The Demise of PTSD: From Governing through Trauma to Governing Resilience
Howell, Alison, Alternatives: Global, Local, Political
This article raises questions about the possible waning of the authority of the diagnosis of post-traumatic stress disorder (PTSD). While avoiding predictions, it points to signs that the authority of PTSD is now being challenged by both the rise of resilience-based models and the increasing authority of biomedical and neurological approaches in the governance of trauma. It explores these challenges in various empirical sites, including humanitarian interventions, Western military settings (especially involving the US Army and North Atlantic Treaty Organization [NATO]), as well as civilian contexts, including national health services, emergency preparedness, schools, universities, and other sectors. The article concludes by stressing some of the troubling politics that surround these new developments, which, like the diagnosis of PTSD, may individualize and govern the experience of traumatic events, including war, in a broad context of social and economic austerity.
trauma, resilience, humanitarian intervention, posttraumatic stress disorder, military mental health
This article sets out to make a challenging argument: that we may now be seeing the beginnings of some major challenges to the authority of the diagnosis of posttraumatic stress disorder (PTSD). That is to say, this diagnosis may be in the first stages of its demise or obsolescence, as has been the fate of so many other psychiatric diagnoses. This contention is illustrated empirically by examining the parsing of the diagnosis and the ways in which the territory upon which PTSD has operated and gained authority is being encroached upon. This authority is being ceded in two distinct directions: first, the resurgence of biomedical models of trauma, and second, as a consequence of increasingly powerful models of resilience which privilege "prevention" in the face of trauma. In this way, the PTSD diagnosis, and the terrain upon which it has operated, is being parsed: moving in one direction to the biomedical and neurological, and in the other direction to preventive or public health models.
This shift is seen perhaps most starkly in military settings. Times of war have historically brought with them major innovations in the fields of psychiatry and psychology. This is particularly true of PTSD, a diagnosis invented out of the experience of the US war in Vietnam and its aftermath for veterans. New developments in a number of Western militaries, including perhaps most notably the US Army, show indications that new biomedical and preventive approaches to trauma are overtaking the diagnosis of PTSD. These shifts are also being mirrored in postcolonial spaces, where post-conflict and postdisaster psychological interventions based on mass diagnoses of PTSD are being challenged first, by biomedical models asserting authority over "severe trauma" and the treatment of the "mentally ill" in such situations, while on the other hand resilience-based modes of intervention are also becoming increasingly authoritative. Further, these developments can also be observed in civilian sectors in Western nations, where resilience-oriented models of mental health care delivery are being taken up not only in national health care systems, most notably the UK NHS (National Health Services), but also in other civilian institutions, such as schools, universities, and in disaster preparedness planning, among numerous other examples.
In tracing these developments, the arguments presented here lead to no clear predictions. Rather, the article aims to draw our attention to new developments in PTSD, in the governance of trauma, and in the mental health field more generally, in order to ascertain whether such changes should be embraced or greeted with skepticism and resistance. I begin, first, with a brief outline of the history of PTSD and of the approach taken here to the diagnosis. I then examine new developments in approaches to the diagnosis and to trauma in war settings: both in post-interventionary societies (where PTSD diagnoses have been ubiquitous) and in the US Army, among other Western militaries, where the politics of PTSD is deeply contested. …