People with chronic or complex trauma will come into a clinician’s office for one of two reasons. The first is that they used to enjoy a normal life, but following a trauma have never had the opportunity to get their brain back to a more normal function. Their lives are characterised by fear and all the debris that goes along with that: paranoia, wrecked relationships, an inability to study and maybe a hundred and one other things besides. They’re not able to hold down relationships, friendships, marriages, jobs. They get angry, they may even be criminal; maybe they’ve been in jail.
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The other reason is that the person already had a brain tuned into trauma or threat. Their attachments are insecure, usually stemming from problems in childhood. They want different attachments, to feel strong boundaries and clear-cut rules. To be told what you can and cannot do is consoling for victims of childhood trauma. Perhaps unconsciously some people join the army because they feel angry and want to take it out on people – but perhaps, more commonly, they are simply seeking greater security.
What, then, if there is a further trauma, perhaps on the battlefield, and out it all pours? Instead of getting just a middle C in reaction to a trauma, what they get is the whole of Tchaikovsky’s 1812 Overture, complete with cannons and trumpets. The whole orchestra starts up.
We live in a time of war. Life for the modern serviceman or woman consists of more or less constant exposure to intense counter-insurgency conflicts. It could be said that we’re breeding a generation of soldiers who are going to be forever exposed to that high level of trauma, and many more will be damaged. What is that going to inflict on society when they’re out?
An alarmingly high proportion of the prison population are military veterans. Homeless charities have reported that a very high proportion of the homeless in London – perhaps as much as 50% – used to be in the armed services. It has been shown, too, that many weren’t able to readjust to ordinary society after combat; they either mutated into vagrancy or found themselves locked up. These people came out of the combat zone, having killed or seen people killed: that became their conditioned behaviour. If they are not allowed to readjust back into society where the rules are different, if there’s no rite of passage for coming back in, then the potential for trouble in their life is high. They’re going to be lucky to get away with the odd shouting match with their neighbours. At the very least they may beat up their wives or husbands. At worst, they’ll commit violent acts and murder.
I was once asked to take on a case in which an undercover soldier in Northern Ireland, a man exposed to constant danger, had returned on leave to his native Manchester and, while in his local pub, had killed somebody he didn’t even know. It turned out the unfortunate bloke had brushed against him, spilled his drink, and the soldier had lost it and throttled him to death with his bare hands. I didn’t take the case on in the end, but it remains locked in my memory.
British Falklands war veterans recently commemorated their 25th anniversary victory celebrations. About 300 men who came home were missing from the parades. They had killed themselves. Many more were battling suicidal thoughts, and veterans of Iraq and Afghanistan are now swelling their ranks.
From 2003 until recently, active servicemen with trauma were treated by the Priory group of hospitals – until recently. It had a contract with the MoD to provide all inpatient psychiatric care for personnel. The bill soon skyrocketed. Older veterans did not qualify for Priory care, because the prevailing government view was that they didn’t suffer from long-term mental health problems any more than the rest of us.
Psychiatrists have reported that soldiers coming back from Iraq developed post-traumatic stress disorder (PTSD) symptoms earlier than in past conflicts, partly because it was such an unpopular war. “Many have been on back-to-back duty,” one told me. “Northern Ireland, Falklands, Kosovo, Sierra Leone, the Gulf, Afghanistan, Iraq. They are being sent back without significant rest periods between. This has left soldiers feeling alienated, confused and abandoned. Some are left feeling downright suicidal. The lessons of the past are being ignored.”
A major problem is the nature of today’s military duties. Troops are becoming involved in peacekeeping duties as well as in full-blooded operational duties. There is a clear conflict of responsibility for such troops, who have to swap one set of rules for an entirely different set, sometimes within one theatre of engagement. This can be very confusing emotionally, especially if troops are attacked during so-called peacekeeping duties by a faction within the community they are seeking to protect. Advances in neuroscience can help to explain the increased vulnerability that goes with peacekeeping duties. If you can fight or flee you are less likely to leave the chemical imprint of the emergency activity behind than if you are rendered helpless and immobilised.
Many returning service personnel have secure enough attachments to draw upon to be able to rehabilitate largely by themselves. If they have developed PTSD, these are the people who tend to do well in treatment. Those people will either detect a change in themselves or have a partner who may accuse them of being hot-headed or warn them about their behaviour, and they change of their own volition because of that insight. Others, hopelessly lost in trauma, will beat up a partner who complains about their behaviour or drunkenness. If they have children who are then exposed to violence in the home, either directly or indirectly, those children grow up in an atmosphere of fear, and they develop different brains from others. The cycle perpetuates itself.
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I received a letter a few years ago from an ex-soldier who had suffered from PTSD since returning from Bosnia with the British army. Today, it sits staring at me on my desk. It doesn’t require any action on my part. It’s a summary of one man’s 15-year battle with his trauma reaction.
Despite feeling suicidal, drinking excessively, having flashbacks and being unable to focus on his job, this ex-soldier, whom I’ll call George, was told by the MoD that he didn’t have PTSD and that the cure for whatever it was he did have was “to pull his socks up”. Convinced, because the “experts” had told him so, that he wasn’t suffering from a trauma reaction, George left the army and went on to make a lot of money running his own business – this despite the fact that the depression that had gripped him in Bosnia never actually left him. His drinking continued and so did the flashbacks. He knew something was wrong, but had no idea what it was; no one had given it a name.
It was only a decade later, when he was in Baghdad after the Iraq war, working there as a private contractor, that he happened to hear a retired Canadian army general, who had been the director general of medical services to their military, describing all his own symptoms for what they were: classic PTSD, and praising the humane and effective way he had been treated. It was then, George said, that some mental switch engaged. Just knowing that what he had had a name was in itself “transformational”, he wrote. “I decided to change my course and get better.” His treatment took several years, but he had wanted me to know that he was now as near fully cured of the condition as anyone could be.
“Recovering from PTSD is the most difficult thing I have ever done and the most rewarding thing I have ever achieved,” said his letter. “It has highs and lows and there are lots of false peaks. I am not sure you ever can become 100% fixed and you are for sure never going to be the person you were before . . . but I am constantly improving myself.”
He had taken legal action against the British army; not for the money, he insisted, but to challenge it on one fundamental issue: “that since the recognition of shell shock in the first world war, the British army is not much further forward”. He subsequently received a formal apology from the MoD for its failure to treat his psychiatric problems. George’s story sums up much of the history of PTSD thus far, and my own journey in trying to understand it.
“The attitude at the time was to think that anyone having this was mad anyway or weak in some way,” George wrote, and he was right. The problem is that this is still the attitude in certain quarters of the military – that PTSD is evidence of some intrinsic fault line within the individual; that it is a sickness.
My view, of course, is quite the reverse: that PTSD tends to develop in people who are strong-willed or in those who are unable to come to terms with a life-threatening event because it just doesn’t make sense. It is the impact of an event which, for some reason or other, the survivor has not been able to process, not because the mind can’t do the processing – because it’s flawed in some way – but because it hasn’t had the opportunity.
Until the trauma imprint has been processed with the help of a therapist, then the symptoms will continue. These include re-experiencing symptoms in which the trauma continues to have a life of its own in the form of untriggered recurrent thoughts, flashbacks and nightmares, or the traumatic memories may be stimulated by cues that remind the victim of the trauma.
There may be avoidance symptoms, such as behavioural changes to avoid people and places that are likely to evoke trauma memories; cognitive changes, such as reduced mental capacity, obsessional thinking or compulsive activity; and numbing symptoms, shutting down of the emotions and social withdrawal.
The cluster of hyper-arousal symptoms closely resemble anxiety states – irritability, insomnia and so forth – but what is most strongly characteristic of PTSD is hyper-vigilance, because those who have been traumatised never want to repeat the experience and so are “on guard”. This can be so extreme that it can mimic a paranoid state.
Recurrent flashbacks, although extremely distressing, are faithful memories that give repeated opportunities to learn precisely what happened – and in a group therapy setting, where those experiences can be shared, my own observation has echoed George’s: that not only is recovery likely, but that you can grow from it as well.
For me, George’s letter remains a symbol of hope. His experience of PTSD by his own admission had been “transformational” – in processing the terrible things he had seen during his time in Bosnia, his journey to recovery was the most rewarding thing he had ever achieved.
Richard Tedeschi and Lawrence Calhoun, both professors of psychology at the University of North Carolina at Charlotte, have reported that “positive growth” experiences in the aftermath of trauma far outnumber reports of long-term psychiatric disorders. “Reports of post-traumatic growth have been found in people who have experienced bereavement, rheumatoid arthritis, HIV infection, cancer, bone marrow transplantation, heart attacks, coping with the medical problems of children, transportation accidents, house fires, sexual assault and sexual abuse, combat, refugee experiences and being taken hostage,” they wrote in a 2004 article in Psychiatric Times.
This is the reality of PTSD. It isn’t just an experience that affects people who have served in the military or in the emergency services. Trauma can affect each and every one of us – it is the lightning bolt that can strike out of the blue. It is the shatterer of assumptions. It is evidence of something that has been hard-wired into us for a reason.
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