Is post-traumatic stress disorder a valid diagnosis?

Sept 11, 2003

Consultant psychiatrist Pat Bracken does not think so. He has worked with men and women tortured and raped in Uganda, and with child soldiers in Sierra Leone and Liberia. Now his patients in Bradford include traumatised asylum seekers.

He is critical of the concept of PTSD, believing traditional Western medical interventions do more harm than good when working with many traumatised people. He will also not use cognitive behavioural therapy. He explains why to Adam James

.....

By day he would treat psychiatric patients. By night he would ponder on Heideggerian philosophy. This was the routine psychiatrist Pat Bracken had settled into the years preceding 1986; the year he completed both his psychiatric training and a BA in philosophy.

It could be said that 17 years later both Bracken's career paths have blossomed. To start with he is consultant psychiatrist at Bradford's Home Treatment Service, an innovative mental health service which the government, among other agencies, has lavished praise on for how it works alongside service users

Secondly, with a Phd in philosophy and mental health from Warwick University, he is senior research fellow at Bradford University's department of health studies.

In addition he was a principal driving force behind the creation last year of the Department of community mental health studies at the same university.

All in all, it's not bad progress for a psychiatrist who, while working from 1987-1990 in Uganda with men and women who had been tortured or raped during the regimes of Idi Amin and Milton Obote, came to conclude that his profession's traditional treatment methods of drugs and psychotherapy offered no meaningful remedy to those he had been sent across the world to help.

But since then, Bracken, who had originally trained in medicine with the sole purpose of becoming a psychiatrist, has become intrinsic to forging ahead with the development of UK mental health services based on social, as opposed to medical, models of mental illness.

For example, Home Treatment Service professionals will not use psychiatric diagnoses on their patients whom are as likely to benefit from self-help guides developed by service users than they are a prescription for anti-psychotic medication. If ever psychiatrists were able to turn their own profession on its head Bracken and his colleagues are showing the way.

Moreover Bracken is an unusual psychiatrist in that underpinning his multi-faceted criticisms of psychiatry's medical model is a scholarly familiarity with the history of the philosophy of mind.

This has been no better exemplified than in his first sole-authored book, Trauma: Culture, Meaning and Philosophy, where Bracken attends to the validity of the in vogue diagnosis, post-traumatic stress disorder (PTSD).

The diagnosis first entered psychiatric textbooks in 1980 after US doctors had been pressurised to officially recognise and validate the effects of combat on Vietnam was soldiers. Twenty years later non-government agencies and United Nations clinicians flock to troubled areas over the world to provide psychological and psychiatric therapies to PTSD patients in-waiting.

But Trauma: Culture, Meaning and Philosophy fundamentally questions both the clinical validity of such work, and the philosophical appropriateness of exporting Western diagnoses rooted in Cartesian, positivist models of mind to countries whose people have little place for the nuances of psychodynamic theory in their less-individualised sense of selves which are more embodied in religion and spirituality.
Bracken not only draws on his experience of working in Uganda, but also with child "soldiers" who had witnessed war atrocities in Sierra Leone and Liberia.

He argues that if therapists encourage victims to see their difficulties as intra-psychic this risks being at best misadvised and at worst damaging.

For example, Bracken explains that Ugandan victims of rape would, when questioned, indeed reveal they had nightmares and other traditional PTSD symptoms. But more pressing problems were money needed to pay for their children to go to school or for a new roof for their house, or how to find the strength and resources to care for six fatherless children.

It reached the point that Bracken decided not to set up the specialist centre for torture victims, something he had been asked to do. "In the end we did not think there was a need for a centre to provide therapy and counselling," he explains.

"But what there was a need for was development agencies that would have helped these women rebuild their way of life."
In Trauma: Culture, Meaning and Philosophy 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 to say that PTSD practitioners, inflated by their expert status, risk "dislocating" victims from already available potential healing resources, such as traditional healers or family and community networks.

Above all, what makes Trauma: Culture, Meaning and Philosophy stand out from most other critiques of medical psychiatry is it is also a philosophical treatise on the implications philosophers from Rene Descartes to Michel Foucault have on how we conceptualise the effects of trauma on humans.

Bracken has been particularly influenced by German philosopher Martin Heidegger who, together with Foucault, challenged the idea of universal truths in social science and psychiatry. Bracken 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 upon which these are built.

"Philosophy can not 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."

Certainly no charge can be made that Bracken is guilty of naïve philosophical musing. Here is a man who can, as well as 20 years clinical experience, support his position in 18 peer-reviewed journal articles, 29 conference papers over the last five years, two co-edited books, and chapters in four other books.

He has also twice been a finalist in the Doctor of the Year award run by the magazine Hospital Doctor.

While he has the authority to prescribe powerful anti-psychotic medication, the softly spoken Irishman who "loves working with mad people" is acutely aware of the limitations of the medical model.

The latest beneficiaries of this position might be the traumatised tortured and raped asylum seekers in Bradford who are being referred to him.

Rather than rushing in with a cognitive therapy he will prioritise pragmatic issues such as dealing with bureaucracy, compiling medical reports, contact supportive services, and "assisting them to negotiate the NHS"

"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."

Trauma: Culture, Meaning and Philosophy (Whurr, ISDN: 1861562802 is priced at £21)

See also: March 2001: Using your resources

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