crisis. This of cause demands a ‘professional’ to take charge and treat, ignoring the life experiences of former generations, a time when family was the principal caring and curing agent. It has become axiomatic that whenever the media reports an incident that they also report that the involved parties have received psychological counselling, without any regard to the type of trauma or respecting timelines in development of the psychological responses.

Another complication of this approach is that past psychiatric history and other vulnerability factors are ignored and frequently not taken into consideration. A traumatic event is often the straw that breaks the camel’s back and set against a background of a significant family history. previous psychiatric illness, childhood adversity, adverse life experiences and previous traumatic events. It is worth noting that in the National Comorbidity survey 88% of men and 79% of women with PTSD had a lifetime diagnosis of other psychiatric illness (Kessler et al., 1995; Qassem et al., 2021).

In praise of the biopsychosocial approach

Providing mental health support in any culture setting should be sensitive to local beliefs and values, available resources and individual life story and circumstances. Every context differs and any needs assessment should involve local health workers and other stakeholders and be sensitive to the beliefs, values and resources available to the population. This embraces the Biopsychosocial approach, much vaunted in training western mental health professionals, but all too often disregarded in the rush to be seen to be doing something when disaster strikes (Wade & Halligan, 2017).

In conclusion

The western diagnostic system including the upcoming ICD11 has left us lost in translation with regards to the PTSD diagnosis without bridging the gap between the origin of the diagnosis from historical battles of war and to a modern society where the diagnosis has become a substitute diagnosis to legitimise daily traumas, which in no way fulfils the criteria for a PTSD diagnosis. We need to develop diagnostic tools and finesse our classification diagnostic tools to meet the need for psychological trauma diagnosis in a modern society. The overwhelming wish to ‘do something’ for victims of trauma makes things worse, consideration for cultural and psychological reactions is disregarded and the PTSD diagnosis is warped to suit the situation. The change in peoples attitude to life and relationships, as families in the developed world fragment and are increasingly unable to look after their loved ones, puts professional healthcare workers, as agents for society, into the breach as rather poor substitutes.

There is a serious need to overhaul the ICD system in the trauma arena. We need credible alternatives to PTSD, not just a reworking of the PTSD criteria per se, a better description of the diagnosis F43.9 Reaction to severe stress, unspecified, instead of just one line. Moreover, we need to look at the cultural impact of introducing ICD and the western psychiatric tradition to other parts of the world where attitudes, family and societal structures are so different from our own.