Letters to the Editor
Reply: Troubles in Traumatology, and Debunking Myths About Trauma and Memory
Dear Editor:
Unusual for a scientific field, traumatology is notable for its many taboos. Certain issues must not be raised and certain questions must not be asked lest the answers to these questions have unintended adverse consequences for victims, therapists, or both. The tone of Dr Cameron and Dr Heber’s letter suggests that I am guilty of taboo violation.
As I and many others have stressed, one need not serve in a combat unit to be traumatized in a war zone (1). Nevertheless, because only a minority of trauma-exposed individuals develop PTSD, one must wonder how much trauma-exposed clerks, cooks, and so forth can help explain “the extraordinary proportions of Vietnam veterans who have been categorized as suffering from PTSD” (2, p 98). As one of the clinical interviewers in the NVVRS, I suspect that additional factors also play a role in explaining why the rate of PTSD was found to be so high, whereas the proportion of in-country psychiatric casualties resulting from acute combat exhaustion was so low (that is, 3.5%) (2, p 86). First, DSM-III-R criteria used in the NVVRS did not require that symptoms cause impairment. Accordingly, some cases were perhaps not considered disordered according to DSM-IV criteria, which require that symptoms impair functioning. Second, some subjects possibly invoked the narrative of delayed-onset PTSD to explain distress arising from diverse sources unrelated to their experience in Vietnam. They might have retrospectively viewed the war as the cause of difficulties whose origins lie elsewhere.
Cameron and Heber are troubled by the implication that either malingering or iatrogenesis may explain the recent skyrocketing number of veterans seeking service-connected disability for PTSD stemming from traumatic events that occurred decades earlier (3). Despite continuing in treatment, the modal patient worsens over time until reach ing a 100% disability rating. At that point, the patient either drastically reduces the frequency of clinic visits or drops out of treatment altogether, presumably when his or her PTSD is at its worst. Other than malingering or iatrogenesis, I can think of only one explanation for these bizarre facts: treatments are inert and therefore helpless to reverse a relentlessly deteriorating disease course.
Advocates of helping patients recover alleged repressed memories of trauma never called themselves recovered memory therapists in the first place, and so I am not surprised that references to recovered memory therapy appear only in articles written by critics of the practice. Cameron and Heber agree with many of my conclusions about memory and trauma, including those about the risks of recovered memory therapy. As they observe, most members of our field now acknowledge these risks and avoid these once widely accepted therapeutic techniques. However, Cameron and Heber forget that expressing concerns about recovered memory therapy was itself once taboo, and anyone expressing such concerns was likely accused of silencing the voices of survivors. Thankfully, what was once taboo sometimes becomes conventional wisdom, even in traumatology.
References
1. McNally RJ. Progress and controversy in the study of posttraumatic stress disorder. Ann Rev Psychol. 2003;54:229–52.
2. Marlowe DH. Psychological and psychosocial consequences of combat and deployment with special emphasis on the Gulf War. Santa Monica (CA): RAND; 2001.
3. Department of Veterans Affairs Office of Inspector General. Review of state variances in VA disability compensation payments (Report #05-00765-137. 2005 May 19). Available: www.va.gov/foia/err/standard/requests/ig.html. Accessed 2005 Oct 7.
Richard J McNally, PhD
Cambridge, Massachusetts
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