Professor Allan Young PHOTO: CLAUDIO CALLIGARIS

A most stressful disorder

BRONWYN CHESTER | A few weeks ago, medical anthropologist Allan Young got a call from a reporter at the Guardian Weekly. British ambulance drivers were seeking compensation for the post-traumatic stress disorder (PTSD) some suffer due to the trauma they confront in their jobs and the House of Commons was considering the matter. What's that got to do with medical anthropology? Well, 13 years ago, Young, having studied the practice of medicine in both Nepal and Ethiopia, turned his attention to a phenomenon in American medicine: PTSD. The year he spent observing patients and medical personnel in a Viet Nam war veterans' hospital resulted in the publication of several papers and a book, The Harmony of Illusions: Inventing Post-Traumatic Stress Disorder. The book, reviewed in the New York Times, as well as in scholarly journals, established Young as a pioneer and subsequent trailblazer in understanding PTSD. For the malady, coined, officially, by the American Psychiatric Association only in 1980, was then unique to the United States, born in the aftermath of that country's disastrous war in Southeast Asia; a collection of symptoms including anxiety, depression and drug- or alcohol-dependence. But what defines PTSD, emphasizes Young, is the fact that the symptoms are considered to result, not from an actual traumatic event, but from the recovered memory of an event -- real or imagined. It is this delay in reaction to the trauma that set PTSD apart from the shellshock suffered in the First World War, notes Young. In fact, he says, there was relatively little psychic breakdown among the servicemen during the Viet Nam war but, by the early '70s, drug abuse was rampant. It was mainly once home in America that mental breakdown began. Young noted in his book that while the classification of PTSD in DSM III, the APA's catalogue of mental disorders, was a victory for the veterans and their supporters because it meant free treatment and compensation, that act of psychiatrizing a grab-bag of symptoms, representing the suffering of thousands of men and women (mainly nurses), was more political than medical. Without the intense lobbying of both the APA and, later, Congress, PTSD would not have been coined and the veterans would have had no specialized help free of charge. But some paid a price in treatment programs ill-suited to their needs. "The patients were constantly saying that when the clinicians would want to talk about their traumatic experiences -- about their feelings, that is -- the patients would get angry about what was going on. These were working class yokels who got dragged into a war by powerful people who didn't care about them or the Vietnamese." Furthermore, argues Young, the public wasn't interested in remembering an often shameful war and they didn't want reminders from the vets. "As [novelist] Milan Kundera says: 'the opposite of truth is not lies; it's forgetting.' It seems to me that it's a crime when people want to forget what history is. The way in which this diagnosis developed and became institutionalized became an alternative history of the Viet Nam war. "It was the job of the clinicians to enforce this collective forgetting. To enforce not what happened but what you felt. They were telling the men that the past was stopping them from moving on." Still, Young does not denounce PTSD within its own cultural and political context. He writes: PTSD is an "achievement, a product of psychiatric culture and technology." As an anthropologist he was there, he says, "to observe the culture and history, to see how scientific knowledge is produced." But he does "not believe all cultures are equal." American culture, in general, and its medical culture, in particular, enjoy far greater influence worldwide than that of any other nation, which meant that diagnosing PTSD became a possibility outside the U.S. That worries Young. What happens, he explains, is that due to the influence of the U.S., "any researcher in 1982 wanting to be published in a top-notch psychiatric journal was going to have to use the terminology of PTSD." Furthermore, due to the power of the American medical establishment, the DSM by approximately 1990 came to surpass the psychiatric diagnoses listed in the WHO's catalogue of mental and physical diseases, the International Classification of Disease. "In other words, if you want your paper to be understood, you'd better use the language of PTSD -- or other diagnoses -- coined by the DSM." Where treatment is concerned, those working in the health field in such wartorn countries as the former Yugoslavia and Cambodia "were instant converts to PTSD," reports Young. "Partly, it's the power of association with the Americans. Partly, it's to be 'with it.' They don't want to be seen to be doing pre-1980 psychiatry in the year 2000." Just as the diagnosis and treatment of PTSD wasn't appropriate for every traumatized Viet Nam vet, nor is it every refugee of a war or natural disaster who wants to discuss their recovered memories, dreams or flashbacks. And it's not every society that believes such an approach to suffering is helpful. Christina Zarowsky, a physician, PhD candidate in anthropology and member of the Division of Social and Transcultural Psychiatry, of which Young is also a member, studied Somali refugees returning to Ethiopia. She found the Somalis put their experience as displaced people into a political and economic context rather than a medical or psychological one. Encouraging individuals to "stew in their distress" is considered detrimental to the survival of the community. "Rage or anger are okay but not despair because your family will die," she says, adding that for Somalis "if you talk too much, you'll go mad." Which is not to say that Somalis are not emotional, Zarowsky hastens to add. "There's a great sensitivity to emotion; they love poetry," she notes. "But they are fearful that emotional excess could threaten the stability of the community." Beyond the cultural imperialism inherent to PTSD, Young believes that the application of PTSD is open to all kinds of abuse, as much for the individual who falsely claims a memory of a traumatic event as for governments who will use the label to avoid dealing with the genuine physical suffering of returned soldiers. He cites a recent CBC radio report on how the Canadian Department of Defence claimed that the symptoms developed by the peacekeepers in Bosnia were in fact related to PTSD, while the veterans' organizations are lobbying for an inquiry into the environmental hazards the men were exposed to in the line of duty. American soldiers in the Gulf War received a similar response from their government. It's ironic, says Young, that in 1980, Congress initially rejected the notion of PTSD, fearing the can of worms it would open in terms of compensation. Now, the "veteran's administration welcomes PTSD because it's easier to deal with than pursuing an investigation of the medical and environmental hazards to which the [Gulf] soldiers were exposed. "Now the people whose problems had nothing to do with the war can claim PTSD while those with genuine afflictions are not getting the attention they need. The real victims get lost in the middle of the mess." And where do British ambulance drivers fit into that spectrum? Young has great respect for the public service of emergency workers. He notes that among the Viet Nam veterans, it was among the paramedics, "dealing with the mutilated bodies of fellow 18-year-old men, where the claim of PTSD was the least debatable. "There's no question that emergency work is very, very demanding psychologically and physically," he says, explaining that most such workers (firefighters, physicians, nurses, police officers, as well as ambulance attendants) have psychological back-up: a team of counsellors skilled in dealing with those particular professions is usually close at hand. And when they are unable to work due to PTSD? "What happens next is a subject that's been debated from 1919 to 1999."