|Trauma Clinical Excellence Diets Ethics CE Comments Symposium 2012 Mind/Body Attachment Mindfulness Anxiety Couples Therapy Clinical Mastery Alan Sroufe Gender Issues Mary Jo Barrett David Schnarch Future of Psychotherapy Attachment Theory The Future of Psychotherapy Couples Etienne Wenger Linda Bacon Great Attachment Debate Men in Therapy Brain Science Wendy Behary Narcissistic Clients Challenging Cases Community of Excellence William Doherty|
|The Long Shadow of Trauma - Page 2|
But they weren't just showing up in his office. In the popular ferment generated by the feminist movement of the Ô70s, women were beginning to tell stories previously never mentioned in public, revealing the appalling ordinariness of rape, wife-battering, child abuse, and incest. Therapists willing to take seriously what their female patients were telling them—which a decade earlier would have been widely dismissed as hysterical fabrications—began learning about an unsuspected and nasty underside of American domestic life. At the same time, two young therapists—psychiatrist Judith Herman and psychologist Lisa Hirschman—were hearing an astonishing number of childhood incest stories from their adult patients. In spite of being told by their supervisors that these stories were most likely fantasies, they began studying the phenomenon and produced first an article in 1977 for Signs, an obscure feminist journal, and then Father-Daughter Incest, a pathbreaking book published in 1981.
Like van der Kolk and many other therapists who were just beginning to peer into this newly opened Pandora's Box, Herman and Hirschman soon discovered that the PTSD diagnosis was simply too narrow to encompass the extent and, frankly, the messiness of what needed to be described. PTSD didn't remotely account for the length and intensity of the abuse these women had suffered, their complex, heterogeneous symptoms, or the damage done to their personalities, capacity for relationship, and physical well-being.
But then, neither did any other diagnosis. Presenting themselves with a muddle of symptoms, such women might be treated for depression, anxiety, agoraphobia, panic, multiple personality disorder and, of course, borderline personality disorder—already a notorious grab bag for troublesome female patients who seemed to have everything wrong with them, but nothing definitive. Even worse, these women were often implicitly blamed for being "manipulative," their problems considered inherent to their fundamentally malicious nature. Advocates for these female patients, like Herman, argued that there was a moral and psychological imperative to agree upon a new diagnosis that actually made sense of these patients' experience. Giving what these women suffered a name, she wrote, would help grant "those who have endured prolonged exploitation a measure of the recognition they deserve." As had happened with PTSD a decade earlier, words would make their suffering real—or perhaps, force people to finally acknowledge what was already all too real. "As long as we live in a world in which there are no definitions and no language for what's wrong with people, we can't do anything about it," observes van der Kolk. "When a diagnosis ignores the reality of what people suffer from, we're living in psychiatric la-la land."
The Power of DSM
In 1980, the Diagnostic and Statistical Manual's third edition (DSM-III) established the field's first standardized, empirically based listing of psychiatric disorders. It became the "bible" of psychiatry--the single, authoritative arbiter of legitimate diagnoses. If what ailed van der Kolk's patients was ever to be recognized by official psychiatry, it had first to be defined and presented effectively to the gatekeepers of DSM-IV, scheduled for publication in 1994.
The DSM is the book that everybody loves to hate and hates to love, but can hardly do without—it's all we have, the one organizing principle standing between the mental health field and sheer diagnostic chaos. The manual's economic, institutional, and social power—its necessity—can hardly be overestimated. Not only is a DSM diagnosis required for private insurance reimbursement, government payment for mental health treatment, and research funding, but it also constitutes psychiatric law for the court system, regulatory agencies, schools, social services, prisons, juvenile detention facilities, and pharmaceutical companies. Absent inclusion in the DSM's authoritative pages, a disorder doesn't exist. The diagnoses it contains aren't written by the hand of God, but they might as well be.
"What happens is this," says psychiatrist Frank Putnam, an expert on dissociation in children and adults, himself a hardy veteran of many trauma-related psychiatric battles, "you need a diagnosis to bill—that's the way the world works. Most of the interventions we do at my center aren't billable—we lose about $220 for every kid we see. You can't just treat somebody without giving a formal diagnosis." As a result, according to Putnam, "the DSM has become the tail that wags the dog." Furthermore, without an official diagnosis, there can be no money for research. "If the diagnosis doesn't exist," says van der Kolk, "you can't study it—you can't go to NIMH and ask to be funded to study a nonexistent diagnosis."