Red Cross founder Clara Barton fought ‘thin black snakes’ of depression by springing into action

http://www.washingtonpost.com/lifestyle/magazine/clara-bartons-enemy-depression/2012/04/04/gIQAdryXzS_story.html

 

How many significant figures of history actually suffered with PTSD? We may never know. The diagnosis, now part of our collective 21st century lexicon, did not exist before 1980. Many historians point to the Civil War with the description of Soldier’s Heart as the earliest attempt to describe emotional consequences of war. Jonathan Shay wrote about warriors from Greece who incurred the invisible injuries we now diagnose as PTSD. The earliest medical descriptions of PTSD started in the 1830s during the early era of railroads. Numerous collisions and explosions resulted in a condition called “Railway Spine”, something akin to mild traumatic brain injury at first, but later described as a psychiatric condition consistent with PTSD.

Did Clara Barton suffer with PTSD? On the basis of Melinda Henninberg’s article, I would say it was quite likely. More importantly, what can we learn from Clara Barton’s rather extraordinary life? I think there are many lessons applicable to modern observers:

  • Her childhood was filled with fear. She grew up in a chaotic and likely violent family. The article describes pervasive and dramatic mental illness, a sister locked away and a brother who committed suicide; another brother robbed banks. As noted in her diary: “In these later years I have observed that writers of sketches, in a friendly desire to compliment me, have been wont to dwell upon my courage, representing me as personally devoid of fear, not even knowing the feeling. However correct that may have become, it is evident I was not constructed that way, as in the earlier years of my life I remember nothing but fear.” Does growing up in a dysfunctional family better prepare you to survive during war, chaos and/or insanity? There is no absolute answer to this question, but a dysfunctional family may actually help you endure the unmanageable. No exotic constructs needed here; if you grew up having to dissociate to survive, you may simply have ‘more practice’- the equivalent of early military training. Conversely, some individuals are less prepared for chaos if they grew up in a ‘crazy’ family. A lot depends upon context, types of stressors, etc. My personal observation is that a dysfunctional family background may make you stronger during a crisis, but in the long term it might make recovery, or at least a balanced recovery, much more difficult.  Early studies conducted at the University of Minnesota described a population of “invulnerable children”. These were kids who grew up with schizophrenic and alcoholic parents but did not have overt problems as adults. In fact, many were highly adaptive and showed no signs of outward difficulty. When this population was studied more closely, researchers learned that outward coping masked many harsh consequences. They later gave up their quest and decided “invulnerable” was a flawed concept. On the flip side, growing up in a safe and nurturing family is no guarantee you will not develop harsh symptoms. We need to consider multiple variables- including frequency of exposure to trauma, intensity of the trauma, duration of the trauma and age of exposure. Invulnerability is a seductive illusion, but even those who look intact may endure severe suffering.
  • Clara Barton’s father may have had PTSD. This may be mere speculation, but as noted in the article:  “Her father, Capt. Stephen Barton, had served under “Mad Anthony” Wayne in the French and Indian War, and “his soldier habits and tastes never left him,” she wrote. He and Barton’s mother, Sarah,”… fought loudly and often.” It is not unusual to see multi-generational trauma transmission. This is something rarely studied but worthy of serious consideration. When PTSD rates in current and past wars are sited, we really should include the family unit. Like so many conditions, PTSD becomes a family problem. Nihilism, cynicism, anger and emotional unavailability are features we often see. Overt family violence is not necessarily an outcome. In fact, emotional distance and avoidance is what we most commonly see, along with intermittent outbursts of anger, often directed at others (road rage is a common phenomenon). The likelihood of physical violence seems directly related to the use or non-use of alcohol and other drugs.
  • Clara may have also struggled with the bipolar disorder, a condition that is now known to have strong genetic foundations. Clara’s brother committed suicide and her mother displayed possible features consistent with a mood disorder.   Kay Jamison excellent book, Touched with Fire describes many figures of history, including Churchill, Lincoln and Hemmingway who probably suffered with the bipolar illness, often mistaken for simple depression. The swings of mood Clara described followed by fits of amazing endurance fit with patterns observed with the bipolar illness. In addition, risk of suicide is also much, much higher with those who so suffer.  It is important to note that the bipolar condition increases risk for alcoholism and addictive disorders. It also increases risk for suicide, and the depth of depression is far in excess of situational depressions. Making this more exotic is the fact that PTSD also mirrors the extreme swings in mood we see with PTSD. Emotions and impulse rule, and dramatic shifts are quite common. Finally, alcoholism mimics the swings in mood observed in PTSD and bipolar disorder. And one more addition to this complexity: mild brain trauma (mTBI) mimics symptoms of PTSD, mood disorder and alcoholism. The bottom line for readers and diagnosticians: many of these conditions travel the same path and are hard to differentiate, even in the modern era.
  • She likely had problems with trust, attachment and relationships.  Not much detail is provided in the article, but Clara never married. Out of the thousands of young men and officers she encountered, she fell in love with a married Union captain who was already married. I cannot speculate as to her actual attachment pattern, but I can say that individuals with early childhood trauma tend to avoid attachments with those who are available and loving, and too often chase the impossible or abusive partner.  More of this will be reviewed in subsequent blogs, but for now, problems with core attachments and “recapitulation” of childhood rejection is an almost classic consequence.
  • Working with those injured or dying can produce PTSD. Originally, it was believed that in order to develop PTSD you had to have first-hand exposure to death and violence. If a bullet or rocket did not come toward you, how could you possibly develop PTSD? We now know that direct violence is sufficient but not necessary in the development of PTSD. Many studies show that those who clean up the aftermath of train wrecks, car crashes and fires have a high rate of PTSD. In fact, medics, nurses and physicians have very high rates of PTSD. It is a core principle we now accept: being witness to or part of the aftermath of violence can be as toxic as direct exposure to violence. Those who prepare or transport the dead are also vulnerable, even if they never heard a weapon fired in combat.
  • She found meaning and relief in her work. This is perhaps the most valuable lesson we can discern. As noted in the article “Her diaries (later discovered behind the wall in her former Glen Echo home, now a national historic site) reveal that she self-medicated through service: She used the most intense, bloody work imaginable to keep the “thin black snakes” of sadness from closing in.” While sited in the article as an antidote to depression, Clara’s dedication to helping others – at first her brother and later countless others – is a great example of ‘giving back’ as a method of healing. I refer the reader to Victor Frankl for a more complete discussion of this potent factor in human survival and transcendence.  Finding meaning by helping others is exceptionally effective, but Clara’s story demonstrates another vital lesson. Any single strategy applied in excess may leave you exhausted, alone and struggling in isolation. As with all healing factors, helping others and finding meaning should be done as part of the journey of finding or rediscovering balance- emotionally, interpersonally, cognitively and in terms of meaningful action. Even good work can become excessive, unbalanced and perhaps shift from ‘self-medication’, as noted by Clara, to a near addictive pattern depriving you of the satisfaction and balance originally displaced by exposure to trauma.

Clara Barton, the founder of the Red Cross, and her struggle with the ‘black snakes’ of depression, illustrates the complex consequences of exposure to and immersion in trauma. While she lacked comprehension to describe the extent of her suffering, her self-described ‘depression’ was insufficient in capturing the multiple and complex symptoms of what we would now call PTSD and co-occurring disorders. Ironically, Clara Barton’s symptoms propelled her into an excessive, perhaps addictive attraction to violence and war, providing her partial relief and affording comfort and relief to millions as well.

Link Between PTSD and Violent Behavior is Weak


 

http://www.washingtonpost.com/national/health-science/link-between-ptsd-and-violent-behavior-is-weak/2012/03/31/gIQApYFZnS_story.html

 

The political and emotional complexities of PTSD and TBI (traumatic brain injury) can lead to stigmatization and inaccurate attributions. It has long been assumed that soldiers, especially those who have served in combat, are at higher risk for violence. Following WW II several congressmen introduced proposals to send returning combat troops to islands for ‘retraining’ before returning to civilian life. Following Vietnam we had Rambo movies and veterans “going postal”. The facts are both simple and confusing: sudden outbursts of violence are rare and very hard to predict.

The article referenced above summarizes some of what is clear: PTSD and TBI can produce shifts in emotional management and changes in “executive brain function” resulting in possible impulsiveness. Complex phenomena like PTSD and TBI are difficult to study and data is scattered, sometimes inconsistent or contaminated by selective sampling or agency agendas. What is clear is that spectacular episodes of sudden violence are extremely rare, despite media attention. There are often multiple factors involved and these include co-occurring disorders, use of drugs or alcohol, lack of sleep, number of tours, severity of symptom or injury, just to name a few. We would love to have instruments that predict these rare outbursts, but they do not exist. We are reduced to the old maxim I learned decades ago: “the best predictor of future behavior is past behavior”.

I do not wish to oversimplify; however, I want to reassure readers, especially military readers, that they are not likely to explode in some horrific headline-grabbing fashion. The title of the Washington Post article is generally accurate. Put aside the complexities of multiple tours, diminished capacity, head injury, partial recall, fugue episodes, sleep deprivation, isolation, and alcohol, and let’s focus on the reassuring take-away message. There is no data supporting the worst fear carried by many. Most veterans are well trained, restrained, disciplined, highly ethical, and filled with a sense of justice, loyalty and honor. Most veterans I have treated live with the dread that they could lose control of their impulses and inadvertently hurt someone. Newspaper headlines about sudden violence and suicide add to their burden of fear. As a 66 year old combat Marine with severe health and mobility problems recently stated, “I am still afraid of what I could do to others.- That’s why I need to stay away from others.” The fear of losing control results in isolation, self-medication, avoidance, and a whole host of symptoms we see with PTSD.

I would argue that the most common symptom is not violence but extreme dedication to work or mission. I do not have the statistics, but from my years of experience I see pro-social zealousness- not antisocial outbursts- as the most common coping mechanism. Over dedication to work/mission becomes almost addictive. It is easy to get lost in working excessive hours, and it is rewarded by recognition and increased revenue. Channeling one’s anger is difficult, but workaholism is an extreme response rewarded in our culture. However, family members can be angry and confused, and the internal burden remains hidden. Sleepless nights, avoidance, occasional road rage and other symptoms flourish, often visible only to a few. Spectacular outbursts are rare. PTSD tends to be a condition that most often fits the following: “Great souls suffer in silence.” (Friedrich Schiller).  The articulation of suffering is often the first step toward recovery.

Jerry A. Boriskin, Ph.D.

April 2, 2012

Accused G.I. ‘Snapped’ Under Strain, Official Says

http://www.nytimes.com/2012/03/16/world/asia/suspect-in-afghan-attack-snapped-us-official-says.html?_r=1&hp

Army sergeant accused of Afghan killings struggled to pay bills, passed over for promotion

http://www.washingtonpost.com/national/army-sergeant-accused-of-afghan-killings-struggled-to-pay-bills-passed-over-for-promotion/2012/03/17/gIQAcZhSJS_story_2.html

 

War Is Brain-Damaging

http://www.nytimes.com/2012/03/18/opinion/sunday/war-is-brain-damaging.html?src=recg

 

What caused Sgt. Bales to snap? A group I facilitate for Vietnam Veterans struggled with this question even before the name of the accused sergeant was released.  Violence, injury, death and war stir intense emotions in all, particularly among veterans who have been up close and personal. The issue of atrocity and slaughter of civilians is, naturally, an incredibly intense and sensitive subject.

My group members wrestled with this for 90 minutes; most had extreme empathy for the cumulative damage war has upon warriors. They could not even begin to grasp the immense pressure put upon younger soldiers, some of whom serve three, four, and up to nine tours. They/we are humbled by shocking reports of soldiers committing sudden violence, some of which is toward family, but more often towards self. They embraced the contributing factors that need be considered: alcoholism, traumatic brain injury, PTSD, financial problems, issues of unemployment, possible relationship problems, a passed over promotion, an unwanted next tour, recent injury, and experiencing the wounding or killing of fellow warriors.

Reports indicated that Sgt. Bales was suffering from many of these factors; he was also reported to be highly decorated, a model soldier, and saved lives of civilians and Americans in some of the hottest conflicts in Iraq. How could a highly trained soldier, a member of an elite unit, trained sniper and leader of men possibly commit such an atrocity? Our group struggled with this question and did not come to a clear explanation. They had empathy and contempt; some launched into politics of the current wars, some blamed the military for too many rotations, some defended the military, others discussed the role of combat, loss of recent friends, PTSD, alcohol, and tbi (traumatic brain injury). The discussions were intense and a few favored certain factors, but no consensus or full explanation was derived.

One thing we did derive: in certain situations our usual narratives fall apart. If the conditions are right, we are all capable of sudden violence or extreme behavior. The media will no doubt speculate on which factor(s) were critical in this current horror. Forensic experts will attempt to definitively opine, but we may never fully know why this particular soldier ‘snapped’ in such a dramatic and horrific fashion. Thousands of soldiers carry the burdens of war. Most struggle in silence and harm no one, and if they do injure anyone, they hurt or punish themselves.

We may never know the full explanation of what went wrong. My personal speculation is that alcohol played a large factor. It is the most common variable in violence: domestic, self or toward others. It also works in tandem with PTSD and traumatic brain injury. What will probably emerge is a complex picture of a determined and accomplished soldier worn down by many variables, military and domestic.  Early reports suggest Sgt. Bales and others were drinking heavily that evening, against military rules. Those early reports also suggested drinking to levels of blackout. Sgt. Bales allegedly had a drunk driving hit and run episode while stateside. Whereas not the sole factor, alcohol might have been the ‘tipping point’. Alcohol is a common way of “self-medicating” or “de-stressing”, but it can have an almost ‘evil’ impact in unleashing primitive emotions. In fact, it is a common but often understated factor in the surging suicide numbers in young soldiers. Alcohol has a long history of violence in so many settings, especially the home. Unfortunately, we continue to deny alcohol’s power or even its presence. Mr. Bale’s attorney alleged his client had not been drinking.

We will know more as facts emerge, but we may never fully grasp what went wrong or why. We do know that war is ugly; it changes people and distorts mind, body and soul. The results of war can make you feel ‘untouchable’ and unique. My hope is that veterans or military personnel reading this blog will recognize that their worst fears are not reflected in the rare disasters. Most people, even civilians, have a fear of ‘snapping’. Exposure to the horrors of war intensify that fear beyond that which most observers can express or comprehend. The vast majority of those who develop PTSD do not snap. Instead, they suffer quietly and deconstruct their lives.  PTSD, especially with co-occurring addiction, is complicated and destructive, but highly treatable. Recovery requires Sleep, Safety and Sobriety, the three “Ss” that are the first steps in separating you from the demons of war.

Jerry A. Boriskin, Ph.D.

March 18, 2012