Give aid, not counselling

April 19, 2002

Pat Bracken questions the validity and appropriateness of the diagnosis of post-traumatic stress disorder. He tells Adam James that sending PTSD experts to places such as Afghanistan may even be harmful

From the situation in the Middle East to the impact of the war in Afghanistan and the continuing ramifications of September 11, the newspapers are full of the kind of events that can leave deep psychological scars on all those touched by them.

These days, the automatic response when confronted with evidence of such scars - repeated nightmares, inability to concentrate, irrational behaviour - is a diagnosis of post-traumatic stress disorder.

But this might not be helpful, says Pat Bracken, senior research fellow at Bradford University's department of health studies. In fact, sending PTSD experts to places such as Afghanistan might prove positively harmful, he argues in his book Trauma : Culture, Meaning and Philosophy .

Despite its ubiquity in the news, PTSD is a relative newcomer to the medical scene. The diagnosis entered psychiatric textbooks in 1980 after US doctors had been pressured into officially recognising and validating the effects of combat on soldiers in Vietnam.

More than 20 years later, non-government agencies and United Nations clinicians flock to troubled areas across the world to provide psychological and psychiatric therapies to PTSD patients-in-waiting.

Bracken's book questions the clinical validity of such work and the philosophical appropriateness of exporting what he sees as a diagnosis that is rooted in western Cartesian understandings of the mind to countries where there is much less emphasis on the individual and where the sense of self is rooted much more firmly in religion and spirituality. He is also concerned about imposing western medical models of suffering on people whose problems are often rooted in particular historical, cultural, religious, sociological and economic causes.

Bracken should know what he is talking about. As well as working with asylum-seekers in Bradford, he spent 13 years in Uganda helping those who had been tortured or raped during the regimes of Milton Obote and Idi Amin. He has also worked with child soldiers who have witnessed war atrocities in Sierra Leone and Liberia.

He believes that if therapists encourage victims to view their difficulties as intra-psychic, they are misadvising them - and perhaps even damaging them.

For example, Bracken explains that Ugandan victims of rape would, when questioned, reveal that they had nightmares and other traditional PTSD symptoms. But more pressing than these problems were financial concerns such as how to pay for their children's schooling or for a new roof for their home, and how to find the strength and resources to care for six fatherless children.

His scepticism about the traditional psychiatric approach to such situations led him to decline a request to set up a centre for torture victims in Uganda. "We did not think there was a need for a centre to provide therapy and counselling," he explains. "What there was a need for was development agencies that would have helped these women rebuild their way of life."

In his book, he adds: "Individual psychological models, such as PTSD, seemed somehow inappropriate and did not fit with what I was hearing. Somehow it felt wrong to reduce the suffering I encountered - which had historical, cultural, religious, economic and sociological dimensions - to any sort of model at all."

Bracken goes as far as to say that PTSD practitioners, endowed with "expert" status, risk "dislocating" victims from already available remedial resources, such as traditional healers or family and community networks.

What makes Trauma : Culture, Meaning and Philosophy stand out from most other critiques of medical psychiatry is its philosophical dimension. It reads as a treatise on the implications that philosophers from Rene Descartes to Michel Foucault have on how we conceptualise the effects of trauma on humans.

Bracken combined psychiatric training with a BA in philosophy in the mid-1980s. He then went on to do a PhD in philosophy and mental health at Warwick University. He has been particularly influenced by the German philosopher Martin Heidegger, who, together with Foucault, challenged the idea of universal truths in social science and psychiatry.

He says: "His [Heidegger's] philosophy can help us ground a critique of traditional clinical approaches to meaning and trauma because it engages with the philosophical assumptions on which these are built.

"Philosophy cannot tell us what to do clinically. But by challenging assumptions and accepted ways of thinking about ourselves and our distress, it can encourage a deepened sensibility with regard to suffering and with this an opening-up of new therapeutic possibilities."

Bracken's questioning of his profession and its emphasis on a medical rather than social model of mental health has put him at the cutting edge of mental health work. He is consultant psychiatrist at Bradford's Home Treatment Service, a mental health service that the government, among others, has praised for its innovation in working in tandem with service users. Home Treatment Service workers do not use psychiatric diagnoses on their patients, and they are as likely to be given advice from self-help guides developed by service users as anti-psychotic medication. He is also one of the driving forces behind the creation of Bradford University's department of community mental health studies, which will open later this year.

As well as his 19 years of clinical experience, Bracken has had 18 articles published in peer-reviewed journal, given 29 conference papers over the past five years, co-edited two books and contributed chapters to four others. He has also twice been a finalist in the Doctor of the Year award run by the magazine Hospital Doctor .

A softly spoken Irishman who says he "loves working with mad people", Bracken's experience has made him acutely aware of the limitations of the medical model of mental illness. His approach can be seen in his work with the traumatised, tortured and raped asylum-seekers in Bradford who are referred to him.

Rather than rushing in with a dose of cognitive therapy, he will prioritise pragmatic issues such as dealing with bureaucracy, compiling medical reports, contacting support services and helping them to negotiate the National Health Service.

"I do give them the opportunity to talk and tell their story," Bracken says. "But I do not do that from a psychotherapeutic perspective, I do that to allow them to relate their experience in a trusting environment."

The timing of his book is fortuitous, as the British Medical Journal has just published a special issue on the over-medicalisation of social problems.

The book's publication also coincides with a significant PTSD legal case. In March, 260 Falkland war veterans went to the High Court to sue the Ministry of Defence for allegedly failing to identify and treat their symptoms of PTSD. The hearing is expected to last about five months.

The veterans' lawyers - if they are courageous enough to get their teeth into post-structuralist analyses of psychiatry - would still have time to consult Bracken, which they might find worthwhile in terms of how their clients should deal with the problems they face.

Bracken, however, believes such a scenario is unlikely. "The legal profession draws heavily on the medical model in dealing with mental-health issues. In a court arena, it is difficult to bring out the complexities and the conflicting discussions that go on all the time in mental health.

"There is no question that the soldiers are troubled and are going through a difficult time, but whether we want to frame this as a mental illness is another matter."

Trauma : Culture, Meaning and Philosophy (Whurr, £21.00).

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