Fassin and Rechtman’s Empire of trauma

The empire of trauma:
An inquiry into the condition of victimhood.

Didier Fassin and Richard Rechtman
Translated by Rachel Gomme
Princeton University Press, 2009
304 pages; $24.95, paperback

Reviewed by Hanna Kienzler (McGill University)

“Trauma has become a major signifier of our age” (xi) and we talk about traumatic events such as rape, genocide, torture, slavery, terrorist attacks, and natural disaster in the same way: “one signifier for a plurality of ills signified” (xi). Didier Fassin and Richard Rechtman, two of France’s leading anthropologists and psychiatrists take on the challenge to better understand and analyze the taken-for-granted aspects of trauma and victimhood by focusing on paradigm shifts in their respective historical and political contexts from the 19th century until the present day. Their objective to “denaturalize” trauma and “repoliticize” victims is based on fieldwork conducted among French organizations providing psychiatric aid in Toulouse, in the Palestinian territories and among French organizations defending asylum seekers. Topics that receive special attention are traumatic neurosis after World War I, the reception of the DSM and the suspicion towards PTSD, the work of the French medical and psychological emergency units, the exportation of psychiatry by French doctors into war-torn areas, and the resistance of NGOs to the exploitation of psychological certificates for refugees. Their study was carried out between 2000 and 2005 by consulting medical archives and assessing the available literature, interviewing individuals working for different organizations, and participant observation in institutions concerned with the provision of (humanitarian) psychiatric aid in various contexts. Although focusing on the French context, the authors are certain that their discussion reveals changes that extend beyond French frontiers and consider their inquiry as part of a “political and moral anthropology of contemporary societies” (xii).

The introduction, “A new language of the event”, refers to psychiatric aid and epidemiological surveys carried out in the aftermath of September 11. All institutions and individuals involved seemed to share a certainty suggesting that survivors, witnesses, television viewers, and residents of the United States in general suffered from the exposure to a traumatic event. Similar views were shared by psychologists and psychiatrists who were among the first to arrive at the scene after the plane crash at Sharm el Sheikh on December 3, 2004, upon the return of survivors of the South Asian tsunami on December 26, 2004, and during wars and natural disasters in other countries in order to provide debriefing and emergency preventive counseling to survivors and their families. However, only 25 years earlier, trauma, its consequence, and forms of intervention were not nearly so clear-cut; victims were perceived as illegitimate and the reality of trauma itself as a condition was widely doubted.

It is this shift from suspicion to the value of proof that interests the authors most. They employ a constructivist perspective exploring “the ways in which trauma is produced through mobilizations of mental health professionals and defenders of victims’ rights, and more broadly by a restructuring of the cognitive and moral foundations of our societies that define our relationship to misfortune, memory, and subjectivity” (6-7). Fassin and Rechtman reject both a naturalization of the concept of trauma as well as a relativism that raises doubts by asking whether trauma exists at all. Instead, they aim at understanding how our current “moral economy” has been rewritten throughout time and ways in which contemporary societies problematize the meaning of their moral responsibility in relation to distressing events.

Part One, “The reversing of the truth”, deals with controversies surrounding the concepts of trauma and PTSD, the origins of trauma, and its conceptual developments until World War I. Current controversies in psychiatry concerning the universalist perspective on trauma are exemplified by the protest in response to Derek Summerfield’s article “The invention of posttraumatic stress disorder and the social usefulness of a psychiatric category” published in 2001. Summerfield argued that PTSD is an example of how society and politics have helped to create rather than discover a mental illness. Not only psychiatrists but also patients responded fiercely to this argument. According to the victim’s point of view, Summerfield had overstepped a boundary by speaking for them and by questioning a psychiatric category that had helped them to defend their rights. According to Fassin and Rechtman, these debates reveal a paradigm shift in the relation between victim groups and medical experts: “this hitherto unthinkable marriage of convenience between social movements and mental health professionals came about not through giving clinicians the task of speaking for the victims, but on the contrary by giving the words of the victims themselves a form of clinical authority based on moral premises” (28).

In relation to this, Fassin and Rechtman argue that to better understand trauma, one has to consider its social—as well as its intellectual—history. In the subchapter, “The birth of trauma”, the authors outline the complex historical developments surrounding the concept of trauma in a clear and structured manner: John Erichsen identified it during the 1860s when he examined victims of railway accidents. He accredited the syndrome to loosely defined neurological mechanisms and called it “railway spine syndrome”. A few years later, Jean-Martin Charcot proposed the earliest psychological account of the syndrome arguing that patients suffering from railway accidents were most likely to suffer from hysteria. Janet and Freud introduced a psychic etiology into theories of trauma. Since the memories are painful and unmanageable, the conscious personality suppresses them from awareness by storing it in the subconscious (Janet) or unconscious (Freud). From a psychoanalytic perspective it is, thus, perceive that the traumatic “is already present even before an event causes it to manifest itself” (33). Despite their differences, Freud and Janet shared the understanding that the traumatic event was not the key feature to the development of trauma neurosis.

At the same time, trauma and trauma neuroses were not only discussed in the academic circles, but also in the “insurance industry” (35). Railroad accidents in particular, and later accidents at the workplace, called for financial compensation. According to Fassin and Rechtman, these developments were the first in which society became actively involved in the discussions and developments of trauma. Yet, these discussions were not necessarily benevolent. For example, physician Edouard Brissaud introduced the term “sinistrosis” which he considered a workers’ disease characterised by patients’ refusal to return to work until they received financial compensation. Similar suspicions arose in military psychiatry during World War I, during which hunting for malingerers became the central goal of medical screening. “Trauma insanity” was considered to run counter to the glorified heroic ideal of soldiers propagated by the military authorities. Psychiatrists adopted this patriotic ideal by adapting their trauma theories accordingly. Common psychiatric practice included electrotherapy, psychological coercion, and persuasion. Unlike other academics, Fassin and Didier do not establish a direct link between the brutalization of therapy and psychiatric practice of the early twentieth century. Instead, the dominant paradigm of war neurosis was that of forensic medicine which fostered the suspicion that soldiers’ main goal was financial compensation.

Although psychoanalysis did not have a direct impact on military psychiatry, it, nevertheless, changed the way in which trauma was viewed by scientists and the general public. Scholars drawing on Freud’s theory were among the first to criticize the therapeutic brutality and to propose psychoanalytic methods instead. Psychoanalysts believed that trauma was the individual reaction of non-ordinary men confronted with fundamental ethical choices which they were unable to take on. Self-confession became the key concept of traumatic narrative and psychiatrists were to help individuals admit why they had been traumatised and why they were different from others. Nevertheless, theories concerned with malingering and compensation did not die out. In order to discern potential trouble-makers during World War II, the British military involved psychiatrists to partake in the recruitment of soldiers. In America, on the other hand, psychologically damaged men were intolerable as they placed into question the heroic ideal of the freedom fighter. As a consequence, the legal and governmental recognition of their suffering was problematic. At the same time, however, American psychoanalysts were increasingly confronted with survivors of Nazi concentration camps. In this case, psychoanalysis as well as the stigmas attached to war neurosis were clearly inadequate answers to problems suffered by survivors.

A new paradigm was called for. Psychiatrists like Bruno Bettelheim, Robert Lifton and Mardi Horowitz all worked on a new clinical entity called “survivor syndrome” (72). It entailed that the traumatic experience was turned into a “testament to the unspeakable” (72). Questions shifted from “who were these men who presented with psychological disorders” to “how had they managed to survive the impossible?” (73) Also during this time, the term “survivor guilt” was coined. In Bettelheim’s early work, he explained that survival was often only possible at the cost of neglecting others which leads to feelings of guilt in the survivors and, thus, psychological problems. Fassin and Rechtman summarize that “it was now the victims who directed suspicion at themselves and gave expression to it in their accounts of their experience” (75). These accounts served not only as confessions but also as witness reports written in memory of those who fell prey to mass killings, torture and starvation in concentration camps.

This important historical shift in the perception of trauma led to the universalisation of victim status, allowing other groups to begin recounting violence they had experienced and their consequent distress. In the 1960s, for example, feminists campaigned against child abuse demanding “incest survivor” compensation. Many argued that symptoms of such abuse may appear only twenty to thirty years later in form of nightmares, anxiety, and panic in the presence of men. While radiologists were the first to generate clinical evidence of abuse (in the form of X-rays of unexplained fractures), the proof that many were so urgently searching came from a branch in psychiatry working to establish a more scientific basis for psychiatric practice.

During the 1970s, the American Psychiatric Association revised its classification of mental disorders with the goal of providing it with an atheoretical basis and a descriptive approach. In the document which resulted—the DSM-III, published in 1980s—the condition previously known as “traumatic neurosis” was changed into a concept free of the stigma of suspicion: posttraumatic stress disorder (PTSD). Fassin and Didier note that “the clinical signs of PTSD remained those of classic traumatic neurosis, but the status of the traumatic event had fundamentally altered, becoming the necessary and sufficient etiological agent” (86). In addition to many feminists, this radical shift was embraced by Vietnam veterans who sought to receive financial reparation toward the end of the war. Since the media had revealed the massacre committed in May Lai by a US company, a central question for the public and professional psychiatrists had become: What led normal men to commit such bloodthirsty crimes? According to Lifton, it was the war and the nature of combat that led men to commit crimes that they never intended to commit. Once again, psychiatrists agreed that “these were ordinary men placed in an extraordinary situation” (90). Through a transformation of the concept of survivor guilt, the men were conceptualised as victims, “broken by what they had witnessed and by what they had done” (91).

Part Two, “The Politics of Reparation”, deals with issues related to psychiatric victimology and illustrates the developments of psychiatric guidelines, the emergence of psychiatric units, compensation, and paradigm shifts taking place over the past fifteen years. On September 11, 2001, Fassin and Rechtman had a meeting scheduled at the office of the Haut Fonctionnaire de Defense (HFD) heading the National Committee for Medical and Psychological Emergencies (CNUMP). Before the interview was started, a shock wave ran through the building and streets as people crowded around radio and TV sets in order to take in the attack of the World Trade Center in New York. Within one hour the civil defence system was activated and the HFD began receiving calls by psychological emergency units ready to “deal with the psychological consequences of an attack” (103). However, besides a few minor anxiety episodes, no intervention was called for. In the US, on the other hand, a large number of psychiatric health personnel was mobilised and alerted the population of the risk of exponential growth in PTSD in the months to come.

According to Fassin and Rechtman, developments surrounding the concept of trauma reflected a tension between clinical approaches to PTSD and social uses of trauma. Similarly in France, such tensions had arisen in the 1990s between psychiatric victimology and medical and psychological emergency units. In 1995, the discipline of psychiatric victimiology came into being and medical and psychological units (CUMP) were set up as a response to the terrorist attacks. Besides the establishment of a response system to violent events, the developments were a turning point in the history of the victims’ rights movement in France. The authors describe the victims’ rights movement from the 1980s to the present-day, referring to notions of stigmatization, suspicion, political activism, set-up of victims’ offices, first epidemiological studies, and influence on the DSM. In the aftermath of the attacks in the mid 1990s, victims’ organisations campaigned using the notion of psychic trauma. Yet, their attempts were hindered by official psychiatry.

In the 1990s, new initiatives in victimology appeared such as the establishment of the Psychotraumatology Clinic at the Saint Antoine Hospital and the Institute for Victimology, the first university degree programs in victimology at the medical faculty at Necker University Hospital in Paris, and campaigns for the acceptance of PTSD. However, “[i]n France even more than in the United States, the dynamic in operation derived much more from the social sphere than from the professional field. It was victims who justified victimology, not the reverse” (126). The authors illustrate these historical developments by referring to the explosion of the AZF chemical factory in Toulouse ten days after the terrorist attacks on the World Trade Center in New York. Following reports and media campaigns launched in the US, the French media adapted the jargon of trauma. Before any assessment had been made, psychological help centers were set up, volunteers were employed, and new victim groups established. Fassin and Rechtman noted that psychiatric personnel outnumbered the victims at times, that there was no consensus regarding support methods, that volunteers largely lacked the necessary skills to provide treatment, and that debriefing was applied as an early intervention despite its iatrogenic risks. The media was quick to catch on to such weaknesses in the intervention field, challenging psychiatrists and authorities. At the same time, mental health professionals began to question one another’s treatment strategies. Such divisions occurred not only in the professional field but also among victims who began to differentiate between direct and indirect victims and engaged in finding factors of defining the “most exposed”, “the most vulnerable” individuals or “the most disadvantaged” social groups (143). To this, Fassin and Rechtman refer as “social map of trauma” that was based on geographical proximity to the explosion as well as social determinants such as economic background, professional status, and immigrant origin. Depending on the combination of determinants, victims benefited more or less from compensations.

Part III, “The politics of testimony”, covers topics related to psychological support services, the beginnings of humanitarianism and moral evaluations, and the need to testify. Wars in Armenia, Bosnia, Kosovo and Palestine serve as examples of such developments. In this context, the concept of humanitarian psychiatry came into being during the international conference on “Trauma: Care and Culture” organised by Medecins sans frontiers (MSF) in Paris in 2002. Topics discussed included psychiatric missions and psychological care programs while phrases such as “psychosocial approach”, “psychotherapeutic intervention”, and “assistance to people suffering from trauma” (158) dominated the discourse. The two most involved groups in the provision of humanitarian psychiatric aid in war torn areas were MSF and Medecins du monde (MDM). Compassionate action and empathy motivated by concerns about justice and human solidarity were the driving forces for their humanitarianism and psychiatric intervention. Fassin and Rechtman argue that “humanitarian psychiatry derives from the recognition of psychological suffering rather than from the identification of mental illness” that is, “it manifests as a stirring of empathy rather than a call for clinical evaluation” (177).

The politics of testimony is described by the authors in relation to the humanitarian crises in Gaza and the West Bank where humanitarian psychiatrists attempted to provide first aid to civilians. Working on the front lines, their missions were restricted and shifted from treating to bearing witness. Teams such as MSF and MDM replaced first-hand witnesses by speaking for them and making their suffering publicly known. Phrases such as “we need to be there” proclaimed to state one’s solidarity and establish one’s usefulness in a situation where chaos prevailed. Thus, humanitarian psychiatrists joined journalists, lawyers, politicians and religious leaders in the endeavour of bearing witness to psychological distress and denouncing human rights violations. In this context, emotions were valued over psychiatric precision, and the power of demonstration over accurate diagnosis: “As a tool of a politics of humanitarian testimony, trauma contributes to constructing new forms of political subjectification and new relations with the contemporary world” (216).

Part IV, “The politics of proof”, deals, on the other hand, with the clinical practices of asylum, torture and the notion of evidence on the body, activist doctors, and the politics of writing certificates for torture victims. In France several organisations which provide psychiatric and psychological aid to immigrants have debated the increasing demands for clinical psychological certificates proving the authenticity of torture experienced by individuals seeking political asylum in France. While such certificates had been used in previous years to attest to physical marks on the body, doctors now aimed to document psychic wounds. In response to this, the Association pour les vicitmes de la repression en exil was formed in the 1980s responding to the idea that “victims of torture are not patients like others and require a very special kind of care” (233) and the well known Primo Levi Center was one of the first to specialise on trauma, offering psychotherapy to victims of torture and political violence. In addition to providing psychiatric treatment, the center defended the rights of asylum seekers and started to raise awareness of the suffering of individuals “psychically traumatised by torture” (235). Thus, clinical practice became a central agent in the support of asylum seekers. In this strained context, a new field emerged in France called psychotraumatology of exile. The discipline is based on the acknowledgment of the unique nature of the experience of persecution and the need to provide special treatment for trauma.

Since asylum seeking is largely a political and juridical process, proof was required that the individual was in fact tortured. According to the authors, the need for certificates and bodily proofs is related to a new kind of suspicion of Western societies toward asylum seekers from non-Western countries: “Contrary to what is popularly assumed, it is clear that reasons of state and the even more narrow reasons of perceived national interest are at the core of the contemporary system for protection of refugees” (255). In order to keep the large and unwanted number of refugees at bay, France raised the bar for approving testimonies. Narratives were questioned and bodies inspected to provide answers to questions related to their credibility. Yet, physical scars turned out to have little to say: they vanish quickly, might have been self-inflicted or might not have resulted from torture. As a result, health professionals have to write convincing reports emphasizing psychic scars imputable to the violence experienced. Such reports are written according to certain schemas which leave no room for the victims’ narratives. Thus, reports do more than provide evidence to French government officials and judges, they “speak the words the individual cannot utter” (273).

Fassin and Rechtman conclude that the truth of trauma lies not so much in the psyche, mind or brain, but “in the moral economy of contemporary societies” (276). Processes involved in shaping our understanding of ‘trauma’ include our chaning relationship to time and memory, to mourning and obligations, to misfortune and the misfortunate. That is, “the validity people are willing to accord to trauma in order to relate the experience of descendants of survivors of the Holocaust, of Armenian or Rwandan genocide, of victims of slavery or apartheid, is not the validity of a clinical category but rather of a judgement – the judgment of history” (284). The Empire of Trauma speaks to a wide range of disciplines including anthropology, psychiatry and psychology, history, and social work. Besides deconstructing taken-for-granted concepts like trauma, PTSD, torture and psychiatric responses to suffering, the authors question intellectual links which have been established between historical events, social processes and psychiatric achievements over time. Yet, this book is not solely about deconstruction. Unlike other intellectual projects, especially those of relativistic psychiatry that deconstruct without offering practical or theoretical alternatives, the authors seek to rewrite and reconstruct the history of trauma and its related contexts in a critical but respectful, highly sensitive, and meticulous manner. This new history points at historical connections as well as ruptures, parallel developments, and radical shifts. The book is an important milestone in the research of trauma, trauma related disorders, approaches to treatment, and connected social, political, and economic paradigm shifts.

Hanna Kienzler is a doctoral candidate in the Department of Anthropology at McGill University. She conducted her Ph.D field research (May 2007 – June 2008) in two Kosovar villages that were hit especially hard during the war in 1998/99. Her research questions focused on issues related to how Kosovar Albanian women deal with trauma, trauma related disorders, resilience, treatment, and local forms of healing.

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