Special Hearings — Conscription Hearings — 1997-07-23

MR KOEN: What I thought I would do is just give an overview of what post-traumatic stress disorder is and how it manifests and then possibly provide some clinical material with somebody who I have worked with just to try and illustrate what it means to suffer from post-traumatic stress disorder.
 Post traumatic stress disorder is a generic term describing the effects of extreme stress on the human mind.  Whilst the symptoms of post traumatic stress disorder are standard according to the DSM 4, the events that precipitate them are numerous.  They can arise from a single episode of life threatening harm and violence such as rape and assault, or disasters, both natural and manmade. My focus will be post traumatic stress disorder as it occurred in specifically war-related incidents.  In this regard the type of war was also important.  
 Guerilla warfare, the type of war fought in the South African borders for the past 20 years contains many unique features not seen in conventional warfare. These include hit and run tactics, surprise ambushes, extensive use of landmines and boobie traps as well as the stress experienced by people who are primarily town dwellers fighting a bush war.  Unpredictability characterises this type of environment and the uncertainty of either attack or safety leads to a high level of anxiety and hyper-arousal in anticipation of the next attack.
 Whilst the majority of the South African troops were not involved in actual fire-fight a significant number were exposed to the conditions exposed above.  It is these soldiers who have been most likely to suffer the effects of such stress.  
 Of particular interest are the personnel from the medical corps, particularly the operations medics for whom no amount of training could prepare them for the type and volume of wounds they encountered, or for the prevalence of death in their environment.
 Once national service was over the individual was expected to slip normally into the mainstream of society, their expectation being that their whole lives were lying ahead of them.  Little attention was paid to that that was behind them.
 A phenomenological understanding of post traumatic stress disorder could be expressed in terms of somebody who has literally been blasted out of time, events in an environment so unlike our normal experience of reality have produced emotions of such intensity and force that they appear impossible to assimilate the daily experience of living.  This aftermath is known as a state of psychic numbness and a discontinuity of being.  In effect the person has been dislocated from life.
 Post traumatic stress disorder is the one syndrome in which death features most prominently in that the anxiety experienced by the person is a radical intrusion of an image feeling of death or an end to life.  The anxiety has to do with the grotesqueness in the absurdity of the image, its suddenness, its association with terror or premature death and its extreme and protracted nature.  
 The death encounter opens up the most primitive fears of human vulnerability and forever destroys the myth of omnipotence. It contains the ultimate in truth about beginnings and endings and forces a confrontation with one's own transiency and the mutability of life.
 The second factor to be considered is what could be termed "survivor guilt" and self-condemnation.  This is a psychological guilt precipitate by an experience of extreme helplessness at the time of the trauma.  Feeling the guilt is what is known as failed enactment which refers to one's instinct at the time of the trauma to halt or prevent the trauma from happening.  One is seldom able to do anything at such times and what one does do is often far from the ideal reaction.  Failing to achieve what should have been done can lead to a form of perpetual self-condemnation and a state of helplessness continuing long after the helplessness induced by the trauma.
 However, guilt is an ambiguous state.  Whilst part of oneself remains stuck in perpetual horror of the suffering another part experiences great joy at having survived.  This joy is in itself ambivalent as the vitality of joy appears sacrilegious in the face of the death and the pain and the suffering of others. 
 Transcending the traumatised self requires one to move beyond the devitalising event with its aspect of personal responsibility and guilt to an awareness of one's common humanity and condition, to forgiveness, relief from guilt and happiness.  Whilst this process does not restore innocence it does re-establish integrity with self and others. 
 A third vital factor is what is known as psychic numbing and this refers to the radical discontinuity that characterises post traumatic stress disorder.  The sense of self is literally blasted out of time and an experience of disassociation follows.  The self is severed from familiar experiences of compassion, community and value.  In effect the person undergoes a reversible form of symbolic death in order to avoid permanent physical or psychical death.  This describes the profound isolation most sufferers experience cut off, not only from the world but also from that part of themselves that could reconnect them with the world.
 A further manifestation occurs within problems related to intimacy and nurturance.  The conflict within the survivor has to do both with the special need for human relationships and an association of weakness with that need.  Any help offered is regarded as a reminder of weakness.  This stems from an experience of having been dependent on other human relationships only to see them taken away in the most violent and grotesque manner. Human relationships are thus characterised by being fragile and unreliable, consequently one guards against them.  
 Another part of this resistance has to do with the feeling of being tainted by death, of carrying the psychic stigma of being annihilated.  Having been treated so cruelly and annihilated so easily one internalises the feeling of being small and worthless.  The survivor emotion to counteract such inner death is often to rage and storm at the world.  One can understand this anger as being a more comfortable emotion than extreme anxiety and guilt.  This anger may also be, for the veteran, the only psychic lifeline when surrounded by images of death.  Unfortunately anger often results in the withdrawal of others from the veteran which exacerbates his feelings of loneliness and isolation.
 I am going to talk briefly about a case.  I will refer to the person as Shaun.  He was an operations medic on the border.  I won't be divulging much more than that.  Shaun brought to therapy a range of severe and debilitating symptoms that intruded upon him and affected him to such an extent he considered his life to be without meaning.  
 Shaun was plagued by a terrible feeling of foreboding that his life was constantly being threatened by a portentous force capable of destroying him.  He was racked by anxiety and tension that left his nerves raw with a feeling of unhealthy exhaustion.  He suffered the most gruesome nightmares and was afraid to go to sleep.  
 For a while he drank heavily but would experience grotesque flashbacks that frightened him sufficiently to cut down dramatically.  He felt desperately alone and isolated, trapped in a world of terrifying experiences from which he could find no relief.  He felt bitter and angry at his isolation directing his anger at others for allegedly not caring and also at himself for having such violent emotions.
 Shaun eloquently described the impact that the trauma had on him by saying that as a result a part of him had died.  His own life force had been extinguished by the brutality and the volume of all the deaths he had witnessed.  His presence was weighted and his words clouded by black funereal despair.
 The aim of therapy was thus to return Shaun to life, to engage with that force within him that brought him to therapy and to lead him to discover the inner strength that enabled him to survive.  Although the initial sessions were typified by certain blankness of expression and absence of emotion the sudden displays of anger and pain were encouraging and that they pointed to the emotional volatility and life that seethed beneath his cut-off and defended facade.
 I had a sense of the need that Shaun had for a place to bring that emotion, to safely express it, to be contained within it and to try and understand it.  I acknowledged that need and in a sign of therapeutic faith I communicated that therapy could provide that space.
 A significant feature of this particular therapy was the faith I maintained in his reparative powers which remained consistently part of the whole process.  Although I could not anticipate the levels of pain and despair that ensued, and at times felt quite broken myself, essentially I never doubted that he would pull through.  
 However, an aspect of faith that I needed to learn upon beginning work with Shaun was patience.  In this respect an understanding of the graphic lack of organisation that characterises a war situation is important.  Events happen without warning and without sense.  The soldiers, unable to conceive of events occurring in a linear or contained fashion, as for instance somebody who was watching a movie on war, there is no sense, there is simply chaos and to urge a soldier back into that chaos without spending time in allowing him to reorganise his emotions and cognitions differentiating past from present is dangerous.
 Necessary mention must also be made of my own expectations of the therapy.  At this point, having had virtually no exposure to post traumatic stress disorder my only understanding was that the symptoms represented powerful repressed emotions experienced by the individual has either been too painful or too destructive to be expressed.  Treatment would then focus on two levels, one thing to normalise the condition by explaining that such reactions are normal in abnormal circumstances. Having established that, this would in turn allow the repressed emotions to be accessed using various techniques which would allow for an emotional catharsis. The dramatic relief that would come following the diminishment of intensity of the repressed emotion would gradually lead to the symptoms fading and the victim's life returning to normal.  However from quite early in the therapeutic process, this perspective changed.  What alerted me to the deeper implications the trauma had on Shaun was his reluctance to confront the impact, the violent nature the trauma had on him.  Instead chastising himself for feeling such emotions for, suffering at all.  The incongruency of his guilt and his self-condemnation in the light of his sufferings led me to consider further the destructive relationship towards himself. That which he had internalised. The therapeutic process thus deepened to include not only a means of dealing with the acute savagery of his symptoms that necessarily required a reexamination of his relationships with the world, with others and with his own frightened and vulnerable human self.
 The early phases of the treatment consisted almost of a sense of many courses in that explanations are made and links are drawn to show how everyday events will remind him of traumatic events.  For instance, dustbin bags would remind him of body bags, the smell of paint would evoke images of a burnt out car wreck. Shaun struggled to accept these explanations and at times it was necessary to intervene very actively to deter him from acting on his impulses as was the case when Shaun wanted to physically assault an irritating friend of his who reminded him of a soldier whose casual attitude allowed somebody to die.
 This process continued throughout the therapy but at a more profound and embroidered level becoming much more than a simple technique. At a much later stage in the therapy Shaun was shown how he bound himself to his traumatic past.  Now he refused to distinguish between somebody running down his university corridor and somebody charging towards his army bungalow to kick the door open and wake him for an emergency. To acknowledge the difference would have meant to feel the pain of the past and just how much he'd been affected by it.  It would have meant to stop getting so angry, not only at the world, but also himself for seemingly being so different from everyone around him and to confront the reality of his hurt. It meant a fundamental shift in attitude towards himself where feeling hurt was not something to be despised but was an acceptable emotion under all the circumstances.  It meant understanding himself and not criticising himself.
 These techniques essentially allow the veteran to focus on the present dimension of his life without succumbing to the potentially overwhelming anxiety of his combat experience.  However in so doing on encounters the myriad of problematic belief systems which still operate in civilian life. The most entrenched belief that Shaun suffered from was that he was a freak because of what he was feeling and although this attitude was also constantly challenged, the revoking of the belief required a fundamental change from Shaun in his attitude towards himself and his suffering, a shift from a punitive and self-condemnatory stance to one of caring and understanding. 
 These belief systems occurred in virtually every facet of Shaun's life including his perception of the world as being filled with uncaring, indifferent people, that he was entitled to behave the way he did because of what he had been through, basically culminating in a recognition that his perception of his own experiences as being filthy and unacceptable was a large component contributing to his sense of isolation. The absence of any tears, any real feeling in the onslaught of human carnage as Shaun described it, is what is known as the psychic numbing. It was as though Shaun remained symbiotically fused with his experiences. The death of the thousands represented his own death.  To grieve for all of them was an impossible task.  It was for the loss of himself that he had to grieve, the loss of his innocence and his own psychic death. To do that he had to separate himself from the deaths. Separation is a loss, he needed to be allowed to grieve his losses without any further loss to himself.
 Shaun approached therapy with a mixture of resentment as well as reluctant dependency. Often his behaviour outside of therapy seemed to point to the fact that that therapy was useless and not helping.  He continued to get angry at, and feel isolated from the world. Other people's behaviour evoked enormous rage in him, relationships continued to disappoint him, his family and friends were either oblivious to his suffering or did not understand it and when he did tell someone like his girlfriend they reacted with horror and then shunned him. What needed to be separated and made quite distinct was the horrific nature of his experiences from the impact such experiences would have on him. His girlfriend played a vital role in making that distinction. She was angry and disappointed in Shaun, not because of the experiences that he had shared with her but because of the way he behaved towards her afterwards.  This could be shown how dramatically and literally Shaun saw himself as being disgusting because of what he had experienced, because what he had experienced was disgusting.
 The shifting of these attitudes was a vital aspect of the recovery process as it demanded that Shaun acknowledge that there could be a different reality to the distorted and hopeless vision he clung to. The point is that to be literally bound to a traumatic experience is to permit oneself no psychic vitality in relationship to the experience itself and to limit vitality in other areas of life as well.  
 One could define the traumatic syndrome as the state of being haunted by images that can neither be enacted nor cast aside. Suffering is associated with being stuck, hence the indelible image is always associated with guilt and in its most intense form, it takes the shape of an image of ultimate horror.  A single image that condenses the totality of the destruction and the trauma and evokes particularly intense feelings of pity and self condemnation in the survivor. 
 Shaun would often chastise himself for having let others die or even accused himself of having killed them. His guilt seemed not only irrational but also completely unfair. Certainly the most painful moment in the whole treatment occurred when he lamented the death of the child, the child who died in his arms and perhaps the most brutal moment occurred when he smashed his fist into his own face, blaming himself for having caused the child's death. The contrast between the two experiences was marked.  The first experience evoked an entirely human reaction, the pain of all those who died becoming sensed around this experience of a solitary child's death. There is nothing more vulnerable and in need of protection than a child and there is little else that shows up the barbaric nature and violence of war than when a child is killed. Shaun accessed this awareness in the most painful way, his grief was shy to the most profound despair. Simultaneously this experience gave rise to the most abusive and seemingly inexplicable guilt and self-condemnation. In this instance what required recognition, understanding and containment, was that there really was nothing that Shaun could do. His feelings resulted from the tragic consequence of being placed in a situation where he was impotent and helpless. His immense guilt was a reaction against this experience of helplessness. The child in his arms was helpless and the child died.  Helplessness is equivalent to death, so rather than acknowledge his helplessness, he would condemn himself for living and blame himself for the child's death. Shaun's fantasy was that if he were a doctor with somehow the skill to save the child it would have been different. This is known as failed enactment whereby the veteran, by simultaneously experiencing the horror of the incident, also has an anticipatory plan of action to remedy the situation and failing to do so suffers the consequences for that failure indefinitely.  
 This profound experience of guilt is not something essentially resolvable. Guilt is integral to the human experience because it's from the experience of guilt that one draws the necessary insights into the morality of our actions. How they affect ourselves and others. As such guilt is necessarily ambiguous and it is this aspect that facilitates a movement beyond this stuckness that characterises traumatic guilt.  It provides the possibility of finding some alternate enactment for the image that haunts one of undergoing personal transformation around that image. 
 Shaun had to recognise not only how much he had suffered but also how glad he was that he was alive. Perhaps the most uplifting moment in the whole treatment was when Shaun welcomed himself back.  He allowed himself the pleasure of living again, bring both relief and joy.
 A final note, just that advice to any therapists who intend working with war veterans is that they should begin sharpening their personal instrumentation as they can expect to encounter horrors on a scale not thought possible.  Images of revulsion, disgust, grotesque discomfort and immense pain and despair are some of the sensations experienced, that being difficult to prepare oneself for any single horror.