A disorder for our times

Since the capsize of the Herald of Free Enterprise nearly ten years ago, I have been involved in treating survivors of many terrible traumatic experiences. Before then, I had never had reason to invoke the concept of posttraumatic stress disorder; subsequently, it is almost a relief to find a client who does not fit the criteria.

When embarking on my work with survivors, a colleague in North America warned me about the problems of PTSD. It had arisen out of the work of people in the US struggling to help distressed veterans of the Vietnam war. Many studies were based on samples of veterans whose support depended on their keeping hold of a diagnosis of PTSD. No diagnosis - no financial and emotional support. So the message was clear. Here was a diagnostic category that had certain value but the supporting literature had to be dealt with circumspectly.

Around this time, Allan Young was a participant observer in an American Veterans Administration inpatient unit that was attempting to develop methods for helping the traumatised war veterans. For reasons that are obvious in the text, he has waited a decade to put into print his impressions of the workings of the unit. The book, then, falls into two sections: a history of PTSD and a description of the unit set up to treat the disorder.

The historical overview traces ideas about traumatic reactions to such diverse events as transport injuries in Victorian times (the famous "railway spine") and industrial injuries in which, from the very start the suspicion of malingering taints the diagnosis. The account of how stress reactions were viewed during the first world war is especially fascinating for the descriptions of the published work of W. H. Rivers and its fictionalised version in Pat Barker's novels. This presumably reflects the anthropological approach to the subject matter - it does not matter whether an idea comes from science or literature, it may be given equal weight in an argument. The well-researched description of the development of the construct of PTSD within American psychiatric circles makes for fascinating reading as the personalities of the players are presented along with their ideas. The only jarring aspect is that the text uncritically adopts a US, neo-Freudian model of trauma and stress reactions, but that has been the dominant model in that continent until recently.

The second half of the book records Young's observations in the VA hospital set up to treat Vietnam veterans with major stress reactions. The model is of intensive inpatient work centred on individual and group psychotherapy of a psychodynamic variety. The staff are dominated by an "alpha male" psychiatrist who leads the team, in other words, one who brooks no disagreement with his outdated views. Anyone who dares question the philosophy and practice of the unit is branded an unbeliever in need of help. When one experienced staff member dares to question whether a particular patient's disorder has been correctly diagnosed, the Freudian Sturmbahnfuhrer insists that as the diagnosis was made by the admissions committee, any problems must be stemming from the inadequacies of the staff member in rejecting the unit's orthodoxy.

Young's argument is that PTSD is a construct of its time, and with that there can be little disagreement. But he seems unaware that the mental health services of the US were also products of their time - or rather of Vienna in the 1920s and earlier. It is unfortunate he did not consider why veterans of the Vietnam war were subjected to inappropriate therapies that had got stuck in a time-warp. But then he, too, is enmeshed in the social forces that help determine socially constructed ideas.

William Yule is professorof applied child psychology,Institute of Psychiatry,University of London.