How should the sociopolitical nature of PTSD as a diagnosis inform our understanding of trauma?
Conversations in Critical Psychiatry
Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.
Janice Haaken, PhD, is professor emeritus of psychology at Portland State University, a clinical psychologist, and a documentary filmmaker. Dr Haaken has published extensively on psychoanalysis and feminism, the history of psychiatric diagnoses, interpersonal violence, the social psychology of remembering and storytelling, and documentary methods. Her books include Pillar of Salt: Gender, Memory and the Perils of Looking Back (Rutgers University Press, 2000), Hard Knocks: Psychology and the Dynamics of Storytelling (Routledge, 2010), and Psychiatry, Politics, and PTSD: Breaking Down (Routledge, 2020). She has directed 6 feature films: Queens of Heart: Community Therapists in Drag (2006), Guilty Except for Insanity (2009), Mind Zone: Therapists Behind the Front Lines (2014), Milk Men: The Life and Times of Dairy Farmers (2016), Our Bodies Our Doctors (2019), and her current project, Necessity: Oil, Water and Climate Resistance. Dr Haaken has received numerous awards for her filmmaking, most recently the Lena Sharpe Persistence of Vision award at the 2019 Seattle International Film Festival.
Dr Haaken’s latest book Psychiatry, Politics, and PTSD is a fascinating critical analysis of posttraumatic stress disorder (PTSD) as a diagnosis, the turbulent debates surrounding the role of trauma in psychiatry that led to its creation, and the institutional and sociopolitical functions it serves in a wide variety of settings such as the military, veterans’ affairs, war zones, refugee camps, and criminal justice system. I was impressed by the adeptness with which Dr Haaken tackles the ambiguity, uncertainty, and the internal contradictions present in the subject matter while resisting the temptation for simplistic answers. This interview delves into some of the broader conceptual and sociopolitical issues surrounding PTSD and psychiatric diagnoses discussed in the book.
Aftab: You wear many different hats (psychoanalytic clinician, critical psychologist, documentarian, and field researcher), which offers you a unique advantage in being able to approach psychiatry from a variety of different perspectives. Can you tell us more about your background and how that has influenced your critical inquiries?
Haaken: My first professional career was in psychiatric nursing, beginning in the early 1970s as a staff nurse in a treatment program for children, and later in medical training centers in California and Oregon. My nursing background was formative to my identity as a professional, even in the course of pursuing a PhD in clinical psychology. Nursing is a traditionally female job, but one that is very hands-on and close to bodily experienced suffering. I value that. As a clinician, I was influenced early on by the women’s movement and its rejection of a lot of the old diagnoses, with hysteria the prototypical example. I have always approached the diagnostic process as a form of storytelling that requires attentiveness to social contexts of mental suffering and to the language available for communicating distressed states. In addition to feminism, I was influenced by the radical psychiatry, critical psychiatry, and the antipsychiatry theories of the 1960s and 70s, all of which shared a critique of the medical model that underpins psychiatry.
When I joined the faculty at Portland State University, my research methods—grounded in critical theory, psychoanalytic-feminism, discourse analysis, and qualitative field research—were considered quite radical, although the department moved to incorporate more qualitative methods over time. I joined the faculty in the era when academic psychology was moving in a more applied direction. During the year that I joined the faculty, the animal lab (which took up an entire floor of our building) was in the process of shutting down. My department was migrating to field studies and taking up messy data and real-world problems that were central to my own program of research. My documentary films grew out of my field studies where initially I used cameras to capture more of the communicative language of participants than audio recordings permitted.
Aftab: Tell us about your most recent book Psychiatry, Politics, and PTSD: Breaking Down. What did you set out to do and where do you think you ended up in terms of your analysis?
Haaken: This new book extends a line of analysis pursued in Pillar of Salt: Gender, Memory, and the Perils of Looking Back, a book that focuses on narrative aspects of psychiatry and how social movements shape diagnostic thinking. In the later decades of the 20th century, trauma disorders, from multiple personality disorder, dissociative identity disorder, to posttraumatic stress conditions, gained enormous currency in the mental health field. There were intensely heated debates over a widening array of symptoms thought to be disguised symptoms of trauma.
In Psychiatry, Politics and PTSD, I revisit some of those debates and the historical and cultural dynamics that shaped the way trauma models took hold late in the 20th century. With the rise of neoliberalism, and the push to marketize everything in sight and the dismantling of public services, the dramatic and morally charged accounts associated with trauma represented an effort to break through the high threshold for responding to more mundane forms of suffering. With PTSD narratives, I was interested in how this diagnosis migrated through this same era and how the scientific disputes over the diagnosis seemed to be symptomatic of a deeper problem in the field. I came to think of PTSD as a forensic diagnosis as it was used in settings where clinicians were enlisted in adjudicating the fates of individuals. There is some consensus that PTSD is a redemptive diagnosis in the sense that it assigns causality to an external force and does not implicate the sufferer. Many progressive clinicians embraced the expanded use of the diagnosis because it seemed to offer a form of sanctuary or protection from more damning labels. I was interested in what was excluded in the differential diagnostic process as clinicians were using this diagnosis, and particularly in the military and the Department of Veterans Affairs (VA), the courts, and other institutional settings.
Aftab: It was fascinating for me to read in your book about how the diagnosis of PTSD emerged from a union of research studies in stress and trauma, and how different the cultures of these traditions were. Stress research had adopted a very mechanical view of psychology, as you point out in your book: “People, like machines, are subject to breakdown under conditions that exceed their operational capacities.” While on the other hand, “To speak of psychic trauma is to position the problem within a moral community of responsibility as well… Whereas stress speaks to the machinery of mind, trauma evokes images of the ghosts in those machines” (p. 8-9).1 How do you think this tension has played out in subsequent research on PTSD?
Haaken: Early in my career, I was highly critical of machine metaphors, associating them with masculinist assumptions in science and dehumanizing modes of intervention. My own field of feminist psychoanalysis holds some affinity with the trauma models in their focus on storytelling, and the ghosts in the machine! Trauma therapists often speak of hauntings, which can be a meaningful way of representing the ineffable or elusive aspects of mental disturbances. But I do think it is a mistake to align metaphors too readily with conventional gender dichotomies, or good vs bad metaphors. The Yerkes-Dobson law, for example, developed by military psychologists during the First World War, is based on what could be described as a machine-model of stress and it remains the closest thing we have to a natural law in psychology. It still explains some aspects of the relationship between increased stress plotted against performance and breakdown. But military psychologists soon realized that the model failed to account for the complex dynamics and factors that mediate stress responses.
You also asked about how the tensions between stress research and trauma studies have played out over time. Until recently, stress has lost ground to the more mesmerizing stories associated with trauma. For a very long time, child sexual abuse, deserving of our attention as it is, has stirred far more public outrage and clinical interest than do the much bigger and prevalent problems of child poverty and neglect.
There have been a number of campaigns since the entry of PTSD into DSM III in 1980 to expand the diagnosis to include chronic or what came to be termed complex traumatic stress disorders. These campaigns failed in my opinion because PTSD has become such a marker of the societal boundary separating the deserving and the undeserving, good individuals who are victimized through no fault of their own from the willfully deviant, and complex trauma attempts to expand and redraw that boundary. PTSD retains its taxonomic legitimacy and forensic status by keeping the diagnosis pretty closely tied to a discrete event or set of events that depart from some demarcated expected realm of normal experience.
Aftab: Your critique is one that is sympathetic to the practicing clinicians, appreciative of the demands and the pressures under which they work, and the bureaucratic systems they are forced to navigate to help the patient in front of them. You write about “how practitioners were enlisting the PTSD category as a way of managing seemingly impossible clinical tasks – situations where they were negotiating various institutional, political, and psychological demands.” (p. 3).1
Another example of this sort of dynamic that comes from your book is that of personality disorders. You discuss how prior to the official acceptance of PTSD as a diagnosis, military psychiatrists were pressured to diagnose traumatized veterans with personality disorders because the traumatic reactions could then be dismissed as deeply rooted character problems. You write, “Some of these troubles were indeed likely influenced by personality factors. But the political context made this avenue of exploration more of a tool for the military than a means of understanding the struggles of soldiers” (p. 9).1 The identification of maladaptive personality styles coming from an empathetic psychoanalytic clinician could be immensely psychotherapeutic in the right setting, but the same identification of personality dysfunctions in a different setting could be wielded as a weapon to silence, stigmatize, or discriminate. This suggests to me that the fundamental problem may really be these institutional, political, and psychological demands. Do you think that critical inquiry in psychiatry sometimes gets sidetracked by focusing too much on these diagnoses rather than on the institutional structures in which they are employed?
Haaken: Yes, I think the enormous investment of resources and campaigning to expand PTSD research has more to do with pressures on the field and professional marketing than it has to do with addressing the sources of mental suffering. One of the interesting boundaries that I take up in a chapter of the book is the line between PTSD and personality disorders. I trace the history of efforts to widen trauma diagnoses as a corrective to over-diagnosing personality disorders, including in the military. One of the reasons that psychiatric casualties were so low during the Vietnam War was that so many service members were dishonorably discharged under the character disorder labels. Doctors were seen by many veterans as complicit in the disciplining of rebellious soldiers through these diagnoses, just as they had during World War I. But PTSD depends very heavily on the concept of normalcy, the claim that this is a normal response to an abnormal situation. This leaves many other individuals and problems outside of the protective fold of the diagnosis.
Aftab: You write, “For those suffering harms more diffusely located in history or based on more systematic forms of violence or neglect, for example, polluted neighborhoods or poorly run schools, the diagnosis failed as a register of their claims” (p. 7).1 I do not know if any diagnosis can register these sorts of claims in a manner that is also adequate for clinical and scientific tasks. Perhaps our collective mistake is to think that we should look to diagnosis as a tool for the purpose of acknowledging systemic oppression?
Haaken: Yes, I do think that the over-expansion of DSM and its burgeoning taxonomy is part of the problem. But PTSD carries a unique history as a disorder in that it was specifically thought to be caused by societal conditions. Progressive clinicians largely embraced the category as a corrective to the systemic problem in psychiatry of over-pathologizing, as well as sexism and racism. Because the diagnosis carries a long history of morally charged campaigns, its expansion has had this inadvertent effect of reproducing some of the moralizing tendencies in psychiatry. PTSD was not simply discovered through some enlightened path of medical progress. It emerged as a kind of compromise formation (like an individual neurosis) at the frontlines where progressive clinicians used the tools of their profession to intervene in what are basically social problems.
The situational stress reactions of prior eras carried expectancies that normal individuals are able to move on quickly from disturbing events. For me, the question is not whether PTSD or any other diagnosis can adequately address societal forms of violence or oppression, but rather why these problems get so loaded onto this category and its exclusionary criteria. Proponents tend to focus on what PTSD includes and exposes in terms of societally produced suffering. I was interested in what this diagnosis tends to exclude.
Aftab: Your discussion of the antipsychiatry movement was quite interesting. You describe it as “a loose collection of intellectual and political projects focused on challenging the societal basis of psychiatric authority” (p. 10).1 You go on to comment with reference to Michel Foucault, PhD, “From a Foucauldian perspective, a critical psychiatry works to decenter the authority of psychiatric discourse by exposing its own historical contingencies” (p. 177).1 It seems to me that any framework that is utilized to deal with the realm of human distress, disability, and deviation will have historical contingencies and will be susceptible to having the societal basis of its authority challenged. Would you agree that even if the authority of psychiatric discourse is given to some other kind of discourse, an ongoing critique of a critical and Foucauldian nature would continue to be necessary?
Haaken: The legacy of Foucault in psychiatry and the social sciences most decisively includes rejection of master narratives of all sorts, whether in Marxism, psychoanalysis, psychology, or other human sciences. There is some recognition, written into ethical guidelines, that mental health professionals must attend to cultural differences and societal factors, and are required to recognize misuse of professional authority. These caveats are included in the preface to recent editions of the DSM. But the traditions of critique that I draw on require a more sustained and deeper engagement with both the ideological side of our professions, the ideas that take hold, and the material conditions of our work, which include things like how services are provided and paid for.
I also draw on critical traditions to recognize how social justice movements have profoundly shaped, even transformed, and how we think about boundaries between normal and abnormal, for example the issue of homosexuality. The APA was pushed by the gay rights movement to remove homosexuality in 1973 from DSM II. I also try to recover some of the ethos of the early antipsychiatry movement that has been marginalized in the mental health field; for example, the idea that patients suffering from delusions or hallucinations have something to say worth hearing.
Aftab: You acknowledge the influence of Peter Sedgwick on your views, referencing his contention that the antipsychiatry theorists often approach mental suffering from too much distance “rather than from the hard seat of the waiting room or the casualty department’s stretcher.”2 The impression I seem to get in this regard is that you are saying: yes, we need to problematize the role of psychiatric and psychological explanations with reference to what we consider to be abnormal, disordered, or dysfunctional, but we should not use this problematization to argue against the rights of individuals to have their distress and disability be registered and the right to receive adequate care within some framework of health or social welfare. Is this an accurate characterization?
Haaken: I do try to hold these complexities in mind and to draw out both the insights and blind spots of those early movements. This is a very interesting time we are living in now, and in many respects, a very hopeful one. After a long era of meager resources for public health agencies (the poor stepsister of medicine and private health insurance), public health and calls for investment in social welfare have gained enormous public support after this horrifying pandemic. The Black Lives Matter movement has pushed for a different vision of society than we have been fed over the past 50 years, particularly in the area of policing. There are calls around the country to move away from policing to a greater focus on crisis services and interventions outside of the criminal justice system. But I also think that a progressive vision of psychiatry requires more in terms of attitudes and thinking about patients suffering from mental illness. As mental health professionals, we should be working to build more receptive spaces in the community for individuals who may seem odd or who process reality differently.
Aftab: You write, “the obsessive tendency in psychiatry to ‘pin down’ PTSD within a stable, trans-historical taxonomy is itself symptomatic of the anxiety associated with this diagnosis” (p. 6).1 Subsequently you write regarding psychoanalysis, “psychoanalysis departs from medical psychiatry in widening the interpretive lens for diagnostic storytelling. It allows for ambiguity, for dynamic shifts in the meaning of events over time, and for the symbolic and metaphorical registers of symptoms” (p. 179).1 I can think of at least 2 sources of the sort of obsessive tendency that you describe, 1) the need for operationalization of constructs for the purposes of scientific inquiry, and 2) the categorical needs of the health care and legal system (such as, to reimburse or not to reimburse, to declare criminally sane or insane). Psychoanalysis has been able to allow for ambiguity, perhaps by distancing itself from these needs and restricting itself to a more clinical role. What do you think mental health systems can do differently to allow for the sort of ambiguity that you value?
Haaken: That is a fair critique of tendencies in clinical psychoanalysis—that its attentiveness to ambiguity and to the layers of meaning and the overdetermined aspects of mental life can feel like a luxury or privilege available to professionals who are remote from the hard decisions and demands of those living precarious lives. My book does include a critique of psychoanalytic interventions, noting that the diagnostic process for PTSD runs counter to many psychoanalytic principles. PTSD tends to focus on single causal factors, an emphasis that also runs counter to much of the scientific literature. But there also are rich traditions of social psychoanalysis and psychoanalytically informed community practices that I draw on.
Some of the problems you describe are bound up in the market economy and how deeply capitalist logic shapes medical training and its ledgers of value. I do think socializing mental health services and moving away from our dependency on private insurance and fees-for-service would be a good thing. Many of the storefront clinics that were part of the anti-psychiatry movement included treatment approaches that were quite nuanced in recognizing the complexity of patients and their problems. It was understood that individuals could be self-defeating and destructive, both victims and perpetrators. I also think there are some wonderful programs carried out in Vet centers and the VA by staff clinicians, programs that I describe in the book. The Hearing Voices movement is also an example of groups drawing on some of that same ethos and working outside of the medical model.
Aftab: At one point you comment, “Disorders can be both socially constructed… and at the same time valid ways of understanding mental functioning” (p. 13).1 I think that is an important point because there is a tendency to think that if something is socially constructed then it cannot be valid. Can you elaborate more on this?
Haaken: I am not anti-diagnosis, but I do generally view them as provisional and contingent on a community of shared meanings, rather than as entities readily objectified and operationalized through the tools of science. But diagnoses also hold currencies, both material and ideological, that are important to recognize. Much of my work focuses on the history of psychiatric diagnoses and forces that shape the migration of categories across some moral divide. I have also written about folk maladies such as codependence and love addiction, as well as syndromes bridging feminism and clinical research, such as the battered woman syndrome. PTSD grew out of the anti-war and feminist movements, and so it interested me as a category bridging social movements, popular culture, and DSM taxonomy. I like working at the messy borders between diagnostic categories. PTSD has this messy etymological and social history, with its collapsing of stress and trauma, present and past.
Aftab: One of my favorite sentences from your book is, “like many religious texts, the DSM is rife with contradictions. Practitioners bring their own interpretations of its arcane truths to the messy world of human experience” (p. 5).1 That is a rich analogy. I would add that like many religious texts, practitioners not only take it more or less literally, but also take it more or less seriously! (I have also observed how there is substantial disagreement when it comes to the philosophical foundations of the DSM, what sort of notion of mental disorder does it have, what it means by dysfunction, its relationship to the medical model, and so on.) One of my dissatisfactions with a lot of popular critiques of the DSM is that they take the manual way too literally and way too seriously, perhaps because our system does too in some ways, but I feel any robust critique has to take into account these contradictions and the varying interpretations they provoke. Your thoughts?
Haaken: Yes, amen to that! After leaving the fundamentalist Christian fold of my youth when I entered adulthood, I developed a deep allergy to religious zeal, including in those fields where I hold allegiances and attachments. But the over-investment in the DSM seems more tied to its use in institutional settings and how decisions are made about patients’ lives when there is some consideration of mental states. There is a great deal at stake. Clinicians working with the courts, military, and in VA settings, including disability evaluations, are required to have considerable fluency in the DSM and its obsessive logic. Clinicians in private practice are required to enter a code on an insurance form, but can remain pretty agnostic about the taxonomy itself. They can bypass the disciplinary side of this manual.
In the last chapter of my book, I tell a story from interviews I carried out with both patients and clinicians at the Oregon State Hospital for my film, Guilty Except for Insanity. One patient, sentenced to the state hospital for 20 years under the insanity plea, had killed his boss after falling from the roof on a construction site. He was diagnosed with a psychotic disorder, based on his preoccupation with numbers and codes. His psychiatrist, a compassionate clinician who frequently spoke on the patient’s behalf before the Psychiatric Security Review Board, was also preoccupied with numbers and codes. At hearings, he cited the canonical DSM criteria and the elaborate codes associated with Oregon Statutes in describing this case. I could not help but see the psychiatrist and patient as each registering some of the madness of the world they both inhabited, a psychiatric hospital that was also a prison. Of course, a crucial difference between the psychiatrist and the patient was in how many of their signifiers were legible to others. That difference decidedly favored the normalcy of the doctor.
Aftab: You comment in the book that the critique of the medical model in the 1960s was complemented by an embrace of alternative states of mind. There is an on-going revival of interest in the use of psychedelics, this time largely within a medical model, with PTSD being one of the conditions of interest. You discuss that the development of the therapeutic use of psychedelics invites us to revisit the work of Timothy Leary, PhD. What is your assessment of current investigations into the therapeutic use of psychedelics for PTSD and what insights do you think Leary has to offer?
Haaken: Campaigns to decriminalize psychedelics and other Schedule I drugs have been vital to the racial justice movement in the United States. In my own State of Oregon, a pair of ballot measures were passed last fall to decriminalize possession of small quantities of Schedule I drugs that have been a leading gateway into the criminal justice system. Many young people of color get arrested on minor drug charges. In my book, I take up some of the history of how drugs migrate across the good drug/bad drug boundary, often through the medical model. In the late 20th century, the trauma movement emerged as a site of rebellion against what many viewed as the excessive use of pharmaceuticals in the mental health field. Trauma required intensive, long-term listening. Perhaps inevitably, PTSD emerged as the modern-day poster condition in this new effort to bridge that divide, partly through its redemptive association with normalcy. It was interesting to me that a small group of multidisciplinary psychiatrists, founded in the 1980s to champion therapeutic use of psychedelics, moved quite quickly from the margins to the mainstream of public policy, if not to the mainstream of the field of psychiatry itself. It is a fascinating story that still unfolds—one that I would love to follow as a documentary filmmaker. There are many cultural dynamics operating here, including widespread interest in alternatives to the mind-numbing and anti-libidinal drugs so often dispensed by the medical profession.
I am glad you asked about Timothy Leary, whose legacy as icon of the 1960s often surfaces in campaigns to promote therapeutic use of psychedelics. In my book, I use this case of psychiatry’s recent romance with psychedelics to revisit the early research of Leary and his lesser known contributions to psychology and psychiatry. Through his studies on the use of psilocybin in group treatment settings in a prison outside of Boston, Leary advanced his theory of what he termed set and settings, with the former referring to the attitudes of practitioners, including to the drug itself, and the latter referring to the environmental context, including the aesthetic and social context of drug administration. Prisoners were provided psilocybin in special rooms with music and group support, and encouraged to set their own goals for self-development. Many of the current protocols for therapeutic use of psilocybin similarly involve long sessions with music of one’s choice, social support, and rituals, including some associated with Indigenous practices. The important insights that grew out of Leary’s work on these contextual influences on drug effects have had little influence on psychiatric administration of drugs in general, and they typically register as confound effects, although some of the focus on social support and aesthetics have been incorporated into protocols for therapeutic use of psychedelics, including here in Oregon.
If these protocols open larger questions about cultural practices and market forces in the mental health field, I think this could be a good thing. It will also be important to attend to how debates over the therapeutic use of psychedelics shape treatment options for patients suffering from major mental illness where clinical sets and settings—to borrow the phrase again from Leary – have been so impoverished.
Aftab: We have seen a lot of discussion around mental health over the past year, especially in the context of the COVID-19 pandemic. I think there is a certain unease in a lot of these popular discussions, where the desire to acknowledge the magnitude and prevalence of suffering coexists with concerns about medicalization of this suffering. Do you have any thoughts on how we as a society can have more meaningful conversations around mental health?
Haaken: The pandemic has indeed opened space for more meaningful conversations around mental health, particularly in the renewed focus on chronic stress as a public health and mental health problem. The internet is awash now with discussions of post-COVID stress disorder and pandemic traumatization, and PTSD has emerged again as a signifier for shared suffering not born of individual failures or deficits. But I view much of this as a diagnostic containment strategy and a distraction from the real issues at hand. Dispensing diagnoses as an intervention in the pandemic is not very illuminating, even with PTSD as the site where societal sources of misery are narrowly acknowledged.
More than offering just a critique of the PTSD diagnosis, psychiatric diagnoses in general or the medical model, I hope my book contributes to self-reflection in the field about how the histories of our disciplines are embedded in larger societal histories, and on our roles in reproducing the very suffering we aim to control. Following psychiatry through military history was particularly instructive in bringing into bold relief the contradictory forces we face as clinicians in keeping individuals healthy in unhealthy places. It is not a conflict we can deliver ourselves from by simply refusing to be part of the system. Those in secure private practices can opt out, but many of us are part of institutions that offer less distance from how we are implicated in the difficult lives of others. But many of these institutional sites, where psychiatry is closest to the heartache and hard problems that exceed its reach, carry potential for greater creativity in a field that has suffered its own inhibiting obsessive conditions. That is why I am so delighted to be part of your Conversations in Critical Psychiatry. Thank you for inviting me!
Aftab: Thank you!
The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.
Dr Aftab is a psychiatrist in Cleveland, Ohio, and Clinical Assistant Professor of Psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Advisory Board. He can be reached at firstname.lastname@example.org or on Twitter @awaisaftab.
Dr Aftab and Dr Haaken have no relevant financial disclosures or conflicts of interest.
1. Haaken J. Psychiatry, Politics and PTSD: Breaking Down. Routledge; 2021.
2. Sedgwick, P. Psycho politics: Laing, Foucault, Goff man, Szasz, and the future
of mass psychiatry. Harper & Row; 1982.