The Silence of Trauma: The Need for the Voice of a Profession

Alexander (Sandy) McFarlane, AO

The role of a health professional allows an intimacy with this world through the lens of healing and scientific understanding. This career brings with it both great rewards and responsibilities because of the need to listen to, imagine and understand the nature of the experience of those who have endured extraordinary confrontations with death, suffering and fear.

The development of the discipline of traumatic stress, following the inclusion of PTSD into DSM III in 1980, has been a surprisingly late development in the fields of psychology and psychiatry, given the scars that were left earlier in the 20th century by the two world wars. Tragically, the lessons learned and the knowledge gained lost their currency when the world returned to peace with the end of war.

It is surprising how, on reflection, the ubiquitous nature of traumatic experiences in civilized societies was not recognized or given adequate consideration as a cause of mental illness once the knowledge of the effects of war had been gained.

Now, the scales of blindness have been removed from the eyes of most clinicians and the destructiveness of child abuse, interpersonal violence, disasters and accidents are better understood. However, clinicians and academics who work in the field of traumatic stress and are brought together by the ISTSS, should not forget how arduous the struggle of bringing recognition to this field has been.

One critical reason for the reluctance to accept the enduring damage to some people's lives that follows extreme stress, is that this acceptance brings with it responsibility. That accountability may lie with government when considering groups such as veterans or emergency service workers. Equally, it may lie with powerful vested interests such as the church in the case of sexual abuse by clergy or the insurance industry when it comes to motor-vehicle and work-related accidents. If damage and injury have been caused particularly by negligence, the need for reparation, the provision of healthcare and recognition sometimes through legal jurisdictions follows. As a consequence, a range of competing narratives arise from those responsible to minimize their responsibility and these must be challenged for the victims of trauma to have a voice.

The struggle between those who have suffered and those responsible for the suffering is one of the driving forces of politics. Hence, anybody who works in this field needs to be aware of the competing forces and conflicts of interest that may pervade the roles we take on, beyond our immediate contact with patients. At times, this requires advocacy, at other times muting the voice of excessive entitlement. These are challenging and conflicting roles for health professionals but embracing this responsibility is critical to democratic debate in a healthy society. However, we will spend remarkably little time discussing the ethics and duties that our field inherits because traumatic stress is not an impartial social discipline.

This concern brings with it a need to understand the nature and responsibilities of a profession. A profession is a vocation or career based upon gaining specialist knowledge through a combination of education and training. Professions however carry with them the responsibility of both providing service to others and objective counsel. The status and prestige of a profession comes from a broad social respect for the knowledge exercised but also through the willingness of the members of that profession to have a strong sense of commitment to the value and exercise of that knowledge above and beyond self-interest.

In any revolution, professionals, academics and intellectuals are the first to be targeted because of their ability to challenge tyrants. In recent times, there has been a tendency to diminish the voice of professionals by politicians in democracies as they disrupt spin by raising the accusation that professions act too often out of self-interest and are glorified trade unions. We must know and understand what our profession is and what it stands for.

A further insidious force of change has undermined us without being much commented on. The way we exercise professional responsibility in the trauma field has been possibly subtly undermined by the way that computers have come to dominate the collection and interpretation of information. There are few fields of endeavour where the stories and meaning of people's experiences have greater relevance to social survival than in the trauma field. Yet modern scientific literature has largely abandoned the case history, unlike the law, which is a profession built on case precedents.

The accumulated generalisations of how people have survived, the challenges they faced and the hazards trauma survivors have observed is what any experienced trauma therapist knows. Sometimes, this is knowledge that goes far beyond the immediate psychological impact of traumatic stress. These observations are about how people make decisions in situations of extreme stress, the ability of disaster planners to know hazards that are critical to survival, just to give several examples. No other group of professionals is likely to collect such depth of information, yet we do not share or collectively acknowledge the implicit depth of understanding that we hold as a group.

The failure to learn from past experience is an issue only too well known to our field. Yet possibly we continue to contribute to this loss of knowledge because we have not developed a method or voice to share the accumulated generalisations that have been built from extensive clinical observation. These observations have a richness that goes beyond the binary representations of numerical computation. While advances in the statistical sciences have transformed the way that we can explore datasets, this knowledge is limited by the fields of information collected.

Clinicians have a much wider scope and capacity to observe subtle trends that lead to critical generalizations. These lessons are important for us to speak of. Traumatic stress is not a dry science. Rather it is one that demands professional advocacy, because so often the voice of those traumatized is silenced by the neurobiological disruptions that are part of PTSD and the suspicion that society has of people who have been hurt and are slow to heal.

About the Author

Alexander (Sandy) McFarlane, AO, is the head of the Centre for Traumatic Stress Studies and professor of psychiatry at the University of Adelaide. His research career has covered a broad range, from the study of disasters, the neurobiology of PTSD and the impact of military service on veteran’s health outcomes. He is actively engaged in advising government about policy concerning the management of the impact of traumatic stress. His leadership positions within ISTSS include, Board of Directors member, treasurer, secretary, and the first ISTSS president from outside the United States. He is the recipient of the 2012 ISTSS Lifetime Achievement Award, the highest honor bestowed by ISTSS, for his significant lifetime contributions to the field of traumatic stress.