Derek Summerfield

The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category.

A central assumption behind psychiatric diagnoses is that a disease has an objective existence in the world, whether discovered or not, and exists independently of the gaze of psychiatrists or anyone else. In other words, neolithic people had post-traumatic stress disorder as have people in all epochs since. However, the story of post-traumatic stress disorder is a telling example of the role of society and politics in the process of invention rather than discovery. The diagnosis is a legacy of the American war in Vietnam and is a product of the post-war fortunes of the conscripted men who served there. They came home to find that they were being blamed for the war. Epithets like “babykiller” and “psychopath” were thrown at them by some who had watched on television the US militarys atrocities against defenceless peasants. This reception was a primary factor in the well publicised difficulties—such as antisocial behaviour—that some military personnel had in readjusting to their peacetime roles. Those who were seen by psychiatrists were diagnosed as having an anxiety state, depression, substance misuse, personality disorder, or schizophrenia; these diagnoses were later supplanted by post-traumatic stress disorder. Early proponents of the diagnosis of post-traumatic stress disorder were part of the antiwar movement in the United States; they were angry that military psychiatry was being used to serve the interests of the military rather than those of the soldier-patients. The proponents lobbied hard for veterans to receive specialised medical care under the new diagnosis, which became the successor to the older diagnoses of battle fatigue and war neurosis. The new diagnosis was meant to shift the focus of attention from the details of a soldiers background and psyche to the fundamentally traumatogenic nature of war. This was a powerful and essentially political transformation: Vietnam veterans were to be seen …

Psychological responses to war and atrocity: The limitations of current concepts

Because of the prevalence of wars, political violence and other forms of man-made disaster in Third World countries many individuals and communities suffer prolonged and often multiple traumas. In Western psychiatry certain conceptions of the response to violence and trauma have been developed, including the widely used category of post-traumatic stress disorder (PTSD). We argue that because concepts such as PTSD implicitly endorse a Western ontology and value system, their use in non-Western groups should be, atmost, tentative.

War and mental health: a brief overview.

This is the third of four articles Series editor: Anthony B Zwi (Anthony.Zwi@lshtm.ac.uk) About 40 violent conflicts are currently active and nearly 1% of the people in the world are refugees or displaced persons. Over 80% of all refugees are in developing countries, although 4 million have claimed asylum in western Europe in the past decade. Many wars are being played out on the terrain of subsistence economies; most conflict involves regimes at war with sectors of their own society—generally the poor and particular ethnic groups, such as the ethnic Albanians in Kosovo. Atrocity—extrajudicial execution, torture, disappearances, and sexual violation—generates terror, which maximises control over whole populations, as does the intentional destruction of the fabric of social, economic, and cultural life. Community leaders, health workers and facilities, schools, academics, places of worship, and anyone who speaks out for human rights and justice are often targets. In many regions such war is a factor in the daily lives and decision making of a whole society. #### Summary points The reframing of normal distress as psychological disturbance is a serious distortion Personal recovery is grounded in social recovery Rights and social justice shape collective healing Researchers must attend to resilience factors and beware of extrapolating from clinic based samples There is no such thing as a universal response to highly stressful events. However, somatic presentations such as headaches, non-specific pains or discomfort in torso and limbs, dizziness, weakness, and fatigue are central to the subjective experience and communication of distress wrought by war and its upheavals worldwide. This does not mean that these people do not have psychological insights but that somatic complaints reflect traditional modes of help seeking and also their view of what is relevant to bring to a medical setting.1 Some researchers see somatic symptoms as physiological responses driven by …

How scientifically valid is the knowledge base of global mental health

Mental health is a construct that cannot be seen as independent of culture, society and situation. Derek Summerfield argues that Western definitions and solutions cannot be routinely applied to people in developing countries

Effects of war: moral knowledge, revenge, reconciliation, and medicalised concepts of “recovery”

Western health professionals and the public have a misguided image of war and its aftermath that is often far removed from the actual experience of non-westernised societies. A British psychiatrist looks at the effects of war and at the belief that the emotional reactions of victims of war should be modified In 1999, a survey of 600 households of Kosovo Albanians by the Centers for Disease Control and Prevention found that 86% of men and 89% of women had strong feelings of hatred towards the Serbs. Overall, 51% of men and 43% of women had a desire to seek revenge most or all of the time.1 Similar findings are seen, for example, with people from both sides of the Israeli-Palestinian conflict.2 The idea that feelings of revenge are bad for you comes from the quietist Judaeo-Christian traditions of confessing, forgiving, and turning the other cheek. The report of the Kosovan survey cast feelings of revenge as indicators of poor mental health, and it concluded by making recommendations for mental health programmes. In Croatia—a part of former Yugoslavia—a foreign led project told Croatian children affected by the war that not hating and mistrusting Serbs would help them recover from the trauma.3 In a recent study of victims of the apartheid era in South Africa—some of whom testified to the Truth and Reconciliation Commission—post-traumatic stress disorder and depression were significantly more common in those who were unforgiving towards the perpetrators than in those with high “forgiveness” scores.4 Such studies seek to give scientific weight to the notion that the mental health of victims is at risk if they do not forgive those who hurt them. The moral economy that operated during the hearings is indicated by the fact that commissioners were not uncomfortable if testifiers wept while giving …

Experiences of torture and ill‐treatment and posttraumatic stress disorder symptoms among Palestinian political prisoners

The relationship between the nature and severity of experiences of torture and ill-treatment and posttraumatic stress disorder (PTSD) symptoms was studied in 550 male nonhelp-seeking Palestinian political ex-prisoners from the Gaza Strip. Results showed that the more a prisoner had been exposed to physical, chemical and electric torture, psychological ill-treatment, and sensory deprivation or bombardment, the more he subsequently suffered from intrusive reexperiencing, withdrawal and numbness, and hyperarousal. Existential problems were not related to torture experiences. Furthermore, duration of imprisonment, health problems during the imprisonment, harassment during arrest and after release, family, marriage and economic difficulties all predicted intrusive reexperiences of trauma. Also, ex-prisoners who continued to be harassed by military authorities and had economic problems suffered more from withdrawal, numbness, and hyperarousal than others.

Mental health, social distress and political oppression: The case of the occupied Palestinian territory

Abstract This paper presents a brief history of Palestinian mental health care, a discussion of the current status of mental health and health services in the occupied Palestinian territory, and a critique of the biomedical Western-led discourse as it relates to the mental health needs of Palestinians. Medicalising distress and providing psychological therapies for Palestinians offer little in the way of alleviating the underlying causes of ongoing collective trauma. This paper emphasises the importance of separating clinical responses to mental illness from the public health response to mass political violation and distress. Palestinian academic research reframes the mental health paradigm utilising an approach based on the broader framework of social justice, quality of life, human rights and human security. Recognising social suffering as a public mental health issue requires a shift in the emphasis from narrow medical indicators, injury and illness to the lack of human security and human rights violations experienced by ordinary Palestinians. Such a change in perspective requires a parallel change in mental health policies from short-term emergency humanitarian aid to the development of a sustainable system of public mental health services, in combination with advocacy for human rights and the restoration of political, historical and moral justice.

An open letter for the people in Gaza.

We are doctors and scientists, who spend our lives developing means to care and protect health and lives. We are also informed people; we teach the ethics of our professions, together with the knowledge and practice of it. We all have worked in and known the situation of Gaza for years. On the basis of our ethics and practice, we are denouncing what we witness in the aggression of Gaza by Israel. We ask our colleagues, old and young professionals, to denounce this Israeli aggression. We challenge the perversity of a propaganda that justifi es the creation of an emergency to masquerade a massacre, a so-called “defensive aggression”. In reality it is a ruthless assault of unlimited duration, extent, and intensity. We wish to report the facts as we see them and their implications on the lives of the people. We are appalled by the military onslaught on civilians in Gaza under the guise of punishing terrorists. This is the third large scale military assault on Gaza since 2008. Each time the death toll is borne mainly by innocent people in Gaza, especially women and children under the unacceptable pretext of Israel eradicating political parties and resistance to the occupation and siege they impose. This action also terrifi es those who are not directly hit, and wounds the soul, mind, and resilience of the young generation. Our condemnation and disgust are further compounded by the denial and prohibition for Gaza to receive external help and supplies to alleviate the dire circumstances. The blockade on Gaza has tightened further since last year and this has worsened the toll on Gaza’s population. In Gaza, people suff er from hunger, thirst, pollution, shortage of medicines, electricity, and any means to get an income, not only by being bombed and shelled. Power crisis, gasoline shortage, water and food scarcity, sewage outflow and ever decreasing resources are disasters caused directly and indirectly by the siege. People in Gaza are resisting this aggression because they want a better and normal life and, even while crying in sorrow, pain, and terror, they reject a temporary truce that does not provide a real chance for a better future. A voice under the attacks in Gaza is that of Um Al Ramlawi who speaks for all in Gaza: “They are killing us all anyway— either a slow death by the siege, or a fast one by military attacks. We have nothing left to lose—we must fi ght for our rights, or die trying.” Gaza has been blockaded by sea and land since 2006. Any individual of Gaza, including fi shermen venturing beyond 3 nautical miles of the coast of Gaza, face being shot by the Israeli Navy. No one from Gaza can leave from the only two checkpoints, Erez or Rafah, without special permission from the Israelis and the Egyptians, which is hard to come by for many, if not impossible. People in Gaza are unable to go abroad to study, work, visit families, or do business. Wounded and sick people cannot leave easily to get specialised treatment outside Gaza. Entries of food and medicines into Gaza have been restricted and many essential items for survival are prohibited. Before the present assault, medical stock items in Gaza were already at an all time low because of the blockade. They have run out now. Likewise, Gaza is unable to export its produce. Agriculture has been severely impaired by the imposition of a buff er zone, and agricultural products cannot be exported due to the blockade. 80% of Gaza’s population is dependent on food rations from the UN. Much of Gaza’s buildings and infrastructure had been destroyed during Operation Cast Lead, 2008–09, and building materials have been blockaded so that schools, homes, and institutions cannot be properly rebuilt. Factories destroyed by bombardment have rarely been rebuilt adding unemployment to destitution. Despite the difficult conditions, the people of Gaza and their political leaders have recently moved to resolve their confl icts “without arms and harm” through the process of reconciliation between factions, their leadership renouncing titles and positions, so that a unity government can be formed abolishing the divisive factional politics operating since 2007. This reconciliation, although accepted by many in the international community, was rejected by Israel. The present Israeli attacks stop this chance of political unity between Gaza and the West Bank and single out a part of the Palestinian society by destroying the lives of people of Gaza. Under the pretext of eliminating terrorism, Israel is trying to destroy the growing Palestinian unity. Among other lies, it is stated that civilians in Gaza are hostages of Hamas whereas the truth is that the Gaza Strip is sealed by the Israelis and Egyptians. Gaza has been bombed continuously for the past 14 days followed now by invasion on land by tanks and thousands of Israeli troops. More than 60 000 civilians from Northern Gaza were ordered to leave their homes. These internally displaced people have nowhere to go since Central and Southern Gaza are also subjected to heavy artillery bombardment. The whole of Gaza is under attack. The only shelters in Gaza are the schools of the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), uncertain shelters already targeted during Cast Lead, killing many. According to Gaza Ministry of Health and UN Office for the Coordination of Humanitarian Affairs (OCHA), as of July 21, 149 of the 558 killed in Gaza and 1100 of the 3504 wounded are children. Those buried under the rubble are not counted yet. As we write, the BBC reports of the bombing of another hospital, hitting Published Online July 22, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61044-8

Proposals for massive expansion of psychological therapies would be counterproductive across society.

In 2007 the UK Government announced a substantial expansion of funding for psychological therapies in England to provide better support for people with conditions such as anxiety and depression. Will these services result in the medicalisation of normal distress? Or are they simply an evidenced-based solution for a previously unmet need? In this debate Derek Summerfield and David Veale discuss the issues raised by these controversial proposals.

“Global mental health” is an oxymoron and medical imperialism

Why do we assume that Western notions of psychiatry translate to other settings, asks Derek Summerfield