Trauma, PTSD and military veterans

On Monday night the BBC broadcast a Panorama special programme which looked at the growing problem of suicide amongst serving soldiers and ex-soldiers (veterans) in the British military.1 Through its own research the Panorama team established that in 2012 a total of 50 soldiers – 29 of them veterans – had taken their own life. Although many had not had a formal psychiatric diagnosis, the suspicion is that most, if not all, of these individuals were suffering from post-traumatic stress disorder (PTSD) and because this was left untreated it eventually led to their suicides.  The programme included footage of a video made by Lance Sergeant Dan Collins on his mobile phone just before he hanged himself in the Welsh mountains. Collins had served in Afghanistan and had already made two previous suicide attempts.

One of the complications with compiling accurate figures is that, unlike their US counterparts, the British government does not record suicide rates amongst veterans. In fact, it does not appear to track any subsequent mental health problems at all once a person leaves the service. According to Ministry of Defence statistics, only 5% of soldiers serving in Afghanistan have developed PTSD, whereas the figure for American soldiers is 20%.

In previous postings I have explored some of the ideas relating to trauma and PTSD, with a particularly focus on what makes trauma traumatic.  Most clinicians, of whatever therapeutic persuasion, agree that traumatic experiences – or rather, the memories of such experiences – are very difficult to process psychologically. This is because they make no sense; they are beyond meaning and comprehension. And most people would probably agree that serving soldiers are likely have had experiences that are beyond their normal comprehension let alone those of non-combatants.

However, one of the key things to remember about PTSD is not its prevalence but rather the fact that the majority of people do not appear to suffer the symptoms of PTSD, even though they may have been exposed to trauma. This has led a number of researchers and clinicians to ask whether there are specific factors, which could be both biological and psycho-social, that make particular individuals more prone to PTSD than others.

Another way to look at this is to ask why some people seem to find it more difficult to process traumatic memories than others. At this point, however, we need to be careful what we mean by ‘process’. Many psychologists and psychiatrists view the human brain as an organic computer, albeit a very sophisticated one, which processes information and constructs meaning. On the basis of this model, the individual with PTSD has real problems assimilating the traumatic memories into his or her existing ‘worldview’ or cognitive schemas. In fact, the work of therapy is to help the individual carry out such a process of assimilation retrospectively.

As I pointed out in my postings on trauma and PTSD, what the cognitive approach to PTSD misses out on is the interpersonal or intersubjective dimension of memory and the construction of meaning. I make reference to a paper by Paul Verhaeghe and Stijn Vanheule who argue that PTSD (which they view as a modern day version of Freud’s ‘actual neurosis’) is a result of a failure of symbolic mediation, which goes back to the individual’s early childhood relationships with his or her primary care givers.2 Put simply, symbolic mediation refers to the role that another person (often the mother or other primary carer) plays in helping the young child make sense of their experience and to assimilate ideas, feelings, perceptions into their view of the world. In essence, the formation of a child’s subjectivity is an intersubjective affair. If this process breaks down for some reason, the child is, to all intents and purposes, left traumatised – because without such symbolic mediation a child’s experience of the world is traumatic; it is senseless; beyond meaning and comprehension. And if the process of symbolic mediation failed in childhood then if the individual encounters trauma in later life, as is quite likely – especially if he or she joins the army, then, according to Verhaeghe and Vanheule, he or she will be unable to assimilate, process, make sense of, such experiences. Such experiences will forever remain alien and persecutory rather than becoming part of the individual’s history.

Of course, what we need to establish is whether there is anything specific in the backgrounds of people who join the armed forces which makes them particularly vulnerable to trauma – in the sense that they may have difficulties in processing or making sense of such experiences. If this were to be the case, i.e. that there had been problems in early childhood regarding intersubjective relations and symbolic mediation, then this might help explain why when leaving the armed forces such individuals encounter great difficulties regarding their mental health.

What I’m suggesting here is that, somewhat paradoxically, the structure and culture of the armed forces provides a form of symbolic mediation; in fact it could be argued that it provides a surrogate family for individuals who may have encountered difficulties with their real family relationships. However, what appears to be lacking is any way that an individual solider can make sense of, subjectify, the kinds of harrowing and traumatic experiences they are likely to encounter when on active service.

Perhaps we need to remember that most soldiers will only spend a small part of their lives in the armed forces, and an even smaller part of that life will be on active service – and an even smaller part will be in potentially traumatic situations. In other words, for most of their lives soldiers are civilians – and therefore are probably as unable to make sense of the kinds of experiences they may encounter, even if only briefly, whilst on active service as would anyone else. We are not talking here about a warrior caste socialised from an early age into a culture of managed violence and all the rituals that go with this culture.

And even if army culture were to provide some form of psychological support in dealing with such experiences, once the individual leaves the service they are on their own – and often very much alone in having to deal with the traumatic memories which may start to haunt them night and day. Another problem is that, often, the symptoms of PTSD do not manifest themselves until months or even years later, so when they do the individual is totally out of touch with his or her service colleagues. In other words, they have no-one to try and share such experiences with.

What I’m suggesting here is that with military veterans we may be encountering a ‘perfect storm’: we have the scenario of individuals who are already potentially psychological vulnerable who then experience extreme trauma whilst on active service and are unable to process such trauma, make sense of it, integrate it into their subjective history. This is further exacerbated by the fact that often such individuals have a deep mistrust of ‘outsiders’; that is anyone who has not shared their military experiences, which makes it very hard for them to seek professional help outside of the service.

The tragedy here is that there are a range of psychological interventions and talking treatments which can be very effective in helping a traumatised individual work through their experiences and assimilate them into their history. Psychoanalysis and psychoanalytic psychotherapy in particular have a long tradition of working with trauma, and are very sensitive to the importance of the intersubjective dimension of the therapeutic relationship in helping the individual make sense of their traumatic memories.

What we are not talking about here, though, is a crude process of the individual ‘reliving’ the traumatic experience, which serves no therapeutic purpose whatsoever. Rather, we are referring to a process of gradually working through the traumatic experiences and situating them in the wider context of the person’s history. In other words, the individual comes to ‘own’ such experiences, however unpleasant they may be, and to realise that they are part of who they are, rather than being alien and persecutory.

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  2. Verhaeghe, P. & Vanheule, S. (2005) Actual Neurosis and PTSD: The Impact of the Other. Psychoanalytic Psychology, 22 (4), pp.493-507. []

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