The suffering he describes is not a mere literary expression of his pain, but is also, medically speaking, the specific symptom of a trauma.
On the night of February 16, a China Airlines flight had difficulty with its approach while attempting to land at the Chiang Kai-shek International Airport in Taoyuan. It stalled and crashed, killing a total of 203 people, including everyone on board the flight and some residents of nearby homes.
This event was, of course, a devastating blow to the friends and relatives of the deceased. According to psychiatrists, an incalcuable number of people in the population at large were also traumatized by the images of the burned wreckage of the plane, the gore at the scene, the people crying over the dead bodies of friends and relatives, and the heart-rending prayers of the Daoist priests broadcast by the media.
Recurring nightmares
Wu Kuang-hsien, head of the psychiatry department at Mackay Memorial Hospital, says that Post-Traumatic Stress Disorder, or PTSD, strikes those who have personally been through a major trauma such as military combat, a natural disaster, a sexual assault, the murder of a loved one, a riot or an automobile accident.
Typical symptoms of PTSD include painful, intrusive recollections of the event and nightmares. Other possible symptoms include feelings of alienation, emotional withdrawal and a loss of interest in life. Some victims become hypersensitive, anxious, insomniac, unable to focus their attention and subject to memory lapses. Those who have lost a loved one or who themselves survived a disaster are particularly prone to feeling guilty about their own survival when others died.
It is worth noting that while most people think that PTSD affects only those who have survived a disaster or those who lost a loved one to some tragedy, You Chien-kuei, a psychologist, points out that rescue workers, members of the media and witnesses are all also susceptible to the condition.
Getting back on the horse that threw you
"Such people frequently work at the bloody scene of a disaster for long periods without sleep or rest. When their work is done, they are often afflicted by nightmares, anxiety, nervousness and sweating as the scene of the disaster replays itself in their minds," says You. He says that psychologically immature people who are subjected to such scenes on the TV all day long, in particular children and those with a pre-existing psychiatric disorder, may also evidence the symptoms of PTSD.
Many psychiatrists, including Wu Kuang-hsien, report treating members of the media in outpatient clinics. Wu says that these major disasters can affect them, too. He feels that schools, newspapers and the broadcast media all ought to provide their students and employees with some degree of psychological education as a sort of vaccine against such traumatization. A still better method would be to make professional counselors available to provide support to those on the "front line" at all times.
Wu says that those with a tendency to panic reactions are especially susceptible to becoming overly anxious as the result of some shock. Those who have previously experienced such a blow may also have old wounds reopened. Still others who have let stresses in their work or life build up may also evidence physical symptoms if subjected to some additional blow from outside.
"Don't let your stress accumulate, or find some appropriate way to release it. At such times, friends and loved ones must provide the victim with support," recommends Wu.
Turning to religion
"As with most ailments, people struck by this kind of psychological trauma have some ability to defend themselves and to recover. There are also external resources, such as family and religion, to help them get over the trauma. Such blows do not always cause permanent damage," says Hu Wei-herng, director of the Taipei City Psychiatric Center. He says that people have always had folk methods of dealing with such crises, methods such as the reading of sutras, Buddhist and Daoist rituals, and the casting of magical charms. All of these approaches have the effect of quieting the spirit and easing the mind of someone who has been unsettled.
In addition to the support of family and friends and these old "folk" remedies, when disaster strikes Taiwan there are public and private organizations which provide comfort and support to victims and their families, including the Social Affairs Bureau of the Ministry of the Interior and Buddhist volunteer groups. In cases where psychological help or counseling is needed, people tend to go to private organizations such as the Suicide Prevention Center or Teacher Chang.
The problem is that in this modern era, these organizations are insufficient to the needs of some. Some people don't have friends or relatives to help. For others, social resources are insufficient. If a victim evidences more serious or pathological symptoms, he must turn to a psychiatrist or a psychologist for help. Such professionals can prescribe medications to alleviate some of the symptoms and can reduce stress through counseling.
However, the symptoms of someone who has personally experienced a traumatic event are commonly repressed or disguised. In the earliest stages, a patient may only experience long-term insomnia, anxiety, deep depression or difficulty getting along with others. They may not be consciously aware of the severity of their condition.
The tip of the iceberg
"Most people respond to a major trauma by trying to push the experience out of their conscious mind. The trauma is never spoken of and is only recognized through the symptoms the victim displays," says Dr. Chang Ta-jen, assistant director of the Provincial Taoyuan Psychiatric Center. Chang says that as most people are unable to recognize the warning signs and symptoms, they deal with a trauma by repressing it or through displacement.
"While this approach brings the symptoms to a temporary halt, it does not deal with the root of the problem; the displacement always ends up creating another problem," says Chang. Therefore, when seeing patients in the outpatient clinic, he usually asks them about their personal and medical histories. He has thus discovered major emotional blows or traumas behind many of their physical and psychological disorders.
PTSD may strike immediately or after a period of time. Acute PTSD involves cases in which symptoms appear within six months or in which symptoms last for fewer than six months. Chronic PTSD involves cases in which symptoms persist for longer than six months. Delayed-onset PTSD describes cases in which symptoms do not appear until more than six months after the trauma.
Of more concern to medical professionals are the delayed-onset and chronic forms of the disorder. Because of the length of time between the trauma and the appearance of symptoms, the link between them is often overlooked. Also, because the symptoms have been accruing over a long period, the condition is often more difficult to treat.
If these symptoms are left untreated for an extended period, they can cause severe depression which can take the form of unresponsiveness to one's environment, a feeling of helplessness, alienation, self-abasement or feelings of guilt. The results can be startling psychoses, including schizophrenia and personality disorders. Suicide often becomes the last resort of these victims of long-term depression.
War and hysteria
With the advancement of medical science, the complex effects of traumatic experiences are gradually coming to be understood. This increase in understanding is also making apparent the inadequacy of traditional treatments and the necessity for professional help.
In her book Trauma and Recovery, Dr. Judith Lewis Herman, a professor of clinical psychology at Harvard Medical School, writes that research into psychological traumas began in the 19th century. The psychologists of that area frequently found themselves treating women who had become hysterical. The women were subject to paralysis, loss of their senses, spasms and memory lapses. Tracing their case histories, these psychologists discovered that most of them had been victims of sexual abuse or incest as children.
In her book, Herman states that the two world wars, and the American involvement in the wars in Korea and Vietnam, made the public aware of the ubiquity of psychological trauma. Soldiers who had been exposed to the horrors of trench warfare, the constant threat of death, who had seen their brothers-in-arms wounded and killed while they themselves were unable to do anything about it, would shout and cry hysterically, or become suddenly rigid. Their personalities changed; they became silent and unresponsive. Some even lost their memories or their senses.
After US involvement in the Vietnam War came to an end, the startling number of traumatized vets served as a stimulus for psychological research and led to the recognition of the symptoms of post-traumatic stress.
During the same period, the women's movement in Europe and the US was leading to more research into and treatment of abused women and children. This, in turn, led to an expansion of the definition of PTSD. Research shows that victims of abuse suffer from many of the same symptoms as veterans, including insomnia, nausea, intense fear and nightmares.
Herman believes that the definition of trauma covers a broad spectrum of conditions which can be distinguished in terms of degree. For example, she categorizes those exposed to violence or sexual abuse for long periods of time as victims of "complex PTSD" because of the complex nature of their symptoms. Only by making these finer distinctions can appropriate treatment be given to those in need.
Like a war zone
To avoid the problem of delays in receiving care leading to illness, psychological professionals in Taiwan emphasize the importance of immediate treatment. Typhoon Winnie struck Taiwan in August of last year, knocking over buildings in the Lincoln Mansions residential development in Taipei County and causing flooding in Tahu Shanchuang in Neihu. Thirty people died in the disasters. In the wake of the storm, staff at the Taipei City Psychiatric Center took the initiative, visiting the homes of victims. They also wrote letters to victims and their families reminding them to be aware of their psychological state and recommending that they make a visit to a psychiatric clinic.
Disaster struck again in October at the 10,000-man tug-of-war organized by the Taipei City Government when the rope broke, causing two people to lose arms and others to suffer internal injuries. Anticipating that in addition to the physical injuries, there would be some who would need to be treated for psychological shock, Hu Wei-herng, director of the Taipei City Psychiatric Center, worked together with a psychiatric team from Mackay Memorial Hospital to evaluate the emotional state of the victims.
"On the day of the accident, a great many of the victims' family members and members of the public saw arms flying through the air and blood spurting on the ground in a scene reminiscent of a battlefield. Many people had a hard time getting a grip on themselves for some time afterwards, even bursting into tears and not being able to eat; in short, evidencing the symptoms of PTSD," says Hu, noting that there were some who were not directly injured whom he nonetheless urged to seek treatment.
"For the most part, those who saw the accident happen but were not hurt felt the symptoms of PTSD immediately. But pain served to distract those with serious physical injuries from their psychological hurt, and they therefore appeared to be calm. Two to three months after the event, however, these victims began to clearly evidence the signs of a psychological disorder," says Hu. He therefore feels that treatment must be long term. Even now, many of the victims of the tug-of-war are still visiting outpatient clinics for counseling.
The support of a group
In addition to the psychiatric clinics of hospitals, there are other groups, often established by public and private organizations involved in counseling and psychological development, where the public can find support and an emotional outlet.
Dr. Chang, who also leads group therapy sessions under the auspices of volunteer organizations, says that people in Taiwan tend to repress the sadness they feel at the death of a loved one. Most avoid talking about it. The people around them, too, try to encourage them by telling them things like "don't dwell on it" and "get out and do some things." But deep inside, these people are hungering for someone to talk to.
At such times, group therapy can provide them with a warm and safe environment in which to express their feelings. Chang says, "By drawing people who have had similar experiences together into a therapy group, the members can understand one another's feelings; it builds confidence and warm feelings. This allows them to give full expression to their emotions and gradually get over the tragedy."
Three years ago, a Ms. Lin visited Japan with her husband to celebrate 25 years of marriage by viewing the cherry blossoms. The next month, her husband made a trip to mainland China on business. While on the airplane, her husband had a stroke and died. She was totally unprepared for this. "My husband was healthy. I had no chance to prepare myself for his passing away." She cried every day and was completely unable to work. She lost interest in life, wearing the same clothes and eating the same food every day.
Although she had been to a psychiatric clinic for treatment, the medication the doctor prescribed for her only made her fuzzy-headed and did nothing to help her mood. Then she saw some magazine and newspaper articles about group therapy and began attending sessions. She discovered that the other members of the group had had similar experiences of losing a loved one, enabling them to understand one another and provide each other with support. She began to feel that getting out really was better than staying hidden away in her home, and began rebuilding her life. Lately, she and some of the other widows in the group have formed a sort of "girl's club," often going out together to have a cup of coffee and making trips into the countryside together on holidays.
Letting the sun shine in
Early this year, Dr. Gao Shur-fen, a doctor in the Children's Mental Health Center of the Department of Psychiatry at National Taiwan University Hospital, used group therapy to deal with the case of some children who had suffered burns.
Six children had been severely burned during an experiment in a "talent" class when, through carelessness, the alcohol ignited causing an explosion and fire. A Mr. and Mrs. Wang Tsung-yuan, who had returned to Taiwan after living abroad in Canada, realized that their badly burned nine-year-old son would need psychological care in addition to physical treatment. They immediately asked the hospital to arrange it for them and encouraged the parents of the other children to talk to psychologists as well.
Dr. Gao immediately formed the 12 parents into a therapy group to help them get through their emotional crisis. "On the third evening after the accident, the parents of the injured children began group therapy. During the three hours they were together, I asked them to talk about what had happened and to express their feelings." Gao says that some of the parents had been at the scene and so were very clear about what had been done to help. They explained it in detail for the benefit of those who hadn't been there, alleviating some of those other parents' anxieties.
They then talked about their view of the whole situation. Some felt guilty and regretted having chosen this particular "talent" class for their kids. Others felt bad that they had sent their kids to the class on the day of the accident. "During their session, the group expressed a lot of support for its members and came to accept what had happened. They really supported and encouraged each other," says Gao.
During the next few sessions, "I allowed them to express their dissatisfaction with the school and discuss the problem of compensation. They quickly reached an agreement. I think the reason that they were able to be so reasonable about this was that they had already given voice to their feelings." Gao says that ultimately, the main thing with which the parents were concerned was helping their kids with issues such as: how to get over the injury and through physical therapy; how to deal with the change in their appearance; how to readapt to school; and how to rebuild their confidence.
What followed this accident was quite different from what follows many accidents in Taiwan. Typically, family members get involved in continuous disputes over compensation and blame. Gao believes, "This happens because they are bound up by too many unsatisfied emotions and can't get out from under this dark cloud. There is no one to help them deal with the real problems, and so they remain anxious and worried."
A broad safety net
The problem is that although people in Taiwan have begun to recognize the importance of psychological therapy after a disaster, and though psychiatric professionals have been encouraged to provide care to victims of several recent disasters and accidents, the work of providing society with a PTSD safety net is progressing very slowly.
"Our response has been too slow!" exclaims Dr. Lu Chung-hsing, director of the Department of Clinical Psychology at the Taipei City Psychiatric Center. Dr. Lu feels that the treatment of psychological traumas should be part of the front line of disaster relief work.
Because so many died in the most recent China Airlines crash, and because the victims came from all over the island, the Bureau of Medical Affairs of the Department of Health (DOH) pressed psychiatric care professionals from all parts of the island to help out. These professionals not only established a counseling hot-line, they also contacted family members of victims directly. Their hope was to persuade them to come in for counseling. Unfortunately, most people rejected the offer.
"We missed our best chance. The best time to approach people would have been at the scene of the crash. But the DOH didn't begin getting people together until a week after the crash. We missed the most important week." Dr. Lu says that many family members were confronted with a scene that looked like hell-on-earth at the site of the crash. Moreover, "The people at the scene handled the situation too crudely. They took the naked bodies and body parts they found and, regardless of whether male or female, dumped them into plastic bags. Families had to identify bodies under these circumstances. These family members suffered secondary trauma, and had obviously given up all hope of being helped. They no longer expected anyone to understand their pain, and didn't believe anyone would help them."
Secondary trauma
"Psychological counselors at the scene could have prepared family members for what they were to see from the time they arrived. Such preparations would reduce the shock of this kind of accident on family members and the incidence of secondary trauma," says Lu.
This also applies to rescue workers, reporters and airport and airline employees. These people, too, suffer a great blow to their minds and their physical senses from such accidents. It only takes a moment's reflection to realize that they should also be given some training or advice before being allowed onto the scene. Many charge right out into the destruction before realizing what it is that they are dealing with. Since they can't turn around and leave, they have to harden their hearts to get themselves through the work at hand. It is only afterwards that they discover the mental toll.
In addition to softening the blow to those involved at the scene, "In the days following, they will mourn and experience a sense of loss. Psychological professionals should be with them and help them deal with these emotions to help them get over the experience." Dr. Lu says that everyone has the ability to heal their own hurts. What psychological professionals do is to stimulate that ability, helping people to face reality and eventually return to their old lives.
Psychologists also do disaster relief
In Trauma and Recovery, Herman also discusses the importance of psychological professionals participating in disaster relief work.
She cites the example of an oil tanker which capsized off the coast of Norway. After the survivors were rescued, they were immediately given counseling by a psychiatric team. The doctors listed the symptoms of post-traumatic stress in a short report which also included two recommendations: first, that the survivors talk about their experience in spite of their reluctance; and second, that they avoid trying to treat their symptoms with alcohol.
One year after the accident, the survivors had a follow-up interview. At that time, many were still carrying the short report which the doctors had given them in their first session in their wallets, its dog-eared state attesting to the number of times it had been read and re-read. The book concludes that psychiatric teams not only can relieve the anxieties of victims' family members, but also anticipate the psychological discomforts of the victims themselves and reduce these to a minimum.
Systemization
Most medical professionals also feel that organizations such as airlines and airports should create a set of crisis management procedures and train their staffs to use them. "Some 60-70% of all airplane crashes occur at airports. In the future, when there is a crash, staff could just follow the procedures that they have been trained in and immediately take care of such things as arranging for someone to accompany the relatives of victims," says Lu.
He says, "Disaster relief has already become a new field of research and work within the domain of psychiatric medicine. With today's higher population densities and advanced technologies, the scale of disasters is growing. We should be thinking about how to deal with such crises before they occur; it is clearly preferable to have something in place that we never have to use than vice versa." Lu says that he has already gathered together a number of psychological manuals dealing with disaster relief from overseas and is preparing to translate them for the local medical community. His hope is that everyone will work together to create a set of crisis management procedures for Taiwan.
Psychologist You Chien-kuei feels that Taiwan should be building a national psychological treatment network beginning at the neighborhood level. "We already have medical clinics in neighborhoods. Now we can establish psychological information centers to provide basic information on psychological health to the public. These could act as a kind of preventive medicine. When something did happen, people would not only know how to deal with their own traumatic experience, but would also know how to give support to family and friends."
Recovery is like a marathon
It is worth noting, as Dr. Wu Kuang-hsien says, "The process of recovery is like a marathon. It does not run a direct course and progress is made gradually. One advances step by step." He emphasizes that one can't have too-high expectations of recovery in the short term.
Sometimes there is a recurrence of the trauma, and there are often obvious reminders of its existence. Things such as the anniversary of the event which caused the trauma may bring the patient down and cause symptoms to reappear. However, during the process of a successful recovery, you should be able to see a gradual change. The patient should regain a sense of security and a better grip on reality. The memory of the trauma should become more distant and interpersonal relations should regain their bloom.
What makes all of this worthwhile to those who have been through a traumatic experience and those who treat them is the deep impression that the process of recovering leaves: they feel life more strongly, their world-view is broadened and they have greater confidence with which to face the future and the crises it may bring.
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Accidents and disasters can strike quickly, often too quickly to be prevented, and the devastation they wreak on people's minds and lives is often far greater than you would imagine. (photo by Chen Cheng-chang)
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One of the greatest pains a parent can experience is walking in the funeral procession of her own child. The kidnapping and murder of Pai Ping-ping's daughter Pai Hsiao-yan was a terrible shock to parents in Taiwan.
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Trying to forget an emotionally damaging experience doesn't always help heal the wound. One must remember to try and find something positive in the experience. The picture shows the plaque memorializing the victims of the February 28 Incident.
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In just a few moments, many of the families living in the Lincoln Mansions lost their homes as a hillside gave way. Residents took to the streets to demand compensation. But can money make up for what they suffered?
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The psychiatric outpatient clinics of the island's hospitals provide valuable treatment to victims of psychological traumas.
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Li Feng-mao, a member of the Academia Sinica's Institute of Chinese Literature and Philosophy, has made a long study of Daoist religion. He has chosen to deal with the pain of his wife's death by viewing it as her having attained immortality and floated away.
p.121
Psychologically speaking, a major disaster strikes the whole of society, causing trauma of a different degree.
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In an example of perhaps the best method for recovering from a trauma, a group of children burned when alcohol they were using in an experiment exploded provided support and encouragement to one another during therapy. (photo by Wang Tsung-yuan)
The psychiatric outpatient clinics of the island's hospitals provide valuable treatment to victims of psychological traumas.
Li Feng-mao, a member of the Academia Sinica's Institute of Chinese Literature and Philosophy, has made a long study of Daoist religion. He has chosen to deal with the pain of his wife's death by viewing it as he r having attained immortality and floated away.
Psychologically speaking, a major disaster strikes the whole of society, causing trauma of a different degree.
In an example of perhaps the best method for recovering from a trauma, a group of children burned when alcohol they were using in an experiment exploded provided support and encouragement to one another during therapy. （photo by Wang Tsung yuan）
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