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PTSD

The great PTSD conundrum

Why do 20% of American soldiers develop Post-Traumatic Stress Disorder (PTSD), and only 3-5% of British soldiers? It’s one of the great conundrums of contemporary psychology / psychiatry – and one of the most contentious, touching as it does on sensitive issues of our countries’ moral characters, and how well our governments care for their soldiers.

Dan Collins, who took his life in 2012 – a year in which the number of suicides among serving soldiers quintupled compared to 2010

The question was revisited this week by a moving Panorama documentary called Broken by Battle, made by Sunday Times journalist Toby Harnden, who won the 2012 Orwell Prize for his book Dead Men Risen, about his time with the Welsh Guards in Afghanistan. The programme traced a sharp rise in the number of suicides among troops who served in Afghanistan, and suggested the Ministry of Defence is not doing enough to help soldiers coming home with PTSD.

Toby tells me:

While I was in Helmand, I’d see instances of ‘battle shock’, where soldiers would freeze in battle, curl up into the foetal position, and be helicoptered away. I’d wonder what would happen to them. I’d heard a bit about PTSD, but I wondered if it was real or some slightly nebulous condition like Gulf War Syndrome. But out in Helmand I got to know staff sergeant Dan Collins, who developed PTSD and subsequently killed himself.

The Panorama programme explores how Dan was sectioned in an NHS mental care facility, and what a blow that was to his pride as a brave soldier (the Army used to have its own psychiatric facility but closed it). We are then shown Dan’s last words, recorded on his phone when he had left his wife and retreated to the hills, self-exiled from human society. We see him, desperately alone, wearing his military kit and the bandana he wore in Afghanistan. He apologises to his mum for being ‘a bit selfish’ in killing himself, and asks for a full military funeral. We’re told that, shortly afterwards, he hung himself from a tree.

Toby says:

After writing Dead Men Risen, I moved to the US, and saw the staggering statistics of PTSD and veteran suicide in the US armed forces. They had clearly identified a huge problem there, while in the UK armed forces, the attitude seemed to be ‘nothing to see here’.

So why the dramatic difference in PTSD rates among US and UK veterans? This is where it gets controversial. UK military psychiatrists like Simon Wessely, director of the King’s Centre for Military Health Research, suggests it’s because the British army is older, has more officers and fewer reservists, and shorter tours of duty – all of which implies that if the US did things differently, it would have a much lower level of PTSD among its veterans. US military psychiatrists bristle at such suggestions, and point out that US soldiers were in much heavier fighting in Iraq – only 32% of UK soldiers reported coming under small arms fire, compared with more than 90% of US soldiers.

US psychiatrists also suggest that cultural differences play a role, and that the British ‘stiff upper lip’ means that (in the words of a New Yorker blog) British veterans are ‘less likely to be told they have PTSD. They are more likely, in turn, to end up abusing alcohol or to be given the less controversial diagnosis of clinical depression, according to William Nash, a retired U.S. Navy psychiatrist and co-editor of an influential cross-cultural anthology on PTSD, ‘Combat Stress Injury: Theory, Research and Management.’

Harnden’s view, meanwhile, is that the Ministry of Defence wants to limit its financial liability for PTSD, so it is deliberately underplaying the scale of the problem. His documentary explored how the MoD don’t keep track of PTSD levels among discharged soldiers, nor of suicide statistics once soldiers have left the Army (although a report will be published on that next year). He also showed how veterans often fall between the cracks of the MoD and the NHS. We have a minister for veterans, Mark Francois, but apparently he doesn’t have responsibility for veterans’ healthcare (so what does he do?). The US has a Department for Veterans and the Pentagon spends a huge amount trialling new therapies for PTSD, both in treatment and in prevention.

Simon Wessely of KCL says the Panorama programme was one-sided

Harnden also points out that the Kings Centre for Military Health, our main source for PTSD incidence in British soldiers and veterans, is mainly funded by the MoD. The head of that Centre, Simon Wessely, retorts that the Panorama programme was one-sided in its exploration of the issue, and that its ‘shock horror’ statistic that more veterans committed suicide last year than were killed in Helmand is sensationalist rather than statistically meaningful. Simon also suggests that the reason PTSD incidence appears to be going up in UK troops could be because stigma about it is slowly being reduced – which is a good thing.

Both, ultimately, want to help British soldiers, and if PTSD is rising among our troops, that may be because of the intense fighting in Afghanistan in the last few years. So how could the MoD do more for our soldiers and veterans? The families of soldiers who committed suicide have drawn up a petition, which has seven demands:

1) Medical notes should be automatically passed onto GPs after a soldier is discharged. (This is to try to get the MoD and NHS to link up better).

2) The Army should carry out mandatory welfare checks on soldiers every six months after being discharged as per the recommendations of the ‘Fighting Fit’ mental health policy paper drawn up by Dr Andrew Murrison MP.

3) There should be residential units to treat all serving soldiers and veterans suffering with PTSD.

4) Serving soldiers should be able to access NHS services.

5) To reduce waiting lists for veterans seeking help for mental health related issues. Waiting lists are currently too long and it should not be left to charities to deal with this problem.

6) Soldiers should be able to ask for help with mental health issues without it going on their permanent Army records.

7) Soldiers’ families should be informed about the symptoms of Post Traumatic Stress Disorder(PTSD) and other mental health related illnesses.

You can sign the petition here.

Permission to be hurt

If there is still a ‘stiff upper lip’ in the British military, then I’d suggest that the military (and all of us) need to broaden our conception of male strength, to incorporate the Stoic idea that being strong means knowing how to take care of yourself, rather than taking out your problems on yourself and those around you. That definition of ‘Stoic’ is not the same as denying or bottling up your feelings, which is how some people misinterpret stoicism.

Personally, I was diagnosed with PTSD when I was 20, and I bottled it up for years out of a sense of shame at my weakness and foolishness (there was nothing heroic about my wound – I’d done too many drugs). Funnily enough, one of the things that helped me come to terms with my woundedness was a book about shell-shock by my great-grandfather, Lord Moran, called Anatomy of Courage.

My great-grandad, who served as a doctor in the Somme trenches

My great-grandfather was a doctor serving in the trenches during the Somme. I was particularly touched by one passage where he admitted his own fear and woundedness. He wrote of how, during the Somme, the man next to him was obliterated by a German shell: “I had a feeling as if I was physically hurt though I was not touched, the will to do the right thing was for a moment stunned…The war had never been the same since, something in the will had snapped…At the time I do not think I was much frightened, I was too stunned to think. But it took its toll later. I was to go through it many times in my sleep…Even when the war had begun to fade out of men’s minds I used to hear all at once the sound of a shell coming.”

My great-grandad went on to do great things – he was Churchill’s doctor during the War – but what touched me was that brave moment of vulnerability and candour in his writing. Even though there is a vast difference between him getting shell-shock in the trenches, and me traumatizing myself with LSD, it still seemed to give me a sort of permission to be wounded.

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In other news:

Talking of the stiff upper lip, this excellent short essay by GK Chesterton argues that the stiff upper lip was invented by decadent aristocrats in the Edwardian era and that actually manly Brits are fine with sobbing like babies.

Cary Cooper, guru of well-being at work at Lancaster University, has published a massive book called Well-Being: A Complete Reference Guide. So that’s that sorted then.

Here’s an interesting initiative: http://www.philosophydinners.org/

City AM, of all places, looks at the revival of the liberal trivium in education and business.

Daniel Dennett gives an interesting interview on religion, why Jesus is a good role model and why we need secular places that make us feel special and loved.

This week I’ve been pondering whether and how ecstatic / revelatory experiences can be ‘tested out’.

Danny Fox of Frieze considers pretentiousness with reference to Eno and Paris is Burning.

The Stoned Age: were cavemen on drugs? Would the Bronze Age have happened quicker if they weren’t?

Finally, the LA Review of Books reviews an interesting-sounding book by Dutch philosopher Peter Sloterdijk, arguing for a spirituality based on the idea of practice, with the goal of saving humanity from itself. Interesting – although the Nietzchean / Foucaultian idea of spirituality as care of the self, which Sloterdijk draws on, is highly individualistic and ignores the idea of religion as relational – as a relationship not just with your self but with your community and God. It also, perhaps, ignores ecstatic experience and the idea of people feeling a connection with God.

However, the title of the book, You Must Change Your Life, hints at the idea of hearing a divine voice – it comes from a brilliant poem by Rilke, where he stands in front of a headless statue of Apollo, god of prophecy (on the right), and seems to hear a voice telling him ‘you must change your life’. Is that his own projection, or the God speaking to him from the ruins of antiquity? Here’s the poem, ‘Archaic Torso of Apollo’ in translation:

We cannot know his legendary head
with eyes like ripening fruit. And yet his torso
is still suffused with brilliance from inside,
like a lamp, in which his gaze, now turned to low,
gleams in all its power. Otherwise
the curved breast could not dazzle you so, nor could
a smile run through the placid hips and thighs
to that dark center where procreation flared.

Otherwise this stone would seem defaced
beneath the translucent cascade of the shoulders
and would not glisten like a wild beast’s fur:
would not, from all the borders of itself,
burst like a star: for here there is no place
that does not see you. You must change your life.

See you next week,

Jules

An encounter with the Mountain King

Right at the end of my book, I talk about a strange experience I had on a mountain in Norway a decade ago. It was, you might say, a religious or mystical experience. I tucked it away at the end of the book for a very important reason: I wrote the book for theists and atheists, and I didn’t want to put off any atheists (at least, not until the very end). Ancient Greek and Roman philosophies are a meeting ground for theists and atheists, a common drinking-spot in an acrimonious time, so I was tempted to leave my own God-thoughts right out of it.  In addition, I wasn’t sure whether to talk about such a private experience, and risk commodifying it. It fact, I only put the account into a very late draft, when my publisher said the book was too short…and I was still in two minds whether to do it.

When I was promoting the book in Holland last week, some interviewers asked me about that moment as their very first question, which showed at least that they’d read the whole book.  So, today, I’m going to talk briefly about what happened, and explain why I still haven’t joined a religion, why I remain ‘spiritual but not religious’, and why I think science is the friend of God and not the enemy.

Back in 2001, I had suffered from post-traumatic stress disorder for roughly five years. It was caused by a couple of LSD bad trips when I was a teenager, which left me scarred, withdrawn, socially anxious and uncertain of reality. For five years, I became more and more lost and paranoid, a stranger to myself. Then, in February 2001, my family travelled to Norway, to the Peer Gynt region, where my great-great grandfather built a hytte. We share it with the extended family, and my family usually goes there once a winter, mainly for the cross-country skiing. Here is a photo of our hytte:

This year, we decided to do some downhill skiing on the first day. We also, for some stupid reason, decided to go down the black slope first. Oh fateful choice! It was snowing up there at the top of Valsfjel, visibility was poor. There was an ill wind from the north. The owls were restless in the trees. We set off down the slope, down the particularly steep slope at the beginning and….I smashed through a fence on the side of the slope and fell…

 

 

 

 

 

thump.

 

I fell 30 feet or so, broke my left femur, broke two vertebrae in my back, and knocked myself unconscious. Then, I’m not sure if it was while I was unconscious or after I had woken up, this happened: I saw a bright white light, something like this:

….and felt completely filled with love, and a knowledge or gnosis that there was something in me and all of us that cannot be broken, that cannot die.  Everything was OK.

I realised where I was and what had happened, and I immediately tried to wiggle the toes on my left foot, to see if I was paralysed. I could wiggle them. So I also knew that the worst that had happened was I’d broken my leg, and that, on a more terrestrial level, everything was OK. It was funny how calm and detached my mind was as it checked out the injury – I think that often happens in a bad accident, before the shock kicks in.

My uncle skied up and I heard him say ‘Oh God’. I tried to tell him that it was fine, that I’d had a remarkable experience, a peak experience (or should that be ‘off-peak’) but the words came out as gobbledy-gook, either because I was speaking in tongues, or I’d knocked myself silly. Then a motor-sledge came towing a stretcher, I was taken down to a hut at the bottom of the mountain, and put on a table while they staunched the bleeding. My father came in to the hut at that point. Here’s a picture of my father:

My father and I had not had a great relationship for the years immediately preceding the accident, because I was so uptight, anxious, and defensive towards the world, particularly the world of work. And, to a large extent, my father represented the world of work to me – the world of the office, the city, the career. My failure in that area of life (I was a business journalist, struggling with social anxiety, and very bad at getting on with co-workers and banker-contacts) felt to me like I was failing my father, who was very good at his city job and very charming with everyone he met. So I was quite defensive around him, which came across as hostility. It didn’t help that my father endlessly offered me advice on how to do things better, from clothing to shaving to even opening a tin of beans, which made me feel a Grade A Dufus. So, we had a somewhat strained and antagonistic relationship at that point.

Well, it was a strangely beautiful moment when he came into that shed – beautiful for me anyway, probably fairly horrifying for him. All that antagonism left, and I was simply his son, who had hurt himself. We’ve had a great relationship pretty much since then (we had a great relationship when I was growing up too, there was just four years in the middle which were a bit tricky…he had no idea I was internally miserable from drug-related trauma. None of my family or friends did. I was a master at hiding my feelings).

So, back to the story. A helicopter came and carried me away. I was taken to Lillehammer hospital, and went straight under the knife. I still have the metal pole in my leg that the surgeon put in that day. I spent a week in Lillehammer hospital, my father visiting me every day. I was very weak and whacked out. I remember I read Somerset Maugham’s The Painted Veil, but to this day I can’t remember a single detail of the plot. Anyway, I felt fantastic – not physically, but spiritually. I felt like the crash had re-connected me to myself, to my heart and soul. For five years, I had felt completely detached from my feelings, or at least, from any good feelings. I hadn’t been able to love, or to relate to other people – all those pro-social feelings had been frazzled by the trauma. And now, for some reason, they came flooding back. I went from paranoia to eunoia. My inner Furies were transformed into the Eumenides. It was like spring after a long winter.

Of course the euphoria died away. But I retained an insight into my condition. I realised what caused my five years of suffering was not necessarily a drug-induced chemical imbalance in my brain, as I had feared. There was nothing permanently wrong with me. In fact, even if the drugs had triggered my trauma, what sustained it was my attitudes – specifically, my fear of others’ judgement of me, my fear of being labeled a failure or outcast. I looked to others’ judgements for self-validation, and this raised other people above me like a God, and made me permanently anxious and afraid of what that God might say. It also created a feedback loop between my idea of self and the reactions of other people. My defensive expectations became a self-fulfilling prophecy, like this: (I have spared no expense with this graph…)

And I realised, on that mountain, that I didn’t need to look to other people’s approval for self-worth. It seemed to me, in that moment, that we all have an immortal and invaluable soul within us, worth far more than any fleeting public approval. It’s always there, it never deserts us, its value does not rise or fall with the approval or disapproval of the world. The Gospel of St Thomas says: ‘The kingdom is like a man who had a hidden treasure in his field without knowing it.’ Rumi said: ‘Why are you so enchanted by this world, when a mine of gold lies within you?’ Experiencing that directly, and trusting in it, I could relax, and not see others as judges or executioners, but simply as fellow humans, as brothers and sisters.

When I relaxed and accepted myself, many of my ‘demons’ calmed down and became friends. By demons I mean parts of ourselves that we can’t accept, that we push away and demonize because they don’t fit our public image. If we learn to accept them, they become allies and give us strength – the Furies become Eumenides. But sometimes we have to let go of our false public images and stop trying to live up to worldly expectations, to accept and placate the demonic bits of the psyche (getting a bit mystical here, forgive me!)

Alas, even that insight faded after a while. I went back to work, hobbling on crutches, and before long I was depressed and anxious again ( I was in a job I disliked, after all). The bad old mental habits came back. And that’s when I discovered Cognitive Behavioural Therapy, and recognised that it fit the insights I had gained on the mountain.  I realised the connection between CBT and Greek philosophy, and the Greeks’ idea of trusting in the God within. CBT gave me a systematic way to change my habitual beliefs and actions – that’s what I needed.

Why, you ask, did I not become a Christian after that experience?

Peer Gynt meeting the Mountain King

Well…I’m still not sure what happened on that mountain. It could have been my unconscious, engineering a situation in which I could be wounded and could go through the healing process I had denied myself. It could have been God…but which god? My own guardian-daemon? Some local mountain spirit? In fact, the mountain I injured myself on, Valsfjel, is famous in Norwegian mythology for being the home of the Mountain King in the myth of Peer Gynt. Peer knocks his head on a rock, goes to see the Mountain King, and learns the essence of the Troll way: “Be true to yourself and to hell with the world.'” Perhaps the Mountain King helped me!

To be honest, I do believe I was helped by something outside of me, and I do think there are benevolent non-human forces in the multiverse that sometimes help us when we need help. But alas, they don’t appear to be all-powerful. The universe is a messy, chaotic and imperfect place, closer perhaps to the Olympian universe than the monotheistic one, and in that universe people can suffer terribly, and unfairly. But I believe, as the Stoics did, that there is a higher law that roughly shepherds gods and men, and that law is connected to consciousness and compassion. It seems to me that humans’ idea of God has never stayed still, it is always evolving, as we discover more about the cosmos. We must be prepared to give up our definitions, and follow the discovery wherever it leads.

Of course, you may think it’s strange that my philosophy should be so much about control, and self-knowledge, and self-mastery, when it emerged from an experience beyond my control, beyond my knowledge, beyond my power. Well, such paradoxes are in Greek philosophy too – it emphasises reason and self-mastery, yet its word for happiness is eudaimonia, which literally means ‘having a kindly daemon within’.  The daemon within us appears to work hand-in-hand with reason. Perhaps in some ways it is reason, although it also talks to us in dreams and  visions.  I don’t know where those insights on the mountain came from – but they made sense to my reason long after the white light had faded from my memory. And you don’t need to believe in God to apply them. In that sense, I don’t see science and spiritual experience as enemies, I see them as allies in our exploration of reality.

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Here are some other links, back on planet Earth:

If you live in the North of England and are interested in community philosophy, the charity SAPERE is looking to train some people in community philosophy facilitation in a course this January. Details here. 

This Tuesday in London, Natalie Banner of Kings College London is giving a talk at Pub Psychology on mental illness. Details here.

Here’s a good Slate piece on Petr Kropotkin, anarchist prince, prison-escapee, and prophet of the evolution of cooperation.

I chaired an event at the RSA earlier this week, where I met the film-maker Stephen Trombley and one of the RSA’s delightful events people – Mairi Ryan. Mairi told me about a competition the RSA organised for young animators to animate their talks. Here’s one of the winners, animating Susan Cain’s talk on introversion.

Well done Obama.  For the Republicans, however, it was a rude collision between faith-based politics and evidence-based politics. A clash, if you will, between the geeks and the bible-bashers. And the geeks (ie Nate Silver) won. Here’s Jon Stewart failing to hide his glee.

I gave a talk today at the British Arts Festivals Association, on philosophy at festivals. Here are the slides.

The School of Life is opening in Australia!

Here’s a nice Guardian piece by Alok Jha (journalist and one of the presenters on the Science Club on BBC 2) on how science became entertaining and grass-rootsy.

Here is a sweet letter from William James to his 13-year-old daughter when she was suffering from low spirits, as he often did (thanks to Francesca Elston for sharing this one).

See you next week – and thanks to the person who did the 24th review on Amazon, I was stuck on 23 for ages! The more the better. Not that it matters, at a cosmic level.

Jules