Recognizing PTSD In Others: What Films Do—And Do Not—Help Us See

An article for Slate, Drowning Doesn’t Always Look Like Drowning, has stuck with me, especially after I helped rescue a boy floundering off a Florida beach.

The author, Mario Vittone, is a former Coast Guard rescue swimmer. He noted that “Drowning is almost always a deceptively quiet event. The waving, splashing, and yelling that dramatic conditioning (television) prepares us to look for is rarely seen in real life.”

The statistic he cites is the disparity between expectations of what drowning looks like and its reality facilitates the drowning of 750 children a year. Simply put: trained by false representations in the media, their parents simply don’t know what to look for. Many of these children drown under adult supervision. 

Not only did Vittone’s article make me think differently about how I perceive the beach but also his assessment of the power of television influenced my thinking and writing on literature and psychological trauma during my graduate study. 

In this post, I borrow Vittone’s idea of dramatic conditioning to refer to the subliminal and powerful training we receive from popular media—such as texts and film—to try to make sense of contemporary representations and understandings of Post-Traumatic Stress Disorder (PTSD). 

I’ll argue that dramatic conditioning—those inaccurate or false representations of psychological trauma that nonetheless influence our understanding of the condition—stem not just from attempts to “sell” but also from fundamental disagreements and disorientation among psychiatric professionals, then and now.

I’ll start by giving a few examples of what I mean (from the film The Pawnbroker as well as the book Sybil and its film adaptation) before exploring how that happened and suggesting what we can do about it—filmmakers, novelists, psychologists, and community members alike.

I’m happy to note that much of the research for this project was undertaken in collaboration with an undergraduate History major from Loyola University Chicago: Andrew Prior. Together, Andrew and I drew from archival material, including The Lancet and other medical journals as well as newspapers, magazines, literature and film to establish the medical and popular discourses surrounding trauma. Andrew tackled the years 1910-1940, a survey which includes traumas emerging from World War I as well as pre- and post-war traumas in the civilian sphere. 

Flashbacks in Film

In his book The Trauma Question, literary professor Roger Luckhurst claims that “the cinema in fact helped constitute the Post-Traumatic Stress Disorder subject in 1980, and that it has continued to interact with and help shape the psychological and general cultural discourse of trauma into the present day.” In other words, much of what we know and understand about PTSD was created and continue to be shaped by film.

Luckhurst cites such films as The Pawnbroker from 1964 as providing a model of traumatic memory that reveals itself in flashbacks. Why? Because the film appeared fifteen years before the arrival of PTSD, and “moreover, that the symptoms of PTSD did not initially include the traumatic flashback as a significant diagnostic element.” 

According to Luckhurst: “Psychiatric definitions of traumatic flashbacks in fact mimic the cinematic representations of memory in films like The Pawnbroker.” 

Beyond this distorted chronology, what makes the notion of traumatic memories manifesting itself in the form of flashback so problematic is that it runs counter to the findings of hundreds of studies by the McNally Lab at Harvard. (Here’s one.) The McNally Lab engages with a wide range of topics, including anxiety disorders, memory, trauma, and grief. 

Without diminishing the lived experience of individuals experiencing PTSD, it’s important to be able to accurately identify, discuss, and address those experiences. Crucially, it’s important to acknowledge that even though flashbacks have been included in the Diagnostic and Statistical Manual of Mental Disorders (the DSM) since 1980 as a symptom of PTSD, that form of intrusive memory is not supported by data. Our survivors and soldiers deserve better.

Multiple Personality Disorder

Multiple Personality Disorder, like PTSD, is considered a stress disorder. After Sybil’s publication, Multiple Personality Disorder became interconnected with traumatic experiences. NPR noted that “When Sybil first came out in 1973, not only did it shoot to the top of the best-seller lists, it manufactured a psychiatric phenomenon. The book was billed as the true story of a woman who suffered from multiple personality disorder. Within a few years of its publication, reported cases of multiple personality disorder—now known as dissociative identity disorder—leapt from fewer than one hundred, to thousands.” 

Another quick example comes from Sybil, the pseudonymous title of Shirley Mason’s narrative of multiple personality disorder (now known as Dissociative Identity Disorder).

For some data behind this, I turn again to Richard McNally, who wrote: “before the 1980s, multiple personality disorder had been one of the rarest disorders in the history of psychiatry”; however, in the post-Sybil era, some psychiatrists suggested that between twenty and fifty percent of psychiatric inpatients suffered from it.

Those of you who are familiar with this story know the central problem: Shirley Mason did not have multiple personality disorder. She acted like another personality to get the attention of her psychiatrist and was never able to disentangle herself from her lie for economic, emotional, and other reasons. 

L0035996 Railway accident, La Chapelle, France, 1879 Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org.

How Did We Get Here? The Origins of the Divide Between the Medical vs. Popular Discourses of Trauma

As a psychological term, trauma developed out of Victorian-era incidents of “railway spine” in Britain—an epidemic of nerve problems caused by train crashes—as well as the rise of psychoanalysis in the 1890s. It was about this time that the word trauma shifted from describing wounds or injury to the body proper to include damage to the human psyche. However, most early diagnoses of psychological trauma were firmly rooted in the physical body. Shell shock, for example, was generally understood as the physical effects of proximity to an explosion throughout World War I (even as cases of shell shock consistently emerged in men who were not proximate to exploding shells).

L0046100 ‘Shell Shock’: image from ‘The Fourth’ magazine Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org ‘Shell Shock’: image from ‘The Fourth’ magazine 1917 By: J.P.D. Hewatt.

Awareness of psychological trauma was dramatically accelerated by the effects of World War I. Unfortunately, as a result of the vast numbers of case studies available to doctors, psychiatrists, psychoanalysts, neuropsychologists, and neurologists had plenty of material to fuel early debates among the medical community.

A 1918 article in The Lancet outright described the possibility for research, in seeking medical professionals to make known their interest in working with shell shock patients: “Now the present war has revealed a vast field for useful work in the treatment of those functional neuroses usually classed together under the heading ‘Shell shock.’…/ As a certain number of medical men who are interested in or may be required, they should send in their names to the War Office as soon as they are called up, stating their wish to undergo a course of training in this branch of medicine.” 

And yet debates raged on over such issues as whether the cause of trauma was physical, psychological, or both; whether responses were short-term or prolonged; and how best to treat traumatized individuals. 

Railway spine, soldier’s heart, and shell shock were all widely covered in medical journals as well as in newspapers, but no consensus was ever arrived at by the medical community for defining, much less treating, psychological trauma as a result of the war. 

A January 6, 1917 letter to the editor of The Lancet, is telling of these disagreements. The writer celebrates finding common ground with another professional, before lamenting the continued use of “shell shock” as a “a misleading and bungling term, covering several different disorders which were familiar before the war…”

In his survey of the origins of trauma theory, Roger Luckhurst distinguishes between hysteria and neurasthenia as diagnoses of trauma. “Hysteria was short-term reaction to the extremity of a particular situation,” he writes. 

“If treated close in time and space to the front, the soldier could be returned to his unit relatively quickly, while evacuation was likely to turn acute problems into chronic ones. A tang of moral weakness hung around hysteria.” 

By contrast, Luckhurst notes, neurasthenia was seen as “the result of prolonged exposure to the perpetual anxiety of the front, causing nervous ‘wear and tear.’ This anxiety neurosis was typically associated with officers, who were understood to suffer acceptably under the responsibilities of command and was considered an understandable collapse, responsive to simple rest and relaxation” and as such was treated with the same rest cure prescribed to bourgeois women. 

It would seem from Luckhurst’s overview that war-time trauma had been codified and thoroughly understood in the period after WWI. However, neither hysteria nor neurasthenia was yet a comprehensive diagnosis, and as a result, traumatized soldiers were often left un- or under-treated both during the war and in the immediate post-war period. 

Today, the medical community remains divided on issues of the long-term effects of trauma and, especially, of traumatic memory. Much remains to be learned and understood about trauma. And yet, some scholars write as if the definition of trauma and its manifestations are established matters of physiology and psychology. One central example of this is the notion that individuals who have experienced trauma can’t remember or can’t speak about their experiences. 

A Gap In the Discourse: Narrative Impairments in Literature and Psychology

Even today, far too many trauma theorists argue that the response to traumatic events is (necessarily) pathological and that traumas reveal themselves belatedly and through narrative impairments (which they call “aporias”). 

Judith Herman, a psychiatrist, asserted that “Psychological trauma is an affliction of the powerless. At the moment of trauma, the victim is rendered helpless by overwhelming force….Traumatic events overwhelm the ordinary systems of care that give people a sense of control, connection and meaning.” 

Cathy Caruth, a literature professor, defined trauma through the presence of narrative impairments, arguing that trauma is “an overwhelming experience of sudden or catastrophic events in which the response to the event occurs in the often delayed, uncontrolled repetitive appearance of hallucinations or other intrusive phenomena.” 

Caruth and Herman are influential commentators, but many experts would consider their theories to be mistaken at each turn. Military historians, to take one group, argue that not all forms of violence are psychologically damaging. Similarly, McNally and others challenge the argument that trauma is defined by a narrative gap. McNally writes that, “People remember horrific experiences all too well. Victims are seldom incapable of remembering their trauma.” 

And Phil Klay, the writer and Marine Corps veteran, perhaps said it best: “If we fetishize trauma as incommunicable then survivors are trapped — unable to feel truly known by their nonmilitary friends and family.”

One significant indication of debates in the medical community is the April 2013 decision by the National Institute for Mental Health, the world’s largest institution focused on mental health research, to move away from the Diagnostic and Statistical Manual of Mental Disorders (DSM). 

Since 1952, the mental health field has relied on the DSM for definitions, categorizations, and diagnostic standards of mental disorders, including trauma-related disorders. But in 2013, Thomas Insel, director of NIMH, stated that: “the strength of each of the editions of DSM has been ‘reliability,’” in that clinicians share a diagnostic vocabulary, “the weakness is its lack of validity.” 

In a scathing review, Allen Frances (who was on the task force for the DSM-IV) claimed that the DSM-V board lowered the statistical criteria for acceptable standards of reliability and accepted agreements among raters that were “sometimes barely better than two monkeys throwing darts at a diagnostic board.”

But where did that leave us? The authors of the enormous treatise Medical Legal Aspects of Medical Records cautions that categories in the DSM are “descriptions, not explanations. One must guard against the tendency to think that something has been explained when, in fact, it has only been named. In other words, giving a condition a label does not explain or confer any reality to it other than the name itself and the cluster of behaviors subsumed under it” (you’ll have to turn to p. 693 to find this quote).

Recognizing PTSD in Others: A More Compassionate Approach

I posit that representation—what we see in novels, and films—is not equivalent to reality, and relying on these sources for evidence of symptoms of psychological trauma is dangerous at best and damaging at worst. 

In recognizing PTSD in others, therefore, it’s time to set aside armchair psychology and the bringing in of assumptions that don’t serve us—us being the survivors of traumatic experience, those individuals suffering psychological consequences of that trauma, as well as the friends, family and community members of those individuals.

Instead, I suggest we do better at questioning the wisdom of relying on representational language—by which I mean the dramatic conditioning inherent in film and literature as well as our human tendency to describe our experiences in metaphors (including those that reference movies and books).

And I encourage us to question the wisdom of relying on representational language rather than representational samples. Books and film have an important role to play in shaping and enriching our lives. I’m just not sure how big that role should be in the medical discourse of psychological trauma. 

In short, I encourage us to listen closely and without pre-judgment; invest in the professionals working to sort out and address these questions; believe survivors; and consume art and literature that makes you uncomfortable or that upends your expectations.

Where to Begin

I suggest:

Please get in touch if you have a recommendation, critique, nuance, or insights. I’d love to hear from you and continue to learn and grow.

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