On the Central Role of Advocacy in the Traumatic Stress Field
October 1, 1997
Editor's Note: With this issue, StressPoints begins a new regular column, "Commentary," which will feature contributions from members of ISTSS on issues relevant to the mission of the Society, particularly matters being newly explored, including those which are controversial. Contributions are invited on any topic likely to be of interest to most members; also welcome are responses to previous columns, including the one from the Editor which follows.
Consider if you will the situation in the United States in the early 1970s: PTSD from rape was unrecognized. Rape victims appearing in an emergency room had a physical exam, perhaps some counseling about venereal disease, and were sent home. About 900,000 people returned to the United States from the Vietnam War with PTSD; few received any diagnosis or treatment. Most who came for treatment at public and private venues were misdiagnosed with another psychiatric disorder. Research into the trauma disorders was largely non-existent.
I was part of an investigative panel convened in Department of Veteran Affairs (VA) headquarters in 1982, triggered by the discovery that, although VA was following Congressional direction by mounting bold new programs for the treatment of PTSD, VA's own Merit Review Board was disapproving funding for most research proposals on PTSD. A review of the reviews that denied PTSD research proposals revealed that they were characterized by unscientific and hostile attitudes toward trauma research and the concept of PTSD. Ventilation of these reviews led to changes in the makeup of the Merit Review Board, and for the first time, substantial VA funding for PTSD research.
Most readers are familiar with the remarkable emergence of recognition and treatment for trauma patients during the past 17 years, including survivors of the full range of traumatic events -- war, sexual abuse, assault, disasters, torture, etc. What is too easily forgotten is that these developments followed years of advocacy by public officials, mental health professionals, patients and others. More recently, the historically cyclical nature of recognition and forgetting of trauma effects over the past 150 years has been further clarified (1,2), demonstrating that "the systematic study of psychological trauma depends on the support of a political movement." (1). Or, to put it another way: There is no trauma field without advocacy.
Advocacy in our field can take many forms, including:
- Preparation of amicus curiae briefs in legal cases, which function to educate both sides and the court itself;
- Writing informational or educational papers or pamphlets for public audiences, going beyond standard clinical and research publications;
- Formulating model curricula for teaching in professional schools.
- Preparation of practice guidelines;
- Advocating research funding;
- Facilitating sophisticated coverage of traumatic stress topics in the media via collaboration with journalists;
- Contributing to enlightenment about political and social issues related to trauma by serving on advisory or consulting committees; and
- Establishing standards for using the PTSD diagnosis in the forensic setting.
It is becoming apparent that in the future these activities will be increasingly necessary in order for treatment of and research into trauma disorders to continue. However, not all professionals need to engage in these activities beyond their clinical or research work: doing advocacy is not to the liking of everyone. What is important is for all who work in the field to vigorously support those who do carry out advocacy initiatives, the success of which is vital to all.
The importance of advocacy is increasing because of the likelihood that intense and international backlash phenomena will continue to emerge as counterreactions to worldwide revolutionary changes in understanding, treatment and research concerning trauma. Following the recent exaggerated attacks on childhood abuse victims and their therapists, other backlash manifestations will appear. These may take the form, for example, of attempts to defund PTSD research and treatment services, and other features of irrational denial such as undermining the diagnostic constructs of PTSD and dissociative disorders. We may see tendencies even within the mental health disciplines to diminish our new understanding of the critical role of events in the etiology of PTSD.
The central role of advocacy is further clarified by understanding the sources of irrational denial of trauma and its effects. These include: organizations that stand to lose financially by paying compensation or damages, and perpetrators of assault or abuse and others who want to protect them from exposure or criminal penalties. Irrational denial also stems from ordinary human aversive responses (fear, shame, horror, etc.) to painful realities such as the Holocaust, war and disasters. Denial is also seen in health-care professionals who have been mistakenly dismissive of trauma disorder in the past and who do not have the intellectual humility to acknowledge even to themselves that they have been mistaken.
Last, but not least, mental health clinicians and researchers who work in the trauma field may experience compassion fatigue, which, either because it is not effectively managed or because it is unconscious, leads them to repudiate trauma survivors by returning to a stance of blaming the victim. All clinicians and researchers in the trauma field are potentially subject to vicarious traumatization and compassion fatigue, which may cloud objective thinking about patients or research. (3,4) However, if we understand the universality of compassion fatigue, and that its effects may naturally appear in any of us, we are positioned to avoid its impact on our work. Therapists have much to contribute to this effort, because by training and experience they may be able to achieve a degree of objectivity about irrational beliefs and reactions, not only in patients, but in themselves.
The study of irrational denial and backlash phenomena, both in clinical situations and in formal research, is itself a requirement for the traumatic stress field, if we are to overcome the cycle of history that has tended to bury the field repeatedly in the past.
Seen in relation to the universality of irrational denial and compassion fatigue, advocacy thus becomes something we do not only without (to the professions and the public at large) but also within, that is, within the traumatic stress field and within each of ourselves individually.
1. Herman J: Trauma and Recovery, New York: Basic Books, 1992.
2. Solomon Z: Oscillating between denial and recognition of PTSD: Why are lessons learned and forgotten? J. Traumatic Stress 8: 271282 (1995).
3. MCann IL and Pearlman L: Vicarious traumatization: A framework for understanding the psychobiological effects of working with victims. J. Traumatic Stress 3: 131150 (1990).
4. Munroe J, Shay J, Fisher L et al. "Preventing Compassion Fatigue: A Team Treatment Model," In Figley C, Ed., Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized, New York: Brunner/Mazel, 1995, pp. 209231. *