Thursday, June 02, 2005
In a strange instance of irony, the two leading medical journals in the US have published articles on the same theme, and both are open-access articles: NEJM published Americans as Survivors by Robert Jay Lifton, M.D., and JAMA published Treatment of Complicated Grief by Katherine Shear, M.D., et.al.
The JAMA article is a technical report of the outcome of a clinical trial, comparing two types of psychotherapy for the treatment of persons who have prolonged severe grief reactions after a major loss. The NEJM article is a thoughtful essay about the ways that survivor reactions to war and to terrorist attacks have shaped society in the US.
I think the most interesting thread that can be picked out of these two articles is this one (from NEJM):
A survivor is one who has been exposed to the possibility of dying or has witnessed the death of others yet remained alive. The responses of survivors vary greatly, depending on the particular encounter with death and on personal traits. But I have found certain psychological patterns to be quite consistent. Survivors struggle with images of death and dying — what I call a "death imprint." They feel a sense of debt to the dead, a need to placate them or carry out their wishes in order to justify their own survival. Survivors embark on an anguished quest for meaning and form, for what Erich Lindemann, in his classic study of the Cocoanut Grove nightclub fire in Boston in 1942, called "an acceptable formulation of [one's] future relationship to the deceased." Human beings are meaning-hungry creatures, and survivors can epitomize this need by undertaking lifelong missions on behalf of the dead. [...]In constructing this series of excerpts, I have left out a lot of the author's points. That's not really fair, but in atonement, I urge everyone to go read the whole article. Twice.
Any experience of survival can connect psychologically with earlier traumas, with the losses and separations of ordinary life. Similarly, large-scale traumas can become intermingled. The war in Vietnam, the attacks on September 11, and the war in Iraq may blend within the individual American psyche, becoming virtually indistinguishable sources of pain and anger. This psychological blurring of the perceptions of events can contribute to collective confusion and a susceptibility to political manipulation. [...]
Leading advisers of the administration of President George W. Bush were also deeply affected by the defeat in Vietnam, which, as the writer James Mann observed, "led to a preoccupation with first regaining and then maintaining American military power." Thus, in an important collective psychological sense, both the Gulf War and the war in Iraq can be understood as survivor missions in response to the Vietnam War. [...]
The war in Iraq is being fought as a manifestation of survivor missions stemming from both the Vietnam War and the attacks in 2001. Yet once any war begins, it takes on meanings of its own. The dead become the ultimate moral focus, and the traditional survivors' mission is to ensure that they did not "die in vain" and to complete their work by prosecuting the war ever more vigorously. This survivor mission began with the first American death in the invasion of Iraq and extends to the continuing deaths of American soldiers and civilians at the hands of Iraqi insurgents. [...]
Most Americans seem to be hovering between traditional and alternative responses to the war in Iraq. Though troubled by deaths in a war whose justifications are seen as contradictory, they are nevertheless loath to admit that Americans may have died in vain. [...]
The author points out that the current leadership contains persons whose psyches were shaped by two wars: Viet Nam, and the Gulf War. They were very different wars, but with a particular commonality. Both wars left unfinished business. He suggests that this led to, or at least increased the probability of, the Iraq war. This is an interesting point, although it seems untestable. Even if the point cannot be proven, it is thought-provoking.
Interestingly, Dr. Lifton's hypothesis runs counter to a common liberal interpretation of the war. Many who oppose the war point out that the top leadership: Bush and Cheney, both avoided military service. They refer to those who avoided service of their own, but started a war to be fought by other people's children, as Chickenhawks. In fact, the New Hampshire Gazette compiled what they can the Chickenhawk database, listing prominent Republicans who avoided service. A site, AWOLBush.com, compiled a list comparing the service records of top Democrats with top Republicans. These took a lot of effort, which implies that at least some people think it is important. They also came up with some graphics to drive home the message:
The liberal interpretation is that leaders who have not actually served in the military do not fully understand the horrors of war, so it is easier for them to think war is justifiable. Lifton's view is that it may be a kind of survivor guilt that motivates such leaders to start another war, to finish the job symbolically, so no one will have died in vain.
The other article, JAMA's Treatment of Complicated Grief, is more straightforward. The authors devised a hypothesis, that a particular well-validated form of psychotherapy could be modified to address the particular difficulties faced by those with "complicated grief." It turns out that there is some evidence to support their hypothesis. This is not a trivial problem, by any means:
Prevalence rates are estimated at approximately 10% to 20% of bereaved persons.17-18 Approximately 2.5 million people die yearly in the United States.19 Estimates suggest each death leaves an average of 5 people bereaved, suggesting that more than 1 million people per year are expected to develop complicated grief in the United States.It is nice to see a group making an effort to address this problem specifically, and to try to improve the rate of treatment response for a group of persons who otherwise may be refractory to treatment.
The NEJM article focused on a sort of collective grief, something that pervades society. The JAMA article looked at the grief experienced by individuals.
Is there any significance to the fact that these two articles came out at the same time, and that they both were made available for free? Most of the articles in those two journals are available only to paid subscribers, or to others for a fairly stiff fee ($30). NEJM will make certain articles available openly on the 'net, if they are deemed to have an important place in contemporary public debate. JAMA usually has one or two articles openly available, but they select which ones will be free based upon criteria similar to the NEJM criteria. So here we have the nation's two leading medical journals, both deciding independently, that grief and survivor guilt are pertinent to contemporary pubic debate.
It makes me wonder, if perhaps the editors have some survivor guilt of their own. Perhaps the entire medical profession does.
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