When speaking of a diagnostic category, such as post-traumatic stress disorder (PTSD), it is imperative to clarify the thing itself we are attempting to diagnose. We need to do so in order to make a judgment about whether we can in fact precise PTSD in such a way that our interventions produce real change. Clearly, I am addressing two issues concurrently, one theoretical and the other clinical, given that the two sustain each other and are simultaneously knotted by ideology. What I mean is that the very words we use to describe PTSD will necessarily condition the way we think about the human experiences of remembering, avoidance, arousal, and alienation such that we diagnose such experiences as “disordered.” If we are to arrive at an adequate understanding of how to best help the suffering subject, this knowledge must derive from the clinic, be refined by theory, and pass through the enveloping function of ideology in order to affect real change. I am proposing that real change for those suffering from the human experience of PTSD is not found in direct engagement with the symptom, due to the fact that the symptom is deceptive, but with the underlying psychological structure that produces the symptom. Nevertheless, we must follow the symptom’s lead into the structure by listening to where it goes awry. “The symptom is deceptive,” you may ask, “The symptom goes awry?” Indeed. Let’s begin in the clinic to see how, such that we might follow it into the structure and help bring about true relief.
I once treated a middle-aged person who had a significant history of childhood physical and sexual abuse. Understandably, this influenced the manner in which interpersonal relationships were experienced and related to. In fact, this person had never had a romantic outing or consensual sexual experience. On the contrary, all sexual desire was vigorously rejected and any hint of its presence or potential emergence produced significant fear, anger and agitation as well as autonomic arousal. Sleep was often times difficult to come by and disturbing dreams occurred regularly. One day, this person arrived a few minutes late to their appointment and apologized profusely. With much curiosity I asked, “What’s the crime?” Rather perplexed, this person provided a straightforward answer about respecting my time. I went on to explain that the session (time) belonged to him/her and as such s/he could arrive at the time of his/her choosing. Suddenly, this person became fearful saying that s/he was confused. S/he seemed frozen and had a difficult time speaking. Regardless of my attempts to help clarify the situation, s/he remained afraid and baffled. As the session progressed it became clear that what s/he heard me say was that it did not matter (to me) whether s/he showed up at all, because s/he did not matter. In fact, s/he felt that s/he had been duped into trusting me and that I had finally shown my true colors.
Consider another person who began a session by indicating that what most others would “say was in the past, for me is always in the present.” S/he went on to describe the personal experience of the past being more present than the present and the future only existing insofar as the ever-present past extends into it. This person had experienced significant interpersonal affronts that included bullying, maltreatment, and neglect over many years and was now struggling with alcohol dependence along with concomitant depression. Moreover, distrust was rampant, as were agitation, sleeping difficulties, social isolation, and a host of accompanying physiological symptoms. During the course of treatment, this person developed a ringing in the ear that s/he attributed to the tapering of psychotropic medication. Enraged, s/he accused me of willfully harming him/her by failing to predict the medication’s effect on his/her body — I should note that I am not a psychiatrist and therefore not licensed to prescribe any medication. Despite this fact, s/he remained fixed on the fact that I had recommended the psychiatrist, knew the medication s/he was prescribed, and that s/he was now being tapered off of the medication. In the end, s/he felt that s/he had no other choice than to defend the self from me by reacting violently against me in my office.
These brief vignettes present us with many symptoms and despite their differences it is plausible to group them via their commonalities. In the aforementioned cases, the commonality would be real life traumatic experiences that appear to disorganize the subject whenever they reappear in symbolic form. According to the American Psychiatric Association’s latest revision of Diagnostic and Statistical Manual (DSM-5), it would be quite reasonable for both of these subjects’ suffering to be captured by a primary diagnosis of PTSD. Moreover, such a diagnosis might very well inform the clinician’s primary approach to treatment. Techniques such as prolonged exposure therapy, cognitive-processing therapy, stress-inoculation training, and/ or EMDR (eye-movement desensitization and reprocessing) may be employed, and understandably so. After all, such treatments have been designed to reduce the subject’s emotional and physiological arousal through controlled re-exposure to the traumatic event(s). But there is some-thing more, some-thing extra in both of these cases that in my judgment cannot be resolved through such exposure. This more is the pure expression of the undergirding psychological structure that eludes diagnosis. In fact, it can only be noted precisely at the moment that it goes awry; at the moment where it diverges from the stereotypic clustering of symptoms.
In the first example, this surplus is experienced in the form of a verbal hallucination. By this I do not mean that the subject had an auditory hallucination of my voice stating that I did not care about whether or not they were present. Nevertheless, they did have the subjective experience of hearing me say something that I did not in fact say. This is also different from so-called flashback phenomena in that there was no disturbance in consciousness. In other words, the subject did not have the sensation that something foreign has invaded his/her current awareness. In this case, the subject heard me say something I clearly did not. Can we categorize this phenomenon as a sequelae of PTSD or does it point us in a different direction? There is no evidence that such an experience is part and parcel of PTSD. Nor is there any evidence that it forms part of another co-morbid diagnostic entity.
In the second example, the surplus is experienced first and foremost in the invasion of the subject’s body, in the form of tinnitus, and secondarily in the conviction that this physical invasion occurred at my behest. Again, these subjective experiences do not conform neatly to our current understanding of PTSD. Once again, the possibility of some form of flashback may be raised, but the difference here is that here the subject “knows” something in his/her consciousness in a manner that does not occur in a flashback. Nevertheless, it would not be particularly surprising to hear clinicians refer to the emergence of any of these symptoms in the context of some form of re-exposure to symbolic traumatic content. This approach, however, would be a mis-recognition of the fundamental set of elements that predetermines the symptom.
I provide these two examples as a way of elucidating how a diagnostic category such as PTSD can veil differing psychological structures. In the examples provided above, a structure called “neurotic” (first example) and a structure called “psychotic” (second example) determine symptom formation and their reification in a construct such as PTSD eludes the possibility of true change. Without getting into the details of how these specific structures are readily recognized, suffice it to say that the former is defined by one’s forced submission to will of the Other, while latter materializes the Other where there is none. Let’s elaborate these enough to where they are more than abstract and confusing concepts.
When my patient hears me say that I do not care about whether or not s/he attends the session, the phenomenon is a result of a pre-existing psychic structure that positions me as the Other that bestows value upon him/her. Indeed, a psychic structure in which s/he feels subjected to my will. This is elucidated when s/he hears his/her own message in my supposed reply. For it is only in his/her saying, “You are the one that assigns value to me,” that s/he can hear me say, “You don’t matter.” This is the surplus that cannot be treated through direct engagement with the symptom. In the case of the subject who was certain that I had caused the tinnitus, s/he created an Other where there was none. In other words, given that there was no universe of coherent concepts to whom s/he could direct his/her question- “Why am I suffering?”- s/he had to create one. In this case, I became this universe that contained these cohesive concepts and which therefore ordered the subject’s world. Therefore, if s/he was suffering it was clearly because I had ordained it! In this case, this is the extra that escapes detection and treatment in the symptom. Therefore, if true change is going to occur in both of these subjects, it is not going to be solely through conventional or even so-called best practices, such as those mentioned above.
Why? For the following reason: If the subject agrees with the diagnosis that their affective and physiological symptoms are in response to a symbolic triggering of a traumatic past event, we might very well help reduce some of their overwhelm due to their cooperation. There is no doubt that our presence, tact, manner, and psychological interventions as clinicians do help. However, the unintended result is a strengthening of the (symbolic) Other who commands submission to their will. Therefore, while they might “learn” to “manage” post-traumatic symptoms in similar situations all they have truly learned is that will of the Other is absolute and that survival requires acquiescence to it. In those with psychological structures called neurotic, such an occurrence will lead to greater feelings of alienation from the self’s desires, whereas for those with a structure called psychotic, such occurrences will only produce greater alienation from the world and those in it.
My aim in providing these examples is to nuance our approach to diagnosis and treatment. In particular, to pay attention to the underlying psychological structures for each subject. Far from exhausting the possibilities of the presenting symptom(s), and even further from suggesting what the correct mode of treatment should be, I believe we could effect real change by looking beyond the symptom. Obviously, I am not the first to suggest this (see Sigmund Freud and Jacques Lacan), and my approach to the topic derives from Lacan in particular. What I am suggesting is that there is more than meets the symptom.