THE HARMONY OF ILLUSIONS THE HARMONY OF ILLUSIONS I NVENTING POST-TRAUMATIC STRESS DISORDER Allan Young PRINCETON UNIVERSITY PRESS PRINCETON, NEW JERSEY Copyright 1995 by Princeton University Press Published by Princeton University Press, 41 William Street, Princeton, New Jersey 08540 In the United Kingdom: Princeton University Press, Chichester, West Sussex All Rights Reserved Library of Congress Cataloging-in-Publication Data Young, Allan, 1938– The harmony of illusions : inventing post-traumatic stress disorder / Allan Young. p. cm. Includes bibliographical references and index. ISBN 0-691-03352-8 (cloth : alk. paper) 1. Post-traumatic stress disorder—Philosophy. 2. Social epistemology. I. Title. RC552.P67Y68 1995 616.85′21—dc20 95-16254 This book has been composed in Times Roman Princeton University Press books are printed on acid-free paper and meet the guidelines for permanence and durability of the Committee on Production Guidelines for Book Longevity of the Council on Library Resources Printed in the United States of America by Princeton Academic Press 10987654321 For Roberta Contents Acknowledgments ix Introduction 3 PART I: THE ORIGINS OF TRAUMATIC MEMORY One Making Traumatic Memory 13 Two World War I 43 PART II: THE TRANSFORMATION OF TRAUMATIC MEMORY Three The DSM-III Revolution 89 Four The Architecture of Traumatic Time 118 PART III: POST-TRAUMATIC STRESS DISORDER IN PRACTICE Five The Technology of Diagnosis 145 Six Everyday Life in a Psychiatric Unit 176 Seven Talking about PTSD 224 Eight The Biology of Traumatic Memory 264 Conclusion 287 Notes 291 Works Cited 299 Index 321 Acknowledgments I OWE a debt to colleagues and friends in the Department of Social Studies of Medicine and the Department of Psychiatry at McGill University: I thank Don Bates, Alberto Cambrosio, Margaret Lock, Faith Wallis, George Weisz, and Laurence Kirmayer for their invaluable advice. I owe a similar debt to Atwood Gaines and Ronnie Frankenberg, who read and commented on earlier drafts. Arthur Kleinman has shown me many kindnesses, both intellectual and professional, while I prepared this book. I am grateful for these favors, but most of all for his sympathetic understanding of my overall project. I am likewise grateful to Ian Hacking for his advice, and I hope that the influence of his ideas on my book will be obvious to my readers. I also want to thank Mark Micale for many helpful suggestions, particularly in connection with the historical sections. The ethnographic segment of this book would have been impossible with- out the many favors shown to me by Jack Smith, Glenn Davis, David Leben- thal, and Susan Johnson. I am likewise grateful for the consideration given to me by both the patients and staff whom I met and was permitted to listen to at the Veterans Administration medical unit described in the following pages. It would be difficult to exaggerate my special obligation to Paul Emery. He has been a friend and a mentor. He has been generous with his time and his knowledge and has treated me with a measure of kindness that will always place me in his debt. I thank William Schlenger, Terrence Keane, and John Fairbank for the valuable information they provided in connection with the National Viet- nam Veterans Rehabilitation Study. I also want to express my gratitude to the Veterans Administration Medical System for its material assistance dur- ing my field research. McGill University has generously provided me with a faculty research grant to support the preparation of the final manuscript. I also want to thank Mary Murrell for her expert opinion, patience, and encouragement, and Vicky Wilson-Schwartz for her meticulous attention to my manuscript. The infelicities and obscurities that remain are entirely my own. The research for this book began in 1986. In the intervening years, I pre- sented drafts of chapters at seminars and conferences in Canada, the United States, the United Kingdom, and Germany. I am grateful to the colleagues who were present on these occasions for their many helpful suggestions. I apologize for failing to express my gratitude to them individually. x ACKNOWLEDGMENTS My greatest debt is to Naomi Breslau. Without her help and encourag- ment, I would never have found my way to the subjects and places that are described in this book. Without her guidance and instruction, I would never have understood the things that I now claim to understand. THE HARMONY OF ILLUSIONS Introduction AS FAR BACK as we know, people have been tormented by memories that filled them with feelings of sadness and remorse, the sense of irreparable loss, and sensations of fright and horror. During the nineteenth century, a new kind of painful memory emerged. It was unlike the memories of earlier times in that it originated in a previously unidentified psychological state, called “traumatic,” and was linked to previously unknown kinds of forget- ting, called “repression” and “dissociation.” The new memory is best known today in connection with a psychiatric malady, post-traumatic stress disorder (PTSD). PTSD was adopted by the American Psychiatric Association as part of its official nosology in 1980, and it rapidly attracted the attention of clinicians and researchers through- out the Americas, Britain, Australia, Scandinavia, and Israel. Soon after- ward, a contributor to the British Journal of Psychiatry reported that he had discovered evidence of the syndrome in the Diary of Samuel Pepys,inthe pages where Pepys describes his mental condition following the Great Fire of London in 1666 (Daly 1983:67). Pepys’s self-reported symptoms are said to correspond to the diagnostic features listed in the official no- sology—intrusive images of his frightening experience, feelings of detach- ment and estrangement, survivor’s guilt, memory impairment, and so on— and the Diary is said to establish that PTSD existed in the past. In the following years, writers uncovered progressively earlier historical evi- dence of PTSD. The shadow of traumatic memory was spied beneath the surface of this passage from Shakespeare’s King Henry IV, Part One (Trimble 1985:86): Tell me, sweet lord, what is’t that takes from thee Thy stomach, pleasure and golden sleep? Why dost thou bend thine eyes upon the earth, And start so often when thou sit’st alone? Why hast thou lost the fresh blood in thy cheeks, And given my treasures and my rights of thee To thick-eyed musing and cursed melancholy?1 More recently, evidence of PTSD has been discovered in the Epic of Gil- gamesh, which takes the disorder and its memory back to the dawn of re- corded history (Boehnlein and Kinzie 1992:598; also Parry-Jones and Parry-Jones 1994). In the following chapters, I argue that none of these writers—neither Pepys, nor Shakespeare, nor the author of Gilgamesh—was referring to the 4 INTRODUCTION thing that we now call the traumatic memory, for this memory was unavail- able to them. In everyday usage, the term “memory” has three meanings: the mental capacity to retrieve stored information and to perform learned mental operations, such as long division; the semantic, imagistic, or sen- sory content of recollections; and the location where these recollections are stored. John Locke and David Hume proposed that memory, in the second and third senses, is intrinsically connected to our conception of “self” and “self-awareness” (Richards 1992:159–161; Warnock 1987:57–60). By connecting self-awareness with the past, memory provides the body with a subject and subjectivity. It is the source of the “I” that initiates the body’s purposeful acts and the “me” who experiences its pleasures and vicissi- tudes and must accept responsibility for its actions. Without memory, the I/me would fail to transcend momentary states of awareness and self-con- sciousness. It would be a string of experientially unconnected points, a “dehumanizing” condition that is associated with certain neurological pa- thologies (cf. Parfit 1984:202–217). Our sense of being a person is shaped not simply by our active memories, however; it is also a product of our conceptions of “memory.” What occupies me in this book is how certain of these conceptions have changed over time, together with the practices through which memories are retrieved, interpreted, and narrated. In eighteenth-century Europe, the prevailing conception was that a memory consists of mental images and verbal content: a person sees, says, or otherwise apprehends the things that he remembers.2 During the next century, the boundaries of memory were expanded to include contents lo- cated in acts and bodily conditions (e.g., automatisms, hysterical contrac- tures) as well as words and images. Further, the very fact that these acts and conditions were “memory” was unknown to the person who owned the memory. This new conception was based on the idea that intensely frightening or disturbing experiences could produce memories that are concealed in auto- matic behaviors, repetitive acts over which the affected person exercised no conscious control. Without the intervention of an expert, the owner of a “parasitic” memory remained unaware of its content and ignorant that it influenced aspects of his life—an idea that would have been literally un- thinkable in the previous century. The discovery of traumatic memory revised the scope of two core at- tributes of the Western self, free will and self-knowledge—the capacity to reflect upon and to attempt to put into action one’s desires, preferences, and intentions (Dworkin 1988:chaps.3 and 4; Harris 1989:3; Johnson 1993:chap. 6; Ouroussoff 1993:287–295). At the same time, it created a new language of self-deception (Rorty 1985) and justified the emergence of a new class of authorities, the medical experts who would now claim INTRODUCTION 5 access to memory contents that owners (patients) were hiding from them- selves.