Post Traumatic Stress Disorder: The Experience of Trauma (Criterion A) is Not Subjective
published at HG Experts <click here>
One of the most difficult lessons for most psychotherapists-in-training is to learn to focus on the patient’s subjective experience—not only on objective reality. Perhaps the key skill of the psychotherapist is the ability to understand and empathize with the patient’s perspective, no matter how unreasonable that perspective may be. For example, a patient who suffers from paranoid delusions and who believes that an ill-defined group of conspirators is spying on the patient and following the patient, should receive empathy from the therapist during treatment. Even though the therapist may attempt to explain that the patient’s perceptions are unrealistic and unlikely—and this very reasonable approach to treatment is notoriously ineffective—the therapist will also empathize with the patient’s reality. “How terrible that must feel,” is what most good therapists might say regarding the patient’s subjective experience of being followed by individuals with malevolent intent, thereby empathizing with the patient’s own experience.
Skillful therapists develop the ability to empathize with the patient’s reality and set aside, or place on the back burner, questions about whether that reality corresponds to the reality we all share, the reality that is objective. When a patient comes into treatment and describes being mistreated and abused by her attorney and the courts in a child custody matter, the first order of business—in order to build an effective therapeutic relationship—is to empathize with the how the patient is feeling. Maybe later, as treatment progresses, it would be appropriate to help the patient understand the bigger picture and to see that, while she might feel abused by the legal process, no one is intentionally abusing her or depriving her of her rights. Exploring the objective reality may be an important part of treatment, but endorsing the subjective experience is at least equally important to build the relationship and make the patient “feel heard.”
Some diagnoses are based entirely on the subjective and upon the patient’s self-report of his or her experience. When the patient describes depression, it becomes moot whether the objective reality the patient describes really “is depressing.” Indeed, some depressed patients lead charmed lives. Amid wealth, health and supportive families, they feel empty and hopeless. They will be diagnosed as depressed based entirely on their experience of the world. The objective fact that there is nothing about which to be depressed is irrelevant to this diagnosis. Similarly, most anxiety disorders are diagnosed based entirely on the patient’s experience. Panic disorder and phobia, for example, are diagnosed based on the patient’s experience of situations. The fact that those situations are not, and should not, be a source of anxiety for most people is moot.
Attorneys and psychotherapists sometimes fail to realize that such subjectivity has no place in the diagnosis of Post Traumatic Stress Disorder or PTSD. PTSD is a diagnosis that is reserved for those who have actually experienced horrific things. PTSD, then, is set apart from phobias, for example, where an individual overreacts to a situation but the situation itself may not be inherently dangerous. For example, individuals who suffer from dog phobias may experience significant fear in the presence of the most harmless of tiny puppies. The objective threat posed by the puppy is irrelevant to both the phobic individual and to whoever is making the diagnosis of phobia.
PTSD, like all psychiatric diagnoses, is determined by a series of diagnostic criteria. Criterion A for PTSD includes the following statement: “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.” Note the use of the word “actual” in this statement; PTSD is diagnosed based on the actual reality, not on how this reality may seem to the individual. PTSD stands apart from most other psychiatric diagnosis by virtue of its linkage to actual, consensual reality.
In legal matters, plaintiffs often include a claim of PTSD in their lawsuits, claiming that some circumstance was so stressful to them as to result in psychological disability. In many cases on which I have consulted or testified, the PTSD claim is inappropriately predicated on an entirely subjective reading of a situation. For example, in an employment case involving claimed sexual harassment and retaliation, a plaintiff might testify that her boss looked at her in a way that made her feel frightened, that the boss seemed so angry that she feared for her life, and that he had a way of making people feel intimidated. Further testimony might establish that the boss in this case did nothing more than glare and had no history or violence, had never acted violent, and had never threatened violence. At the same time, the patient might claim to experience many of the symptoms of PTSD: recurrent images of the glaring boss, flashbacks to the time when the boss confronted her, anxiety symptoms like racing heart, nightmares, and avoidance of looking at the boss, thinking about the boss or going to locations where the boss might be present. All the symptoms of PTSD are present, but does the patient suffer from PTSD?
The answer is emphatically in the negative. Patients like this may well suffer from psychological sequelae of an adverse employment situation, but their diagnosis should not be PTSD unless something of a life threatening magnitude actually occurred at the workplace.
PTSD is often misdiagnosed in the context of civil litigation by plaintiff’s psychological witnesses. Sometimes, this misdiagnosis is the result of a lack of understanding of the criteria for PTSD. Sometimes, the diagnosis is made, not by the independent expert evaluator, but by the treating therapist, who is sympathetic with the patient’s suffering and bends over backwards to provide a diagnosis that captures the degree of pain the patient feels. Independent experts conducting evaluations for litigation, and who have no treatment relationship, also sometimes misdiagnose PTSD. This is not only the result of a poor understanding of the diagnostic criteria. Sometimes these expert witnesses actually argue in court that the diagnostic criteria themselves are at fault, and that PTSD should apply to instances in which the victim feels traumatized despite the fact that the alleged trauma was not objectively life threatening, or even objectively dangerous.
In sum, PTSD has been overused in civil litigation by plaintiffs attempting to emphasize their perceived injuries and to link these injuries to the actions of others. One must remember that the actions or events that lead to PTSD must be objectively horrific. If they are not, a different diagnosis must be given.
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