Posttraumatic Stress Disorder: Malady or Myth?

Some of the Marines who survived the battle of Iwo Jima never got the smell of death out of their memory. Few of these men, however, would ever consider themselves to be victims or in need of any specialized postcombat debriefing beyond what happened on the troop ships that steamed away from that island. At the outset of this book, the author notes how much has changed in our culture: “Today we expect that survivors of major terrorist attacks will be offered counseling.” The presence of mental health officers among Coalition troops deployed in Iraq underscores the change in our cultural perception about what constitutes good posttrauma professional practice.

This volume is well organized, is clearly written, and uses the current research about trauma’s impact on memory. Beginning with an overview of the clinical and cultural aspects of the disorder, Brewin moves to detailed discussions of trauma’s impact on identity, the puzzling ways in which trauma is remembered, and the debates around the false memory syndrome. He outlines the dual task for both survivor and therapist: addressing the posttrauma intrusive memories and reformulating the posttrauma identity. In a chapter titled “A Crisis of Identity,” Brewin details the variety of ways major trauma affects the self-identity of trauma survivors. Typically, survivors reinvest themselves in family, help other survivors, or demonstrate “an increased involvement with religious and spiritual issues.”

The author’s distinction between declarative and nondeclarative forms of memory provides us with a helpful way to understand how trauma continues to affect a patient’s life. Drawing on neuroscience research regarding the way memory functions, he observes how trauma’s capacity to overturn long-held assumptions is reminiscent of catastrophic interference overwhelming an established information system in ways that prevent the system from integrating the new lessons of the trauma with the older and more established patterns of declarative memory. The brain’s way of storing and making this new trauma-induced information available to the patient is by storing the information in nondeclarative memory, where it is “automatically elicited in a rather inflexible way under conditions that bear a strong similarity to the condition of the original learning.”

Finally, Brewin presents a three-step schema around which responses to survivors of large-scale trauma may be implemented. Immediate posttrauma intervention should be limited to “demonstrating safety, acknowledging the trauma, making support available to those who want it and providing information with a focus on supporting natural recovery.” The next 4–6 weeks should be spent “systematically monitoring” trauma victims “so that one can detect any failure of victims to adapt.” Finally, he urges that those victims who have “failed to adapt” receive “scientifically established interventions” that will help them recover.

Brewin asks clinicians and researchers to show “the same flexibility and resourcefulness shown by survivors” as we provide comfort and counsel to people “suddenly confronted with the unexpected, the unwanted and the unimaginable.”