Essays	Print

by Dr. Stuart B. Kleinman
Volume 2 , Issue 2 (Nov, 1988 | Kislev, 5749)

Forty-three years ago Eli was liberated from Auschwitz. Forty-three years later Eli remains haunted by the Auschwitz nightmare. The legacy of the concentration camps for Eli and thousands like him, has been recurring dreams of the camps, insomnia, jumpiness, irritability, gnawing guilt over having survived, horrific memories which involuntarily intrude into daytime thoughts, headaches which defy treatment, fatigue, deep aching sadness, and various other ?post-traumatic? difficulties.

Eight years ago Sarah was returning to Haifa from a pleasant day of picnicking with her husband in Jerusalem when suddenly the bus upon which she was riding was blasted by machine gun fire and boarded by heavily armed Palestinian terrorists. Although it is now eight years later, Sarah's life remains fettered to those hours she spent aboard the Egged bus on that ?beautiful? spring day. She experiences attacks of emotional pain so excruciating that she sometimes screams aloud and vivid nightmares of bodies burning which often awaken her from her sleep. She startles easily, frequently breaks into tears for no apparent reason, and feels numb and distanced from those whom she loves the most. Each time she passes the monument to the victims of this attack on the Tel Aviv-Haifa highway, images of her murdered husband flood her mind.

Many others, such as victims of rape, incest, mugging, automobile accidents, and military combat also suffer emotional difficulties as a result of being traumatized. Despite the large number of individuals who are plagued by post-traumatic difficulties, only recently has the American medical community come to appreciate and understand the psychological effects of trauma.

Consequences Of Trauma

The understanding of stress response syndromes has changed dramatically during the past decade. It is now generally accepted that although a person's past history may contribute significantly to the form which this disorder takes, virtually everyone when faced with certain overwhelming events will develop a post-traumatic stress disorder (PTSD).

One useful way to conceptualize the symptoms of PTSD is to divide them, as suggested by Horowitz, into intrusive and denial categories. Intrusive symptoms are thoughts, feelings or behavior which involuntarily intrude upon the individual. Examples include: painful memories, e.g., of one's dead spouse; distressing feelings, e.g., inconsolable guilt for being alive while friends or family are not, or for experiencing any sort of pleasure; flashbacks in which one feels and acts as if the traumatic event is reoccurring, e.g., feeling and acting as if one were once again riding in a bus under attack by automatic gunfire nightmares of the incident, hyper vigilance--a state in which an individual is exaggeratedly watchful--as if the event might happen again at any moment; and startle reactions, exaggerated physiologic responses, e.g., racing of the heart, sweating, literally jumping out of one's seat; or to minimal environmental changes.

Symptoms of the denial stage include emotional numbness, e.g., inability to feel warm, loving feelings toward one's child; amnesia for all or part of the traumatic event; denial of themes related to the event, conscious suppression of thoughts related to the event, ?I will not think about it;? avoidance of symbolic reminders of the event, e.g., avoidance of trains; and frantic over activity which does not allow the individual time to ponder the past. Often, as part of the denial phase, people will distance themselves from those with whom they're closest. Their withdrawal may be perceived as rejection by their loved ones who feel slighted and themselves respond by withdrawing just at the time when their closeness and support are most needed. Some individuals attempt to deny their past through the use of alcohol or other drugs. Sleep disturbance, either too much or too little, may be present in either the denial or intrusive phase.

When Healing Goes Awry

In order to heal, the victim must somehow make sense of the outrageous, a traumatic event which was absolutely alien to the individual?s pre-trauma world. The survivor may literally be without words to describe the horror of his or her experience. Recovery, however, depends on the survivors finding the means of reconciling the way he or she previously understood the world with the reality of the traumatic experience. The intrusive and denial phases may represent the mind?s way of reconciling these two worlds. The intrusive phase is the work phase in which the mind recalls the trauma over and over again in different ways in attempts to understand it and give it meaning. The intrusive phase, however, can be quite disturbing and when the level of discomfort becomes too great or the individual encounters a new event of higher priority (in terms of survival), the denial phase begins. When an individual is again able to tolerate the discomfort of the ?recovery work?, or the event which precipitated the switch to the denial phase is no longer of such import, the intrusive phase returns. These two phases oscillate until the individual comes to terms with what has occurred. For a variety of reasons, including the nature of the trauma and an individual's psychological and biological make-up, the ability to accept and resolve devastating experiences varies widely among individuals. The wide range of duration of post-traumatic symptomatology, e.g., one to greater than forty years reflects this varying ability.

One particular post-traumatic symptom, survivor guilt, merits special consideration. Survivor guilt, an intrusive-type symptom, is the belief that one does not deserve to have survived a traumatic incident. Those who suffer from survivor guilt torture themselves for the fact that they did not die ?with the others,? that they remain alive. Krystal and Niederland, who found that survivor guilt was present in 92% of the concentration camp survivors they studied, felt that survivor guilt was responsible for much of the depressive and anxiety reactions of the camp's survivors.

Aggressive feelings, were also found to play a major role in the production of post-traumatic symptomatology. Powerful aggressive feelings were unleashed in response to the Nazis' horrific treatment. The conscious experience of this overwhelming aggression often produced such great anxiety in the survivors that they sought relief from their intolerable anxiety via the employment of various defensive psychic maneuvers. These maneuvers, intended to help the individual cope with disturbing feelings, sometimes prove to be maladaptive themselves. One mechanism, turning of aggressive, violent feelings back upon oneself, produced a self-punitive depressive reaction. Another mechanism, disavowal of aggressive feelings by their projection onto others, produced in some a paranoid state in which the individual believes that it is others and not him or her-self who possesses angry, hurtful wishes. Another mechanism used was the anesthetization of oneself to feeling, a mechanism labeled ?psychic closing off? by Lifton. By numbing themselves to their rage, the survivors often numbed themselves to other feelings as well and became emotional invalids. One other mechanism, somatization, led to the development of the headaches and fatigue experienced by many of the survivors.

Some of the individuals who were unable to find a way to deal with their aggressive feelings were consumed by them, destroying themselves with their obsession for an unobtainable revenge.

Enduring Effects

Post-traumatic problems may endure for great periods of time. Survivors of the Nazi concentration camps continue to experience significant difficulties four decades after their release. Former American and Australian Japanese-held prisoners-of-war have been found to have PTSD more than forty years later as well.

Traumatic after-effects express themselves in various forms. In my own studies of Vietnamese boat people presently living in Israel (of which there are approximately 250) who were attacked by pirates during their journey to freedom from Vietnam, PTSD, but, surprisingly, not survivor guilt was found. The absence of survivor guilt, a new finding, may be the result of cultural factors. Those Vietnamese who believe that their friends or family members who died trying to help them earned ?merit? and as result will be reborn to a better life, may be less likely to feel guilty for having lived. Additionally, the Vietnamese (as well as other Asians) whose sense of identity traditionally, unlike for many Westerners, is intimately linked with the family, feel that even if one family member survives it is as if the entire family has survived and thus believe there is little reason to feel guilty for having survived.

Although those I have studied do not seem to suffer from survivor guilt, some do suffer from intensely painful feelings of shame. These people feel shame, a prominent sentiment in Asian culture, as a consequence of their belief that they did not conduct themselves properly during the pirate attacks, that they were ?weak.?

The emotional difficulties suffered by victims of trauma are in some circumstances not solely the result of the traumatic event. The survivors are often, as has been described by Symmonds, ?secondarily victimized? by the society to which they returned. Irrational beliefs, such as the fear that association with victims increases the likelihood of being victimized oneself (fear of contagion), have led to the avoidance or shunning of survivors by many in society. Such avoidance recreates within the victim the deeply disturbing sense of isolation and powerlessness previously experienced during the original victimization (the feeling that no matter what one does one will be shunned) and caustically abrades the victim's open psychic wound.

Coping And Treatment

Several mechanisms have helped people to cope during traumatic experiences. Survivors of a terrorist attack upon a kibbutz in Ma'alot reported in interviews conducted by Soskiss and Ayalon that religious thinking and behavior as well as caring for other hostages was helpful. Individuals aboard Dutch trains hijacked by South Moluccan terrorists who fought back against the terrorists were found by Baastiaans to suffer from less severe emotional after-effects. For Israeli civilians aboard a bus hijacked by Palestinian terrorists whom I studied, altruistic activities (one women used her hand as a bandage to cover the bleeding wound of a man who had been shot), concentration on the present coupled with avoidance of consideration of possible negative outcomes (one woman concentrated on the coins scattered on the floor of the bus and tried to avoid thinking of the possibility that the bus might explode), fantasies which provided a sense of strength or power, belief that one was not abandoned by one's family or friends and the sense that one's destiny was at least in part under one's con?trol helped many to cope with the traumatic situation. Several of the Vietnamese victims of piracy whom I studied were aided by their having successfully overcome previous trauma and the ?confidence? such success engendered, advance knowledge of the possibility of being attacked, strong religious belief, altruistic actions, belief that they would survive unharmed, and distracting physiologic sensations, e.g., overwhelming thirst distracted one man from the terror of watching a pirate hold a gun to the head of his friend. Sylvia Jacobson, a passenger aboard a plane skyjacked by Middle Eastern terrorists, wrote that group unity, e.g., mothers aboard the plane with small children who sat with each other, helped the hostages to cope with their ordeal.

Survivors utilize various techniques to help them with their pain and suffering. Some seek psychiatric help. Post-traumatic Stress Disorder is generally treated with psychotherapy, a verbal therapy which through the use of a supportive, empathic, trusting relationship allows people to safely re-experience the trauma which they often have been pathologically avoiding, to resolve the conflicts they may have concerning ways they behaved or thought during the trauma, to place the trauma into context with their present life and ultimately to liberate themselves from the toxic effects of the trauma. In addition to psychotherapy, psychiatrists in certain instances may use various medications which help to diminish some of the more disturbing symptoms of PTSD such as rage attacks, disabling anxiety, severe insomnia and depression. Medication does not cure PTSD and should be used only in conjunction with psychotherapy.

Other measures which are sometimes helpful although rarely curative in and of themselves include religious belief, altruistic activity, actions which enhance self-esteem, e.g., return to school or finding a new or better job, and a future-oriented focus. Most people at some point attempt to avoid thinking about their past. Although useful to a degree, when done excessively this thought suppression impedes the healing process.

Prevention, as in the case with all illness, is the best treatment. For those at risk of becoming victims of violence, detailed information concerning the event which might be encountered (particularly if provided by those who have actually experienced similar violence of the nature which might be encountered), participation in mock episodes of violent attack and reinforcement, especially for those who lack strong religious beliefs, by an individual's country, community or family of its unwavering support for the potential victim may help inoculate against the negative effects of future trauma.

Hope

Sadly, victims often suffer silently. Many avoid professional help fearing that by discussing their painful past they will somehow repeat it. Although therapy can be a difficult process, it helps victims face their past in such a way that they remember and resolve rather than remember and endlessly repeat their traumatic history.