Thursday, January 1, 2009

Review: Allan Young. The Harmony of Illusions:Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press, 1997 (first paper

The concept of psychological trauma arose in the nineteenth century in the context of litigation over railway accidents. In the twentieth century its history has been tied to wars and more recently to concern over sexual abuse. Throughout, the interests of various groups in issues of responsibility, compensation and punishment have made thinking clearly about psychological trauma difficult. Since 1980, however, when the American Psychiatric Association formally included the diagnosis of Post-Traumatic Stress Disorder (PTSD) in the third edition of its Diagnostic and Statistical Manual (DSM-III), the notion that psychological trauma is caused by memories has acheived the status of fact. In the spirit of Ludwig Fleck, Allan Young’s valuable book attempts to trace the perceived timelessness of this fact to a “harmony of illusions.”
Young is an anthropologist and the core of this book is the field work he did in 1986-7 at a U.S. Veterans Administration unit for the diagnosis and treatment of Viet Nam veterans suffering from PTSD.The book is divided into three sections; the first two discuss aspects of the history of the concept of psychological trauma and the third is devoted to Young’s anthropological work. A lot of recent psychiatric research and treatment has been staked on the view that memories of trauma cause symptoms and that remembering heals. Each section of this book takes aim at this proposition from a different vantage point. Young’s fundamental concern is with the difficulty knowing, in an particular case, whether there is a causal link between the memory of a “traumatic” event and an individual’s current symptoms, or whether this link has been constructed after the fact to make narrative sense of troubling and mysterious symptoms.
The first chapter is devoted to retelling the history of the concept of psychological trauma in the nineteenth century. Young argues that while some nineteenth century ideas about psychological trauma gave memory an important role, others did not. In the second chapter he reinterprets the career of the anthropologist and neurologist W.H.R.Rivers, who has served several recent authors as an emblem of enlightenend treatment of shell shock during World War I. By a close reading of Rivers he shows that Rivers believed “that, in most cases, it is not the traumatic memory that produces the physical and emotional symptoms of the war neuroses…but rather the reverse: the symptoms account for the memory.” (p.83)
The second section of the book traces the development of DSM-III and the construction of the diagnosis of PTSD. Intruigingly, Young points out that while the authors of DSM-III were determined to root out all causal attributions in its classification scheme, the diagnosis of PTSD managed to have a causal theory central to its definition. The story of the political and socal forces that resulted in this anomaly is a fascinating one.
In the third section of the book Young describes the unit for the diagnosis and treatment of PTSD where he did his field work. He demonstrates how institutional and personal motives drive and sustain a particular understanding of a set of psychiatric symptoms. His demonstration, through transcripts of therapy sessions, of how “ideology,” or the theories of therapists shape the meaning given to the thoughts and actions of participants in therapy is particularly valuable.
Young does not discuss sexual abuse or the debate about false memories. While this is a loss, it does allow him to keep his focus on the more fundamental questions of the construction of diagnoses and the uses of casual attributions. This is a book that should be read by anyone interested in the history of psychiatry as well as those interested in the cultural history of the United States.

reviewed by Edward M. Brown M.D., Clinical Associate Professor of Psychiatry, Brown University

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