Cultural Aspects of PTSD, Part II: Narrative and Healing

Bremner et al. 2000.  MRI showing decreased hippocampal volume in Vietnam veterans diagnosed with PTSD.

Narrative and memory are interwoven in our consciousness, and thus explorations into trauma from both humanities and social science perspectives almost invariably discuss narrative in one form or another. An ongoing debate within psychological research, for example, ponders whether the coherence of trauma stories is correlated to the amount of emotional distress associated with a given traumatic memory. It is hypothesized that the greater the distress, the less organized the narrative. If this were the case, we might expect that the coherence with which an individual is able to talk about the trauma would increase as the memory is processed and resolved, a finding for which we have some evidence.

We do know – when it comes to Post-Traumatic Stress Disorder (PTSD) – that narrative matters. As I wrote in an earlier post, the most effective therapies yet proven for reducing PTSD symptoms are the exposure therapies, particularly Prolonged Exposure (PE) therapy. These therapies are more effective for reducing the full range of PTSD symptoms than any pharmaceutical yet identified. And the crux of these therapies rests on telling the story of the trauma, sometimes over and over again. This simple practice, this process of speaking, has been reliably demonstrated to result in an improvement of PTSD symptoms for many patients.

But for all its clinical benefit, this extraordinary observation tells us very little about the mechanisms of psychic healing after trauma. Instead, it points to a growing body of evidence that suggests it is not just narrative that matters in PTSD, but, more intriguingly, that it is the type of narrative that matters. Unstructured psychodynamic therapies, for example, have not been demonstrated to lessen the severity of PTSD, even among patients who continue in therapy for years. And yet certain ways of narrating memory do make a difference, and this phenomenon once again points to a role for anthropologists and other culturally-minded researchers in exploring the cultural-emotional-physiological-environmental interactions at play in post-traumatic processing.

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Cultural Aspects of Post-Traumatic Stress Disorder: Thinking on Meaning and Risk

Over the past year and a half, I have been conducting research among male U.S. veterans who have served combat tours in Iraq and Afghanistan, most of whom have been diagnosed with Post-Traumatic Stress Disorder (PTSD). An anthropologist myself, I planned to follow the trail originally blazed by Victor Frankl and Robert Jay Lifton, psychotherapists who wrote a great deal about meaning in their descriptions of trauma and PTSD.

Early on, however, a psychiatrist whose work on trauma I admire opined to me that crises of meaning belong to the realm of depression rather than PTSD. He suggested that combat PTSD was best thought of as the physiological effects of living under conditions of extreme stress, while more meaning-related struggles were best understood as a symptom of depression. Given the frequency of comorbidity between PTSD and depression, I was for some time inclined to go along with his analysis.

Then two things happened. First, I began the work of talking with veterans themselves about their stories of trauma and PTSD, listening to how they describe their own experiences. And second, I began to explore the increasingly dominant Prolonged Exposure model of PTSD, which views the disorder as a pathology that develops when individuals fail to process their traumatic memories in the normal way.

Some background is important here. A recent RAND report suggests that as many as 18.5% of combat troops have gone on to develop PTSD after serving in Iraq or Afghanistan; alarming as that number is, it nonetheless demonstrates that the vast majority of combat-exposed individuals do not develop PTSD. However, most of the veterans I’ve spoken with – even those without a formal PTSD diagnosis – report experiencing some PTSD symptoms for a period of time following their combat deployment. Many of them dealt with such symptoms for a while – a month, three months, a year – before passing through this period of processing their memories and going on with their lives. They may be changed by their experiences in the war zone, but they are not broken by them, and may even describe them as resulting in personal growth and other positive effects.

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