Paul Valent

Paul Valent

MBBS, DPM, FRANZCP
Consultant liaison psychiatrist, psychotherapist, traumatologist,
Co-founder and past president Australasian Society for Traumatic Stress Studies,
Writer.

From Survival to Fulfilment

Talk St Vincent’s Hospital
Ed Harari Seminar
March 11th 2022

First of all, I want to thank you for having bestowed on me the great honour to speak at this inaugural Ed Harari seminar. I have known Prof Harari for many years. I have always appreciated his friendly open and enquiring mind.

I have been asked to speak on ‘whatever is on my mind’. This is very trusting, and I appreciate the confidence. In the spirit of Ed’s open invitation, combined with my own age, and not owing my current professional survival to anyone, I will speak as openly as I can about how I regard mental distress in this time of pandemic, fire, flood, and war.

The flame that has kept me enquiring about stress and trauma has been my childhood experience of the Holocaust. I think it propelled me into psychiatry, liaison psychiatry, and quarter of a century in emergency departments. It seems that I needed to understand my own distress through helping others in theirs.

My psychiatric career started in London, in a hospital associated with the Maudsley Hospital. The ruling paradigm there was organic, meaning that psychiatric illnesses were seen as disorders of the brain, possibly influenced by genes. Illnesses had to be diagnosed as this one or that one. Treatment was of the brain with antidepressants or phenothiazines.

Luckily my consultant had an open mind to psychodynamics and he encouraged me to secretly attend lectures at the Tavistock Hospital, where I listened to Anna Freud and Bowlby among others.

The Maudsley and Tavistock lived in different worlds and were contemptuous and hostile to each other. Maudsley said that the psychodynamic Tavistock used magic to treat the worried well. The Tavistock retaliated saying the organic Maudsley had no mind, let alone soul.

With the Diploma of Psychological Medicine now in my pocket, I happened to be working in a psychiatric hospital in Tel Aviv around the time of the Six-Day-War. We were inundated by outpatients complaining of symptoms for which we had no diagnoses. For instance, wives were convinced by portents that their husbands and sons had been killed in battle. A soldier was admitted riven with guilt for having participated in killing and looting. In others Holocaust memories flared up.

Once outside the ‘Is it this or that and treat it with this or that’ model, psychiatry seemed to both be mysterious and also have no limits.

Back in Melbourne at Prince Henry’s Hospital, my first job was as liaison psychiatrist in a medical ward. I was given the task of finding what bothered dying patients most. It wasn’t dying, I found. One man felt humiliated having to wet the bed because nurses didn’t bring him a pan. A 99-year-old man was depressed because he anticipated that after his 100th birthday party he would be abandoned to die.

My next job was in the emergency department. I picked random patients to interview and almost all had some unacknowledged psychological distress. For instance, a young man had his little finger amputated when it was caught in a mangle. The finger was treated surgically, but no one thought to treat the man for the much more distressing belief, still felt, that his whole body was about to be mangled.

Another time I was looking after a chronic schizophrenic while waiting for her to be taken to a psychiatric hospital. For the sake of doing something, I asked her my favourite question: ‘Of all the things that worry you, what worries you the most. A flicker of emotion rippled through her face. ‘Being raped as a teenager.’ ‘Have you ever told this to anyone?’ ‘No.’ ‘Why not?’ ‘No one ever asked.’

The heads of Prince Henry’s psychiatric department had trained in Rochester and espoused a biopsychosocial model. That helped to shine a light into many otherwise confusing clinical presentations. The matter for me was clinched when I saw a distressed resident scooping sperm from the vagina of a recently raped young woman who was in total shock. I understood how biological, psychological and social were separate but indivisible.

I was encouraged to have psychoanalysis. I was anticipating to be at last talking through my Holocaust experiences which I sensed were resonating in the background. However, my analyst, who I later discovered was herself traumatised in Budapest during the war, concentrated only on my aggressive and sexual instincts. Bombing was only relevant through my supposed sexual excitement in the crowded bomb shelter. She reflected, I came to believe later, Freud’s move from acknowledging trauma and its consequences, to neuroses resulting from innate sexual and aggressive drives.

Back in the emergency department, while I demonstrated how patients benefited from a biopsychosocial view, doctors said they hadn’t been trained in this type of medicine. Nor did they have time to delve into psychosocial perspectives. Physical was sufficiently complex for them. And truth to say, in the psychiatric department, most members preferred to only concentrate on the psychosocial.

I started to realize that biological and psychosocial, represented by medicine and psychiatry, and organic brain as against psychological mind within psychiatry were ruled by different paradigms. They were the same ones that I had already seen in London between the Maudsley and the Tavistock hospital.

These conflicting paradigms could take took on political dimensions. Before my very eyes the Tavistock type Department of Psychology at Melbourne University was overtaken by the Maudsley type. Its Bible, DSM promulgated this or that diagnosis, trying to emulate physical medicine. Freudian/Tavistock psychiatry was denigrated and kicked out.

In 1982 the major Melbourne hospitals undertook the most extensive disaster exercise in Victoria till then and since. Because of my association with the emergency department, for the first time a mental health professional, myself, participated in the exercise. I was amazed at the biopsychosocial manifestations enacted in the exercise.

Around this time, 40 years ago, trauma inserted itself into psychiatry. It had been there before, when Freud described sexual trauma leading to neuroses, but it was generally accepted following wars, when masses of suffering soldiers could not be ignored.

For World War One Kardiner coined the diagnosis traumatic neuroses of war. In World War Two combat neuroses was the trauma term, and after tens of thousands of Vietnam War veterans clamoured in the streets for a psychiatric diagnosis, in 1980 DSM reluctantly provided Post-traumatic stress disorder (PTSD).

Why reluctantly? Because DSM (diagnostic and statistical manual) was ideologically oriented to be part of quasi-mathematical ‘scientific’ somatic medicine, and PTSD disturbed that paradigm. It was neither due to brain disorder nor genes.

As for me, with my prior emergency department and disaster exercise experience, and now trauma being acknowledged, I was primed for a real disaster- the Ash Wednesday bushfires. I led an exploratory team from Prince Henry’s Hospital to fire-affected Macedon and Mt Macedon.

Three days after fire swept through the area, we saw burnt-out houses, smoke and remaining spot fires. We entered a pub, still standing. We asked a group of men in the pub what worried them most. No, it wasn’t anxiety or depression. ‘My house is still standing,’ one replied. The others nodded. We were flabbergasted ‘Why is that your worst worry?’ ‘My neighbour’s house burnt down. It should have been mine.’

Survivor guilt, we twigged. And it had a purpose, because the guilty appeased their guilt by looking after their bereft neighbours. In time guilt turned to anger. ‘Why are they still here?’ The balance between guilt and anger, between caring for and being cared for played out not only between the domiciled and the homeless, but also between neighbours, spouses, parents and children, and so on.

Many survival responses fluctuated at a great rate. Some firefighters hid in a roof in order to not see flames anymore. They were not cowards. Previously they risked their lives for others. But now they needed to curl up and shut down.

People helped each other as never before, though later they struggled against each other, also as never before.

Over time, we made sense of these varied survival manifestations in terms of an octave of stress responses, which because they served survival using different strategies, I called survival strategies.

They had all been well-known, but never before had they been assembled together. Fight and flight were well known since Cannon described them in the 1930s, and they were acknowledged in PTSD. But there were other similar survival strategies.

Actually, long before Cannon, Darwin described competition and struggle as a means of survival. Perhaps less known, Darwin had also described cooperation as a means of survival. Attachment, such as children to adults and adults to fire fighters was described by Bowlby in the 1970s. He also described the pain of separation when attachment failed. Fire fighters, like soldiers and workers were motivated by goal achievement. Their morale could fail if they did not achieve their goals. Sometimes they had to surrender their goals and adapt to new circumstances. Selye’s general adaptation syndrome, described in the 1930s, and Bowlby, Parkes and others’ loss and grief, all dealt with the stress of adapting to new circumstances.

And so, as a result of observations in the bushfires, an octave of stress responses, described in different pockets of scientific literature, were brought together for the first time. To summarise again, the octave (or four pairs) of stress responses called survival strategies were: rescue and attachment, fight and flight, goal achievement and goal surrender, and competition and cooperation. And each had biological, psychological and social features. And each fluctuated over time according to current local needs, in individuals, families, and communities.

There is one other dimension I have to mention beside time, place and person. In previous cases we already noted feelings of abandonment, shame, and humiliation, emotions that are purely human, and can cause more distress than an illness or even survival. In the fires this became more salient.

A man raged at the injustice of his well-prepared house burning down while his slovenly neighbour’s shack was unharmed. When the neighbour offered the man shelter, the man nearly had a heart attack.

Some individuals saw the fire as a demonic enemy that had to be killed. Seconds later they fled it in cars. A woman saw the flames as an angel whose wings were about to embrace her. A fire fighter snatched her away from the flames just in time.

A boy asked his mother to retrieve his favourite toy from their burning house. She screamed back at him. The screaming mother with flames behind her seemed like a witch to the boy. He curled up motionless on the floor of the escaping car and swallowed a magic pill for protection against the witch mother. The boy’s fear of his mother continued until we helped mother and son to see the situation from each other’s perspective. Then they re-established their prior loving relationship.

My point is that as well as survival strategies playing out biopsychosocially in times, places, and persons, they also had a spiritual dimension, ranging from moral judgements of guilt, shame and injustice, through to values, sense of identity, ideologies and religion. In this dimension spiritual survival may trump physical survival. People may sacrifice themselves for an ideal or a god, which symbolises a greater self than their bodies; or they may kill people who symbolise evil greater than a real current danger.

In order to encapsulate survival strategies with their biopsychosocial expressions over time, place, person, and spiritual dimension, in one concept, I coined the term wholist perspective.

Let us now skip to current times and see briefly how the wholist perspective applies in current times. We could have chosen flood, fire, or war, but in this case I have chosen the pandemic.

Let’s start with the well-known fight and flight.

Fight.

Survival here depends on the maxim ‘Kill or be killed.’ Kill the virus or it will kill us. In this case kill or be killed battles occur on the cellular level between the virus, and our immune cells and vaccines.

Nevertheless, fight impulses made their appearance also on biopsychosocial levels. On the psychosocial level, people were suspicious of the infected and those who tended to them, to the extent that to avoid abuse, nurses stopped wearing their uniforms in the street.

Other hostile boundaries emerged between ‘us’ and ‘them’, according to geography, ethnicity, race, and nationality. Graffiti appeared calling on foreigners to go home, and our government encouraged them to do so.

Protests and riots developed around the world as if governments, not the virus, were the enemy. Freedom was the call to arms against the government. In the US political divisions hardened around belief in or denial of the virus and spread to ideological conflicts around freedom and conspiracy theories such as of secret cabals wanting world domination.

Hostility reached international proportions. China was blamed as the source of the virus and for allowing its spread. International relations deteriorated as the pandemic progressed.

Flight
Avoiding, distancing, shutting down, masking and hiding were the most efficient strategies in the pandemic before vaccines were developed.

However, bunkering down and isolation had their own problems. Children missed school and socialisation. Businesses collapsed. Ordinary interactions were missed as people lived in their bubbles.

Fear pervaded individuals and societies, which manifested in a variety of ways.

Rescue and Care for Others

This is a strong even if often overlooked instinct. It involves the strong sacrificing themselves for the weak. Parents for children, employers for their workers, doctors and nurses for their patients.

Even our government, within days, somersaulted from its sacred ideology of budgetary surplus to the greatest debt ever. It suddenly found money for health services, even for psychiatry.

Stress on health care workers was enormous. Burn-out, compassion fatigue, fear of infection, anguish, guilt, having been neglectful or caused death were all intense and took a toll.

Even worse than being drained in the process of care was not being able to care. To have to distance, abandon and not care even for the dying caused immense anguish.

Attachment; Seeking Rescue and Care
Rescuers’ impulse to save and care were reciprocated by need to be rescued and cared for. Isolation meant separation and aloneness. Yearning, need for touch were curtailed between loved ones, and the worst nightmares, dying alone, feeling abandoned, came true for too many.

In this needy scenario, once the government manifested care, trust in it akin to a protective parent was such that populations gave up rights they had battled for for centuries.

Goal achievement
The virus threatened supplies of food, shelter, and work. Macho men were forced into idleness and uselessness. Children could not go to school. On a larger scale, economies slumped, trade diminished, businesses spiralled into bankruptcy. Morale diminished. Horizons constricted. Concentration and memory decreased. Frustration increased. Individuals, groups, and nations rubbed against each other.

Goal surrender; Loss; Adaptation
Everyday goals had to be surrendered. Losses of all sorts were ubiquitous. Work, functions, parties, celebrations, entertainment, even funerals, all ceased.

On the one hand, humans are very adaptable and populations changed their everyday habits from one day to the next.

On the other hand, people were stunned, shocked, and wounded. They cushioned themselves with variable success against sadness, grief, depression, and despair. Sometimes they entered a state of fatigue and hibernation in which time both dragged and flew. A woman curled up in bed and was too fatigued to stand up. After weeping for her losses she regained her energy.

Competition; Struggle
People struggled for food and toilet rolls in supermarkets. From hospitals to nations, individuals and groups struggled for masks, respirators, and vaccines.

The rich and powerful fared better than the poor and powerless. Rich countries had preferential access to vaccines. Super-rich individuals and companies increased their profits. On the lower rungs of the ladder the poor, isolated, migrants, elderly, and sick, as well as poor nations, fared worse.

Some individuals and groups felt marginalised, humiliated, and defeated. Some tried to retrieve a sense of power and agency through dominance and violence in the home. Others formed counter-groups, which indulged in demonstrations, and violence, providing a sense of power.

Cooperation
‘We are all in this together’ was the mantra as individuals and societies cohered, cooperated, and coordinated against a common enemy.

Neighbours who had never spoken to each other now formed bonds and helped each other. Indigenous tribes formed common mobs. Even political parties cooperated for the common cause.

People became creative in ways to overcome their isolation. Many worked, communicated, and entertained themselves by utilising the internet.

Hopes rose for similar cooperation and creativity on poverty and climate change, but betrayal of such hopes has remained a constant possibility.

Let us take a breath. I’ve raced ahead a bit into a strange complex territory. After all, though we hear that mental health effects are widespread in the community, we only hear of anxiety and depression.

This is a paradox: Here we have a major world disruption obviously causing much mental disturbance, but all we can come up with is two words, anxiety and depression, and even these terms resemble lay meanings of those words rather than psychiatric syndromes.

Let me dive into the nub of the problem. The problem is that the pandemic has caused much stress, but we have no generally accepted conceptualisation of stress. We have post-traumatic stress disorder, but this highly confusing term actually hides the fact that we deal mainly with stress. It is stress responses for which the population is clamouring understanding and relief.

As we saw, it is stress that causes GP and hospital attendances to surge. It is stress that leads to communal anger, currently seen in demonstrations, riots, and dangerous national divides. Ignoring stress is hazardous.

Yet psychiatry has insisted on it, not only in its DSM diagnosis. I recall that even as in the bushfires we helped people with severe stress reactions, the College of Psychiatry was fulminating with anger that we had no business to intrude as they ascertained that there was no increase in psychiatric illnesses. Similarly, when mental health professional came together to form a Society, I suggested it be called the Australasian Society for the Study of Stress and Trauma. I was outvoted. We were to follow the nomenclature of the International Society for Traumatic Stress Studies.

This takes us to an important story that we are reliving in our disciplines. Remember the split between Maudsley and Tavistock, organic and dynamic, brain and mind, body and soul?

This split, as typified between somatic brain and psyche mind has a long history. As in the 17th century science started to overtake religion, the philosopher Descartes struck a bargain that is called the Cartesian duality. The physical brain had domain of the physical parts of people, while the mind was ephemeral, part of spirit and soul, what made people human, and this belonged to religion and the humanities, not to science.

Organic psychiatry maintained that split. Human existential dilemmas was none of its business. Psychodynamic psychiatry, which transgressed the Cartesian duality was punished as being magical and not part of science.

Now I would like to suggest that actually the split between organic and dynamic, mind and brain, Tavistock and Maudsley has very deep roots. For me, unknowingly, the deep roots started in my medical career in the anatomy room.

As I was dissecting the brain, it was obvious to me, as it is obvious to everyone, that the brain is divided into two halves. The left half was said to be dominant. After all, it was the verbal brain. It had words, thought, logic, will, awareness, and self-awareness. I was told that the right hemisphere was silent, at most it contained some emotions.

We now know that the right brain indeed has no words, thoughts, sense of time, or self-awareness. But yes, it is the place of emotions and motivations. Importantly from our point of view, it is the site of instincts, of survival strategies and their stress responses.

It is the part of the brain that has connections with the involuntary nervous system and through it it evokes psychosomatic manifestations. You recall that in the bushfires physical symptoms increased commensurately to intense stresses being forgotten. The right brain is the site of biopsychosocial and forgotten stresses.

And importantly, because these intense but forgotten stresses and traumas based on different survival strategies in the right brain compound with ever-higher functions of the right brain, survival strategies evolve their own different morals, values, and meanings. We are not aware of the sources of these morals, values, and meanings, and we don’t understand how they can oppose each other in different survival circumstances. And so, while our left brains have made huge technological advances, our right brains are still debating the issues philosophers did 2000 years ago.

In medicine and in much of our everyday thinking we often attempt to find the overt diagnosis and the overt solution: this symptom, this drug, this symptom deconditioning. To have 8 survival strategies swirling with their particular biopsychosocial symptoms from individuals to nations, from survival drives to existential concerns, can seem to be too much to take in for our logical left brains. It is around now that you may wish to opt for DSM, or at most anxiety and depression.

T counter such incipient despair, let us remind ourselves that as well as left brain yes/no ‘logical’ minds, we have right brain ‘metaphorical’ minds. Think of playing the piano. Each note is a designated part of an octave. (Recall the octave of survival strategies.) We can play a single note, or combine it with other notes. Notes may be simple combinations as in a ditty, or may reach the complexities of symphonies. The music may be aesthetic, religiously inspiring, but even one note can ruin a symphony and many false notes can scramble the whole music. Representing phases of disasters, music has an introduction, a body and a conclusion. Lastly, it may be played all the way by individuals, concert groups, and groups around the world.

Looked at from this whole, or what I call a wholist perspective, it may not be too difficult to diagnose which notes are off key, examine in which way they are damaged, and what consequences derived from them. In fact the question ‘Of all the things that worry you, what worries you the most?’ may lead directly to the most off key notes and central concerns. They can then be examined with left brain exactitude.

I believe our mental health sciences need to respect each half of the brain, rather than take sides and be contemptuous of the other side.

Let me attend to some outstanding issues.

So far I have been indistinct about distinguishing stress and trauma. Stresses are states of tension resulting from challenges to life-preserving states. Traumas are where such states are irreversibly altered. Stress is like bending a bone. Trauma is like fracturing it. Though both reside in the right brain, their trajectories differ. Bent bones may eventually straighten without deleterious consequences. Fractured bones remain unaltered in the right brain, only to be relived when cued in the left brain, or be bottled up in right brain wordlessness and unawareness.

Why have stress responses been slow to be recognised, conceptualised and aggregated? Perhaps because survival strategies to which they belong are located in our hidden right brains, and because their recognition evokes threat, pain and traumatic helplessness and hopelessness.

I have worked 25 years in emergency departments but I have seen psychiatrists who were terrified of the place and its stresses and traumas. And apart from biological psychiatry, even psychoanalytic psychiatry drew the line at trauma. Freud turned away from it and declared innate sexual and aggressive drives underpinned neuroses.

Psychoanalysts ignored Holocaust survivors’ experiences. My psychoanalyst interpreted my bombing experiences as sexual anxieties aroused from close proximities of bodies in the air raid shelter.

Once we overcome the taboos stemming from our existential anxieties, we can classify them. Survival strategies allowed us to classify stresses, but they can also classify the biopsychosocial hells we fear the most.

In order of survival strategies these hells are: having caused or allowed death; being cast out to die; exhaustion, powerlessness; giving up, surrendered, not worth living, succumbing; horror of having murdered, being evil; panic, inescapable shock, being overwhelmed, paralysed; terrorisation, elimination; and fragmentation and decay.

Survival strategies help us classify our anxieties and depressions. Let us take anxiety. Anguish is the anxiety regarding not being able to save those we love and care for. Reciprocally, threat of losing our protectors and carers is separation anxiety. Anxiety of powerlessness and failure negate goal achievement. Terror is the anxiety of inability to escape and being overwhelmed. Anxiety of killing and destroying belong to fight. Defeat holds the fear of humiliation losing out in the pecking order. Betrayal and abuse are the fears of exploitation rather than mutuality and cooperation.

Similarly, with depression, which is a generic term for different losses and defeats. In order of survival strategies, they comprise not having saved patients, children, comrades. Loneliness and helplessness is the result of insufficient attachment. Sadness and grief are steps in adaptations to loss. Demoralisation stems from inability to achieve goals. Hopelessness and despair are features of goal surrender. Feeling defeated stems from competition and struggle. Betrayal lovelessness and disintegration stem from abuse rather than cooperation and love.

We don’t need to be obsequious to physical medicine, nor to left brain yes/no, is it this or not, apparently ‘scientific’ observations. Instead, we can expand medicine to incorporate a science that incorporates right brain observations. In that way we may help medicine to understand and heal the 40-60% of symptoms that it cannot diagnose.

Let me give you an example. A young man, survivor of the bushfires, had experienced severe nausea for which he was operated, but nothing was found. He explained to me that he felt the nausea for the first time when he found a severed hand in the bushfires. ‘Why didn’t you tell the surgeons?’ ‘They didn’t ask me.’

Lastly, my talk is titled ‘From Survival to Fulfillment’. Medicine is not only disease and unhappiness. In mental health disciplines we retrieve health and joy of life. Like architects help rebuild more stable and more aesthetic homes after disasters, the more we understand the architecture of brains and minds, the more we help fulfilment of more stable and wise humans.

As Hippocrates said, ‘Illnesses were not visitations by the gods, but due to changes, especially major changes.’ Understanding these changes may help medicine retrieve its ‘soul’.

In the end, I have been lucky. From trials of survival came fulfilment. What was its essential ingredient? Some people say a positive transference. Some may even say compassion. I have already trespassed by using the word soul. Now I’ll use the ultimate taboo word from the Cartesian perspective: love, and I’ll apply it to our discipline.

We feel compassion for and we devote ourselves to our patients as we want to rescue them from their inner hells. In turn they trust and rely on us for their salvation. We love and are in awe of our work and grieve what we cannot achieve. We fight for the right to practise the work we love, and when threatened with annihilation, we retreat to our fortresses and keep the flame alight. While of necessity we have a hierarchy between patients and ourselves, ultimately it is a sacred cooperative bond which enlarges the humanity in us both.

Perhaps this is the best place to stop. I hope that I have contributed a little to Ed’s continuing quest.

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