H
Survivors and Shooters
Ian P. Palmer
599 This chapter is a personal view written from a British perspective. It is the product of 28-years experience as an Royal Army Medical Corps (RAMC) Medical Officer and Psychiatrist and historical study as the Tri Service Pro- fessor of Defense Psychiatry.
Shooters
Thou shalt not murder
Shooters are a unique band of humans. In war at least, they are sanctioned to kill without legal censure. The First World War was perhaps the last, and possibly only, war of the modern era in which soldiers faced soldiers and civilian casualties were limited. During all subsequent conflicts, civilians have endured death and injury, generally resulting from air attack. This chapter focuses on “military-on-military” action.
Although killing in war is premeditated and may reflect extreme self- interest, it is not generally a psychopathic act. Unless truly sociopathic, self- examination is an inevitable consequence, for all who kill will be changed by their experience. The true “psychopath” has little place in an army, as by definition they are too self-referential and absorbed to be able to fit into a body of men where reciprocity of interest and self-sacrifice is a key part of the “warrior” ethos.
Within Her Majesty’s Forces, there are many methods of delivering death, and these may be classified by the distance from release to point of impact. Unlike soldiers, sailors and airmen seldom see the result of their handiwork to the extent that their killing would seem to have achieved the status of a computer game. Distance affords emotional protection, as does the incomprehensibility of large numbers killed, even when viewed in the media. However, only when the reality of death is visited upon ships or air- craft are shot down will unconscious defense mechanisms be challenged or abruptly removed, and only at this time are sailors and airmen likely to endure a soldier’s experience of combat.
Issues of class, opaque yet inherent, are involved in this process and reflected in the language used by Navies and Air Forces who have always attracted the “brighter” sections of society’s youth. They use terms that reflect the “precision” involved in their technocratic structure; they talk of
“surgical’ strikes and compare them, favorably, with the ‘butchery’ of combat. However, it could be argued that a soldier is actually more surgi- cal and much less likely to kill civilians than their naval or air force coun- terparts. Therefore, this chapter is related to the more intimate forms of killing undertaken by soldiers.
There is an ancient “martial” code within soldiery. Many nations have demanded that their young men prove themselves in combat or other trials of strength derived, in the West at least, from chivalric codes of combat between equals. Perhaps the “idealized” duel between equals lives on most vividly in the Royal Air Force (RAF) in the “dog fight.” In some societies, killing may be seen as the “ultimate” male experience in contrast with birth being the “ultimate” female experience. It has long been held that it is easier to kill your enemy if you hate him, but there are few soldiers who despise their enemy unless they have transgressed the code of combat and behaved despicably towards comrades or civilians. Interestingly, it is easier to loathe your enemy the further you are away from them, and efforts to engender
“blood lust” were spectacularly unsuccessful in the Second World War.
For many years and many reasons, British society has remained ambiva- lent towards those soldiers who undertake its dirty work. Soldiers are soon forgotten, marginalized, or quarantined after combat in order that society is not infected by what these merchants of death have done and seen. I have met few real combat veterans who like to talk of their experiences other than with their comrades. Most fear distressing those they love by telling their tales, and all loathe those in society who wish to vicariously and voyeuristically see action by association.
Few soldiers kill without weapons. I have seldom encountered these cases professionally or socially. Hand-to-hand combat is a struggle to the death that when the soldier subsequently cogitates upon it might engender regret, but regret tempered by the innate drive to survive in a life-or-death situation.
Weapons protect individuals by inserting distance into the equation of killing, most noticeably in air- and sea-delivered modes of death. Combat and killing can only partially be prepared for in peace, and despite the media’s perception, it is my clinical experience that the events combatants encounter are a problem for only a few. This is because psychological reac- tions, short of psychosis (which is rare in combat), are multifactorial in genesis and meaning is integral to etiology. Such reactions are the product of an interaction between the individual, the event, the environment at the time and after, and the culture from which the individual hails and to which he returns. Meaning is generated from within individuals from all their experiences and, therefore, where they are in their life cycle; no one is a tabula rasa. The most difficult cases I have seen have nearly always had
problematic issues and experiences earlier in life that have only surfaced after combat exposure.
Killing is an experience that requires assimilation and accommodation.
Most soldier’s internal dialogue will at some stage search for understand- ing, whether consciously or unconsciously, and seek to find some reason for what happened. These may include social and religious values such as good versus evil, necessary evil, just war, super-ordinate national goals and inter- ests, and to save my life or that of my comrades. In these intra-psychic debates, rationalizations will alter with the level of threat at the time and where the individual is in their life cycle. Many live fulfilling lives after combat, but are troubled by their experiences in later life when their fac- ulties fail and they sustain losses such as the bereavement of a partner and the like. Do individuals need to seek help? I would counsel against it unless symptoms are intrusive, distressing, and interfering with relationships or the ability to function in other areas of life.
Society wants demonstrable remorse in those who kill for it. It strikes me that society may have more of a problem with the fact that most individu- als can kill in combat without remorse or intra-psychic distress. While talking is believed to be beneficial, there are costs to the individual, includ- ing shame and guilt at sins of omission or commission. To tell of killing also runs the risk of “abusing” the listener, which may engender feelings of being an abuser (repeating the killing); feeling different and alienated; anger by talking, especially when the listener is shocked, distressed, rejecting or pejo- rative in their reaction[s]. Even pride and self-esteem may be undermined when listeners do not understand what the soldier went through. But who is listening? Are they loved ones whom you do not want to turn against you, which they would “if they knew exactly what I’d done,” my “guilty secret”. Does the listener have an agenda (such as media, pressure groups, inexperienced “counselors,” etc.)? While others may think about killing, to have actually done it sets one apart. Inexperienced therapists may feel scared, as may the individual who knows what it is like to take another’s life; could they do it again? Other emotions include feelings of vulnerabil- ity when telling an emotionally charged story; how can grown men who have killed receive warmth and “holding” from loved ones? As few civil- ians will understand soldiers’ experiences, they may either be over- solicitous or over-protective and run the risk of pitying, demeaning, or patronizing soldiers, thus setting the scene for regression and dependency.
Alternatively, they may protect themselves by distancing themselves from listening. As talking is generally not a socially sanctioned behavior in young males, it may engender mixed feelings of impotent, inexpressible rage and helplessness and having faced and dealt death, risk-taking and tempting fate is possible and not uncommon.
Survivors
You never hear the bullet that kills you
What is it like to be shot? A veteran of World War I once told me it was
“like being hit with a crow-bar, it f*****g well smarts.” Others feel nothing until later. Some stoically remain silent while others scream terribly.
Fear is endemic in combat,1,2especially for “combat virgins”. Experience brings understanding and calm, but later, superstitions come to the fore and luck may be felt to be running out for some. Consequently, anxiety rises.
Sequelae are physical, psychological, and sociocultural. How do individuals come to terms with being a target, being singled out for death?
Injuries survived may be a badge of honor or courage, and the Americans have gone as far as honoring an injury with a medal, the Purple Heart. Like scars won in a duel, they may tell of heroism and may mark the survivor out as having cheated death. A wound, honestly obtained, is an honorable hors de combat removing the soldier from danger. It may serve the survivor as a reminder of painful memories, of potential loss, or of insights gained into the meaning of life. “True” soldiers are able to draw upon their military codes to remain steadfast in adversity and to continue the fight towards health and return of function. Others are less fortunate, but as in service, a “can do” mentality helps mental health when allied to support from comrades. Many find charity demeaning and counter to their military mores. As with most cases, pre-morbid personality is a potent pre- dictor of post-trauma outcomes.
Some injuries have organic psychiatric problems such as head injury.
However, most, if not all, will have to adjust to altered body image, limita- tion of function, and revise their spiritual beliefs. Many who survive when others have died see it as their duty to continue in life, to count their bless- ings, and to honor the memory of those who lost their lives.
Postcombat Mental Health Outcomes
While everyone involved in combat will be changed, such change may be positive, negative, or a mixture of both.3,4Furthermore, only a minority of those exposed to the same event will develop a mental disorder; the fol- lowing may explain why. Post-traumatic mental disorders are multifactor- ial in origin, that is, the product of an interaction between the following, largely uncontrollable variables: The Individual—strengths and vulnera- bilities [genetic, physical, cognitive, emotional, social, cultural]; The Event—threat [through personal meaning], severity, duration; The Environ- ment—before, during and after; The Culture of the individual and group—
shared cultural values, mores, and support. The same mental disorders
and illnesses may occur in both shooters and survivors; such disorders are seldom psychotic. Mental illness and disorders may present with psycho- logical and/or physical symptoms. Somatic preoccupation may lead to unnecessary investigation and possible iatrogenic harm, especially when no cause can be found for the individual’s complaints—so called medically unexplained symptoms.
Psychological problems include Post-traumatic Stress Disorder (PTSD) (which is not as common as the media would have us believe) and Post- traumatic Stress Reactions (PTSR), which are common.
Post-traumatic Stress Reactions may be erroneously diagnosed as PTSD, as their symptoms are similar, varying only in degree, duration, and context.
They are probably ubiquitous and a normal psychological response in a way similar to grief reactions. Post-traumatic Stress Disorder is only one metal-health outcome and should not be considered synonymous with postcombat mental disorder (Tables H-1 and H-2). It should only be diag- nosed following expert assessment when an individual has been exposed to exceptionally life-threatening events and the symptomatology interferes significantly in numerous areas of their life.
Table H-1. Postcombat, mental-health outcomes Mental health
Grief reactions
Post-traumatic stress reactions (PTSR) Mental illness
Mental disorder i. Depression ii. Anxiety
iii. Post-traumatic Stress Disorder iv. Phobias
v. Substance misuse/abuse
Adjustment reactions to physical injury, disfigurement, and disability
Medically unexplained symptoms—War syndromes Personality change
Table H-2. War syndromes Nostalgia
Rheumatism
Disordered Action of the Heart Effort Syndrome
Neurocirculatory Asthenia Dyspepsia
Agent Orange Syndrome Gulf War Syndrome
Source: Adapted from Jones E, et al., Reference 1.
The cardinal symptoms of the PTSR and PTSD are re-experiencing, avoidance, and arousal phenomena with their associated behaviors.
– Re-experiencing: Recurrent, unwanted, intrusive thoughts, images, sounds, smells. Triggers leading to distress and physical arousal, Nightmares, “As if” phenomena or “flashbacks.”
– Avoidance: Avoiding thoughts and things associated with the event, Feeling emotionally isolated, Loss of interest in things previously enjoyed.
– Arousal: “On edge,” unable to relax, Irritable and aggressive, Difficulty in sleeping and concentrating, Forgetfulness.
– Associated behaviors: Substance abuse, especially drinking, Relationship problems, Risk-taking activities and impulsivity, Survivor guilt, Depression.
Like grief, PTSR usually settle within six to twelve weeks, or sooner, but are problematic for some individuals. Indeed, grief is a good simile, as coming to terms with the psychological impact of traumatic events is like a mourning process.
Post-trauma mental illness may reveal itself in many ways and at varying times after an incident. Those closest to the individual are usually the first to notice any change, as relationship problems are common. If work is suf- fering, it is important for work mates and management to encourage indi- viduals to seek help.
Some changes are fundamental to our being and may alter our schemata for world and self-view, challenging our beliefs about our invulnerability, the predictability and order of daily life, etc. The personal meaning of trau- matic events is idiosyncratic and may cause more problems in rehabilita- tion than any physical injuries. Some will feel guilty about sins of omission or commission, and where there is abnormal or delayed coping, individuals may fail to acknowledge, accept, assimilate, and accommodate to change or loss, which may lead to avoidance and maladaptive behaviors.
Prevention is only possible if exposure is prevented, but this is impossi- ble for soldiers if they are to engage in combat; however, unnecessary expo- sure can often be minimized without damage to the mission. There is little one can do about the individuals exposed to trauma other than to ensure they are well trained, briefed, supported, led, and not exposed unnecessar- ily. Generally, nothing can change the traumatic event at the time, but it is possible to alter the environment in which soldiers operate—before, during, and after exposure to reinforce mutual support and help inculcated through training and shared hardships.
Individuals should be allowed to talk about their experiences when they want to. They should not be forced, as there is no evidence that shows this prevents post-trauma mental illness or disorder; indeed, interventions such as Critical Incident Stress Debriefing may actually be harmful if instituted too early or inappropriately.
For those suffering mental illness, psychiatric interventions work.
However, as the genesis of post-trauma mental illness is complex, some individuals will require in-depth or long-term help—they will be the minor- ity. Any assessment should search for treatable mental disorder; appropri- ate medication must be prescribed and followed-up vigorously. Cognitive, behavioral, and imaging techniques will be required to aid an individual to gain control over their symptoms and to help them address, assimilate, and accommodate to the changes wrought in them and their social world in order to get on with their life. Such processing requires time and effort and is similar to grief “work.” Individuals who become preoccupied with blame and remain angry have a poorer prognosis.
Somatic problems may be part of a mental disorder such as depression;
while they improve as the disorder is treated, other cases are no so straight- forward. Medically unexplained symptoms are numerous and vague in nature for which no “organic” cause can be found. Patients are usually subject to batteries of tests, generally in increasing order of risk without result; this can lead to a souring of the doctor–patient relationship, which may become adversarial. Patients may become even more focused on an organic etiology and may believe the doctor is withholding information or is not doing the right tests, etc. The doctor, on the other hand, may see the case in increasingly psychological terms, usually vigorously resisted by the patient on the subtext that “you thought it was physical, now you think I’m mad!” Until the inevitable impasse, both parties have been stuck in Cartesian Dualism, and to relinquish such beliefs may lead to loss of face for one party. This is counter-therapeutic, but not an uncommon situation.
Without acceptance, overt or covert, of the psychological dimension by the sufferer, treatment is difficult.
Such conditions are common after all combat and have been seen since wars began.They have attracted the sobriquet of War Syndromes and reflect the current societal health preoccupations of each generation.
References
1. Jones E, Hodgins-Vermaas R, McCartney H, Everitt B, Beech C, Poynter D, Palmer I, Hyams K, Wessely S. Post-combat syndromes from the Boer war to the Gulf war: A cluster analysis of their nature and attribution. BMJ. 2002:
324:321–324.
2. Palmer I. The emotion that dare not speak its name? Br Army Rev. 2003:
132;31–37.
3. Palmer I. War based hysteria—the military perspective. In Halligan P, Bass C, Marshall JC, eds. Contemporary Approaches to the Study of Hysteria—Clinical and Theoretical Perspectives. Oxford: Oxford University Press; 2001.
4. Palmer I. Malingering, shirking & self-inflicted injuries In: Halligan P, Bass C, Oakley D, eds.The Military in Malingering and Illness Deception. Oxford: Oxford University Press; 2003.
