In the past 30 years, post-traumatic stress disorder has gone from exotic rarity to omnipresent. Once chiefly applied to wartime veterans returning from combat, it is now a much more common diagnosis, still linked to traumatic events but now including those occurring outside the battle zone: the death of a loved one on a hospital bed, a car crash on the highway, an assault in the neighborhood park. Many would argue that this is a good thing: greater recognition of psychologically distressing events will lead to more people seeking treatment and a decrease in the preponderance of PTSD – a win-win.
Stephen Joseph disagrees. In his new book, “What Doesn’t Kill Us,” the professor of psychology, health and social care at the University of Nottingham (in the U.K.) warns that our culture’s acceptance of PTSD has become excessive and has led to an over-medicalization of experiences that should be considered part of ordinary, normal, human experience. This has kept us from proactively working through our grief and anxiety: We’ve become too quick to go to the shrink expecting him to fix us, rather than allowing ourselves the opportunity to grow and find new meaning in our lives as a result of painful, but common, events. Joseph advocates for a push toward post-traumatic growth as therapy to treat the stress of trauma, which he distinguishes as being different from the hokey, blue skies and rainbows, pop psychology that he claims has exploded in our culture in the past decade.
Joseph spoke to Salon over the phone to discuss our misunderstanding of the disorders, the meaning and usefulness of suffering, and if some cultures are more prone to PTSD than others.
How would you define a traumatic event? Is it subjective or are there some basic requirements that must be met?
I see trauma as a psychological rupturing. It’s when something happens to us that ruptures our psychological skin. Or, something which shatters our assumptions about ourselves in the world. That’s what I think of as traumatic, and in a way that can be many things. So, that can include a wider range of experience, and I can understand trauma in that broader way. There are lots of different experiences, such as being in a road traffic collision, or experiencing an illness – those sorts of things can be traumatic to people. It can be experienced as psychologically traumatic. But whether it’s necessary to create a psychiatric diagnostic category to capture those experiences is perhaps not necessary.
Do you believe that PTSD is over-diagnosed?
Well, that’s a really, really tricky question to answer because in a way it’s diagnosed pretty much exactly as it’s described in the Diagnostic and Statistical Manual (DSM). So whether the definition of PTSD is too broad is a different question, if you see what I mean. When PTSD was first introduced in 1980, it was defined much more tightly. The gatekeeper criterion to the diagnosis was: Have you experienced a traumatic event? In 1980, it was defined in such a way that only people who had experienced an event that was really outside the range of usual human experience, [like] Vietnam or the Holocaust, had experienced the sorts of experiences that were thought to elicit PTSD. So if you experienced something like a car accident or a traumatic birth, then you couldn’t get a diagnosis of PTSD, because, by definition, you hadn’t experienced a traumatic event.
In 1994, the definition changed in such a way as to include other, broader experiences. Equally persistent was the person’s subjective experiences of what they thought was traumatic. When that happened, people who had experienced car accidents, traumatic births, what we would have otherwise thought of as more ordinary life events, insofar as they are not statistically unusual, could then be diagnosed as a having PTSD. So now we are in a position where lots of people are able to receive the diagnosis of PTSD. So it’s not that it’s being over-diagnosed in that sense. The difficulty or problem, if there is one, is whether, generally speaking – PTSD would be part of this – the DSM over-medicalizes human experience. Things which are relatively common, relatively normal, are turned into psychiatric disorders.
Can you describe some of the typical symptoms of PTSD?
When people experience trauma, when their assumptions about themselves and the world come crashing down, there’s often a period of avoidance. People just try to block out what happened. Switch off. Turn their attention to other things. That’s quite understandable. Then, over time, that gives rise to memories and emotions that come flooding in as the person sort of begins to try to make sense of what happened, and that can become so powerful and distressing that they have to push that away again and go back into a period of avoidance. So sometimes people go through that, periods of avoidance and intrusion. That seems to me as a healthy and adaptive way of working through something painful, emotionally painful, that has happened to us. So those are the experiences. PTSD is when those experiences become so overwhelming that the person can’t function anymore – at work, or school, or in their social life. It takes over so much. But otherwise the symptoms of PTSD are fairly normal, natural ways of dealing with adaptation.
It’s important to see those experiences as quite normal and natural. They are not symptoms of a disorder by themselves. They’re just the way that people deal with an upsetting event in order to be able to make sense of things and to move on. It’s only when they become so overwhelmingly intense that they might be considered a disorder. I think that’s where we get into the problem with what PTSD is: when people are going through that normal experience, but they see it as having a disorder rather than a normal process of adaptation.
That will diminish over time?
Exactly.
Is the emotional pain overblown in such cases?
The suffering is very real. We’re not saying that people don’t have difficult emotional experiences and aren’t suffering. What we’re saying is this is not necessarily a disorder that people are experiencing, and if people think like that, it can be very disempowering to them.
What is the detrimental effect of over-medicalizing these more common human experiences of grief and pain?
When we think of ourselves as suffering from a disorder in a medical sense, well we go to the doctor and we expect the doctor to prescribe whatever the medical treatment is. We’re not in the driver’s seat. We go along – we tell them [our] symptoms, they listen to us, they diagnose what the problem is, and then they work out what the appropriate treatment is. That’s the mind-set when we’re working within a medical framework and we think of ourselves as suffering from a disorder. We sit down in front of the therapist and we expect the therapist to be like a doctor – to be looking out for what the symptoms are so that they can make the correct diagnosis and prescribe us the right treatment. The language of PTSD invokes those ideas, and I think it’s those ideas that can be quite unhelpful at times. For what we’re talking about here, if it’s a normal, natural process, what’s really important is for the person to be in the driver’s seat for themselves – to make their own choices, their own decisions, because we’re dealing not with a disorder, but a battle within the person to find new meanings and new ways of understanding the world. That’s what they have to do. Nobody else can do that for them.
What is "post-traumatic growth"?
Post-traumatic growth is when people come out of trauma having learned new things about themselves and about the world and about their relationship with the world. People develop new philosophies of life. They develop new priorities in life. People learn an awful lot about themselves: their strengths; what they’re good at; having new respect for themselves. They sort of see their lives as divided into two halves: before the event happened and after the event happened. There is a clear demarcation. And they recognize that something happened to them that sliced their world in half in that way, and things for them are now completely different. How they lead their lives has been transformed – their priorities about life, their relationships.
I think one of the things that captures that the most [starts with] the idea that, sometimes, people lead their lives in a way that is dictated by external forces of status and wealth, which are very much big drivers in our capitalist society. We often, in our everyday lives, forget about the small things that are quite important – our relationships: remembering to nurture them, to look after the people around us, to be giving, to be compassionate. When traumatic events happen, people are often shaken back to reality, and remember what really matters to them. Often it is those other things – remembering somebody’s birthday; nurturing our friendships; looking after our parents, the people around us; really embracing our relationships; and letting go of a more materialistic outlook. People often describe it as getting back to who they really are, or feeling more true to themselves, or being more genuine or more authentic. Somehow the idea of the false self that people create around them is shattered, like Humpty Dumpty falling off a wall. The essence of who they are emerges.
Yes, becoming truer to oneself captures the idea very well. Realizing that life is short and sometimes there isn’t as much time left as we thought to put up facades.
This kind of makes trauma sound like a blessing (you even mention people describing it as a “gift”). Is finding meaning the same thing as condoning the traumatic event? And doesn’t this talk of growth all sound very “kumbaya-ish” and unrealistic?
One of the reasons, sometimes, that post-traumatic growth can be seen unfavorably is that it seems like saying that trauma can lead to greater happiness; that for people who have been through trauma, it’s a good for them – they’re happier. That’s just so not the message. It’s not saying that trauma leads to happiness, in terms of smiling and feeling good and laughing and joy – not that type of happiness. What we’re talking about is how trauma can lead to a deeper, more existentially meaningful and fulfilling life, and that in turn may lead to greater happiness further down the road. But, post-traumatic growth is not about happiness in the sort of yellow, smiley face sense.
In essence, post-traumatic growth is a very simple idea, but it has been overshadowed by this mass of psychiatric literature over the past 30 or 40 years about the overwhelming destructive side of trauma, and about how these lead to medical problems. It’s a very simple idea, but [post-traumatic growth] sits, on the one hand, very uncomfortably within mainstream culture of the world of psychology and psychiatry, and on the other hand it seems to sit very comfortably with some other parts of Western culture, such as positive thinking, but it also clashes with some of that literature which is quite superficial, and not grounded in scientific research, and makes unsupported claims.
So, no, post-traumatic growth] doesn’t mean that [people] value or cherish the bad thing that has happened to them. They just accept that it has happened to them. People will often say they wish it hadn’t happened, or they wish they could go back, but there is a realism that they know they can’t. So it’s accepting that they can’t go back; they can’t change things. The only way forward is to go forward. It’s when people can’t accept that something has happened, and they [try] to go back to how they were before, is when they struggle. Acceptance is just being realistic – not seeing it as a good thing.
And someone not experiencing growth -- or experiencing PTSD -- is that person always trying to go back?
I think that often that’s what gets people stuck – trying to go back, trying to rebuild their lives exactly as it was before. That can lead people to get very stuck because it just isn’t possible when traumatic events happen and we’re presented with new information about the world, or with losses. It just isn’t possible to go back and make things as they were. We have to somehow accept what has happened to us and move on.
Is post-traumatic growth something completely in opposition to PTSD or post-traumatic stress? Either you have one or the other?
They can sit together. The way I see it, post-traumatic growth mostly arises out of post-traumatic stress. So it’s how people deal with the post-traumatic stress; how they manage to deal with the intrusive thoughts that are plaguing them; and the new sense they make of their experiences. So it’s through the post-traumatic stress, through the struggle of post-traumatic stress that post-traumatic growth arises. So often there’s a period of time in which people will begin to talk about post-traumatic growth but they will still be suffering from post-traumatic stress. They’re not in opposition. In a way, they are opposite sides of a coin.
You make a claim that true happiness is something that in and of itself cannot be pursued, and one is doomed to fail if one tries. How is that?
Well, that’s an idea that some philosophers have put forward. Some of the research seems to suggest that what’s really important to finding happiness is meaning and purpose in life. If we think our road to happiness is through seeking hedonistic pleasures night after night, then that’s not likely to lead to a deep, fulfilling level of happiness. But, if we find ways of finding meaning and purpose, wherever that might be, then we’re not setting out directly aiming for happiness but that’s what we’re going to get. We’re going to find a more fulfilling life. Happiness is a byproduct, but in a sense it’s more guaranteed.
When we think of psychological therapies, and the helping professions in general, they often have been about helping people feel better. [For] people with various problems of depression, anxiety or post-traumatic stress, therapy is about getting the person to have a more positive emotional state. That’s been, really, what the therapy world has been about for 50 years, and yet that’s only half the picture. The other half is about the meaning we put on things, our purpose in life, our sense of ourselves, our sense of autonomy, our relationships. Psychology can also be about those things. I’m not saying that therapists have ignored them altogether; for sure, they haven’t, but those more existential ideas have been overshadowed by trying to feel good. This is the idea between what psychologists call subjective well-being, which is about feeling good, and psychological well-being, which is what you could call “meaning-good,” and it’s just about getting the balance between those two things right.
Are there some cultures that are more prone to post-traumatic growth?
That’s a really good question. I don’t think the research has really documented that yet as to whether it may be more common. What the research has shown, however, is that post-traumatic growth is something observed in pretty much all cultures that have been investigated, though differently defined in slight ways. “Post-traumatic growth” sounds like a very Western idea, but [it’s one that] gets back into history and into all sorts of cultures. It’s an idea that’s very resonant with Buddhist and some Chinese philosophy ideas, as well as ideas in Western religion.
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