A Discussion on Post-Trauma

I Have Walked The Divide
I have walked along the highest mountain ridges,
Accompanied by the wind, the sun and the sky,
For these companions have walk alongside me, yet more often than one would wish,
I have walked the divide between life and death.
As I walk the rugged ridge, I am reminded of the beauty of life,
And fear the coldness of death, though I am warmed by the brightness of the sun
As it glistens on the white snow faced mountain,
With its welcoming warmth, it is the warmth of life,
It is the sparkle in one’s eye, as the sun shines off the blanket of snow,
I have walked the divide between life and death.
From the precipice, I have looked long into the darkness of the valley of death,
A valley frigid and without life, it is an endless abyss,
I have ventured too close to the edge,
So close that I could feel the gripping cold and hear death’s rattle,
I have walked the divide between life and death.
I have walked the ridge and held the sun’s warmth to my face, and life in my hand,
I have seen many cross the mountain’s crest into the deep cold chasm,
I have held their hands and looked into their silent eyes,
And I continue to carry their voices, voices that filled my ears with their cries,
I have walked the divide between life and death.
I know that my day will come when I too will cross into the great abyss,
Until that day; I will continue to walk along the ridge,
And as I do, I will do so with a heavy heart,
For the guilt that I am laden with by those who slipped from my hand.
I wish to rest, and ease my burden, but I must continue for
I have walked the divide between life and death.

This article on post-trauma is presented to raise subject awareness outside of the psycho-social discipline in order to provide a better understanding of high risk professions and to pursue trauma mitigation methods.
 
You may wonder why I open with a poem. It is a way of conveying my experiences with multiple traumatic events in Naval Special Operations and Law Enforcement. The words convey the images and emotions that surface when reliving the many events and the helplessness felt when unable to intervene. It is the struggle with post-trauma, it is a way to share what I see and feel with those who have not walked down my path, and it is a way to connect with those that have.

It is important to understand the clinical perspective of post-trauma in relation to human suffering and establishes a baseline comprehension of the subject. Statistical information illustrates the human toll and the impact of post-trauma on casualties, families and society.

My exposure to traumatic events is centered on a 21-year military and policing career involving multiple experiences with violent deaths, near death experiences, and vicariously re-living traumas. I have seen children and adults lose their lives, and I have held their hands while death takes them. I deployed overseas at the start of a war, and returned a different man. What you realize over time and experience, is that the Grim Reaper does not announce the coming of death, but rather, it is announced by the all too familiar sound of the death rattle.

WHAT IS TRAUMA?
The Israeli Trauma Centre defines trauma as “a painful emotional experience, or shock, that creates substantial and often lasting damage to the psychological development and well-being of the individual. Traumatic events are exceptional situations of helplessness and distress that a person experiences at first hand, witness or hears about, and which jeopardize the physical and/or psychological integrity of the individual or those close to him. Typical traumatic events are natural calamities, violence, serious accidents, the death, injury, or serious illness of next of kin, and war-related stress. Trauma can appear after a single event, a series of events, or a particularly upsetting period of life of a traumatic nature.”

The Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association, indicates that traumatic events include: combat, sexual or physical assault, robbery, kidnapping, taken hostage, terrorist attacks, torture, disasters, severe accidents, life threatening illnesses, witnessing death or serious injury, and child abuse.

WHY DISCUSS THE PSYCHOLOGICAL IMPACTS?
In 2005, the World Health Organization indicated that “there exist many misconceptions among the general public, politicians and even professionals regarding the concept of mental health. This is due to the fact that mental health is in many ways undervalued in our societies. The concept is often confused with severe mental disorders and associated with societal stigma and negative attitudes. It is also often the case that curative medicine focusing on health problems attracts more attention than public health questions of prevention and, even more so, of promotion. The positive value of mental health, contributing to our well-being, quality of life and creativity as well as to social capital, is not always seen.”

Governments and the public are now recognizing the impact of trauma due to our returning casualties from combat operations in Afghanistan. What about emergency services personnel, aid workers, or the thousands who are victims of war, crime, or disasters and have no one, or nowhere to turn to, and must remain within the environment that caused their trauma? In accepting that both responders and victims of traumatic events may develop psychological ailments, consider the following Canadian statistics:

• Post-traumatic Stress Disorder (PTSD): According to the Statistics Canada survey the one year and lifetime prevalence of PTSD is 2.8% and 7.2% for members of the regular force and 1.2% and 4.7% for reservists.
• Veteran Affairs is already reporting a three-fold increase in psychological clients over the last five years. Of 10,670 veterans receiving disability benefits for operational stress injuries, about two-thirds suffer from PTSD. A military report last year on the screening of 2,700 troops who had returned suggested that about five per cent suffered from service-related PTSD. Another 5% reported major depression, four per cent reported suicidal thoughts and 17% reported symptoms of high-risk drinking.
• Of the 10,252 (Veterans Affairs) clients with a psychiatric condition, 63% have a (post traumatic stress disorder, or PTSD) condition, said a briefing note prepared for Minister Thompson last summer. “Over the past five years, the number of clients with a psychiatric condition has tripled, increasing from 3,501 to 10,252; the number of clients with a PTSD condition has more than tripled, increasing from 1,802 to 6,504 as of March 31, 2007.” The statistics represent those who are no longer serving in uniform. The Defence Department keeps its own, separate tally of members suffering from stress injuries. Figures obtained last summer by The Canadian Press show that of 1,300 Canadian Forces members who served in Afghanistan since 2005, 28 per cent had symptoms suggestive of one or more mental-health problems. The numbers are based on post-deployment screening.”

One point to stress is that these numbers capture only ‘those’ who were traumatized. What about the families, friends and communities who provide support to the casualties?

WHAT ARE POST-TRAUMA EFFECTS?
I remember it being said years ago, prior to entering the military, that in battle, it is better to wound the enemy than to kill him, for it takes two more men to render assistance whereby reducing the number of enemy you have to fight. As you review the effects of post-trauma (we primarily discuss PTSD), consider the toll and collateral costs not only to the casualty, but all those who render assistance.

Though post-traumatic stress disorder is an ever increasing mental health condition and concern for military personnel, this disorder is not exclusive to the military. In fact, as defined earlier, numerous other causes may initiate the onset of post-­traumatic mental health conditions.

The following psychological disorders and symptoms are presented as primary post-trauma effects as reflected by an online psychology resource (AllPsych online):

Primary Effects: Disorders and Symptoms

• Post Traumatic Stress Disorder: Symptoms include re-experiencing the trauma through nightmares, obsessive thoughts, and flashbacks.  An avoidance component exists where the individual avoids situations, people, and/or objects which remind him or her about the traumatic event.  Finally, there is increased anxiety in general, possibly with a heightened startle response.
• Acute Stress Disorder: Symptoms include dissociative symptoms such as numbing, detachment, a reduction in awareness of the surroundings, derealization, or depersonalization; re-experiencing of the trauma, avoidance of associated stimuli, and significant anxiety (irritability, poor concentration, difficulty sleeping, and restlessness). The symptoms must be present for a minimum of two days and a maximum of four weeks and must occur within four weeks of the traumatic event for a diagnosis to be made.
• Dissociative Disorders: The main symptom cluster for dissociative disorders include a disruption in consciousness, memory, identity, or perception.
• Depersonalization: Characterized by feelings of unreality, that your body does not belong to you, or that you are constantly in a dreamlike state.
• Dissociative Amnesia: Symptoms include memory gaps related to traumatic or stressful events which are too extreme to be accounted for by normal forgetting.
• Dissociative Fugue: This disorder may include abrupt travel away from home, an inability to remember important aspects of one’s life, and the partial or complete adoption of a new identity.
• Dissociative Identity Disorder: This disorder is the existence of more than one distinct identity or personality within the same individual. The identities will ‘take control’ of the person at different times, with important information about the other identities out of conscious awareness.”
• Major Depressive Disorder
• Panic Attacks and Agoraphobia: a fear of public or open spaces.

Secondary Effects
Secondary effects describe the development of complications associated to the onset of primary psychological trauma that may present as co-morbidity. Research indicates that individuals afflicted by post-trauma disorders are susceptible to developing one or a combination of the following conditions:

• Alcohol abuse
• Drug Abuse
• Abusive behavior including sexual and physical abuse of others; self-harming and self-mutilation
• Suicidal ideation and attempts / Suicide
• Gambling addiction
• Internet, pornography, sexual addictions

The danger associated with secondary effects is that without intervention, the ability to address and resolve the primary cause become more difficult and may lead to the development of tertiary effects.

Tertiary Effects
Conceding that the impact of trauma may lead to the development of primary and secondary effects, we seldom consider the ‘obscure’ or tertiary effects which should be considered as ‘collateral damage’. Failure to mitigate tertiary trauma effects may result in what I term the ‘Conflict Continuum’ through ‘Trauma Transference’. The following tertiary effects are offered for consideration as catalysts in the conflict continuum and trauma transference:

• Negative Social and Economic Impact
  – Workforce reduction: Through the development of primary and possible secondary trauma effects, the potential exists that without intervention, an individual may become occupationally ineffective and unemployable.
  – Strain on Social Safety Net: The potential exists that social programs may become strained by the increasing number of casualties who are unable to recover due to lack, or refusal of treatment.
• Trauma Repatriation: Dangerous, Criminal or Violent behavior: Trauma repatriation reflects upon individuals who return from experiencing a traumatic event(s) and display overt signs of a psychological disorder. The trauma survivor may not be able to control their emotions and or actions, and depending upon the severity of their disorder, may act upon their fears and terrors whereby victimizing others. Since the start of the war in Iraq and Afghanistan [2003], a number of homicides and suicides by U.S. and Canadian combat veterans have occurred. The repatriation of post-trauma casualties can lead to re-traumatization, traumatization of others and the resurgence of violence and conflict.
• Strained Health Care System: As with the economic and social impact of trauma, the health care system is also vulnerable to increased demands. Primarily afflicting health care providers and systems in less developed countries, consider the strain posed by treatment of physical traumas and psychological traumas. Unfortunately, most health care systems are unable to manage all casualties, hence the prioritization to treat physical injuries.
• Trauma Transference: Clinical information indicates that trauma transference and vicarious trauma are one of the same. I would suggest that trauma transference is different and described as the transferring of trauma experiences to others by the dysfunctional behavior of a casualty, causing traumatization of others. Contributing factors include dysfunctional relations and/or communication skills.
• Vicarious Trauma: This particular method of traumatization has received media attention following the September 11th attacks of 2001. In 2001, the New England Journal of Medicine reported that a number of Americans were assessed with substantial stress symptoms from media exposure to the devastation of the ‘Trade Centre’ buildings collapsing and the associated loss of life. Therefore the experience of watching or hearing of traumatic events may be harmful.
• Creation of ‘Chosen Trauma’: Dr. Vamik Volkan’s theory of ‘Chosen Trauma’ implies that the trauma suffered by a society, is generationally transferred becoming embedded within their social identity. This transference, though not necessarily causing trauma to other generations, is a contributor to the continuance or possible resurgence of conflict, a byproduct of traumatization. The danger with this development is the potential for frustration to be acted upon through violence where re-victimization may cause conflict or progress the ‘Conflict Continuum.’
• Conflict Continuum: I believe there is another aspect of post-trauma that could lead to the continuation of trauma through resurgence of violence or conflict. In the field of conflict resolution, the term conflict continuum has a number of meanings, but taken literally, the inability to mitigate the effects of post-trauma may lead to a cycle of conflict and traumatization. Therefore, in the absence of trauma intervention psychological post-trauma effects may lead to a ‘Conflict Continuum.’

What does this mean?
Conflict exists when experiencing the perception of incompatible goals or objectives. Communication of the conflict may result in an immediate resolution (through communication) or induce a fight or flight reaction. Where the fight reaction is acted upon, the conflict is intensified. The conflict or hostilities stage could lead to a resolution (whether voluntary or through intervention) with a subsequent state of calm.

How does the ‘Conflict Continuum’ apply to the post-trauma mind? Consider the scenario of a former combatant who has returned home after witnessing and experiencing numerous traumatic experiences. If suffering post-traumatic effects such as violence, anxiety, and anger, this individual may experience or create conflict as a coping mechanism. The cycle of ­conflict is now enabled, jeopardizing the family environment by victimization/ traumatization, thereby creating the propensity for trauma transference and ‘Conflict Continuum.’

Through the conflict continuum, we can better understand post-trauma, its effects and the toll on an individual or ­population.

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Serge E. Vidalis is a retired naval officer and a post-trauma casualty who served in the Canadian Navy’s Clearance Diving Branch conducting Special Ops. In addition, he served as a Police Officer in British Columbia and a security consultant. Currently, he is pursuing his doctorate at the University of British Columbia on National Security, Defence and Public Safety matters.
© FrontLine Defence Magazine 2009