Feeling Our Way

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Not Every Disaster Is a Trauma

A new, old terminology for PTSD.

One of my triggers is the promiscuous description of unfortunate events as traumas and of associated unhappiness as post-traumatic stress disorder (PTSD). I try not to think about this tendency among clinicians; recollections intrude on my peace; I become irritable and morbid about my profession. Please stop traumatizing me.

The PTSD label seems to metacommunicate that the problems are not the patient’s fault. Certainly that was Judith Herman’s intention in switching from the label, “borderline personality,” to the label, “complex PTSD.” There was a time, of course, when “borderline personality” also meant that the symptom picture was not the patient’s fault; the label suggested that the attachment process went badly but the person developed enough surface skills and psychological defenses to avoid psychosis. The borderline’s impulsivity, splitting, self-diffusion, and projective identification could be seen (and still are by many of us) as heroic attempts to maintain ongoing connections with others at his or her own expense.

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But people with borderline personalities are unpleasant to interact with, and eventually that unpleasantness conditioned a similar response to the label as well, which is now (often correctly) perceived as an insult rather than as an effort to understand. A similar conditioning has occurred with the term, “mentally retarded,” which was originally a nice way of saying slow, which in turn was a nice way of saying incapable. (Those who hail the newest term, Intellectual Disability, are in for a surprise when they find that they are limiting people by saying they are incapable rather than merely behind.) Every term for unintelligent has been greeted as impartial and later rejected as insulting—imbecile, moron, idiot, cretin. This tendency to shy away from currently correct terminology reflects our profession’s difficulty managing its own aggression, but when it comes to people with intellectual disabilities or borderline personalities, the use of euphemisms does no real harm.

The spread of the PTSD label does real harm. It doesn’t hurt sexually abused children, combat veterans, or battered women who need a diagnosis to gain entry into therapy (as long as the therapist can tell the difference between PTSD and regular symptoms, coping strategies, and organizing principles). It hurts people with trauma, that biological coping strategy, probably evolved to facilitate immediate functioning after a life-threatening or extremely painful event, that in short makes the immediate environment seem unreal. The method of harm is that our profession is forgetting how to identify people with trauma, and these people need special treatment. (A brilliant discussion of these differences can be found in Mary Jo Peebles’ book, Beginnings.)

Because (I’m simplifying, not for you but for me—if I don’t simplify complex ideas, I can’t use them clinically) their world seems unreal, normal methods of therapy don’t “take.” You can try graduated exposure to frightening stimuli, but the person dissociates during the exposure process, so the repertoire (or self, if you will) that gains comfort with the scary stimuli doesn’t affect the repertoire (or self) that operates under stress or in the middle of the night. You can talk about what happened and rely, as you usually do, on the therapist’s calmness, interest, and safety to change the conditioned response to the painful material, as usually happens. You can try this, but with the genuinely traumatized person, your calmness, interest, and safety have no effect, because the person is so absorbed by accommodating the recollected event or by avoiding it that you become invisible. It would be like trying to condition a person into a sense of safety by playing soothing music when the person is wearing headphones playing a horror movie soundtrack.

It seems like we have lost the battle over labeling PTSD. Instead of a life-threatening (or extremely painful or shocking) event, even vicarious trauma now will do. This switch was imported from tort law, where in many jurisdictions you can sue someone for negligent infliction of emotional distress only if you witnessed their negligence first-hand. Judges decided that hearing about negligence, if it caused, say, the death of a child, should also allow you to collect damages (the legal term for money). But we don’t need diagnostic labels to express our sympathy for patients or our sense of justice; we need them, if we need them at all, to tell us what to do. We have also lost this battle because PTSD has entered the lay language. Further, the word trauma, used in medicine to mean severe bodily injury, confers legitimacy for psychological reactions among those who think that psychological reactions need legitimacy.

Instead, we need a new term to designate people who have that physiological reaction to catastrophes, disasters, tragedies, and even bummers. (I had a true case of extremely mild PTSD in high school after getting hit by a baseball from an unexpected source. The flashbacks, and ridiculous efforts to duck them, lasted about three days.) I propose “shock” or “psychological shock.” This terminology avoids the question of how great a stressor is needed to qualify for the diagnosis; it emphasizes the physiological reaction; and it alerts the therapist that the patient might not be in a state to converse with normally. It also takes the terminology back to its “shell shock” roots.

Michael Karson, Ph.D., is a professor of psychology at the University of Denver.

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