Myth Memory and Meaning: Psychoanaltytic Reflections on Treating Combat Veterans in Time of Hidden War

Myth Memory and Meaning: Psychoanaltytic Reflections on Treating Combat Veterans in Time of Hidden War by Martha Bragin. Presented at the IPA 2011 Mexico Congress.

This paper will use the situation of combat veterans in the US as a case study with which to discuss the ways in which split off derivatives of the aggressive drive are enacted in the world and re-enacted as symptoms when complicity in political violence is denied.

Martha Bragin


Introduction

According to the US Department of Defence (DOD) Task Force on Mental Health, 30% of members of the armed forces returning from Iraq and Afghanistan are diagnosed with posttraumatic stress disorder (PTSD) and another 10% with depression (DOD Task Force, 2007). In 2009, 334 active duty service members committed suicide (Donnelly, 2009). Milliken, Auchteronie, and Hoge (2007) found symptoms of mental distress are directly related to exposure to combat and other extreme violence, but manifested during the reintegration period. That means that while the statistics initially suggest that only a minority of those who have fought return with emotional sequelae, when those numbers are adjusted for combat exposure these sequelae are almost universal in those who have been in prolonged and/or repeated active combat (Litz, 2007). Likierman (2008) found in interviewing military psychiatrists, that it is not a question of whether a combat veteran will have a reaction but when that reaction will occur. The Milliken et al. study also revealed that there was no difference between the mental status outcomes of those veterans who had received evidence-based treatments for PTSD and those who had no treatment at all (Milliken, et al., 2007).
I wish to propose here that it is the idea that survivors of extreme violence, are “ill” because they are changed by them, and that they should receive treatments that oblige them to live as though they do not know what they have come to know because of those experiences, is what is in fact a major cause of their distress and suffering.
To enter into this discussion I propose a twin set of propositions, based on psychoanalytic understandings of war and the human condition:
Combat veterans are different from other people. The violent fantasies that psychoanalysts believe that all people may have dreamed about, played at as children, seen in movies or played out in video games have been enacted in real life before their eyes (Bragin, 2003; Freud, 1919; Klein, 1928, 1930) They have been protagonists as victims, observers, and perpetrators. They know that there is no nightmare too horrible to happen in real life (Bragin, 2004, 2004a, 2007).
Combat veterans are the same as other people. The violent acts that they have participated in are the same ones that other people dream about, play at as children, or are entertained by in movies or video games (Klein, 1927, 1930). They appear to be common to most human societies (Freud, 1913, 1930, 1931). The wars that veterans have volunteered to fight in are paid for by tax dollars, and as Freud noted in his letter to Einstein (1933) they represent the enactment of unconscious instrumental aggression on the part of the members of the society as a whole.
Civilians in the U.S. often “forget” that these are their wars as well as those of the people who volunteer to fight them. This disavowal, sometimes called “knowing and not knowing” is a normal defence against conscious connection to extreme violence (Laub &Auerhahn, 1993; Perry, 1999, 2002). However, such disavowal can be painful for combat veterans, who may then feel that they re-enter the peacetime community as unwelcome reminders of the violence that the whole society pays for and of which, clinical theory suggests, all people may be capable, but which they are free to repress.
This process of distancing has been known to cause some clinicians to feel inadequate; as though they do not have the capacity to contain the patients’ experience. Some clinicians may feel that they have no right to try, since they have not suffered as their patients have (Oliner, 1998). This can leave many veterans feeling as though they are alone, as many Holocaust survivors did, with only fellow veterans and their enemies to understand their suffering (Bragin, 2007).
Today in the United States, combat veterans and their experiences are treated sympathetically, but nonetheless as “other” by the society at large. There is no universal transition home, unlike the tradition of communal rituals or purification, repentance and reparation that were practiced in non-Western societies cited by Freud in Totem and Taboo (Freud, 1913) and provided in clinical programs in global south. By the absence of these collective rituals of transition, the society beyond the consulting room forces veterans to maintain a rigid separation between the world that they experienced in combat, the world from which they came and that to which they return. The veterans’ failure to develop a perfect amnesia for this recent experience as well as their failed attempts to maintain the perfect separation that society appears to demand of them may then contribute to what is subsequently seen as a disorder, PTSD (Shay, 2002).
As long as the veteran is seen as alien other, whose changed view of the world is to be treated not as a normal response to extreme violence, but as a sickness from which recovery is to be achieved; it may be difficult for veterans to heal and equally difficult for society to grow (Shay, 2002). In this schema, the clinician’s role is to support the society as well as to support the veteran. It is hoped that by supporting the society to take in the veterans’ changed knowledge as part of its own, the clinician can contribute to healing the veteran as well as the body politic (Lira, 1995).
To provide effective clinical care of this type, clinicians may be required to “take in,” and to integrate the violent nature of the world in which they and the veterans live, in order to help their patients to do so. Bion referred to this dialogical process of taking in and integrating as “learning from experience” (Bion, 1962). Further, lessons from Klein and Freud suggest that in order for this to be tolerable, opportunities for reparation must be made available. In fact many authors have pointed out that even when they are not, veterans often band together to find them.

Learning from Experience: Psychoanalytic Understandings of the Effects of Violence on the Human Psyche

Psychoanalysis, from its inception, has addressed the issue of what it is that makes some external events traumatic, or more than the mind can endure.
Freud (1896) first developed his theory of trauma when listening intently to young women in Vienna, who were having serious symptoms as they pushed unacceptable memories from consciousness. He discovered that when some part of current life evoked a memory of violence and abuse from earlier life, the unacceptable meaning of the experience caused the mind to do everything possible to push it away from consciousness. In Victorian Vienna, sexual abuse was common place, and violent sexual crimes were widely discussed, but the moral code of the time made ownership of one’s own part, and society’s part as a whole, of sexual impulses forbidden. So part of what had to be kept from consciousness by Freud’s young women was that they knew something about the world that everyone else also knew and was guilty at the very least of not preventing; the unsafe sexual world of children in families. They were also aware, through their conflicted responses, of another universal truth, that even in Victorian Vienna, sex was not something reserved for specific classes of people; sexual passions lived in all of us.
At the dawn of the 21st century, violence is everywhere, but individual acknowledgement of it or of aggression as a universal drive remains elusive. People whose life experience has brought them into contact with uncanny reminders of the extreme violence that may be in part a universal legacy are once again coming to clinicians with an odd set of symptoms that keep them from knowing terrible things about themselves and the rest of the social world (Mitchell, 2000).
Freud’s work with veterans of the First World War soon led him to a similar discovery regarding war, violence and internal aggression. According to Freud, it was not the sound of shells exploding near the heads of combatants that caused shell shock, the PTSD of its day. The shock was caused by the fear of making meaning of the impulses connected with those sounds, and the forbidden nature of the knowledge of violent impulses in both the individual and in society (Freud, 1919). In 1920, he changed his theory to encompass what he referred to as a death drive that included what he called the dark and dismal impulses (Freud, 1920; Titchener, 1982).
World War I tank commander, decorated war hero, army psychiatrist, and psychoanalyst Wilfred Bion used his wartime knowledge to develop and elaborate a theory of thinking. His experience with the confusing nature of war and the effects of violence on every aspect of cognition gave rise to conceptual innovations regarding the way that people metabolize thoughts in a confusing world (Likierman, 2008). He describes the process by which unmetabolized and often violent internal experiences become thinkable through the connection to the mother. It is through the creation of such “links” that treatment is able to occur.
US army psychiatrist James Titchener (1982) first noted a phenomenon he labeled “Post-traumatic decline” in which some veterans entering treatment for PTSD became worse, not better, over time. In his clinical experience, the violent and destructive drives that war releases are an essential factor in the psychic life of veterans. These destructive drives must be addressed in the course of treatment in order to avoid “post-traumatic decline”–that is, a lifetime of symptomatology that paralyzes the survivor. The way to prevent this decline, is to address the unconscious material rooted in the aggressive drive that has been brought into consciousness through excessive exposure to violence in wartime, and to help surviving warriors to incorporate it into their postwar world view.
It was Titchener’s view that the difficulty arises when both warrior and society see his or her task as preventing the entrance of violence, real or imagined into the city gates, and thus believes himself or herself required to split off genuine experience from expression in the peacetime community. The violence is then locked within the warrior, split off, not understood, but lying in wait to cause outbursts or debilitating depression at any moment.
Monteiro (1996) and Honwana, two African theorists (1998, 1999, 2006) discuss the utilization of traditional African mechanisms for cleansing those who had participated in war before their return to the community in reintegration programs designed for combatants reintegrating from civil wars in their own countries. Their writing supports Freud’s view (1913) that ceremonial purifications and welcoming rites acknowledge that war involves aggression, violence and the taking of human life, all taboo in time of peace. They assume that once a person has broken these taboos, the breaching of them will cause psychic distress, both to the warrior and to the community. However, they emphasize it was not only those who participated in combat but those who welcomed the combatant home who were implicated in these experiences. Thus the community as well as the fighters were cleansed, the ex-combatant forgiven for wrongdoing toward the enemy; the community for wrongdoing toward the ex-combatant and his or her family by engaging them in the violence.

Learning from Experience: Dave’s Story

Dave, a tall and lanky young man, sauntered into my office. He folded himself into a chair where he fidgeted as he spoke. At first, it was difficult for him to get started, but once he did, he spoke for more than an hour, telling a great deal about his life.
Dave’s journey started in Eastern Europe and his family had come to the US for a better life. He adapted well, playing ball in the street with the other kids. School was not important to him, but since he was very bright, he discovered that he was able to get by and pass with a minimum of studying.
His father could no longer work at his profession in the U.S. and found work as a livery driver, along with many others from his country. His mother went to school at night and got a technical degree. A few years after the family arrived in the US Dave’s parents divorced.
Dave described two real interests. One was hanging around with his Dad and the other men from his country, listening to stories. His Dad, despite his lowered status, found ways to use his skills at adapting to solve other people’s problems, whether with a landlord or an employer. He loved joining his Dad at being helpful, and was sorry that this did not seem to count for anything with his Mom. He had fantasies of finding ways to impress her through his other interest, sports. Being tall, and good at the game, Dave hoped to earn a basketball scholarship as a way to college, impress his family and “be somebody, a real superhero, you know.”
However, a minor schoolyard injury put him out of the game during a crucial year for team building and his “hoop dreams” were dashed. When it came time to graduate high school, Dave’s high rate of truancy limited his options to the local community college. That would have kept him hanging around the community, a good thing from his point of view, and a disaster from his mother’s.
Mom had a solution. She met with a military recruiter and signed Dave up when he was just seventeen. He deployed immediately upon graduation.
Dave was not originally targeted to be a gunner, but he was good at it, so that became his job in the military. He rode on the back of trucks with the job of “taking out” any threat that he could see. The problem was that Improvised Explosive Devices, the biggest danger to convoys, were not something that you could see very easily.
While Dave stated that his immediate superiors “knew what they were doing,” he described the mission itself as “messed up.” He mentioned that he was a really good shot, and so he could do a “precision job,” and stated that he was proud of his role in saving the lives of his comrades in arms on many occasions. On the other hand, his unit took a very large number of casualties, and he hated the fact that he had not been able to save everyone. He felt that this was due in part to the problematic nature of the command center and the “higher ups, not our own people.” He found himself haunted by things that he had seen, done and not done, the cries of wounded friends he described as “falling apart,” quite literally, in his arms.
Dave returned to base camp in the US with the surviving members of his unit.
He had left at 17; gone to war at 18. Now he was in his early 20s, with only a high school education, and a person who had lived through life and death on a daily basis, not as part of a film or video game, as his friends had. He stated that war is different from even basic training, because of the “reality of it.” All of a sudden people really get hurt, suffer and die. You could be one of them. Your friends are some of them. The guys on the other side they are really doing things to kill you and at the same time they are taking s—t as well, and dying… real humans, falling apart, guts falling out, screaming in pain, dying, not dying.”

He enrolled in college and was a serious student, studying first to be an Emergency Medical Technician and hoping to be able to concentrate sufficiently to enter a premed program, to heal and not to kill. He was serious and hard-working taking on two jobs to supplement family income, while trying to succeed in school.
When asked to identify the most difficult thing about reintegration he stated that it was looking at his mother. According to Dave, his mother, who signed him up for the military at 17, now cries all the time when she looks at him. She tells him that she feels guilty about signing him up and placing him in harms’ way. She says that she thought they would get him an education instead they made him kill. He says that he tells her that he’s home safe and a serious man now, but all she sees is the ways that war has damaged him. According to Dave she should see that she got what she asked for, a changed man. He states that she seems not to understand that when she signed him up for the military, she had signed him up to fight in a real war, with real weapons.
This he says, highlights his most difficult experience in being home: that he knows that he is a different person, affected in every way by what he has seen and done in the military. On the other hand, he feels that people who recognize that want him to be “cured” of the experience, and others want him to just “forget about it.” As a result he states that he only feels comfortable among other vets.

Discussion

Dave longs to connect to others, to tell his stories and be understood, yet felt that he is separated from those close to him by a chasm too large to cross.
Bion suggests that the treatment relationship that must contain or take in those experiences that are too difficult (in contemporary language, too “traumatic”) for the mind to bear, in order to makes it possible for the person to digest raw experiences of violence and turn them into symbolic form (1962).
But for that to happen, both parties would have to be able to keep the violence in mind. Each party, starting with the clinician, would have to be able to take in and acknowledge, as opposed to splitting off, their own anger and aggression. This is what Dave’s mother is unable to do. The clinician therefore attempts to acknowledge the complexity of her own feelings hearing violent and gruesome tales, so as to make it possible for the patient to tell them. It is through evidence of this capacity to form a link that it becomes possible to build the bridge of connection that in turn facilitates the capacity for thinking (Bragin, 2007).

Love, Guilt and Reparation

According to Klein, the love that the child feels for caregivers gives rise to “a profound urge to make sacrifices” (1937, p. 311), the very same impulses that often brought the combatant to war and us as clinicians. However reality in wartime has duplicated the violent images that have been both imagined and repressed. If the combatant is to allow these images to enter the conscious mind, making healing possible, opportunities for reparation, both tangible and psychic are essential. In reparation lies the opportunity to once again identify with the nurturing image of loving parents and partners as well as to be forgiven for violent or aggressive acts. In his narrative, Dave sees his mother as nurturing for having sent him to the army to “straighten him out” and for the love she felt for him over the years. Yet he also describes his mother as an angry person who cannot forgive him, his father, or others who don’t meet her standards. She sends Dave to the army, and then is horrified at the fact that he did violent things there, and believes that they have damaged him.
Opportunities for reparation are a critical part of allowing Dave and others like him begin to feel clean, purified and able to live in the world again. This makes it possible to bear the pain of integrating wartime and peacetime reality (Bragin, 2004, 2004a; Shay, 2002; Winnicott, 1963). The provision of this opportunity for reparation may be what allows the patient to begin to tolerate forming a link to the therapist.
Co-constructing a Consistent, Shared Narrative
Treatment can then be facilitated through the co-creation of a consistent narrative, shared by both therapist and patient, that binds past to present, and invites the possibility of future. This task requires the therapist to acknowledge the ways in which all members of society, not only veterans, are complicit in knowing about the violence that combatants participate in on their behalf. More important is the therapist’s ability to acknowledge that both she and the veteran know that terrible things happen in war. The clinician would have to leave the paranoid/schizoid state that denies this reality, in order to make a link to the veteran and contain that veteran’s reality. In this way, she is different from Dave’s mother, who splits off what she knows and projects the damage onto him. After containing the veterans’ reality, both the shared and the unique, within herself, and linking to the veteran, the clinician can move toward enabling a co-constructed narrative of past present and future to begin to form in the consulting room, and allowing the veteran to begin to heal.
In acknowledging the reality that the veteran, the therapist and the society are together in this process, perhaps not only the veteran, but also the family, community and the body politic can begin to work toward transforming the future.
“In regard to cruelties committed in the name of a free society, some are guilty but all are responsible.” Abraham Joshua Heschel

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