It’s remarkable how far we have come from a view of psychiatry and mental illness shaped by Foucault and from a critical medical anthropology in which anthropologists wrote as angry outsiders, critics of what they perceived to be the dominant medical paradigm. Critical medical anthropology still has an important place at the table; anthropologists are able to see structures of power more keenly than the psychiatrists who work within the system. But anthropologists have begun not only to challenge the DSM, but also to redesign it as members of the team. They publish within the medical literature as well as about it. They coauthor with psychiatrists, and some psychiatrists have received anthropological training and are sometimes as ethnographically sophisticated as their anthropological colleagues. This has produced a new form of engaged psychiatric anthropology, and an anthropology within psychiatric medicine as much as an anthropology of psychiatric medicine.
The book under review represents a mature coming-of-age of this engaged psychiatric anthropology approach. It is edited by a psychiatrist (Devon Hinton) with full anthropological training who knows his ethnographic community deeply, and by an anthropologist (Byron Good) who has been immersed in mental health care in Indonesia for years. Their excellent essays bookend this collection and give us a more complete, more balanced, and more sophisticated approach to PTSD than we have ever had before.
This is striking, because PTSD is a controversial terrain. Some people (more commonly, psychiatrists and traumatologists) argue that the condition (as quoted by Richard McNally on p. 117) “appears to be a universal reaction to severe stressors that has transcultural diagnostic validity.” Others (more commonly, anthropologists and historians) argue that it is not: They say that, to use Alan Young’s formulation, PTSD is “glued together” by the practices and narratives of those who treat and study the condition (p. 117). As the DSM was being revised (yet again) and as debates about global humanitarian outreach have challenged the Western import of PTSD more and more, Hinton and Good decided that time was right to explore what had been learned by anthropologists and anthropological psychiatrists about the validity of the PTSD concept and its variability: What they call the “fit” between the diagnosis as defined in the nosology and used in clinical research, and the local expressions of illness.
As a group, the essays come to three conclusions. First, they conclude that while there are indeed phenomena around the world quite similar to those picked out by the PTSD category in Europe and North America, the validity of the formal category obscures the diversity of the responses to trauma. Second, they find that the diversity of those responses is indeed considerable. The way trauma is expressed by Cambodian refugees is quite different from the way it is expressed by Native Americans. Third, the authors demonstrate that there is something like a broad symptom pool for trauma that is far broader than the symptom pool picked out by the formal diagnosis. In other words, trauma and post-traumatic stress disorder are certainly real phenomena, but if a clinician questioned a patient using only the criteria listed in the DSM, the clinician might miss important signs of the condition.
The essays range widely. In addition to the framing pieces, there are essays on the history of the concept from Richard McNally, Allan Young and Naomi Breslau, and James Boehnlein and Devon Hinton; essays (often harrowing) on the experience of PTSD among young Native Americans (Janis Jenkins and Bridget Hass), Mexicans (Whitney Duncan), and highland Quechua (Duncan Pedersen and Hanna Kienzler); and essays exploring causation by Carmela Alcántara and Roberto Lewis-Fernandez; Brandon Kohrt, Carol Worthman, and Nawaraj Upadhaya; Tom Ball and Theresa O’Nell; and Erica James.
This is a very good book. There is a more nuanced account of biological pathway, for which Devon Hinton’s fine chapter is largely responsible, than one sees in most works of psychiatric anthropology. The political challenge comes from the final essay by Byron Good, Mary Jo Good, and Jesse Grayman: “Is PTSD a ‘Good Enough’ Concept?” This essay responds with anger to the work challenging the value of identifying a condition as PTSD when, in the words of the challengers, people identified with PTSD are having a normal human response to suffering.
To the challengers, labeling the condition with a psychiatric term diminishes the humanity of those who suffer and misconstrues the meaning of their experience. Here is Derek Summerfield:
For the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counseling are applicable. These concepts aggrandize the Western agencies and their “experts” who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems and active priorities. (p. 390)
“Is PTSD a ‘Good Enough’ Concept?” sets out a comprehensive answer. The authors use quantitative and qualitative data to demonstrate that subjects in war-torn Aceh in fact met DSM criteria at stunningly high rates. These subjects did indeed look recognizably similar, and the basic criteria picked out the shared vulnerability of their condition, although it did not pick out everything important about that condition. The authors show, in short, that the basic DSM diagnosis is both valid and reliable. They point out that critiques such as Summerfield’s have the unfortunate consequence of suggesting that such subjects need no care, no government subsidies, no medical teams who are paid to help. The essay further points out that the interventions that are sent out need not be presented as foreign intrusions. In Aceh, the intervention teams were local and the language of the intervention was local. No one was forced into catharsis or into a therapy that they might not choose. Yet many subjects spontaneously volunteered their memories, which seemed to be as alive to them then as in the moment of the events. Finally, the intervention worked. Again, the essay uses qualitative and quantitative data to make a convincing case that people valued the intervention and were better of for it. The authors state:
Describing PTSD as a pseudocondition or a natural response to the ravages of violence misses a critical dimension of PTSD—that it is a condition that persists beyond the expected natural recovery from violence in those settings where the violence has ceased. Such a description tends to devalue the level of persistent suffering and disability experienced by many in postcolonial communities and may lead international donors and policy makers to give inadequate attention to the profound mental health needs of such populations. (pp. 402–3)
The astonishing thing is that in this case, it is the psychiatrist (Derek Summerfield) who is arguing against the psychiatric intervention and the anthropologists who argue for it. Thus, this volume illustrates something that is becoming increasingly apparent. As psychiatry globalizes, it needs anthropology. Good psychiatric research needs the acuity of anthropological knowledge about cultural specific, and anthropological contributions have much to offer both to intervention and to scientific knowledge. We are no longer sitting outside the table.