Tribe book review

Tribe Cover

Tribe – On homecoming and belonging by Sebastian Junger (4th Estate, 2016)

We have a strong instinct to belong to small groups defined by a clear purpose and understanding – to ‘tribes’. This tribal connection has largely been lost by modern society.

Combining history, psychology and anthropology, Sebastian Junger demonstrates that regaining it may be the key to our psychological survival.

As someone who has worked and volunteered in a number of closely knit groups, including the military, I found Tribe very insightful. Sebastian Junger is making an enormously important point in attributing some of the problems of reintegration of ex-military personnel to the loss of their tribal identity. Too many authors lump all such re-integration problems together under the umbrella of PTSD rather than recognising that there are many factors that may alienate ex-service personnel from their civilian counterparts, including classical PTSD but also ‘moral injury’ and the loss of the group as described in Tribe. However, in my opinion the book portrays an overly optimistic view of the tribe and the benefits that might accrue from recreating elements of tribalism within contemporary civilian society.

I’ll freely admit that my view is coloured by my own negative experiences, so bear that in mind as you read the review.

The examples used in the book illustrate that the ideal form of tribalism (with resource sharing and punishment of individual exploitation of power or resources) emerges under conditions of considerable adversity. The ‘military unit as tribe’ analogy glosses over the fact that abuses of power and psychological trauma to members of the tribe are depressingly common when the bonding factor of adversity is not present, and not exactly rare even when it is. A substantial fraction of military PTSD is related, not to combat, but to sexual assault or bullying within the unit, and one can appreciate from the general argument made in the book that this would be additionally traumatic because it is fundamentally a betrayal by the tribe.

The book also talks about the potential benefits of being able to recreate some degree of tribalism in settings such as contemporary US society, and the barriers to this at a societal level. The reader is left with the impression that the worst that could happen is a maintenance of the staus quo – that the returning serviceman loses his or her ‘tribe’ and suffers because of that loss.

What is overlooked in the discussion is that things can be made worse. There is a risk that in seeking a replacement ‘tribe’, the former member may be drawn into and exploited by a group in which the illusion of tribalism masks the fact that the group exists for the benefit of an individual or small elite (eg a cult, although there are many less extreme examples which are nevertheless exploitative), and after becoming either disillusioned enough to voluntarily leave or being involuntarily expelled, the ex-member suffers a compounding of their loss.

These omissions do not detract from the overall message of the book, but I have to say that I came away from reading it just a little disappointed.

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Invisible repairs to the soul

Fragile-Tape

For many years I accepted without question the idea that my recurrent depression was merely a neurobiological aberration, a chronic relapsing condition that would require potentially  life-long medication. Psychotherapy might help me to live with it, or to develop more constructive thinking patterns, but it wasn’t a real treatment. All this, despite the fact that the drugs didn’t really make me better – in fact may have made me much, much worse – and that therapy was what had actually kept me alive through the darkest moments. I accepted it simply because it’s what I’d been taught: the biomedical model of depression is the one most widely promoted by – and to – general practitioners, psychiatrists and the general public.

However, in the course of withdrawing from antidepressants, going back into long term therapy and reading more widely on mental health and social issues, I’ve gained a very different perspective (not to mention a huge source of material for future posts). One of the things that has emerged is a better understanding of the role traumatic events in my past have played in shaping who I am today. Exploring and dealing with those traumas has been the current focus of therapy.

In common with many people who’ve experienced adversity or loss, something with which I’ve struggled is the desire for things to be as they were before. Wanting myself to be like I was before. I know how easy it is to become trapped in searching for the elusive point in time at which everything was ok and trying desperately to find a way back that simply does not exist. I am coming to see that a large part of healing from trauma involves coming to terms with the reality that one cannot go back, and in finding a new and different way of being that is hopefully “good enough”. It’s an approach which ties in well with the philosophies of some of the adjunctive therapies I am using, including yoga and mindfulness meditation (in addition to general meditation classes I’m currently participating in a Mindfulness Based Stress Reduction – MBSR – program).

One particular incident in therapy gave me a sudden insight into the way I had been thinking and has made it a little easier to change course and to work more constructively:

My therapist’s chair was a little the worse for wear, and he had patched it up with the packing tape used to mark parcels as fragile. This annoyed me intensely, and one day towards the end of a session I brought it up. I said that it looked like he needed a new chair, and he replied that he preferred to fix things instead of just getting rid of them, and he liked having made a feature of the repair. I told him that if I was repairing a chair I would have researched how to to repair vinyl and plastic so as to do it properly, or at least used tape the same colour as the chair, so that you couldn’t see the repair and it looked as good as before. A lightbulb moment occurred as I realised that this whole conversation was a metaphor for our different approaches, and I began to ask myself if what I expected from therapy was that I would go back to being “as good as before”, with seamless and invisible repairs. I have finally begun to accept that I must work with where I am now. It’s still hard work and is going to take a long time, but it’s definite progress.

(Oh, and for the record my therapist did eventually get a new chair).

ANZAC Day 2016

Treating a simulated casualty.

ANZAC Day is an appropriate time to reflect on my RAAF service.

My time in the RAAF was one of the most professionally rewarding periods of my career. I met many wonderful people and had some amazing experiences. Without the sponsorship I received through the ADF Undergraduate Scheme I would not have been able to afford to study medicine. To a large extent I owe where I am today to the ADF.

But along with the opportunities it offered me there were many challenges that people outside the military may not appreciate. Even if you never see combat you are forced to confront aspects of yourself and others that you would often prefer not to acknowledge – that under pressure you are perhaps not as brave, not as tough and just not as nice as you once believed. As a military doctor you continually face conflicts of loyalty and moral and ethical dilemmas. And then there is the issue of the ADF having more or less complete control over your life – not only your working conditions and your career path, but your living conditions and social circumstances as well.

During my time in the RAAF I saw a young colleague deployed to Rwanda 6 weeks after she was married, who was never the same afterward. I knew servicemen suffering PTSD after being involved in aircraft or industrial accidents, at least one of whom refused to seek further treatment for his condition because he was concerned about the impact on his career of revealing the extent of his problems. I saw families with husband and wife both serving who were deliberately posted apart. I saw members facing medical discharges who were devastated by a process that felt as if they were being pushed out of their own family. I saw our forces increasingly deployed for purely political reasons, with those whose lives were actually on the line caught between a government’s bravado and an often hostile public.

I  experienced few of these adversities myself, partly because I was never deployed overseas but also, I suspect,  because retaining medical officers in the ADF has always been difficult so they tended to be treated a little better.

The recent news reports of the appallingly high rates of PTSD and suicide among veterans, many of whom feel abandoned by the ADF after suffering physical and psychological injuries as a result of their service, are something I have been reading with dismay.

The ADF is a resource which should not be squandered: it should be appropriately resourced for its purpose and its members well trained, thoughtfully deployed and well supported both during and after their service.

What are they thinking?

ABC-news-logo

“Cable ties and restraint chairs are set to be approved for use on children in custody as young as 10 if new laws pass the NT Parliament next month.”

http://www.abc.net.au/news/2016-04-22/cable-ties-restraint-chairs-could-be-used-on-child-detainees-nt/7350092

This is apalling. Not just in terms of the potential consequences for individual detainees, but what it says about the level of staff training and the underlying policies and attitudes.

There is already one example of this level of restraint being used on a minor in the NT for the alleged reason of “preventing self-harm” – completely counter-productive in this setting and guaranteed to compound the trauma that leads someone to consider self-harm in the first place. Detainees of any sort do not resort to serious self harm merely to get attention or to evade authority. It is an act of desperation.

The NT Attorney General is also quoted as saying that “achieving de-escalation is entirely in the hands of the detainee if they’re playing up”. This is patently untrue, and reflects a very poor understanding on his part of the psychology of power and the dynamics of imprisonment.

Yes, there will be extremely challenging situations in prisons. But especially when they involve individual detainees, and adolescents who lack the capacity for mature and considered decision-making, this is not the way to deal with those situations.

In a timely coincidence, last weekend I re-read some of the details from Phillip Zimbardo’s famous Stanford University Prison Experiment and some of his later writings, including discussion of how the knowledge gained from this research could have been used to anticipate and prevent situations such as occurred in Abu Ghraib prison, and attempts to replicate elements of the experiment by others (with exactly the same results). I can attest to the ease with which such situations develop based on my own experiences of well-intentioned but poorly thought out exercises in the military. Repeated experience tells us that we cannot pretend that “this will not happen to us”- it will.

We can do better.

ADDIT (27 May 2016) Unfortunately this law has now been passed.

ADDIT (26 July 2016)  Human Rights Commissioner Gillian Triggs has called for an independent inquiry into the treatment of Northern Territory children in detention, which was revealed on the ABC Four Corners program on 25 July.

 

 

Mental Health Week – suicide prevention and mental health care in Australia

paint your own sunshine

As my contribution to Mental Health Week, I’d like to talk about suicide and mental health care in Australia. A confronting topic, but important to discuss. As a doctor and also someone who has experienced a number of episodes of depression, it’s something I can talk about from both sides of the bed, as it were.

R U OK? Day last month drew a lot of attention to identifying people at risk of suicide. I found the campaign very frustrating for two reasons. Firstly, what they’re not saying is that you really shouldn’t be asking the question unless you’re prepared to deal with the answer. Secondly, no-one is talking about what happens next. I think many people assume that in this situation it’s a tidy little sequence: you get admitted to hospital – where you’re safe – they treat your mental illness, you get better, then you are discharged and go on your way with the medications which will keep you well. The reality is not quite so simple.

Suicide is NOT just about mental illness. People commit suicide because they feel trapped and in pain, believing that things will never get better and that there is only one way out. Everything except that pain becomes less real – people, memories, the sense of hope. And because those things are less real, leaving them behind doesn’t really seem to matter. Mental illnesses such as depression may take you some of the way to that point, but other factors are nearly always involved: personal loss, social isolation, poverty, trauma, violence, substance abuse, lack of meaningful employment – in its broadest sense – and sometimes, really not having many options in life. Sometimes mental illness is the least of the problems.

Hospitalisation can be truly helpful, but … there are a lot of buts. It’s a lot harder to get admitted to a psychiatric hospital than you might think. And if you are admitted you’re thrust into a highly stressful situation away from familiar surroundings, subject to an externally imposed schedule of mealtimes, sleep times, medication rounds and treatment sessions, alone among strangers – often quite disturbed strangers. Hospitalisation can be helpful if you can’t take care of your own basic needs. It can provide a respite from the stresses of work and family pressures, give you access to more intensive treatment and allow you to be monitored more closely. But it’s not a guarantee of safety. People do sometimes commit suicide in hospital. Equally disturbingly, a 2013 report by the Victorian Mental Illness Awareness Council (VMIAC) revealed that 45% of women in the state’s psychiatric hospitals had been sexually assaulted or harassed while in their care.

If an adequate level of outpatient care is available, there’s a lot to be said for being around healthy people, sleeping in your own bed, eating familiar food, seeing familiar faces and keeping to something like your normal schedule.

As for medications: yes, they play a role in treating underlying mental illnesses, and when they work they can produce amazing results, but they don’t work immediately, they don’t work for everybody, and they can have nasty side effects. Antidepressants in particular can sometimes make things worse, either by triggering a manic episode if you happen to have bipolar disorder, or by making you more suicidal or even violent or homicidal.

The things that really make a difference are having (or building) a life worth going back to, one where you feel you belong and are truly valued; and, whether in or out of hospital, individual support – a person or people who will really listen, who will help you find better ways of coping with your problems, who will remain calm and hopeful for you even when you are in crisis, who are able to mobilise extra help for you if necessary. And who can do all this for as long as it takes. Support for a suicidal person is not a one-time thing. Suicidal thoughts and feelings and the desire to act on them wax and wane in intensity, often over quite a long period of time. The level of support that is needed is above and beyond what can be asked of friends and family.

Our society is increasingly fostering a culture of divisiveness, fear and xenophobia and a mentality of scarcity, marginalising and isolating anyone who is different or who is judged undeserving. We are systematically destroying opportunities for people to build lives worth living by our failure to provide individuals and communities with equity of access to basic infrastructure, education, employment and an adequate welfare safety net.

And we are not funding the necessary levels of psychological treatment and support for the people who need it. Medicare and private health funds will cover part of the cost of treatment by a psychologist for a limited number of sessions per year, however not all psychologists are prepared to manage actively suicidal patients. Medicare funds a higher number of sessions per year for a psychiatrist, but those who offer psychotherapy are few and far between and the out of pocket costs can be far greater (and will be even more so with the impending cuts to the Medicare Safety Net). Even highly successful publicly funded programs, such as the Perinatal Depression Program and various youth mental health initiatives, struggle with chronic under-funding or the withdrawal of existing funding. Lifeline, the telephone crisis counselling service which is advertised in nearly every single news article about suicide, relies predominantly on volunteer staffing and private funding.

My own experience was that treatment with antidepressants only worked for some of the symptoms, some of the time, and on one occasion I became much worse while taking them. However, I’ve been very fortunate in being able to access good quality psychotherapy over an extended period of time and in having considerable educational, employment, financial and social resources in my life to fall back on. I am well aware that my situation is the exception rather than the rule.

If we’re serious about reducing suicide in Australia, we need to work on building a society worth living in, and on providing appropriately funded and accessible services that address ALL the issues relevant to suicide.

(originally published 8 October 2015. The artwork is Paint your own sunshine, one of my previous Mental Health Week poster competition entries)