Abstract
Janice Haaken's Psychiatry, Politics, and PTSD: Breaking Down describes the progressive push to recognize and incorporate post-traumatic stress disorder (PTSD) in recent editions of The Diagnostic and Statistical Manual (The American Psychiatric Association, 1987, 2013). One line of argument queries this progressive coup, as its intentions for change become caught in the coils of the DSM's psychiatric taxonomies. A second theme introduces psychoanalysis in its relationship to trauma and explores the tensions within PTSD diagnostic premises. Finally, the book “looks at how political and historical contexts of stressful and traumatic events enter into diagnostic thinking” (p. 7).
Her first chapter, “Listening to Distressing Stories”, recounts how one attends to stories of war trauma. Haaken argues that when understood as an exceptional and time bound event, war trauma has the merit of recognizing the importance of external events. However, as a concept/diagnostic category, trauma fails to touch upon an expanse of factors affecting a soldier's suffering and his, her or their reaction to the event that is considered a trauma. This failure constrains the military's therapeutic interventions in dealing with war trauma. Firstly, its promotion of “post-traumatic resilience/growth”, a “healthier” reaction to trauma cultivated in pre-deployment training to mitigate individual suffering and keep the soldier in the field rather than in treatment. Secondly, if a trauma of war re-emerges five years after discharge, should governmental resources be available, or is there another underlying cause that re-litigates the war's causality in the soldier's suffering?
The reification of trauma into a one-time exceptional event certainly does not reflect the hopes of the anti-psychiatry movement when PTSD first emerged as a diagnosis. Anti-psychiatry's clinical revolution had intended to open psychiatry to addressing the effects of chronic stressful and traumatic conditions often experienced by marginalized groups as well as soldiers. This would have at least two socially radical effects. It would broaden psychiatry's scope to include the chronic effects of systems of oppression. It would also alter the more individualistic bias of psychiatry so that its forms of treatment and theorizing would consider both singular approaches and collective approaches. Such an approach would enable an understanding of social systems as traumatic.
Other chapters make a deep dive into the tricky maneuvering that allows PTSD to maintain certain criteria, whether in relationship to pre-existing conditions and/or personality disorders, as well as trauma's historical and current relationship to the body as itself a symptomatic and symbolic record of trauma. For example, following her exposition on the social and political context of PTSD, Haaken interrogates the ways in which disability adjudications and legal entanglements show how PTSD forces a reckoning with the “distribution of responsibility for emotional suffering” (p. 123). Her penultimate chapter points in fruitful directions for collective and symbolically powerful ways to “healing” group trauma.
Haaken's concluding chapter calls for a more mature, progressive “anti-psychiatry” as the aspirations of anti-psychiatry have animated much of Haaken's book. An inclusion of French and Italian influences on this movement would have been beneficial, given that psychoanalysis was more explicitly involved in anti-psychiatry in France, and thinkers/analysts such as Maud Mannoni, Félix Guattari and Franco Basaglia offer different interventions to counter the influence of psychiatry. Still, Haaken properly praises the push of anti-psychiatry to implicate social systems and factors, expand the form and scope of services, humanize “patients”, and question the social control in which psychiatry participates.
Anti-psychiatry must also challenge today's psychiatric nomenclature, even seemingly enlightened categories of “psychopathology” (like PTSD) with their unintended effects. Thus, as Haaken argues, the knowledge produced by the editions of Diagnostic and Statistical manuals does not address the moral injury inflicted by unjust social practices and systems. These injuries are hardly reducible to a singular exceptional traumatic event, whether one speaks of soldiers or children, women, gender non-conforming persons, those without wealth, black, indigenous and people of color, and migrants. Indeed, the psychiatric use of PTSD faltered in the face of an obvious extension to different “target” populations, thereby failing to address the social dimension of trauma. Clinicians work within an intellectual, political and practical context that keeps their work within the framework of an individual's suffering. Given the changing contours of the diagnosis and its efforts to dodge being extended to a more social and systemic idea of etiology, Haaken's narrative suggests that the evolution of the meaning of PTSD functions primarily to support the scope of practice and institutional context, while reacting to political pressures from advocates and those affected.
PTSD does presuppose a different interaction between the social world and the psychological one, especially given the individualistic perspectives of most approaches in mental health where the patient is the problem. This shift away from individual psychopathology to social context is a solid step in a progressive direction, one welcomed by feminists and veterans. Still, Haaken notes caveats to the progressive promises of the diagnosis. She indicates that differences in the subjective experience of one's world and its stresses, and the psychological conflation of past/present/future, are a lot less distinct and marked than psychiatric diagnoses allow. Can one really create a demarcated time frame for effects from a previous traumatic event? And if time and memory are involved, how do we understand the very complex nuances of memory itself (Haaken, 1998, 2021)?
The politics determining when a PTSD diagnosis is made are essential to Haaken's project and, as Haaken shows, to the iterations of the diagnosis of PTSD. If such background scaffolding is inextricable from the premises of PTSD, how does the changing parameters of the diagnosis itself negotiate its amboceptor status in relation to the social and the individual? And does the diagnosis of PTSD serve the creeping reach of psychiatry as much as it does the range of individual suffering? These are the circles of thought which, for Haaken, outline the history and function of this diagnosis and the politics of its use.
The meaning invested in PTSD, and who is served by this diagnosis, can be seen from how social prejudices and pressures shape the application of the diagnosis. More concretely, acting as a criminal after a lifetime of abuse or shooting your abusive relative plays much differently, depending on how your actions fall into line with the layers of meanings that have come to inhabit the rhetorical power of a diagnosis of PTSD. For those who have “personality disorders” – even as that diagnosis has mutated – no amount of prior trauma seems sufficiently exculpatory if their behavior crosses a legal limit. Similarly, for those who retaliate against their abuser, the distinctions that legitimate PTSD as a defense are fickle.
As further evidence of this politics, Haaken draws telling comparisons between sexual and child abuse, as well as the military's reaction to war trauma. These are traditionally gendered domains and the effect of PTSD opens new ways of envisioning such gendering. Thus, ever watchful for malingering, psychiatrists are less likely to be engaged in intramural professional warfare over whether soldiers' and veterans' actual memories are “false” as is the case with childhood abuse or sexual assaults, previously secret or repressed. Furthermore, psychiatry allows a soldier's recounting of the effects of trauma to go hand-in-hand with warm attachment to military service; however, seldom is such ambivalence of feeling allowable with respect to victims of sexual assault and their abusers, although that ambivalence may hold clinical import in both domains. And when the issue of Military Sexual Trauma (MST) is brought forward by women in uniform, military culture and women's empowerment clearly diverge. Haaken notes that if sexual violence and military machismo are confronted more aggressively, reforms might lead to less stigma for the survivor, a feminist objective in military and civilian life.
In Psychiatry, Politics, and PTSD, Haaken attends to how histories of gender, colonization and race display the myriad ways that suffering, especially of the variety that PTSD touches upon, is diminished within psychiatry as a plausible psychosocial issue affecting the experiences of individuals and groups whilst inflecting the historical moment, at any given time. Rape, for example, is never only an act of sexual violence but also incarnates and symbolizes multi-faceted meanings, which are imposed through/by cultural traditions, systems of formal and informal power and perpetuated by clinical practices. All of these broader factors impact questions of the victim's “believability” and the recognition of their rights as a citizen.
Haaken's sage efforts to underline the cultural and symbolic positioning of trauma are well argued. Yet, her text does not address all of the implications of the critical issues that she raises. Is trauma, with its modern roots, a phenomenon that participates in re-defining ontological dimensions of humanity? How do these encounters, called traumatic, affect our understanding of time and our sense of who we are as humans? For example, even in popular culture, childhood events are part of the essence of the adult. Roberts (2018) argues that trauma becomes more salient in a world in which the human is situated as a finite (non-divine) being whose life is deeply informed by temporality, that is, history and memory. Psychiatry bravely stumbles into these changes in oneâ s foundational sensibility of time and meaning – dimensions underlying what it entails to be human.
The later Foucault astutely interrogates this foundational ground in a way that might augment Haaken's conceptual frame. Foucault traces the religious and ethical beliefs and practices from antiquity to modernity, uncovering the evolution of contemporary psychological life. Christianity demanded soul searching, institutionalized practices of confession, and shaped the rise of psychiatry. According to Foucault (1999), by the time of Protestantism, one must endlessly examine all of one's yet unknown failings in the face of an enigmatic God (no concrete sacrifices to placate the Divine, no recourse to papal intervention). With the rise of science, this infinite inner searching for the truth of one's self is retooled and positivized by psychiatry (Foucault, 1999). Psychiatry relieves the void of one's lack of self-knowledge and offers a moral bearing, once given by religion. Thus, inventions such as PTSD are an instantiation of bio-politics, aka psychiatry, taking up the ethical and religious reflections/practices of the past.
Foucault (2005) excavates the ontological and existential changes that arise when religious and epistemological paradigms change. Cultures must indeed offer its citizens ways of mediating the vicissitudes of life, the presence of others, and install a body into a system of speaking, with its limitations, as any bilingual person knows. I might call these parameters, noted by Foucault, the infrastructure of cultural life. Furthermore, additional reflection on the above noted parameters could draw Haaken's work towards queries on how we currently derive the truth of who we are and how that “inner search” crisscrosses the emergence of a lexicon of trauma and PTSD as viable categories of human experiences. Indeed, Haaken resonates with the later Foucault in seeing how a medical undergirding of trauma could be transformed into a more strident claim of moral injury.
In Psychiatry, Politics and PTSD, Haaken relies upon psychoanalysis just as she affirms her feminist allegiances. She might also acknowledge that psychoanalysis, when less influenced by psychiatry, makes an unqualified stand for the inmixing of “internal” psychic life and the contingent and normalized outward events a person experiences. Moreover, part of the cultural context to which she alludes is obviously the scaffolding afforded by language itself. Thus, her discussions of symbolizing and of the “talking cure” could fruitfully acknowledge that the cultural is inevitably brought into the clinic. Psychoanalysis exploits the interface of the body who speaks and is spoken of and the subjective position which results. Culture is evoked from inside of that speaking. Within the clinical process, any exchange may be the inflection of singular or social inscription of the meanings the exchange carries. It is most likely both.
Certainly, as Haaken outlines, the interventions and the diagnosis reflect much more than the experiences of the person who is the recipient of treatment. There are also the survivors” appeals to a subjective truth as valid. Perhaps this truth and its coordinates are located far outside the covers of the DSM-5. When we forget to bring culture and political disparities into the clinic, we mistake the struggles of subjectivity (as a position in relation to the world) with an individual – a political/social category.
This book is a critical read for clinical psychologists, critical psychologists, and those cross-fertilizing feminism with other sectors of critical thought. It also makes a compelling and practical argument to offer a stiffer yet more refined resistance to a mental health field in which psychiatry too often holds the final say.
