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“First Do No Harm:” Emerging Guidelines for the Treatment of Posttraumatic Reactions

Despite its many problems, publication of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980) set the fields of psychiatry and clinical psychology on a solid empirical footing and fostered great advances in epidemiology and in the evaluation of various theories and therapies. But this progress came at a cost, which is perhaps most clearly illustrated by the concept of Posttraumatic Stress Disorder (PTSD). The DSM-III heralded a new positivistic paradigm with imbedded unexamined assumptions that neglected important issues, which then progressively faded from memory. Two decades later, these issues have now resurfaced in therapeutic controversies surrounding PTSD. PTSD is concerned with a ubiquitous human condition, reaction to adversity. Humans have long tried to cope with adversity, using a multitude of strategies. Modern therapies for PTSD date back to the middle of the nineteenth century with the increased involvement of physicians. A historical perspective on these early therapies will shed light on the nature of current controversies and put contemporary therapies for PTSD in context. In this chapter, we present an overview of this history while also highlighting important findings in the recent scientific literature on posttraumatic reactions. By synthesizing key findings from both the historical and recent scientific literatures, we derive four emergent lessons that we believe may prove fruitful in directing future intervention efforts. Our central thesis is that the history of adversity-linked emotional disorders has been shaped by the history of medical beliefs about these phenomena. An interaction occurs between professional and patient, who translate their common understandings into physical and mental complaints (Shorter, 1992, 1994). The present positivistic paradigm of mental disorders (the belief that suffering has an objective physical basis independent of the assumptions of the observing healer) neglects the influence of this healer‐patient dynamic in raising or lowering expectancy of recovery. The hope is that this chapter will restore an appreciation of the therapeutic and iatrogenic influences of the healer.