Dr. Dror Green

Post trauma: mental illness or injury


Many soldiers, including myself, were also physically wounded during the war, and were recognized by the military administration as war invalids. When wounded during military sercice one immediately receives medical treatment by physicians who do their best to cure all demages. In cases of total damage in hearing, sight or cut off organs, invalid army veterans are entitled to long term support, additional to financial and occupational support. 
It is easy to identify physical injury, to diagnose it and treat it with proper medical means. War veterans who suffer from phisical damages are treated with respect by society. It is much difficult to identify emotional or ‘mental’ damage, as it is wrongly entitled. The term ‘mental’ is an abstract term, and has no unequivocal definition that enables diagnosis and treatment. Combat fatigue and post-trauma are treated as ‘mental damages’, and this enables the support system to prevent post-traumatic veterans prove that they suffer and get the appropriate treatment. 
Identifying the post-traumatic symptoms  
PostTraumatic Stress Disorder (PTSD) is a normal reaction to unusual shocking event that causes anxiety. 
It is not easy to identify the symptoms of PTSD, since they often show only many years after the traumatic event. Each PTSD victim experiences it in a different and unique way and most of them and their families are not aware of the meaning of these symptoms, which they connect to many other causes. 
Sometimes even therapists that work with PTSD victims find it difficult to recognise the source of these symptoms. The main sorurce for certified diagnosis is the DSM-IV, the American Psychiatric Association's Diagnostic and Statistical Manual. By its definition PTSD sufferers are those have some of these symptoms: 
A. The person experiences a traumatic event in which both of the following were present:
  1. The person experienced or witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. 
  2. The person's response involved intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in any of the following ways:
  1. Recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions. 
  2. Recurrent distressing dreams of the event. 
  3. Acting or feeling as if the traumatic event were recurring (eg reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those on wakening or when intoxicated). 
  4. Intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event. 
  5. Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma) as indicated by at least three of:
  1. Efforts to avoid thoughts, feelings or conversations associated with the trauma. 
  2. Efforts to avoid activities, places or people that arouse recollections of this trauma. 
  3. Inability to recall an important aspect of the trauma. 
  4. Markedly diminished interest or participation in significant activities. 
  5. Feeling of detachment or estrangement from others. 
  6. Restricted range of affect (eg unable to have loving feelings). 
  7. Sense of a foreshortened future (eg does not expect to have a career, marriage, children or a normal life span).
D. Persistent symptoms of increased arousal (not present before the trauma) as indicated by at least two of the following:
  1. Difficulty falling or staying asleep. 
  2. Irritability or outbursts of anger. 
  3. Difficulty concentrating. 
  4. Hypervigilance. 
  5. Exaggerated startle response.
E. The symptoms on Criteria B, C and D last for more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
(American Psychiatric Association. 309.81 Posttraumatic Stress Disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Association, Washington 1994:424-429). 
The DSM diagnosis of PTSD is not an accurate scientific definition, but a list of symptomse, each of them can occur separately during the life course of any human being. Only the presence of some of them at the same time means, according to this diagnosis, that there is PTSD. 
According to my personal experience and my encounters with many PTSD veterans I can add to this list some fundamental characteristics: 
  1. Anxiety.  This is the main experience that is common to all PTSD victims. This is not a fear but a physical paralysing reaction, accompanied by chest pain and breathing difficulties. Sometimes these symptoms are similar to heart attack. Anxiety happens with no actual stimulation in different times. Sometimes it is a reaction to forced changes (going out of the house, taking a stand, certain actions, etc.) or external pressure. 
  2. Flooding. This is a sense of inner clarity and concentration and at the same time inability to respond to external stimulations (to react to other people, to take responsibility, to be in crowded or noisy places). 
  3. Cognitive damage. Despite intelectual achievments or inteligence many PTSD victims suffer from memory difficulties, and others are dyslectic. 
  4. Accidents. Sometimes, especially with PTSD victims who are not aware of their symptoms, aggravation shows itself through a series of accidents: work accidents, road accidents or small domestic accidents. 
  5. Crises. PTSD victims have to cope with so many difficulties that repeated crises are inevitable. These crises damage and prvent the potential of normal life. They often cause divorces, disemployment, disconnection from family and friends, etc. 
  6. Self-sestruction. Many victims of combat fatigue believe that they are responsible for their trauma, or blame themselves for surviving while their friends were killed. The same happens to rape victims, who blame themselve for cooperating with the rapist. This feeling creates a pattern of self-destruction, which destroys all achievements (professional, career, creative, relationship, etc.). Many PTSD victims cannot prepare for the future and find themselves with no permanent job, no pension and no family members to support them in old age. 
A new definition to PTSD 
The conventional definitions of PTSD are vague and faint, since they are based on the vague definition of ‘psychotherapy’ and the pretence to heal ‘psychic’ symptons that have no accurate definition. In my research I found more than 400 different approaches to psychotherapy, based on different and even contradicted assumptions concerning the ‘mind’. I also found out that there is no way to identify successful treatment or a failure, since such treatment or ‘therapy’ can not be described by terms that are not subjective. 
The faint definition of PTSD reflects the basic assumptions of psychiatry and the psychotherapeutic approaches that accept the DSM-IV diagnoses. According to these assumptions mental health has two poles: one is normality and the other is pathology. Therefore, severe mental damage means severe pathology. 
But PTSD is not pathologic, i.e. an illness that can be cured, although it is a severe damage. The posttraumatic damage is similar to limb amputation, which severely disrupts the body’s functioning. It is impossible to restore such damage, and it demands new adaptation that can be learned. Psychiatry treats PTSD with medications that reduce the symptoms but also disrupt the proper functioning. The psychoterapeutic approaches that refer to post trauma as pathology fail to fix the damage that can not be fixed. In some cases they try to restore the traumatic memory, which may also increase the damage. The cognitive-behavioural approaches are more effective, since they are not based on mental definitions. 
My new approach, ‘emotional training’, which I will present in the next chapters, is based on a different model of the mind (or the mental activity). Instead of the vague definitions of ‘normality’ and ‘pathology’ I suggest two other poles of emotional health: one is ‘anxiety’ and the other is a ‘safe place’ (or ‘secure frame’). Anxiety is the natural response to dangers in reality, and especially to death that we all meet during our life circle. The ‘safe place’ is the frame we create in order to protect ourselves (a house, a family, religion, country, culture, etc.). When the ‘safe place’ is not strong enough our anxiety increases correspondingly. All ‘mental’ damages are, actually, a manifestation of the weakness of the ‘safe place’ and the increase of anxiety. 
Severe trauma, such as combat shell or a rape, is a manifestation of extreme anxiety and almost total lack of a ‘safe place’. 
Anxiety, as well as a ‘safe place’, are not natural situations, deriving from our organic system, but acquired skills that enable us to cope with reality. Therefore, we cannot ‘cure’ anxiety and expect that the ‘safe place’ would also be rehabilitated by itself. Traumatic damage means a destruction of the skills to create a ‘safe place’, which we had acquired slowly during our lives. Instead of ‘curing’ the trauma I suggest that we have to recreate the emotional system, so it will enable us to recreate the ‘safe place’. This it the purpose of ‘emotional training’. 
The trauma of being aware of the trauma 
The traumatic damage increases with every new traumatic experience. Unfortunately, when one becomes aware of the trauma one experiences a new traumatic process that may increase the trauma or postpone the appropriate treatment. Contrary to the psychoanalytic assumption that awareness relieves or decreases the traumatic symptoms, the awareness to the trauma does not bring any relief. Veterans who realise that they suffer from post-trauma must cope with more difficulties and new kinds of traumatic pain. 
The reason for this phenomenon is simple. Self-awareness of the trauma shakes the foundations of one’s biography and forces new understanding of the personal history. Post-traumatic victims are forced to re-evaluate their whole life system, their choices, their values, their professional career and their family and personal relationships. No wonder why many veterans who recognize their trauma lose their jobs, divorce and draw away from their social circles. 
I was aware of my traumatic experience in the 73’ war between Israel and Egypt, but it took me more than thirty years to recognize my post-traumatic symptoms, although I was an expert in this field and have worked with post-traumatic victims for more than seven years. My professional experience did not help me, and the revelation was traumatic and painful. I was forced to face the symptoms when one of my coleagues reflected my behaviour, and it hit me like a blow in my face. I can also remember the reaction of my students, who were family doctors, when I demonstrated a simulation with a post-traumatic victim. They were moved by the autenticity and by the convincing play, while I have realized that I had exposed a personal experience without being aware of it. It took more than six months until I could tell my wife about it.
Other PTSD victims experience the first awareness of their symptoms with even more tarumatic reactions. Some of them become violent and aggressive, and have to cope with disemployment and divorce. Others, who are still serving in elite military unites in their reserve service, refuse to face their symptoms. Their wives and partners tell me about panick attacks, about nights without sleep and about emotional difficulties that damage their family lives. 
The trauma of coping with family and friends 
When one decides to share his secret, concerning PTSD, with his family and partner, one has to cope with a new kind of traumatic experience. There are various kinds of reaction by close relatives to such exposure, but simple understanding and support is seldom one of them. Since PTSD is interpreted by the public as a kind of mental illnes, many people are still deterred by the stigma. 
When I told my wife, Efrat, that I sufferred from PTSD, she was frightened. She thought that this might ruin our family, that I will not be able to work and make a living, and that I would not be able to function as a father. At this stage, as many other PTSD victims, I was very sensitive, and her reaction increased my symptoms. I could not go on and hide my weaknesses. I started craying and weeping in strange times with no reason, I became aggressive and while being frustrated I could kick the furnitures and break glasses. 
When I told my father about it he treated me like a liar who pretends to be a war invalid and ask for privileges. I felt betrayed and could not talk to him for a long time. It still hurts me that he have not tried to talk to me about it until today. 
These kinds of reactions are so painful and traumatic, that many PTSD victims disconnect themselves from their partners and families, and do not expose their difficulties any more. 
At this stage, when my whole life system was shaken, I decided to support myself with my new therapeutic method, ‘emotional training’. I was lucky to have my wife’s support and cooperation, and we both decided to accept the PTSD as part of our lives and learn how to cope with it. This was very productive, since the identification of the traumatic symptoms made us understand some strange behviours and signs that had no explanation before. 
My wife’s support was the cornerstone of the new life structure, in which I could face the traumatic smptoms and cope with them. Such a support in the early stage of coping with PTSD is essential but also rare. 
The trauma of coping with the bureaucracy of the helping system 
Israel colud be the international center for methods and information concerning PTSD. Wars and terror are part of everyday life in Israel, and hundred of thousand of Israelis were exposed to traumatic experiences. Paradoxically, the terms ‘shell shock’ and ‘post-trauma’ were not accepted by both the professional jargons and the spoken language. The military administration did not want to recognize shell shock and post-trauma and believed that such recognition might weakent the spirit of the soldiers. The civil society, which is not tolerant to people who are deviating from the conventional system, label post-traumatic victims as traitors, spoiled or insane. Although the term PTSD becane familiar in the last decade, the helping system and the administration is still alienated, most of PTSD victims are not treated and no serious researches were made in order to develop new therapeutic approaches. 
This is true for other countries, in which trauma can be caused by wars, terror, natural disasters or violence. Post-trauma is not visible as other kinds of injury, and human beings prefer to ignore intimidating phenomena as much as they can. For PTSD victims, who need support and recognition, this reaction is hard and distressing. 
Soldiers who were exposed to traumatic events during the war, or civilians, who were persent in terror events, need to be treated by the official helping system within a short time after the event. Unfortunatelly, pots-traumatic symptoms come out a long time after the event. It can take weeks, months or many years after the traumatic event. The helping system does not support people who were exposed to traumatic events, and in most cases they have no means to support people who ask for help after the traumatic event. No one can anticipate the long-term effect of the trauma and each PTSD victim process the symptoms in a special and unique way. The best support at the time of the event can be made by family members and close friends, who can accept the trauma and offer a continnuing emotional support. 
PTSD victims approach the helping system a long time, usually many years, after the traumatic event. They do so after coping alone with the increasing symptoms, the traumatic process of being aware to the trauma and the traumatic reactions of their family members. The interaction with the helping system is hard and traumatic, since it involves meetings with officials and administrators that have no helping qualifications, and demand proofs for each claim. 
In this stage PTSD victims are vulnerable and anxious, and each interaction enhances their pain and their disbelief. Now they have to see specialists and medical boards, and hire lawyers that will represent them. This exhausting process may take months or years, and many PTSD victims prefer to give up and stop it before there are any rusults. 
PTSD victims who can survive this painful process and are entitled to be supported by the helping system must be depended by the administration as long as they need support. This means that in spite of its proclaimed role, the helping syste m is also a factor that enhances the trauma. 
PTSD as a social disease 
People were always scared of emotional or so called ‘mental’ symptoms. Such symptoms, which represent invisible characteristics of the human nature, are regarded as demons that can endanger the social structure. 
Paradoxically, in most cases these emotional symptoms, as most symptoms of PTSD, can be found separately in any normal person. Emotional symptoms are often a sign of a social disease. This is especially true for PTSD victims. PTSD victims that were involved in military activity or rape are responsible for their pain. They are the victims of a social activity in which they were forced to be involved. Social systems never like to expose their weaknesses, and it is conventional to blame the victims for the social disease. 
The atitude toward PTSD victims may rate the social disease. A negative attitude concerning PTSD victims expresses a high degree of social anxiety, while strong and secure societies are more tolerant to such weaknesses. Posttraumatic society, like the Israeli society which is exposed to traumatic events for more than sixty years, develop the same symptoms of PTSD victims: anxiety, violent behaviour and xenophobia and tends to racism and fascism. 
This means that post traumatic victims, whose trauma is common in wide parts of society, will not gain the help and support they need. As sad as it may sound, in areas where the trauma is widespread, less effort will be made to learn and to develop methods lf rehibilitation. 
Post-trauma is not a mental illness but an injury as any physical damage or a limb amputation. It is an amputation of the sense of security, which is essential for adaptation to reality, and it is also a deep damage of the emotional skill that creates the sense of a ‘safe place’. Post-trauma does not require thrapy (psychologic or psychiatric), but a restoration of the emotional skill of creating a ‘safe place’. This can be made by learning and training, which is the essence of emorional training, to which this book is dedicated.