How Many Times Must the “PTSD” Label’s Harm Be Exposed?

Paula J. Caplan, PhD
33
2071

A recent Wall Street Journal (WSJ) article and a recent American Psychiatric Association (APA) press release reveal the power the APA has wielded through its various DSM editions in pathologizing the effects of trauma.

What’s Wrong With the “PTSD” label?

Before I examine the problems with the article and press release, it is important that readers not assume that if “PTSD” (“Post-traumatic Stress Disorder”) is a harmful label, “PTS” (just removing the “D”) is fine. There is little difference, because “PTSD” is so widely used—even by people who rightly criticize the use of other psychiatric labels—that it will be generations before people stop thinking “Disorder” when they hear “PTS.” Instead of using either term, what is accurate and useful is to call the trauma what it is—war trauma, rape trauma, hurricane trauma, etc.—and to call trauma’s effects what they are, such as terror, grief, fragmentation, moral injury, loss of ability to trust, total exhaustion, etc.

As with any psychiatric label, its application subjects the labeled person to a vast array of kinds of harm, ranging from plummeting self-confidence to loss of child custody, employment, respect, all possible human rights, and even death.

Neither the WSJ article’s author, Andrea Petersen, nor the unknown author of the APA press release ever questions what “PTSD” means in the DSM, what people will assume it means, and whether there is any scientific validity to it at all.

As I found when on two DSM-IV committees, there is no scientific validity to it. Still worse, when it first went in a DSM edition as a description of (some) reactions to trauma, there was a sentence noting that these were normal responses to abnormal situations. That meant it was weird to include it in a manual of mental disorders, but the DSM authors have rarely worried about consistency in their rush to include as many labels as possible. But that sentence was useful for traumatized people to see, because sometimes it made them feel less like they were overreacting and “crazy.” However, even that little bit of help vanished when Allen Frances headed DSM-IV’s Task Force, for that sentence was removed.

Not only is “PTSD” not scientifically derived, but even caring therapists apply the diagnosis without ensuring that their patients even meet all the DSM’s required criteria, as researcher Meadow Linder wrote in a chapter in Bias in Psychiatric Diagnosis.

In a way, that is irrelevant, because what good does it do to stick scrupulously to arbitrarily chosen criteria? But this means that, as I have written elsewhere, “PTSD” now consists of shifting sands on shifting sands—an unscientific label, unscientifically and unsystematically applied.

When a Label Has No Validity, It’s Absurd to Study What Helps “It”…and Other Problems

The Wall Street Journal author starts by referring to the pandemic, wrongly assuming that it is creating skyrocketing rates of “PTSD”—rather than NONpathological suffering, and reviewing what she says therapists have described as “new” and needed treatments for the “disorder.” It is especially troubling that she mentions that the most common reports of “PTSD” during the covid-19 pandemic in a large study were about loneliness and worries about the virus. Does it make sense to call loneliness and worries about the virus signs of mental illness?

And she mentions another study, this one of frontline healthcare workers during the pandemic, in which 16.7% are said to have “PTSD.” Does it make sense to claim that it is a mental illness for people constantly exposed to a mysterious, dangerous, contagious illness to be traumatized? What is the point of all that, other than to alarm people and provide more money, power, and territory for therapists?

What the author mentions only briefly in her lengthy article is how helpful self-help groups for traumatized people can be. Instead, she writes endlessly about one drug after another after another and various forms of traditional talk therapy.

The author then zooms ahead, naming the psychiatric drugs (she calls them “medications”) Zoloft, Paxil, MDMA (called “Ecstasy” on the street), and ketamine, all of which have negative effects ranging from upsetting (e.g., sexual problems) to dangerous (e.g., increased violence against self or others). Acknowledging that only small percentages of people who take these drugs are helped, she asserts that “Scientists” (who?) are seeing (based on high-quality research…or not?) “early” (oops) “positive studies combining psychotherapy with certain drugs.” Even so, she does note that “About 40% of people who received the MDMA treatment reported side effects including anxiety, headaches and nausea.” She might also have cited this report of even more serious kinds of harm.

Petersen also reports that an unspecified “growing body of research shows that transcranial magnetic stimulation, which uses a high-powered magnet placed on the scalp to stimulate neurons in certain parts of the brain, can ease PTSD symptoms.” To begin with, I know from direct experience with one of the top marketers of such devices that they often fail to warn of negative effects and fail to disclose that these devices cannot be targeted to particular neurons, so little is known about what effects they will have—good or bad—in any given individual.

Further food for thought is that leaders in the movement challenging the traditional mental health system have asked the rhetorical question, “Why should we assume that when these marketers say that their devices are safe because they send LESS current through people’s brains than traditional electroshock, we should believe them?”

Petersen asserts that the best psychotherapies for “PTSD” are cognitive processing and prolonged exposure therapy. In my decade of listening to military veterans, as well as to other traumatized people, I have learned that sometimes the former—examining one’s beliefs that cause them suffering—helps and sometimes not, because often the moral injury and powerful emotions caused by trauma and the painful isolation are never addressed. And I have learned from them that exposure therapy—going over and over the trauma—helps some people but is horribly retraumatizing for others, and it, too, does not in and of itself include working on the moral injury, the isolation, or the other strong emotions.

Toward the end of the article, Petersen does mention the potential effectiveness of aerobic exercise, though only combined with prolonged exposure.

In summarizing concerns about the WSJ article, it is important to note that it is always a good thing to allow people to try anything that has helped some people who are similarly suffering, but it is essential for those people to be told in advance and fully what the potential benefits and the known kinds of harm are.

APA Wants Exclusive Control Over Prescribing Drugs for Veterans with “PTSD”

In a September 24, 2020, news release, the APA’s headline came across as gloating: “Successful APA Advocacy Assures Veteran Patient Safety Regarding MH Care.” The piece was about the House of Representatives’ Veterans’ Affairs Committee removing a proposal from suicide prevention legislation that would have given psychologists the right to prescribe drugs to veterans. A major problem in the release is that they automatically assume that the veterans who killed themselves had “PTSD.”

Unsurprisingly, after a lengthy description of its lobby efforts about this matter, the release included this quotation:

We will continue our work with the VA, Congress, and partner organizations to improve the mental health and substance use care available to our veterans through the VHA and beyond,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A. 

We must work with policymakers on genuine solutions that promote the recruitment and retention of critically needed psychiatrists, psychologists, and other mental health providers who are in short supply within the VA system. Meanwhile, with the help of our members, we have avoided the enactment of a false solution that could have put many veterans at risk, without any improvement in access to the care they truly need.”

Note that Levin acknowledges that psychologists can help veterans but that allowing them to prescribe drugs would be “a false solution that could have put many veterans at risk,” as though psychiatrists prescribing drugs does not put veterans at risk. This is reprehensible in light of the well-established fact that so many psychiatric drugs increase rates of suicide. My own view is not that it is worse for psychologists than psychiatrists to prescribe these drugs but that the fewer people of any discipline who are prescribing them, the better.

What would be amusing if it were not so frightening is that Levin is also quoted as saying:

We believe that nothing is more important than ensuring that veterans are given high quality mental and physical health care by qualified, appropriately educated, and trained medical clinicians, not more prescribers and more prescriptions….”

Nowhere in the news release is there mention of any attempts to prevent suicide except through psychiatric drugs, and all the gloating is about how impressively the APA prevented psychologists from doing this. Wouldn’t it have been great if he had:

  • surprised everyone by saying that psychiatrists should be prescribing fewer such drugs;
  • said that traumatized vets should be told they are having deeply human, understandable reactions to trauma instead of pathologizing them by saying they have “PTSD,” and pointed out that labeling people as “mentally ill” increases the chance they will be put on drugs;
  • mentioned any of the many nonpathologizing approaches to helping traumatized people (such as the many at this website)?

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

33 COMMENTS

  1. Do you think mental health treatment has created a colonization that needs de-colonization? If one holds the potential to apply science through better management, then how can the more oppressed group, denied often from being thought worthy to even participate in LIFE, create a better, healthier reality forward? But in knowing that even trauma has a supply and demand curve, how come We, the mis-treated can give rise to a different economy that is structured in units of time? See : https://www.ethicalmarkets.com/about/research-advisory-board/edgar-s-cahn/

    Perhaps there might be a way, that through our values, we can create a way out of this one false economy that seemingly is robbing people of their lives, to one where an ethical praxis become rooted in “No-Throw-Aways!

    Even time, is a dimension for one to understand as being important in the creation of healing space!

  2. Thank you, as always Paula, for speaking out about the fraud that is the psychiatrists’ DSM “bible.” Truly I hope the VA will stop defaming the veterans with PTSD, or ANY of the “BS” DSM disorders.

    And we’re not going to end the veteran suicide problem, until the VA ends their mass drugging of legitimately distressed trauma survivors, with the neurotoxic psychiatric drugs. Especially since those drugs are already known to cause violence and suicides, NOT cure legitimate trauma or distress.

    Thank you also to MiA, and its contributors, for your many recent blogs and articles pointing out the common adverse and withdrawal effects of the psych drugs.

  3. Great piece.

    what is accurate and useful is to call the trauma what it is—war trauma, rape trauma, hurricane trauma, etc.—and to call trauma’s effects what they are, such as terror, grief, fragmentation, moral injury, loss of ability to trust, total exhaustion, etc.

    Exactly. Lots of other excellent observations too, this was just the first.

  4. Great point about the D in PTSD. I think the same applies to GAD, and all the so-called neuroses as well. Disorder, like disease, goes with the labeling, or rather, the insulting process. In fact, the more serious the disorder, the more serious the insult, which may go some ways to explaining something fundamental about the difficulties in recovering the so-called “seriously affected” face. Sure, words are used to communicate, the same words that are used to intimidate, isolate and destroy. Once you get pushed to the wrong side of the counter so-to-speak, the question becomes how do you return to, how do the doctors phrase it? Oh, yeah. Functionality.

  5. I have a personal beef against “PTS” and “PTSD.” This acronym (or initialism) was already taken! It meant something else to me already, because in my training (which is mental health related) it stood for a different set of words. By “taking over” this expression, psychiatry entered a near-permanent confusion into the larger field of mental health (yes, the field does extend beyond the boundaries of psychology and psychiatry!).

    In my experience with the world of “common” English, many DSM expressions have become so ubiquitous (due partly to their constant usage in entertainment, including movies and TV shows) that many people use them without any regard at all to their clinical meanings, but simply as a shorthand way to describe various emotional responses. Similar to how someone might say “I have a cold” without any real concern about what actually caused their symptoms and without the feeling that it actually needed any medical handling. These expressions have been lost into the shared vocabulary of millions, as has “xerox” and “kleenex.” For most people, the use of DSM terminology may no longer imply to any great degree that they are speaking of an actual disease. Yet, as long as the formal connection between these terms and various medical interventions exists, the potential for misuse remains.

    Many DSM expressions connect with phenomena that are recognizable or “real.” That must be a part of what gives them power. Our task is to break that totally irresponsible link between the expressions and our ordinary concept of “illness.” My favorite strategy is to separate “mind” from “brain” at every opportunity. I realize that others may not be so certain of this distinction. But I believe that since it is a distinction that actually exists, it will eventually be the downfall of the “medical model.”

      • Well, this is a point we disagree on. I believe “health” can be interpreted widely in ways that bypass or even totally leave out psychiatry. I don’t want to create a world in which, if someone comes along and tells me “I feel sick” my only answer is, “sorry, nothing I can do for you.” That doesn’t mean I should have the option of sending they guy to a psych.

          • They are your opinion, oldhead, they are. “The mind.” It’s a noun and it stands for an object. It exists as a complex energy pattern around us. It is full of mechanisms. You don’t have to believe all this if you don’t want to. But this idea of the mind is workable. There are technologies based on it that work; both helpful and harmful technologies. You can leave all this business to someone else if you want. But I can’t.

  6. Please remember almost everything today is considered a disorder. I heard a new one on tv recently; “election stress disorder.” According to whoever; it’s supposed to cause “relationship problems” amongst married couples. I don’t know. The point is this: yes, they can make a disorder out of anything; which means that people suffering real trauma will get the proverbial “short-stick” thus further increasing their trauma. What it also means that in reality, it is not the trauma survivor or any survivor that has a disorder; but it is the world itself or rather the “powers that be” that are “disordered.” Therefore, the only real conclusion to make is: “It’s them, not us!” Because, if you look at the world today, is the “disordered” who are the most “ordered” and the most “sane.” Thank you.

  7. I think we can go too far in trying to emphasize how reactions to trauma are normal, and trying to deny that there is anything problematic about them. The problem that is caused by doing this is that people might start thinking that their reactions are inevitable, and there is nothing they can do to change them – which means they are stuck with them. We’ve just induced helplessness.

    If a hurricane hits my house, it throws stuff around, stuff isn’t where it would have been. So it’s a normal reaction. But it’s also fine to call it disorder. Calling it disorder reminds me that it doesn’t have to be that way, it can be rearranged into order again, I don’t have to leave things the way the hurricane left it. Trauma can be that way too – it throws everything around, or we throw ourselves around in trying to cope with it, that’s normal, but they way it leaves things is a disorder when it comes to trying to go one with life, so there’s some need to reorganize.

    I agree with Paula though that huge problems come when we assume that disorder means illness means the person needs drugs or some simplistic one size fits all “treatments” that don’t address the full spectrum of people’s humanity.

    • With all due respect to your comment, there is something troubling about what you wrote. I, myself, have lived through hurricanes, tornados, superstorms, blizzards, even a few earthquakes. And, yes, there is disorder. There can be disorder in one’s home, in the town or city you live, and in nature. Actually, this is normal. In nature, that disorder actually prevents further disorder down the line and it does restore itself, sometimes with human help and sometimes, not. Even after the Mt. St. Helena’s eruption, May 18, 1980, nature began to restore herself. On a daily basis, each one of us confronts disorder everyday and each one of us, uniquely, orders that disorder. Therefore, in my manner of thinking, disorder is the natural order of the day and our ability to create order from that order is what we humans do. So, in my humble opinion, what we need to do is not label someone as disordered or even claim it helplessness or more horrific than it is. We just need to realize that disorder is a natural part of life and the goal should be across all areas should be to assist each person how to value their unique way to put order into that disorder. Nature deals with it. We are part of Nature. Let’s just learn to live in Harmony with Nature and with Ourselves. All this labeling, diagnoses, treatments, therapies and drugs, etc. just causes more forced disorder and harms more than helps. As usual, we, silly humans, try to fix what is not broken. Thank you.

    • And there is a difference between someone telling me I’m disordered and me saying that I have disorder in my life. There is also a huge difference between my neighbour saying I’m not right in the head and if a therapist or psychiatrist says it.
      I mean why tell someone that? Only a hateful psychiatrist would diagnose someone. In fact, no therapist needs to write down WHAT he thinks about the person.

    • It seems like most of those who have commented on my comment emphasize how people should be able to work out for themselves what is “disorder” or not. I would agree with that – I would also point out that “post traumatic stress disorder” is generally not a label that people have forced on them, it’s usually a case where someone knows they have a problem and the PTSD label connects the problem with the trauma that happened earlier.

      I agree with Steve that it is important that people get the message that any disorder may be temporary, rather than some “judgement of insufficiency” that is not expected to change. And there is a problem where some people (professionals or not) just expect PTSD to last forever. But that isn’t inherent in simply saying that the person has troubles or a disorder that are a reaction to bad things that happened to them.

      I didn’t see anyone respond to what I think is a more crucial part of my comment, where I pointed out that if we get too caught up in denying that there may be anything “wrong” or “disordered” in someone’s reactions, we may actually be harming them by making them more helpless, by convincing them that their troubles are just an inevitable result of what happened to them, and there is no possibility of them changing their reaction to something else and so getting more control over their lives.

      I would argue that we have to watch out for people doing things they think will be helpful, but that backfire, at each stage of the process of reaction to trauma. For example, when people experience trauma, they might feel threatened by thoughts about what happened and try to push them out of their mind, but this may backfire when the thoughts pop back in later in the form of flashbacks and they get caught up in an endless war of trying to suppress thoughts and memories. Professionals may then try to help, but at times their drugs or other approaches will backfire and make things worse. Then those critical of professionals may jump in and try to make things better – but there can also be problems with how they put things, especially if, as I have pointed out, they make people feel their reactions to the trauma are the only reactions that are possible for them.

      This may seem a little complex and tricky, but I believe (as a trauma survivor who had to work through my own disorder, as a therapist, and as a critic of our mental health system) that this is just the nature of the territory.

      • “…by convincing them that their troubles are just an inevitable result of what happened to them, and there is no possibility of them changing their reaction to something else and so getting more control over their lives.”

        I don’t think someone needs to believe there is something “wrong” with them to consider the possibility of changing their reactions/coping mechanisms. My emphasis has always been on how they WANT their lives to proceed as opposed to how they can be “fixed” in the sense of “returning to ‘normal’ (as defined by our social norms).

        • Steve, I don’t know about you, but I don’t usually put a lot of effort into changing something I’m doing unless I think there may be something “wrong” with it, something that is leading to less than an ideal result.

          I certainly do agree though that the goal should not be some presumed “normality” especially since, as David Oaks likes to point out, normal people are destroying the planet.

          So if we don’t want to tell people that they are wrong and should think like others do and value what others do, what should we tell them?

          Should we tell them that however they think, and whatever they are valuing, is completely right?

          That has its own problems, because the way the person is thinking or processing or valuing may be setting the person up for difficulties and distress down the line, or may be heading them towards harming their loved ones, etc.

          I think the best therapy approaches this as a kind of inquiry or dialogue, exploring possibilities, it does accept that people will have to decide for themselves but doesn’t presume that those decisions will always be for the best – instead it is constantly questioning.

          • The difference is that I get to define what I think. is “wrong” in the mental/spiritual realm. If a doctor tests and finds I have low thyroid, s/he can then tell me what is “wrong” and we can make a plan. But no one can tell me it’s “wrong” for me to have flashbacks or feel anxious. Sometimes feeling anxious is absolutely RIGHT – it is my body warning me that I’m in danger! Sometimes it is right but not very helpful, like if I’m going for a job interview and there is a “danger” that I won’t get the job. Sometimes it was right at an earlier time but is being applied to a situation today where the application doesn’t work. So I would be “wrong” for applying it to this situation. But the anxiety isn’t in itself “wrong.”

            Establishing order is what we do as humans. So “disorder” can certainly be perceived as “wrong.” But someone else telling me that my emotional state is “wrong” because it doesn’t meet their criteria for “normal” is judgmental and is frequently destructive.

            As a therapist, I have no problem asking a client, “What’s wrong?” from the perspective of the client. But I would NEVER tell a client, “Your reaction to being sexually molested is ‘disordered’ (AKA WRONG!)” It’s not my job to decide, and that’s why the DSM labels are problematic. It makes people feel “wrong” for feeling the way they do, instead of helping them see the challenges they face in a new light, which is what therapy should be doing.

      • This can get so heavy! I feel the need to “shake out” like we used to do before dance class. I just want to repeat that there is additional information out there about these issues that people are actually using successfully that almost no one on a venue like this has any idea about. I urge all involved to take a step back and look at the larger scene. Check your most basic assumptions about what is true and what isn’t. Maybe there is data out there suggesting your assumptions could be revised. I know this is sort of cryptic, but I think it needs to be. We can all slog on down the paths we have set out for ourselves or we can look up and realize there are others on other paths who maybe we should get into communication with.

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