So What Do We Do About Trauma?

Herbert Peyser, MD

Disclosures

Introduction

We're at war. There's going to be trauma, lots of trauma; it's inevitable. How should we handle it? Should we have professionals come in and "debrief," ask people to talk about it and abreact, give meds, put people in therapy: individual, groups? Should we leave it up to them? Should we ignore it?

In her book published several years ago, Regeneration, Pat Barker, winner of the 1995 Booker Prize in England, recounts the story of the treatment of the war-traumatized English poet, Siegfried Sassoon. While an infantry lieutenant in the trenches in France in World War I, he wrote a letter of protest against the war. Coming from an officer, that was most improper, but he also suffered from what was then called shell shock ("And the hallucinations? The corpses in Piccadilly?"). Instead of being court-martialed, he was evacuated to a hospital-rehabilitation center back in England where soldiers were being treated for "shell shock" by a brilliant English neurologist and social anthropologist, Captain William Rivers. Rivers had developed a particular medical-psychiatric approach toward these conditions (Lancet, Feb. 2, 1918).

At that time there were many who denied the real existence of these disorders, just as General Patton did later, in World War II, when he hit the American soldier who had a traumatic war neurosis. These people did not see them as true illnesses and felt the soldiers were malingering, should be punished and forced back to duty. Rivers felt, however, that these were valid conditions requiring attention. But not too much attention, just enough as needed, no more, and then it would be best if they could resume as much of their lives as possible, even go back to duty. Deal with it but don't make too big a deal of it.

Freud saw our central nervous system protected by a Reizschutz, a stimulus barrier protecting it from excessive stimulation flooding in. In trauma, the barrier was suddenly and violently breached, overwhelming the nervous system with an influx of stimuli it could not bind or handle. The person, the barrier, the central nervous system, all needed support, rest, and psychiatric help to build up the Reizschutz again. How much of each would vary with the individual, the situation, and the trauma, depending on the amount of trauma, the nature of the situation, and the constitution and psychology of the individual. One size doesn't fit all.

There was, on the other hand, an implication that excessive support and rest might lead to regressive adaptation at a dependent level, causing a picture that might be called a "compensation neurosis," with legitimation of the regressive adaptation that served to justify removal from the traumatic situation, obtain secondary gain, and relieve the guilt at having survived it. It was up to the physician to feel his/her way, through empathy and experience, to see just how much regression was required, when to encourage initiative, and how much time it would take for recovery. Rivers had to find the best way for each soldier, feeling his way as he went, conscious of the soldier's sense of guilt and responsibility, the "survivor guilt" that the soldier felt, removed from combat while the soldier's buddies were still in it, trapped in the trenches and dying. The last words of Pat Barker's novel show Rivers, having successfully completed Sassoon's treatment, writing in his chart, "Discharged to duty," knowing that Sassoon, now better, will go back to France and may still want to die with and for his fellow soldiers trapped and dying there too in the trenches. Rivers accepts this. Now that he is better, it is entirely up to Sassoon himself.

Between that World War and the next we forgot those lessons, and in the earlier part of the second World War in the European Theater of Operations, the agitated soldier suffering from an acute war neurosis was given intravenous sodium amytal, "narcosynthesis," asked to tell about the trauma, perhaps other traumas, abreact the emotions, and then be evacuated to a hospital behind the lines. The amytal itself caused the soldier to be a litter case, increasing the necessity for evacuation.

As this went on, experience revealed the consequent development of chronic war neuroses associated with the necessity for legitmation of the regressive adaptation. So later in the war, as it shifted to the Pacific, Colonel M. Ralph Kaufman, Chief Consultant Psychiatrist to the Southern Pacific Theater of Operations, adopted a new tactic. At the battalion aid station, close to the front lines, the physician would avoid amytal (and the necessity for a litter and evacuation), would use light hypnosis instead to gain control of the soldier's breathing and calm the soldier down, let the soldier talk about the trauma, then give the soldier some warm soup, a hot shower, a cot, and back to duty. This lesson's positive results were learned and adopted by the Army.

Later, during the Korean War, I was a young psychiatrist just out of residency and stationed in a training center in Arkansas where cannoneers were being trained to go overseas into combat. My job was to figure out who, of the ones with psychiatric problems, could go overseas and do full duty, who should do more limited duty, such as being a clerk-typist, and who should be discharged. But how could I tell?

I heard that Dr. Kaufman was to talk at the Medical Field Service School at Fort Sam Houston in Texas. He was heading the Psychiatry Department at Mt. Sinai in New York City, and I planned to go there after my service time was up. I wangled a pass and drove to Fort Sam, listened to his talk, and went up and asked him how one could decide about this full duty, limited duty, or discharge business.

He said he didn't know, no one knew. Of course, he said, if the soldier was psychotic, saw an angel of God descend and speak to the troops, then forget about it. But short of that, he said, there are too many variables. A passive soldier would be fine until the platoon leader was killed and might then go to pieces. An active, aggressive soldier wouldn't mind that, might take over, but that soldier couldn't tolerate sitting in a fox hole for hours, perhaps days, being shelled, or, worse, shelled by "friendly fire." Too many variables to tell in advance. No substitute for trying a person out on the job.

But, he hastened to tell me, don't, for heaven's sake, underestimate the person. You don't do a person a favor by telling that person he/she is no good, not when they are good. You have to know, and that's what one's psychiatric training is for.

I remembered that and went back to my camp. There was a soldier there who kept fainting all the time. "Captain," he said to me, "how can you send me out every day to fall on my face?" I said, "It's easy, I'm a shit. Maybe there's another explanation, but it's easier for you to think I'm a shit."

So he went out every day, fell on his face, but less and less, and he completed his training and went on to some advanced signal corps training. I would see him as I walked around the post, cocky as hell, walking jauntily, grinning when he saw me. Because I hadn't told him he was no good.

The infant, nursing at the bottle or breast, stares not at the bottle or breast but at the face of the mother. In that face the infant reads himself/herself, derived, hopefully, from what the mother has truly read in the infant and fed back into him/her. "You're wonderful, lovable, worthy." Hopefully that.

The toddler falls, bumps a knee, looks up at the mother to see from her face how bad it is. A disaster? Or a little thing? The mother says calmly, "I'll give it a kiss." Or, frightened, "We'll have to go to the doctor, maybe get stitches." The infant learns about himself, the world, and trauma out of this dialogue.

The soldier in Arkansas looked at me, Sassoon looked at Rivers; the traumatized person looks at the counselor, psychologist, psychiatrist, whoever comes at the time of the trauma. What is critical is that in this context it must be understood that the giving of medications, even the wonderful ones that we have now and are so useful, often so necessary, nevertheless do tend to convey to the traumatized person that he or she is ill, that the matter is very serious. We must be fully aware of that communication and be cautious. We must remember Rivers and Kaufman.

Deal with it but don't make too much of a deal of it. Feel into the individual and go with that. We don't do persons a favor by telling them they're inadequate when they're not. We should reach in and show them their adequacy.

I worry that with our guilt over Vietnam we may have lost this lesson again and may tend to overdo intervention at times.

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