About that van der Kolk profile in New York Mag last week . . .

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Hey there everyone—

The anthropologist and historian of science Danielle Carr, who is currently an Assistant Professor at UCLA’s Institute for Society and Genetics, published a piece in the most recent issue of New York Magazine profiling therapist Bessel van der Kolk’s trauma work, academic career, and the ways trauma has become “America’s favorite diagnosis.” As most of the folks reading this newsletter likely know, The Body Keeps the Score has been a New York Times bestseller now for 250 weeks, a fact that stuns even van der Kolk himself.

When I read the 126 comments on Carr’s piece, I was surprised to see how many readers found Carr “snarky,” and thought she was not persuaded of their suffering. They also took the profile to be a verdict about trauma therapy—whether it works; whether it’s silly; whether trauma survivors are victims; whether it’s the brain or the body that is the ultimate source of trauma symptoms. Though Carr does briefly survey these questions, she does so to locate van der Kolk in the history of psychiatry and to explain why he’s shifted from a person who used to rely solely on psychodynamic and pharmaceutical approaches to trauma and who now is more interested in neurobiology, yoga, and somatics, today’s popular interventions.

But as Carr’s title indicates, her abiding interest is less in whether trauma is “real”; whether somatic practices bring relief; whether van der Kolk was rightfully censured for bullying behavior by his former place of work; whether he’s a trauma god or a narcissist, and more about what it means that the term “trauma” has become such an important public concept, at once malleable and vague, ubiquitous and scorned, capable of explaining at once highly personal experiences and at the same time large cultural and political events, such as immigration, refugee camps, economic inequality and social injustice.

Carr’s piece was immediately taken up by David Brooks, who saw Carr’s skepticism and critical exploration of these questions as evidence that she was in his anti-therapeutic camp. He wrote a characteristically subtle opinion piece called Hey America Grow Up!, attributing to therapeutic culture the narcissism, fragility, and victimhood that are so characteristic of today’s young Americans, who use their “trauma” as a badge to avoid personal accountability or participation in civic culture, and most importantly, to unmoor themselves from a solid moral foundation—preferably backed by an institution like a church or other organization—that could give them the firm back and stiff upper lip of a mature adult.

When I read Carr’s profile I was reminded of her NYTimes opinion piece, written in the thick of the pandemic, Mental Health is Political. She’s less oblique in that one, diving into the ways the discussion of America’s “mental health crisis” was either kind of a no-brainer: How did you expect people enduring a pandemic and witnessing or experiencing the death of others to feel? Or, instead, a sleight of hand that implied that both the source and the solution to American distress was therapy or other mental health services, rather than a thorough investigation of the complex network of systems undergirding the chronic stress, economic inequality, and lack of access to healthy food, exercise, and clean water that could be said to be the crisis’s ultimate source. Carr, at least in that piece, looks like a structuralist more than a conservative, eye-rolling at the snowflakes.

Because I wanted to respond to Carr’s piece in a timely manner, and because it would take me pages to fully explore the structural implications of trauma—as a cause of trauma; as a source of suffering; as a “cure” for mental health—I’ve decided instead to use her piece to share some questions it raised for me, ones I may write about in greater detail in future, especially if you tell me in the comments which ones you find interesting, and would like to me to write about. (I’m not fishing here; I really want to know what you think.) So, herewith:

A brief history of PTSD, and some questions about trauma from Carr’s piece

PTSD is perhaps the only category in the Diagnostic and Statistical Manual that locates distress outside the self, the mind. It is inherently social, because an act of violence is the impetus for the traumatic event. That said, the wording of the diagnosis is cautionary: it avoids the word “cause” when it discusses the relationship between a traumatic event and the eventual presentation of PTSD symptoms in the person. To this day, the category of PTSD accounts for acts of interpersonal violence—even combat happens between groups of people—but does not account for vectors of structural violence like patriarchy and white supremacy. 

One of the reasons I am interested in the history of medicine and psychology is because it gives us information about the context in which a disease or a diagnosis is identified. The story of PTSD’s creation is fascinating and political. In the late 1960s, the social workers and psychologists who were working with Vietnam veterans identified a “syndrome” they named “The Delayed Grief of Soldiers” to account for the problems they were hearing in “rap groups”: groups of Vietnam vets who refused to seek care at the VA, because the VA was diagnosing veterans with antisocial personality disorder and addiction. (To be fair, this was in part because “Gross Stress Reaction,” the diagnostic category that had been used to diagnose war trauma in the past, had been removed from the DSM II.)

At this point in the war, public representation of Vietnam veterans was generally negative: their addiction, their domestic violence, their houselessness, their rootlessness, their refusal to return to society and participate in the workforce, their anti-war activism—these depictions of veterans not only dismissed their distress, rewriting it as a selfish refusal of personal responsibility, but flattened the veterans’ complex range of political responses to the Vietnam war, portraying veterans as similar in behavior and politics.

In response to the public’s denigration of veterans and the VA’s refusal to acknowledge American war crimes, the organization Vietnam Veterans Against the War and the clinicians working with Vietnam veterans came together to advocate for their needs. By naming “The Delayed Grief of Soldiers” a syndrome, those clinicians advocating for veterans had two goals: first, to normalize veterans’ responses to their witnessing and participating in atrocities in Vietnam as a form of moral reckoning. Second, to document the effects of these veterans’ distress on the lives of those they loved, and on the larger social order. The advocacy for veterans, that is, was at once interpersonal, social, and political. 

It is no surprise that the American Psychiatric Association took a dim view of those who sought recognition for the syndrome. It was only after more than a decade of effort on the part of activists and clinicians that the APA ratified and published in the DSM III the diagnostic category of PTSD. In doing so, it transformed the syndrome into a diagnosis and stripped the veterans’ distress of its social and political context. PTSD was a diagnosis that a clinician could identify and differentiate from other diagnostic categories by parsing its set of symptoms. In order to validate those symptoms as universal, rather than particular to any political context, the kinds of trauma out of which PTSD could emerge was broadened to include not only combat, but also rape, childhood sexual abuse, assault, car accidents, and natural diasasters (with Mother Nature acting as a kind of vengeful self). 

The DSM III was a repudiation of psychoanalysis, which had been the organizing framework of the DSM II, and a turn toward making psychology and psychiatry more scientific, more in line with medicine. The focus of the subcommittees who gave us the DSM III—out of which the current DSM arises—was to regularize diagnosis, eliminate diagnostic unreliability across clinicians, which was rampant, and buttress the fields of psychiatry and psychology from the critiques of the anti-psychiatry movements of the 1960s and 1970s. All of the diagnoses in the DSM III were scrutinized and regularized in an effort to make psychology more legitimate from a scientific standpoint. The publication of the DSM III in 1980 coincided with Regan’s presidential campaign and what would become the successful containment of the protest movements of the 1960s and 1970s.

What’s interesting about this moment in time, and about Carr’s piece in NY Mag and her opinion piece in the NY Times, is that we are again in a moment of mass protest that is asking hard questions about structural violence. You can feel today the unresolved tension between the two frameworks for understanding trauma that animated the political advocacy for veterans in the late ‘60s. You can hear the people who are in treatment, arguing over the methods they’ve tried—somatic, pharmaceutical, psychodynamic, polyvagal, EMDR-–and you can hear voices like Brooks, who sounds exactly like the APA members who fought hard to delegitimize the arguments about veterans’ suffering. It’s this fight that gives rise to arguments that “everyone is traumatized” and that the term is thus evacuated of meaning. 

Things I’m wondering:

If you are a clinician, how do you understand and work with trauma?

If you see your clients' trauma as ultimately a response to larger structural issues, such as economic inequality, systemic racism, health disparities, or gender-based violence, how do you address the relationship between individual symptoms and interventions, and broader sources of psychological distress?

Is there a professional or personal ethical obligation for health-care providers to work against violence, either interpersonal or structural, in order to prevent trauma?

How do you understand what’s said to cause America’s current “mental-health crisis” and the sub-crisis of distress among teenagers, particularly those who identify as women? 

Carr talks about health-care providers validating the pain of their clients, asking if people are attracted to trauma because it is a “thing” that has legitimacy, that they can use to make sense of their suffering. Is it the responsibility of health-care providers to witness and validate their clients’ personal pain as “trauma,” even if they think the person is not traumatized in the clinical sense?

Is it possible to secure some amount of healing for the individual by current treatment methods, even as the ultimate sources of distress remain unchanged?

I’m wrestling with these questions all the time, as a clinician who believes that structural violence is real, and that white supremacy and patriarchy are more powerful vectors of violence than much of what happens between individuals (though certainly not all). I write out of my pride in what I accomplish in my work with individual clients and my frustration with the ways good therapists can be seen as the ultimate salve, or sponge, for the lack of action at the political and social, which could create much broader relief than I do, hour by hour, day by day. (I’m thinking about the loss of health-care subsidies, of pandemic relief for children and poor families, about the Supreme Court’s rollback of rights, about the delegitimizing of entire groups of people’s needs by castigating them as complaining, seeking to be “victims,” and thus inherently immature.) I write from a place of two-ness: that what healers of all stripes are doing, what activists and community providers and teachers are doing is absolutely crucial and personal, and what is not being done, in part because we as a culture as so rooted in individualism as a source and cure to large social problems, is in part justified because of our presence.

Stay safe out there this week—

xo

Rebecca