Trauma: Culture, Meaning and Philosophy

Patrick Bracken

Whurr, £21, pp 230

ISBN 1 86156 280 2

Rating:

Pat Bracken, who has doctorates in both psychiatry and philosophy, has written a remarkable book. He describes how Western societies now frame the impact of violence and other types of suffering, and questions of responsibility and morality, through the sciences of memory and psychology. Orthodox psychiatry presents us as creatures whose nature lies in the ways our brains are wired and our memories stored. Bracken is critical of the cognitivist view of the brain as a processing machine, in which the meaningful nature of reality is seen as something arising from programmes or schemas running in individual minds. Therapy is directed at these supposedly disrupted schemata. He queries the assumption that psychiatric classification systems capture universal truths about distress and madness when they largely ignore the meaning the patient attaches to what he or she has passed through. This connects to critiques of the medicalisation of life published in the BMJ's recent theme issue (13 April 2002).

Psychiatry and psychology see a breakdown in the meaning of things as a scientific problem, but this is to ignore its anthropological, sociological, and philosophical dimensions. Bracken owes a debt to Ivan Illich, author of Limits to Medicine (reviewed BMJ2002;324:923), and the French philosopher Michel Foucault, but he points in particular to the German philosopher Heidegger for an antidote to the dominance of Cartesianism in the humanities. Heidegger saw the meaning of being in the world as residing not in cognitive schemata, but in a background intelligibility generated by engagement in everyday life. This certainly chimes with my experience of working with refugee survivors of torture and war. Even in psychiatric referrals, the “trauma” seemed largely to be something that had happened in their lived lives, not in the space between their ears.

Is the spectacular rise of “trauma,” both as psychiatric category and as cultural idiom, connected to the hopes and fears of modern life? We live in brittle, individualistic times, with social vitality dependent on ever widening patterns of consumption requiring identification of new needs and desires. At the same time there has been a withering of religious and other transcending meaning systems, and Bracken queries whether this has left us with a sense of vulnerability about our belief in a coherent and ordered world. Thus unpleasant experiences, which we now label “traumatic,” may be more likely to leave us shaken and doubting.

As befits a consultant psychiatrist who started an innovative home treatment mental health service in Bradford, and who has the ear of the Department of Health, Bracken has written a book about practice as well as theory. He and his colleagues practise what they call “postpsychiatry,” in which questions of social context, values, and the patient's own model of the illness are central. The emphasis is taken off diagnostic pigeonholing without refuting the tools of traditional psychiatry. Bracken also traces the export of Western psychiatric categories—not least post-traumatic stress disorder—and practices to non-Western settings, noting how this has promoted professional elitism and institutionalised responses to distress, as well as undermining indigenous healing systems. The Western medicotherapeutic view is culture-bounded and there are other interpretations of the world.