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Memory, War and Trauma


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 (ISBN-13: 9780521716253)

Memory, War and Trauma
Cambridge University Press
9780521887847 - Memory, War and Trauma - By Nigel C. Hunt

1    Background and purpose

I was recently asked to write about the health consequences of war (Hunt, 2008). I started by trying to trace the number of casualties in the wars of the twentieth century, but quickly gave up trying to obtain any sort of accurate account; records were often not kept, or were lost during wars, were deliberately manipulated by the winners or by the losers, or the records are still (presumably) in secret files. I then tried counting the number of wars during the century; this too became very difficult, as so many of them are relatively minor in terms of casualties (unless you are a participant). In the end I gave up trying to look at every war. I ended up focusing on those wars where there were more than 1 million dead. Accounting for the wounded and sick, and those with psychological problems, these are wars with possibly 5 million casualties – and then there is the impact on surviving family members and friends. The twentieth century had around 26 such wars – if we count episodes such as Stalin's campaign against the Kulaks and Chairman Mao's killing of the Chinese, which were not strictly wars, but were internal actions that still led to millions of deaths. On the basis of the figures available, I calculated that, overall, around 240 million people (give or take 50 million) had died as a result of these large wars in the twentieth century – not counting the victims of smaller wars. Adding the injured, that makes possibly 1 billion casualties. And that does not include all those psychologically damaged people, many of them civilians, who have had to live with their memories for the rest of their lives – memories of torture, massacres, death of family members, starvation, exile and rape. There are also the thousands or millions of perpetrators who carried out these acts, but whose voices are rarely heard. They are still people who have had to live with their memories of what they did. They are still, in some ways, victims.

These numbers are too large to comprehend. They are also probably widely inaccurate, but they do serve to show the scale of modern warfare, and how it impacts on so many people across the world, either directly or indirectly. This book is about the psychological casualties of

war. Casualties are not just those who are killed or wounded, or civilians who are caught up in the fighting or just happened to get in the way of marching troops; they are ordinary people who cannot bear their memories of what has happened – the traumatised. We cannot accurately estimate the number of victims of war who are psychologically damaged by their experiences.

This book is an account of the psychosocial impact of war in its broadest sense – that of understanding memory not just as individual memory, but also as the ways in which other people, society and culture, and history, all affect how we remember. It considers the relationship between memory, war and traumatic stress. Many people have psychological problems as a direct consequence of war; many have terrible memories of these experiences that they find difficult to deal with; and many never do learn to deal with these memories. How can you come to terms with killing people, the loss of a child, or being raped multiple times, or remembering that you have killed civilians, or that you have had to permanently leave your home and your family?

On the other hand, we also know that the majority of people who go through these experiences do not have serious long-term problems, and that they are able to handle their memories and emotions and get on with their lives, more or less successfully. Many may still experience intense emotion when they think of what they have been through, but that does not mean they are traumatised. There is ample evidence to show that many of the psychosocial responses that we observe within a culture are not universal, that in some historical periods more people are likely to have problems, and in different cultures and historical periods they have different kinds of problems. Why is this so? What is it about memory, war and traumatic stress that make it so difficult to fully comprehend? Psychologists have studied memory for well over a century. We have studied the impact of war for just about as long. We have developed good theories and effective ways of treating people traumatised by war, yet still our understanding has serious limitations. It is argued here that some of these limitations are due to focusing too much on the individual, and not enough on the social and cultural world in which we live.

While there is a lot of good research – fascinating, detailed and useful theories about traumatic stress, and, perhaps most importantly, therapies that help people to cope with the overwhelming response – our understanding of memory and trauma still has something missing. Memory is not objective; it is not some kind of computer-like registration, storage and retrieval system. Memory is flexible, permeable, changeable, and – critically – affected by the social and cultural world

in which people live. We live in the world as social beings; we do not and cannot live in isolation. No matter what the Zeitgeist says – that we live in an increasingly individualistic society – in the end we depend on culture and we depend on each other. These are essential to psychological health. This is why social support consistently comes out as being the most important factor concerning how people deal with stress and difficulties in their lives.

The other key concept that is used throughout the book is that of narrative. We constantly narrate our lives, creating and telling stories about who and what we are, and why we exist. We are natural storytellers and natural audiences (you can see the link to social support). Narrative is an essential function. We use and manipulate our memories, consciously and unconsciously, in order to present ourselves to the world in a particular way. Our life stories are constantly changing according to our circumstances. We do not have any choice in the matter. We are compelled to narrate.

Low perceived social support is seen as a predictor of traumatic stress. If a person experiences a traumatic event and they do not perceive that they have good social support, then they are more likely to be traumatised than if they perceive that they have good social support. Our fundamental need for narrative is met by interacting with others, by being able to narrate their problems, work them through, with someone who will listen appropriately. Social support is used to help people resolve their issues through discussion.

While narration is about storytelling and the construction of narratives that may relate closely to how events actually happened, or they may be largely fabricated, the argument is not that we fabricate our lives, but that psychological reality is more fluid, social and malleable than we usually think. In the context of the response to war then, this must be taken into account when we are building our theories, when we are trying to treat people with war-related psychological problems, and when we are just listening to war stories.

We must include the social and narrated worlds in our psychological theories. In order to do this effectively, psychological research is not enough. If we are to understand the nature of war, and the impact it has on people, then we must examine other approaches to understanding, through, for example, literature, history and the media. This book weaves together the story of memory, war and trauma by drawing on these different elements to increase our understanding of the lived experience and impact of war. Any psychologist who tells you that they can only learn about human nature from reading a psychology journal article or textbook, without considering the contribution of a good

novel, play or poem, is naïve. We are studying behaviour, in all its shapes and forms, and good literature is part of that tapestry of understanding, along with historical accounts, sociology and politics.

Narrative, social discourse and collective memory

These concepts are central to the arguments presented in this book. Individual narratives are what we all have as explanations of our selves, our immediate environment and the world. Our narratives provide us with memories and with the sets of beliefs by which we conduct our lives. They are more or less coherent, more or less individual, and more or less meaningful, depending on the characteristics of the person and their situation.

These narratives must have origins, and there are a number of sources for them. Narratives, life stories or autobiographies1 depend on social discourse – the main themes and threads of argument that are the social world. This is everything from common notions of the representation of the sexes, race or homosexuality, through to the use of particular terms that have ambiguous and changing meanings, such as ‘cripple’, ‘lady’ or ‘queer’.

The importance of social discourse – the way people interpret events – should not be underestimated. The example below is contentious, and is intended as such, because it illustrates how our personal narratives, our ways of thinking, are affected by social discourse. ‘Holocaust’ is a term that most people agree pertains only or mainly to the killing of Jews in the Nazi era. Indeed, denial of this is a crime in some countries, as David Irving found to his cost in Austria when he was imprisoned for this offence. The recognised social discourse is that the Holocaust was the most terrible, evil series of events known to mankind. This is the social discourse that – not surprisingly – began to be created immediately after the war by the surviving Jews. They wanted people to remember. They knew it was important to tell people about what had happened, to inform future generations, to try and keep it as a living memory, in order that it would not happen again. The stories of the extermination camps, the brutality and the cold-blooded murder are unquestionably horrific. Few would argue that what happened to the Jews in the Second World War was utterly abhorrent, a crime against humanity, and something that is very difficult to comprehend by those who were not there. But there is an alternative social discourse – that there have been many

periods in history that have been just as bad as the Holocaust – for example, the Stalinist era of the USSR, the Maoist massacres in China, Pol Pot's regime in Cambodia or the ethnic cleansing in Bosnia. This is not about scale (though some were on a greater scale than the Holocaust); it is about the depth of human tragedy.

Another example where the term ‘holocaust’ may apply is the destruction of the native people of North America. Many of the terms that generally applied to Nazi Germany are at least as applicable in the nineteenth-century USA context. For instance, Lebensraum represents the idea that the white man wanted the whole of North America for himself, and that there was no room for the untermensch (the native people). This was genocide (the natives of North America were destroyed in the same way Hitler intended for the Jews) and, to use a more modern term, ‘ethnic cleansing’. The term ‘holocaust’ may be even more appropriate to nineteenth-century USA than to twentieth-century Germany because the state – the USA – deliberately set out to cleanse a continent of its indigenous people and replace them with Europeans. They succeeded almost completely, while Hitler tried to remove one tribe from Europe, and only partially succeeded. We now see that tribe thriving in Palestine (the Holy Land, Israel – take your pick of social constructs), while the few survivors of the North American tribes live mainly in reservations, perhaps better described as concentration camps.

It is not that the destruction of native North Americans was conducted in the same way as the destruction of the Jews in Hitler's Germany, nor that the intentions of the perpetrators were necessarily the same; it is that the nature of the social discourse – the ways in which the events are interpreted – plays a crucial part in people's individual and collective memories of those events.

If we are to understand our narratives of war – or of anything else – we must understand the power of the social constructions we use when describing our behaviours and our thoughts and feelings. The examples above are not wrong; it is just that society – at least Western society – accepts a particular social construct. If the allies, including the USA, had lost the war against Germany in 1945, then the situation – the social construct – would be very different. The history books, which contain the social constructs of a society, would contain very different stories.

There is a relationship between individual narrative and social discourse, with one impacting on the other, but there are other key variables that must be included in the equation: the first is ‘collective memory’. Collective memory is information about society that is accumulated over the years and develops into a kind of ‘social fund’, and is drawn upon in the development of social discourses and individual narratives.

Collective memory is important for the notion of commemoration and memorialisation – so important to many societies, and individuals, when remembering war.

A second key area is that of the relationship between memory and history. There is an increasing need to define these terms clearly and consider their interaction. The link between psychology and history is central to this book. Traditionally, memory studies have focused on the memory of the individual person, or sometimes on the notion of a collective memory, but still focused on actual memories. History has been the systematic and relatively objective study of the past, whether that is concerned with individuals, societies or politics. There is now a blurring of the edges – as is to be expected from the increasing interdisciplinarity we are finding throughout academia – and the distinction between memory and history has become blurred. For example, the growing field of oral history – loved and hated by both psychologists (hated for not being the scientific study of memory, loved because it focuses on real remembered memories) and by historians (hated for not being sufficiently objective and relying on unreliable eye-witness accounts, loved because it is personal and social) – exemplifies the strength of an interdisciplinary approach, drawing on the resources of the historian and the detailed memories of individuals who lived through the times of interest. Psychologists are increasingly interested in the study of individual detailed memories outside the narrow confines of the laboratory, as it is only through this approach that they can begin to understand the complexities of the mind. These are explored in later chapters.

Thus narrative is central to our understanding of self and identities. These narratives depend on the social context, including the audience they are designed for, as well as individual motivation and desires. Memory itself is constructed partly through narrative and the social context. If we wish to understand war trauma, we need to take into account these narratives and the socio-cultural situation the person lives in. At the same time, there are also fundamental underlying universals regarding memory, the stress and fear response and other variables which also determine the response to traumatic experiences such as war, and through which psychologists have developed a good understanding via laboratory and other research.

War trauma

An agreed definition of the central concept of war trauma is difficult to obtain, as there is disagreement over the terms that should be used when discussing the psychological effects of traumatic situations such as war.

The distinction between stress and trauma is critical; while most authors would agree there is a distinction, this is not always made clear. The term ‘stress’ was used by Cannon, an early pioneer in the area, to describe a stimulus – physical or emotional – that disturbs a person's internal homeostasis or balance, and that may be pathological if it reaches a critical level (Cannon, 1929). Selye (1956) defined stress as changes within a biological system that occur as a response to ‘stressors’, environmental stimuli that evoke such internal changes. Mason (1975), building on the work of Selye, argued that whether or not a stress response occurs depends on a range of individual variables such as appraisal, coping style and – critically for our discussion – the social world. Levine and Ursin (1991) define stress as a situation where the body anticipates or determines that there is some threat to the organism, and organises the body's defences against that threat in order to restore homeostasis. The stress response is a normal and predictable response to environmental threats. It only becomes a problem when the threat is sufficiently prolonged or intense that it overwhelms the body's resources.

Traumatic stress is fundamentally different to ‘ordinary’ stress, in the sense that there is a fundamental rift or breakdown of psychological functioning (memory, behaviour, emotion) which occurs as a result of an unbearably intense experience that is life threatening to the self or others. It is usually a time-limited experience (even within the context of war, traumatic experiences usually occur relatively rarely) of such intensity that the resources of the person are overwhelmed. There are a set of symptoms associated with these changes, including intrusive recollections, avoidance and emotional numbing, and hyperarousal. The overwhelming nature of the event is such that it leads to important and often permanent changes in the physiology and mental state of the individual. A traumatic memory is formed, a memory that is at once cognitive, emotional and possibly behavioural. The traumatic memory does not exist in normal ‘stress’. The traumatic memory relates to the person's initial unconscious response to the traumatic event. As the person survived the event, the memory is indelibly fixed within the mind. This is adaptive. The person experienced a life-threatening situation and survived, and so if the same traumatic situation arose in the future, they should behave in the same manner again, hence increasing their chances of survival. So in this way, the traumatic response can be an evolutionary useful process. Unfortunately, owing to the mechanisms involved (which will be explained later), that response contains memorised bodily and psychological responses that are potentially damaging to the psyche.

This traumatic response can recur in different ways. For some people, the memories of the event are overwhelming and continuous, and they

are traumatised. They find it difficult to cope with ordinary living, because their memories are emotionally unbearable. In response to this they may withdraw emotionally to help them cope, and so find themselves withdrawing from their family and friends – their key social support. This can lead to a range of clinical problems. Other people manage to suppress their memories, whether through conscious or unconscious mechanisms. They are able to avoid thinking about them. They may need to avoid reminders such as the place where the event took place, or the people involved, but they successfully manage to get on with their lives. When they do think about what happened, they manage to deal with the memory. Another group of people actively think about what happened – their memories, their emotions, their bodily responses – and they ‘work through’ or cognitively process their responses, change their narratives of the time, and perhaps even learn from what happened, maybe becoming a better person. The final group of people, perhaps the majority, who live through a traumatic event are not traumatised at all. They have no difficult emotional memories or problems. They can probably look back at the event and perhaps they get emotional, but it does not really bother them unduly or in a prolonged manner.

The details of the traumatic response will be discussed later in the book; suffice to say now that war trauma is concerned with the responses of people to their war experiences. We are concerned not only with those for whom the experiences are genuinely traumatic, but also those who live through these events and are not traumatised. By understanding the individual factors that determine whether or not someone is traumatised, we can perhaps learn to help those who do have difficulties.

But what is a traumatic stressor? The clinical classification of a trauma has changed throughout the years in which it has been represented in the classification systems DSM and ICD. When post-traumatic stress disorder (PTSD) was first introduced in 1980, as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edn (DSM-III, American Psychiatric Association, 1980), there was an attempt to objectify the stressor, to say that the event must in some way be extraordinary, outside the range of normal human existence. The attempt was to include things such as war, disaster or rape, but to exclude events such as the death of a loved one. In later editions (DSM-IV, American Psychiatric Association (APA), 1994), a more subjective interpretation has been accepted; the interpretation of the individual was then considered to be more important. Rather than closely define the traumatic event, there was a greater emphasis on the person's response (fear, horror, helplessness) to the event. If there was an event and a response

of fear, helplessness or horror, then it was considered satisfactory for a person to have that diagnostic criterion.

This change came about because there was no acceptable answer to the question regarding which kinds of events could be traumatic. The argument is that an event is traumatic if it traumatises the person. What is traumatic for one person may not be for another. The argument is circular, which is why understanding both the psychological and bodily response to the event is critical. The event, to be traumatic, must cause changes in bodily coping mechanisms that effect possibly permanent changes to the individual. These should, in principle, be measurable both physiologically and psychologically.

Researchers have studied a range of phenomena that have been classified as traumatic. These include short-term, usually isolated events such as rape or armed robbery, man-made disasters such as the sinking of ferries, natural disasters such as earthquakes or floods, and often longer term, chronic conditions such as war and child abuse. The negative psychological effects of these disparate traumatic events are very similar, though Herman (1992) and others have drawn a useful distinction between simple and complex PTSD. Simple PTSD usually, but not necessarily, relates to a single event. Complex PTSD refers to the response to complex events such as war or chronic child abuse. We will, of course, be mainly concerned with the more complex forms of the disorder. Though the general symptoms are similar, there are complicating factors, which will emerge in our discussion of war trauma.

Post-traumatic stress disorder

War trauma is not the same as PTSD, as the range of symptoms is much broader in the former, but the construct is in many ways a useful one. This will be discussed in more detail in Chapter 4, but it is helpful to have an outline of the disorder here.

The Diagnostic and Statistical Manual of Mental Disorders, 3rd edn (DSM-III) (American Psychiatric Association, APA, 1980) provided the initial diagnostic criteria for PTSD. These criteria have since been revised several times (DSM-III-R, APA, 1987; DSM-IV, APA, 1994; DSM-IV-TR, APA, 2000). The key criteria, apart from the event itself, now include intrusive re-experiencing, avoidance, emotional numbing and hyperarousal. In order to be classified with PTSD there must also be a significant impact on social, occupational or family functioning. Finally, there is a temporal component, to include acute (over 30 days), chronic (longer than 3 months) and delayed-onset (symptoms appear after more than 6 months) PTSD.

The main symptoms are, in themselves, often normal responses when the situation is normally stressful. Someone distressed by everyday events, whether students sitting exams or someone going for a job interview, will experience intrusion and avoidance. If a person has to sit an exam, then they may spend hours worrying about it unduly. They may also spend hours in avoidance – perhaps visiting the pub or going for a long walk in the country. These symptoms are normal. It is only when someone is devastated by a terrible, overwhelming event that these normal responses – or coping strategies – become abnormal, the memories become unbearable, emotions run riot, and it is impossible to live one's life in a normal manner.

A traumatic event, by definition, breaks down the accepted social and personal structures and belief systems of the individual. If you believe in the essential goodness of other people, then your experience of trauma will demonstrate that belief to be false. If you believe that terrible events will not happen to you – perhaps because it is statistically unlikely – and you are on a ferry that sinks, then in the future you may not want to go near a ferry because you now believe that it is likely to sink. This can make life very difficult for the traumatised person, and any treatment must try and rebuild their belief system, not one that is identical to the pre-trauma system, but one that includes the new knowledge provided by the traumatic event. In the end, as argued in Chapter 6, this can lead to someone knowing that they have psychologically benefited (or experienced positive growth) because of their experiences and that they are in some way wiser, more knowledgeable and more caring than they were before.

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