Abstract
Since its introduction into the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic category of post-traumatic stress disorder (PTSD) has dominated public and legal discourse about the harm of sexual violence against women. There is, however, disagreement among some clinical psychologists and philosophers over whether a PTSD diagnosis further harms the victim. Clinical psychologists claim that focusing on a PTSD diagnosis risks undermining a victim’s agency and subjectivity if therapists neglect the victim’s own voice and experiences. Philosophers who acknowledge PTSD in identifying the harm of sexual violence look to victims’ experience of PTSD symptoms rather than how it is used in clinical practice. They conclude that PTSD symptoms are compatible with agency and subjectivity insofar as they help illuminate what it is to be an agent and a subject. I argue that the latter are too optimistic and the former are too pessimistic. An examination of these conflicting views traces the disagreement to unacknowledged discipline-specific boundaries. I conclude with the very tentative suggestion that moral injury could bridge these boundaries.
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Notes
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Lamb (1999, 132–3), Marecek (1999, 180), Gavey (2003, 136–7), and Gavey (2009, 97). Gavey objects to the charge that Foucauldian social constructionism itself undermines agency. In basic terms, the objection is that if one cannot escape social constructions entirely, one will always be determined by some socially imposed meanings and practices. Gavey argues that this is “unnecessarily overdetermining” since it relies on a view of agency as a “pure asocial subject” (Gavey 2005, 89–90). I am not arguing that Gavey and the other psychologists I discuss here need to endorse an “asocial subject” to preserve PTSD, but only that their notion of agency is incompatible with a PTSD diagnosis.
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I have cited Marecek above, who envisions trauma therapy as excluding the victim any active role in her own healing. Consider Lamb, too, who compares PTSD and trauma syndromes to a teenager who lacks interest in school due to poverty or neglect. She points out that such a teenager’s boredom, acting out, irritability and so on could count as a syndrome “school dissociation disorder” (Lamb 1999, 112). Lamb submits that the reason it does not count as a syndrome, but PTSD does, is because PTSD applied to victims of sexual violence serves a social function of preserving a particular view of women.
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Gavey has a more nuanced view of this, stating that psychiatric diagnoses still have some value for helping victims: “While the framework of trauma... might be limiting and problematic in many ways, from a feminist point of view, it has to be seen and judged alongside the other cultural resources that are available... That is, victim-blaming, shame-inducing... discourses through which abuse is perpetrated” (Gavey 2003, 137).
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Gavey (2009, 97): “In order to stop rape, we would need to sidestep assertions of its overwhelming horror and of women’s vulnerability.” The DSM-IV-TR states that a necessary condition for PTSD is exposure to a traumatic event, including “sexual assault” (APA 2000, 463). The DSM-V changes this to “sexual violence,” including “e.g., forced sexual penetration, alcohol/drug-facilitated sexual penetration, abusive sexual contact, noncontact sexual abuse, sexual trafficking” (APA 2013, 274). While the inclusion of examples suggests an effort to broaden the category, it still excludes those whose sexual violations Gavey identifies from counting as PTSD.
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As Brison notes, hypervigilance is not exclusively cognitive (Brison 2002, 80). But insofar as hypervigilance includes beliefs about one’s safety in the world, it is worth considering whether such beliefs are justified. See Freedman (2006) for a theory of justification for this and similar post-traumatic beliefs.
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The committee that revised PTSD in the DSM-V favored a “broad” over a “narrow” construct that allows overlapping with other disorders (Friedman 2013, 550). This further increases the potential to overlap with moral injury.
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Culverhouse, Z. (2019). From Mental Illness to Moral Injury: Psychological and Philosophical Perspectives on the Harm of Sexual Violence. In: Teays, W. (eds) Analyzing Violence Against Women. Library of Public Policy and Public Administration, vol 12. Springer, Cham. https://doi.org/10.1007/978-3-030-05989-7_7
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