Saturday, December 14, 2013

Of Guilt and Self Punishment

A testament to how little is written or discussed of the lifelong emotional impact of watching other people die, even a voracious lay consumer of psychological and medical research and studies as myself hadn’t heard the word “survivor’s guilt” used in the context of my mother’s early childhood until seven years ago. Not a single doctor treating my mother has ever expressed it, and the countless doctors who treated my maternal grandparents for a variety of ailments never made any connection. None have ever seemed to comprehend how and why she’s still so traumatized and often acts, by the standards of practitioners of Western medicine, erratically, irrationally or with extreme sensitivity and volatility. As a teenager, my husband watched as someone very dear to him killed herself. This, to me, is an unimaginable horror – the stuff of nightmares, the kind I’ve had. It’s especially challenging for me to articulate empathy in any profound way that would make my mother understand how passionately I strive to recognize the emotions she experiences. Sharing such emotions isn’t easy and it may not be healthy. Those nightmares were chronic in my early childhood and pre-adolescence, and only began to taper in frequency in my mid-teens. Many would be of what I imaged as concentration camps or people hovering over mass graves as their loved ones were piled into pits like compost. Naturally all these images were based on what my mother and her parents had endured.

My mother with her mother, 1949. My mother with her
father, 1947. Both photos taken in Hanover, Germany. No photos exist of my mother before the displaced persons camp in Hanover. 

Sigmund Freud referred to survivor’s guilt following his father’s death, in a letter to his friend, otolaryngologist (ear, nose, and throat doctor) Wilhelm Fliess, referring to “that tendency toward self-reproach which death invariably leaves among the survivors.

Simply put, it’s the feeling that you have harmed others, especially loved ones, just because you were spared death when they died. The term "survivor syndrome" was coined in 1961 by psychoanalyst W.G. Niederland, who in the 1950s began studying concentration camp survivors.

Among survivors of World War II concentration camps, guilt is sometimes manifested in strange yet subtle forms, such as behaving as if they themselves are dead, inhibiting themselves from success or engaging in self-destructive acts in response to survivor’s guilt in regard to a dead parent or sibling, A H Modell revealed in a seminal article published in 1971 in The International Journal of Psychoanalysis. I recall one instance when my grandfather lied down under his car, acting as if he were dead. I was a young teen. I was horrified. I knew it had something to do with his experiences, and I felt guilty for lacking the psychological study to identify his condition. (I have an unsupported theory that survivor’s guilt is passed down to the next generation more so than other forms of guilt.)

“Survivor's guilt constitutes the failure of the psychological immune system to grapple with tragedy of great magnitude. Like an infection that overwhelms the body's immune system, survivor's guilt overwhelms the psychological immune system. Instead of exaggerating the difference between oneself and a victim, the similarity is what strikes people as most obvious. ‘That poor guy was no different from me; it could just as well have been me instead of him.’  With survivor's guilt, the differences between oneself and another person shrink, and so too do the differences between what actually happened and what could have happened. As with a bad infection, the best recourse is medical treatment,” writes Neal Roese, Ph.D., in his 2005 book, “If Only: How to Turn Regret Into Opportunity.”

I find this fascinating, as I've often wondered if there was any correlation between people of my mother’s (and grandparents’) immigration and a proliferation of autoimmune diseases. I rarely share this premise, as finding Western medical professionals who even discuss something that’s not published in a study they read or wrote is generally impossible. In any case, I know more than most people outside of endocrinology about autoimmune diseases as it took decades for me to find a doctor to properly diagnose mine. I'd been confident for years that I had some form of autoimmune hypothyroidism, as my maternal grandfather suffered from hypothyroidism and my mother had a thyroidectomy. My grandfather wasn’t diagnosed until it was too late, when he was hospitalized for what may have been delayed symptoms of a nearly fatal car crash that he “miraculously” survived, doctors and first responders told me at the time. (At 15, I was in the ambulance and in the operating room with him.) My mother’s hypothyroidism also went undiagnosed and untreated for decades. Doctors blamed my symptoms on anything else, even my own behavior, and refused to send out blood work for a quick, simple and cheap test of free levels of triiodothyronine (T3) and thyroxine (T4), which together regulate your body’s temperature, metabolism and heart rate, because my "TSH (or thyroid stimulating hormone) is fine." Finally, I found a doctor who’d written an article on a study that articulated exactly what I’d been telling other doctors, and he immediately diagnosed me with Hashimoto's thyroiditis, a genetic disease. My mother’s mother had rheumatoid arthritis, and my sister is afflicted with RA, along with Lupus and Raynaud's phenomenon (RP) – all autoimmune diseases.  So many people I knew growing up from the same immigration also suffered from various autoimmune diseases, while diabetes and heart disease was extremely rare in this community. These people grew their own vegetables and fruits, fished and only bought meat if they knew how the animal was slaughtered. This was in the third-largest city in Massachusetts and fourth-largest in New England. My grandparents kept hens in a perch of shelves that my grandfather build into a one-car garage, grew dozens of vegetable varieties and berries, and even kept and slaughtered their own pigs. I often went fishing (at a nearby lake) and mushroom picking (at a nearby forest) with my grandfather. I picked berries from the small yard and helped collect eggs from the hens. My grandfather volunteered as a beekeeper at the monastery where he’s now buried on his vacations from factory work and brought home the equipment to keep hives in the yard.

My unexamined autoimmne hypothesis aside, there’s been even less done to psychologically diagnose these people and treat their obvious survivor’s guilt and often posttraumatic stress disorder (PTSD). This is an unforgivable failure of our mental health system and our society at large. America has welcomed the “wretched refuse of your teeming shore” but it has done nothing to help those huddled masses heal from the incomparable suffering of surviving war after war. PTSD and survivor’s guilt is so rarely used in conversations about anyone but U.S. military veterans. Unarmed civilians suffer far more than soldiers. PTSD and survivor’s guilt are often confused, even by trained specialists, but they are very different phenomena. While PTSD is psychopathological phenomenon, survivor’s guilt is more of an expression of a normal concern for other human beings, both as individuals and as a society.

My intention is never to undermine the struggle of soldiers. My father was a decorated veteran who served in the South Pacific and in Korea, and is immortalized in The New Orleans D-Day Museum. Many men in my family have served in numerous wars and conflicts. But when they volunteer or they’re drafted or recruited, soldiers are warned of the trauma to come, even if they cannot effectively prepare for it. Even the most distressed societies make an effort, and often a promise, to protect civilians, yet no adult or child ever is warned of the sudden terror that leads to destruction of what was a civil society. My mother also was robbed of a childhood, adding another level of stress to her guilt.

“The various effects that adults who were child survivors experience can be attributed to many aspects of their traumatic exposure. Children and adults were treated differently in the camps and consequently their emotional reactions were different. Children were likely too traumatized during the war to experience ‘true’ childhood,” writes Fara Kaplan in “Holocaust Survivors and Their Children: A Search for Positive Effects” published by The American Academy of Experts in Traumatic Stress. “Also, because the child's identity had been in a state of development, their experiences may have remained buried in their memory (i.e., unconscious). This may have impeded their ability to empathize with others and likely negatively affected their adjustment to their own offspring.”

For my mother, the survivor’s guilt from early childhood is compounded by the losses of her parents and my father, all of whom she cared for at home until their deaths from very serious illnesses. The Russians (and Eastern Slavs) I knew growing up did not sentence their sick and old to death in nursing homes. “How can I do that to my parents when they didn’t let me die?” my mother has said, or stated, many times. Of course, she was equally compelled to care for her dying husband. My grandfather’s illness was, mercifully, short-lived: he died about a year after he became bed-ridden, his wife and his daughter as his constant bedside companions. After he died, my grandmother was bedridden for nearly nine years, her (long undiagnosed) brain atrophy prohibiting her from speaking. She would, however, sometimes cry in a chanting tone that clearly signified the mourning of her loved ones, especially her infant sons.  My father was diagnosed with Stage IV colon cancer, metastasized to the liver, shortly after my grandmother died. I’ll spare the details of what such care involves, as I know most Americans lack the palate for visceral reality. But my mother completely gave up her life from 1987 until 2002. She hasn’t recovered from that trauma enough to indulge in what are very basic creature comforts for the average American, such as treating herself to a movie or a vacation – ever.

In a 1972 article in Psychoanalytic Quarterly, Stephen M. Sonnenberg, M.D., cites a case study involving a patient who felt guilty that her husband had died during surgery she authorized, after caring for him during a nine-month illness. “She also expressed feelings of guilt concerning the murder of her parents and younger sisters by the Nazis,” notes Sonnenberg.

“With (her husband’s) death, she not only felt guilt concerning him but she lost the opportunity to expiate her long-standing guilt by being a good nurse. In her unconscious, it was as if she had willed the suffering of her past loved ones in an effort to be close to them. Thus, guilt over past events became overwhelming. It would seem that this patient was a guilt-laden woman who lost a guilt-expiating object and at the same time underwent an experience that confirmed her past and present guilt. Signing for 'experimental' surgery was perhaps the final burden, and her obsession over it became clear in her treatment. While she insisted that her husband's good health had been her goal, she also felt that she was a 'murderer.’ Depression was present when anger at the lost object was conscious and when identification with the lost object did not exist. It was the strength of her guilt that made her feel so hopeless and depressed.”

Shulamith Kreitler, Frida Barak, Yasmin Alkalay and Nava Siegelman-Daniel conducted study of 195 family members of cancer patients who had been involved in the care of the patients and had a continuous relationship with them, which found that that survivor’s guilt is prevalent among the caretakers of cancer patients.

“It is distinct from the experiences of guilt and of remorse,” they wrote in paper “Survivor’s Guilt in Caretakers of Cancer” based on the study. “Survivor’s guilt is an affective response rooted in deeper layers of the personality. Most importantly, the observations about the correlates of survivor’s guilt six months following the patient’s death support the theses that survivor’s guilt exerts a pro-social impact on the person’s behavior and that it helps maintain the presence of the deceased in the life space of the survivor. Both of these effects led the deceased a kind of metaphorical immortality, thus helping the survivor preserve his or her own sense of immortality and the sense of continued contact with the deceased. In these respects survivor’s guilt contributes to overcoming death, at least on the psychological level.”

This desire to commune with the dead also plays into my mother’s religious beliefs and practices. Russian Orthodox Christians do not close the casket until it is taken from the church to the cemetery. My grandmother’s body was returned to my parent’s home where she died after being taken to the funeral home. A wake was held at home, with many non-Orthodox Christians in attendance, and kept my grandmother there until being transported 166 miles away to the monastery church. (I drove my mother’s car, following the hearse, which was nearing speeds of 100 mph. It was exhilarating.) Psalms are read over the body continuously and throughout the night until the funeral begins. In the words of the fathers of the seventh ecumenical council: “God re-created man in immortality, thus bestowing upon him a gift which could no longer be taken away from him.”

Nietzsche said Dostoevsky was “the only person who has ever taught me anything about psychology.” In Dostoevsky’s work, guilt and sin are existential conditions of man, and each of us is somehow guilty of everyone’s sins. Nietzsche began reading the work of Dostoevsky, who died in 1881, in 1887, finding inspiration in a fellow challenger of the fundamental world view of the Enlightenment. Religious belief is what divides the two. Dostoevsky ultimately believes in salvation and therefore an afterlife, a view Nietzsche boldly rejects. But they share a very similar perspective on guilt.

The confession of Raskolnikov, which leads the protagonist in Dostoevsky’s Crime and Punishment to prison, clearly had a profound impact on Nietzsche’s philosophy.

"Throughout most of human history, punishment has not been meted out because the miscreant was held responsible for his act, therefore it was not assumed that the guilty party alone should be punished: but rather, as parents still punish their children, it was out of anger over some wrong that had been suffered, directed at the perpetrator, but this anger was held in check and modified by the idea that every injury has its equivalent which can be paid in compensation, if only through the pain of the person who injures. And where did this primeval, deeply-rooted and perhaps now ineradicable idea gain its power, this idea of an equivalence between injury and pain? I have already let it out: in the contractual relationship between creditor and debtor, which is as old as the very conception of ‘legal subject’ and itself refers back to the basic forms of buying, selling, bartering, trade, and traffic." _ Nietzsche, On the Genealogy of Morals (1887).

It’s impossible for me to imagine a guilt more “primeval, deeply-rooted” than survivor’s guilt.

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