On completing my psychiatric training, I had two clear priorities: to work at a major university and to become a psychoanalyst. Opportunity knocked in the form of an appointment at Duke University and a position at the Durham North Carolina VA Medical Center. My plan was to backstop my income for a few years with a reliable Veterans Administration salary, complete my training at the UNC/Duke Psychoanalytic Education Program, and then move on to university life centered on the practice and teaching of psychoanalysis. Little did I realize that, 20 years later, I would still be at the VA and that I would be weaving psychoanalytic ideas into national VA and military programs designed to meet the mental health needs of combatants in a global war on terrorism.
The history of psychoanalysis and of psychiatry is inextricably bound up in the history of 20th century warfare. Freud, who first defined psychoanalysis in terms of psychological trauma, had to revise his theory of dreams because of the combat nightmares of World War I veterans: He simply could not find a way to interpret these horrific, repetitive dreams as wish fulfillments. His concepts of repetition compulsion and the death instinct both derived from practical experience with the psychological effects of war. His colleagues Ferenczi, Abraham, Simmel, Jones, and Kardiner made important contributions to theory and practice during WWI.
Freud's own 1920 Memorandum on the Electrical Treatment of War Neurotics, prepared for the Austrian Commission for Enquiry into Violations of Military Duty, helped pave the way for new psychological treatments in military settings around the world. As Freud put it in his 1919 introduction to Psycho-Analysis and the War Neuroses, “Medical men who had hitherto held back from any approach to psychoanalytic theories were brought into closer contact with them when, in the course of their duties as army doctors, they were obliged to deal with war neuroses.”
The history of psychoanalysis and of psychiatry is inextricably bound up in the history of 20th century warfare.
A generation of young American psychoanalysts, including Grinker, Spiegel, Lidz, Kolb, and Greenson, helped revolutionize military psychiatry during the Second World War. Their successful application of psychoanalytically informed treatments propelled psychoanalysis to the forefront of American psychiatry in the years following WWII. Henry Krystal, Robert Jay Lifton, and Chaim Shatan were among the many psychoanalysts who brought public attention to the concept of massive psychic trauma in the 1960s and '70s. Their perception, integrity, and courage have inspired me. Their work culminated in the inclusion of posttraumatic stress disorder (PTSD) in The Diagnostic and Statistical Manual of Mental Disorders (DSM) III in 1980. This paradigm has defined the language and the conceptual framework of military psychiatry for combatants around the world for the last 25 years. It has also found broad application in work with survivors of rape, domestic violence, sexual abuse, terrorism, and natural disasters. Psychological trauma is as central to psychiatry at the start of the 21st century as it was to psychoanalysis at the dawn of the 20th.
I have been part of a generation of mental health professionals that trained just after PTSD was defined and that has advocated for its recognition. As such, I have spent two decades talking with patients and their families about war and war dreams, about flashbacks and strained family ties, about avoidance of war reminders and dissociation of war memories. Clinical experience with veterans of WWII, Korea, Vietnam, and the first Gulf War have, in my experience, lined up closely with classic case descriptions and theoretical considerations spanning the entire history of psychoanalytic thought.
Research into the biological markers of PTSD and its psychopharmacological treatment (in which I have also played a role) have only deepened my respect for the importance that personal meaning plays in psychological traumatization and in the treatment of its effects, which, in addition to PTSD, frequently include major depression, substance abuse, family dysfunction, and social impairment. It was, in part, because of my balanced experience in biological and psychoanalytic approaches that I was asked to help lead a joint VA and Department of Defense Clinical Practice Guideline on PTSD. [See ]
As a VA psychiatrist trained in psychoanalysis, I believe that listening and trying to understand (operations fundamental to psychoanalysis) are as essential to good outcomes for veterans and their families as are the most effective biological interventions.
Harold Kudler, M.D., is coordinator for Mental Health Services for Veterans Integrated Service Network No. 6 and co-chair, VA undersecretary for Health's Special Committee on PTSD. He is also associate clinical professor of psychiatry and behavioral sciences at Duke University Medical Center and an affiliate member of the North Carolina Psychoanalytic Society.
During the 1990s, I had grown increasingly concerned that, although current practice provided a number of evidence-based treatments to the combat veteran and his/her family, it rarely allowed them an opportunity to be listened to or understood. During that “Decade of the Brain,” the dominant message was that PTSD was best understood as a form of neural injury. Talk ran high about shrinkage of the hippocampi and misfirings of the amygdala, but the personal meaning of horrific events and the possibility of recovery by working through that meaning were rarely considered. Fortunately, change is at hand.
Talk ran high about shrinkage of the hippocampi and misfirings of the amygdala, but the personal meaning of horrific events and the possibility of recovery by working through that meaning were rarely considered.
As Department of Defense and VA clinicians and planners attempt to provide effective mental health interventions for a new generation of combat veterans, they have found that a narrow conceptualization of combat readjustment within the DSM terms of PTSD does not meet the needs of these veterans or their families. The observed cluster of PTSD, major depression, and substance abuse among returning war fighters speaks against the presence of a single biological defect or character disorder as the lynchpin of traumatic stress. Mental health experts are finding it more helpful to conceptualize the problems of returning veterans in terms of an imbalance rather than “break” and of adaptation rather than pathology.
These perspectives open the door to new interventions at the levels of individual, unit, family, and community that complement rather than compete with biological conceptions and psychopharmacological interventions. These incorporate progressive outreach and engagement of new veterans and their families. This is a preventive model that goes above and beyond screening for one or more discrete diagnoses. It affords people the opportunity to talk about their experiences and to be heard and understood by professionals, peers, and family members. It refuses to pathologize or stigmatize responses to deployment that are so common that they can only be considered normal. It instead centers on individual, group, family, and social dynamics and is implemented thorough active listening and consistent facilitation of the veteran's and his/her family's own adaptive processes. In short, this new approach, dictated and driven by pressing necessity, is, in essence, a resurgence of a psychoanalytic approach to the trauma of war. This rapprochement between psychodynamic and biological perspectives carries with it the potential to reorient and revitalize the practice of psychiatry, military and civilian, for years to come.