The editors of the online journal Geschichte der Gegenwart (translates as “History of Present”) Svenja Golterman and Gesine Krüger, both professors of history, in conversation with the psychotherapist and psychiatrist Andreas Maercker.
Svenja Goltermann: Andreas you are a psychotherapist and psychiatrist who has been working therapeutically and within research for many years now, especially in the field of posttraumatic stress disorder (PTSD). You have examined the psychological consequences of the experiences of political prisoners of the German Democratic Republic, war veterans of WW2, and Swiss indentured child laborers, amongst others. The term “trauma” is used frequently in the media, whether it is related to war, accidents, sexual abuse, divorce, or political defeat. What do you think about this wide use and how does it relate to your research?
Andreas Maercker: The boom in using the term is not related to the disciplines that deal scientifically with trauma, i.e., psychology and psychiatry, but the influences of culture and the media. Professionally we have a much tighter definition of what trauma is. We talk about trauma when a person experiences an event that is life-threatening, where a person fears for their life, or where there is sexual violence. These unfathomable experiences affect people extremely or humiliate them to a considerable degree so that they can cause emotional and mental harm.
S.G.: You say that everyday use of the term trauma has developed separately from its scientific usage, but in Europe the term became popular relatively late in the 20th century. To be precise, this was after the diagnosis posttraumatic stress disorder was included in the official classification system of the American Psychiatric Association in 1980. Which is why I ask myself if there is a connection. Have we seen an increase in the diagnosis of PTSD in the last 35 years?
A.M.: Yes, that is true and I have watched with interest the interplay between the tighter professional definition and the wider use of the term. Of course, our increasing affinity with psychological terminology and the general psychologicalization of our culture plays a role here. But I do think that we have to consider another important point here: The phenomenon we’re talking about is called posttraumatic stress disorder. Trauma is actually a term that originates from emergency medicine and it describes physical damage or a wound. The psychological sciences have partly adopted the term as it is understandable for people because they can see trauma as a long-standing wound that affects a person’s well-being. In that respect, I can of course see a connection to the professional use of the term when the everyday use states: “I have been inflicted with a wound, I am a victim.” But that would not fit when we speak of “shock” or “stress.”
S.G.: Acceptance is the keyword here. Long-term mental health problems were much more stigmatized until well into the 20th century. And that has changed dramatically in the last decades, especially in relation to trauma. The MD and social anthropologist Didier Fassin and the psychiatrist Richard Rechtman have developed an interesting idea in connection to this. They argue that PTSD is categorically something new because the diagnosis assumes that an external event is the cause for the long-term or late-onset mental and emotional impairment. This wasn’t the case with earlier concepts such as neurosis, where it was assumed that disposition or personality played a role. Does this then have a de-stigmatizing effect.
A.M.: That’s an interesting point you make. It really is about a paradigm change when we recognize something external as the cause of a mental disorder and through that then de-stigmatize those who are affected. Psychiatry has always taken into account event-dependent, reactive changes, but in doing that we only consider the short-term mental changes. However, the paradigm shift is related to the new cognitive memory theories of Chris Brewin and others, which say that an external event can cause a sustained memory disturbance for which there must not be a predisposition for. This plausible conclusion has unfortunately been so simplified in various circles, including psychiatry, that essentially only the event and its magnitude are viewed as determining what happens mentally. That’s why we see expert psychiatric reports that focus on the seriousness of the events and do not investigate what is going on emotionally or mentally.
S.G.: The concept of PTSD has changed again since 1980. The initial idea that extraordinarily stressful events cause a trauma in most people certainly has not been maintained. Already in the 1990s, psychiatrists and psychologists were much more careful. They didn’t assume that an event such as war or sexual abuse would automatically lead to emotional and mental damage. Do you also believe that is the case?
A.M.: I would even say that the idea that the seriousness of the event is more important was always a matter of simplification. Around that period, there was another group of scientists, the psychodynamic-oriented Mardi Horowitz, among others, who were very interested in investigating the symptom patterns of those affected, such as the different sensory qualities of the flashbacks, the continued heightened alertness, or the persistent feelings of shame and guilt.
S.G.: If we look at the field of humanitarian aid in the late 1990s and the projects that were developed within the United Nations (UN) to help war and crisis areas, we find many descriptions of PTSD and its distribution. There are statistics that state that 70% of the people living in the Balkans during the war were traumatized. There are war zones in Africa where the percent affected is even higher, up to 95% in some countries. How are such figures calculated? Are they based on the events and that posttraumatic consequences are related to how atrocious they were? Or are these statistics based on studies? You have said that research is based on a much stricter definition of trauma. Is that the case here too?
A.M.: A lot of these statistics are not based on serious scientific work. Let me clarify this a little. We make estimates of what we call prevalence on the basis of samples that can be representative or random. What shouldn’t be used for such studies are the wonderfully named convenience samples, i.e., that would mean that the researcher, for example, went to a clinic in Bosnia and investigated the patients there. Or the researchers advertise that the local hospital in Banja Luka is looking for people to take part in a study. From such convenience samples we would find rates of PTSD from 60 % to 90 %, but these numbers are not applicable to the general population. In a study of previous political prisoners, we wrote that 60% of them had experienced PTSD at some time in their lives, and that many of them recovered since. But then in the press, they present it simply as “60% traumatized!”