POST-TRAUMATIC STRESS DISORDER AMONG VICTIMS OF ORGANIZED VIOLENCE: A REPORT FROM BULGARIA
by Toma Tomov and Evgueni Guentchev
This study originated in the authors' curiosity about the applicability of the ICD-10 diagnostic category of post-traumatic stress disorder (PTSD) in the Bulgarian cultural context. [ICD-10 (the tenth revision of the international classification of diseases) is a complete list of all diagnostic categories recommended by the World Health Organization for use by the medical practitioners and the health authorities of the member-states of the organization.] lt appeared from the beginning that the country's health-care system, plagued as it was by rigid bureaucratic thinking, would not easily accommodate a diagnostic category that did not fall neatly into either the mental or the physical domain. As we have stated elsewhere (Tomov et al., 1989), the division between the domain of the body and the domain of the mind in the socialist model of health care was extreme at all levels including medical training, diagnostic practices, health administration, and patient behaviour. Having searched for a medical, or social, or mental-health, or any other setting in which we could anchor a study on PTSD, we finally discovered that child abuse, sexual abuse and even physical abuse were topics which were out of bounds in Bulgaria: propriety did not tolerate public or professional discourse on such issues. Our search also indicated that natural or man-made disasters in Bulgaria were typically experienced in terms of material and physical losses only: becoming vocal about the psychological pain associated with them (as we tried to do in connection with homelessness in the town of Strazhitsa, hit by a major earthquake) was looked down upon or met with indifference.
Since these human practices and predicaments - which are shown to generate the majority of cases of PTSD in the absence of mass immigration or war- were so inaccessible for research for cultural reasons, our enthusiasm for a PTSD study quickly began to wane. And then political violence suddenly loomed large in the public life of Bulgaria following the dramatic events of 1989, thus offering itself as a research topic (Guenchev and Tomov, 1990).
OBJECTIVES AND METHOD
Organized political violence had been more or less standard practice in Bulgaria from World War II until I962 and had remained unchallenged until I989, when groups of former prisoners and detainees from labour camps identified themselves as victims of such a practice and formed the Club of the Repressed. Having established contact with the Club, the research team developed the following objectives for this study:
l. To assess the frequency of the late sequelae of political repression among the members of the Club, all of whom we took to be victims of organized violence (VOV), with an eye to the rate of PTSD.
2. To record the clinical profile of the PTSD cases and compare it to the classical descriptions of the PTSD syndrome which emerge when the diagnosis is made a short time after the stressful event
3. To test out management and treatment approaches that would be appropriate to the problems of this cohort of VOV.
To address the first objective, we drew a random cohort of 100 out of a total population of 562, the overall number of individuals on the membership list of the Sofia City division of the Club when the study was contracted (spring 1991). The Bulgarian version (Savov 1988) of the 30-item General Health Questionnaire (GHQ) (Goldberg, 1978) was posted to the home addresses of those in the random sample, with a request to answer the questions and return the form.
To meet the second objective, we asked the respondents, in an accompanying letter, to report to us if they were interested in getting feedback about our findings; to this end we provided a telephone line for appointments. In addition, we put up a notice in the Club office with the name, address, and telephone number of one of us (T.T.), with an indication of our research interest and field of competence, and a brief description of the services we provided. This message was addressed to all members of the Club, irrespective of whether or not they belonged to the random sample.
To meet the third objective, we (T.T.) offered help to all those who reported for feedback or clinical guidance.
The whole undertaking operated from the basis of the clinical practice set up within the Neuroscience and Behaviour Research Programme, intended to provide clinical clerkship opportunities for a postgraduate certificate course in family medicine. This programme was affiliated to the New Bulgarian University in Sofia, the first non-governmental school in the country chartered by Parliament in August 1991. The family medicine training package incorporates (a) sensitization through brief exposure to a therapeutic setting; (b) personal therapy (experience in small groups of the interactional, couples or psychodrama type: 500 hours or more); and (c) clinical supervision (two years or more) (Tomov, 199l).
(I) RATES OF DISTURBANCE
Of the l00 forms, 55 were returned in due course, and 47 of these were properly filled in. The male-to-female ratio was roughly 8.5 to 1 among the respondents and l0 to I in the initial random sample (as in the overall population of members. of the Club). All the respondents except three were over sixty, and about a quarter of the whole group were over seventy.
Thirty-one out of the 47 individuals who responded were screen-positives - in other words, the proportion of cases with high GHQ score was 66 per cent. Taking into account the sensitivity and the specificity of the Bulgarian version of GHQ, the expected prevalance was estimated at about 62 per cent.
Overall, 30 individuals made appointments for clinical interviews: 15 did so in response to the letter accompanying the questionnaire; I5 came because they had read the notice in the Club. All agreed to undergo a mental-state examination. The clinical interview was preceded by some semi-structured questioning about the trauma experience based on items from the Survivor of Torture Assessment Record developed by Turner et al. (Turner, 1991). A total of six cases were diagnosed as having had PTSD and having developed, as a result, enduring personality change after catastrophic experience. This was the most common diagnostic category used (with the exception of the category 'no diagnosis' received by 10 respondents).
(Il) THE TRAUMA EXPERIENCE
All respondents had been submitted to internment, imprisonment, detention in labour
camps or combinations of all those. All had been physically abused to varying extents,
deprived of food, sleep, and medical care, kept in isolation, brutally forced to work, and
threatened. The families of all had been subjected to varying extents to harassment,
internment and extortion. All cases had been hastily pushed through court on false
accusations related to endangering the security of the state, and with a blatant disregard
for the human rights of the detained.
(III) PTSD CLINICAL PROFILE
All subjects, including those who were free of complaints at the time of the interview, reported experiencing various PTSD symptoms in the past. A feeling of detachment from others, outbursts of anger and efforts to avoid thoughts and emotions associated with the trauma were reported particularly often; these experiences were readily recognized as deriving from, or related to, traumatic memories. These symptoms, however, were seldom revealed spontaneously by the respondents. Most often they were revealed only in answer to specific questions, and were accompanied by signs of embarrassment and a tendency to belittle their importance. There was often a related feeling of guilt.This was expressed openly only late in the interview - when, and if, rapport developed.
Case Description 1
Mr G, aged fifty-nine, university graduate, married with two grown-up sons; currently living with wife, employed as a design engineer by a government building company.
History: In his first year at university, more than thirty-five years ago, Mr G had been wrongly accused of being involved in disseminating anti-Communist propaganda among his fellow students. He had been forced to admit to these charges; at his trial he was found guilty and imprisoned. He was released from prison several years later, and cleared of all charges shortly afterwards. Of this he had been officially informed, but also instructed to keep this knowledge to himself. He had, however, been given every assurance that he could enjoy life as a person whose past was unblemished
Nothing turned out to be further from the truth, though, as he soon came to learn. The stigma attached to his name remained, severely restricting his individual freedoms to this day: 'I never did anything again purely for the sake of it, but somehow always because of having to clear my name. I finished my university studies in order to turn my back on my prison days and start life anew; I married to gain a footing and find a purpose in life; I excelled in my job to live up to and be considered equal to the rest.... My life has been thwarted beyond recovery . . .'
Presentation: Mr G presented with a cautious, almost demure inquisitiveness. He inquired carefully about the qualifications, motives, professional experience and objectives of the therapist. Only when he got answers that were to his satisfaction did he reveal a problem. He was worried that he had lost the respect and liking of his family, his wife included. He blamed this on himself more specifically on attacks of rage to which he was falling prey. He never did or said anything violent: only wished he could do so.
One such attack would throw him off balance for several days: he would feel disgusted with himself, withdraw into memories of particularly traumatic experiences from his prison days; sever all emotional contact with his family; stay awake night after night; consider putting an end to his life; totally abandon his professional duties, missing appointments and deadlines.
Once he was past the description of his complaints and symptoms, Mr G revealed some of the dynamics of his emotions. He had kept his part of the bargain, he said, referring to the episode when they had talked him into admitting to the dissemination of the propaganda; they had not kept theirs. He could not stop blaming himself for having ended on the losing side. He was pretty sure his wife and sons despised him for this.
Case description 2
Ms D, aged sixty-two, finished secondary school; single; unemployed.
History: In her twenties Ms D had had an amorous involvement with an employee at one of the West European embassies in Sofia. This was found to be sufficient grounds for accusing her of conspiring against the security of the state. After several years' detainment in a labour camp, Ms D never managed to resume a course in life to her satisfaction. She never re-established emotional contact with her family - particularly her mother, who had disapproved of her involvement with the foreigner in the first place, and had been silly enough to resort to police assistance in an attempt to force her to drop him. Instead, Ms D had remained in some ('perverse', as she called it) relationship with her tormentors which was mutually advantageous: they gave her protection; she, it transpired, repaid them with services she would not name.
Presentation: Ms D was a very lonely person whose memory did not function well; she wanted to be put under nursing care. She had recurrent nightmares; she was void of emotion, and felt doomed to unhappiness. She easily became frightened or angered by people, and her relationships did not last. She met every question with a long, silent stare at her interviewer, her body bent forward, oblivious to the discomfort her position should have been giving her. She said very little, and by the time she left she had not made up her mind whether to attend again.
The clinical setting for the study was very unconventional by all standards of Bulgarian health care. Offering services in terms of programmes of care was confusing to people who were used to being shuffled around by medical staff, and being denied all competence in matters of their own health. Contracting tended to get stuck when the therapist avoided the paternalistic stance, and indicated instead a preference for partnership.
Awareness of this would provoke tension and uneasiness in the patients: they would tend then to restrict themselves to pointing to somatic problems only, and ask to be referred to 'reliable' consultants for those matters. ('Reliable' often took on a political connotation.) This request would be accompanied by promises to resume contact at a later point in order to attend to the psychological issues. These promises were kept only on a couple of occasions.
Referrals were always through personal contact or by telephone with consultants who had been introduced to the project and had agreed to collaborate in it. They had all been made aware of the authors' opinion that the existing health service had not been tailored to handle this type of patient. The attempt to focus on the psychological aspects of the patients' situation, and to involve them in the search for solutions, always seemed to come too early, even when it was made after two or three successful somatic consultations. The results so far have been withdrawal from the contact and estrangement from the programme. The case below is a typical illustration of this development.
Case description 3
Mr P was another case of PTSD. He had a history of over three years in labour camps that resulted in pulmonary tuberculosis. Once the diagnosis had been made he had been informed that his condition was beyond recovery owing to a lack of appropriate medicines. However, he had contacted the Red Cross in Switzerland, and obtained a supply of medication. He said that he had used his own judgement in deciding on dosage and regimens because he had not trusted the medical staff, and also because they had 'written him off'. Survival had become a 'matter of honour' for him. 'They had all the power, and yet I found a way to defeat them,' he said.
Mr P presented with pronounced emotional instability: he kept bursting into tears, getting into a rage and glorifying the new political developments. His one main concern was that he could not contribute to the positive change in the country because of the 'poor state of his mind'. He went on to describe this as 'failing to concentrate and think logically and productively', or as 'impotence' of the mind which would not 'deliver', no matter how sincerely he tried 'impressive' solutions. This was in dramatic contrast to his wife, also a victim of organized violence, who had managed to preserve her 'creativity' in the face of all adversity. His wife, he said, was now retired, but kept producing 'literary pieces of amazing brilliance'.
The kind of therapeutic contract that Mr P thought he would like had to be built around the 'restoring of the functions of his mind', damaged by the strain of life in labour camps and under Communism. 'Abandoning poor mutilated Bulgaria' for 'blissful living' abroad (which he had repeatedly been invited to do) was a solution he rejected on moral grounds. Staying behind, though, was of little use if his mind could not 'deliver ideas'.
Mr P had absolutely no idea how this therapeutic goal could be achieved. He was convinced that it was entirely up to the therapist to decide. Asked to imagine that the change had occurred, and to describe how his behaviour and life situation would be affected by it, he fancied himself leader of a cheering crowd. This he revealed shyly and somewhat bitterly: it became clear that unless his mind 'delivered' the idea that would attract the crowd, his dream would not come true. Asked how he could start working towards this end, Mr P took a deep sigh, said he knew he could not be helped, and left.
The psychiatric morbidity among the victims of organized violence (VOV) in Bulgaria was shown to be very high. The prevalence rate in a group of 562 former prisoners and camp detainees was estimated at 62 per cent. The reported rate was twice as high as the rate found with a comparable technique among polyclinic attenders in the city of Sofia in a study done several years earlier (Tomov et al., 1989). The VOV group was predominantly male and some what older compared to the polyclinic group - differences which could not account for a twofold increase in morbidity. The findings support the expectation that victims of organized violence are at very high risk of developing lasting mental-health problems.
The diagnostic composition of a cohort of thirty cases from this group, who volunteered to undergo a psychiatric examination, was shown to contain six cases of PTSD and/or enduring personality change after catastrophic experience, despite the fact that the clinical assessment was carried out two to three decades after the subjects had experienced the forceful intrusions that had dislodged most of them for the rest of their lives. These people had lived with their symptoms for many years without undergoing - or even considering - mental-health examination and treatment.
Much of what in the West would be regarded as illness our clients took to be a negative experience contingent on an individual choice made earlier in life. Awareness that in today's world illness was too high a price to pay for commitment to political ideas was only occasionally present: it was almost as if involvement with politics was taken to imply an acceptance of violence and its consequences. This was very much the feeling conveyed by the families and the larger community too: the blame was laid on the victims for being victims. This attitude was evident in the fact that little more than lip service was paid to these people's contributions, while their emotional needs remained completely unnoticed. When, in the clinical setting, attention was drawn to the emotional aspects of a victim's experience, declining to contract psychological therapy was the standard response. The suggestion that therapy might be indicated, even when it was made very carefully, was often perceived as threatening. Such a client would feel impelled at this juncture to reiterate his or her political pledge and to glorify, in emphatic terms, self-sacrifice as the only tenable world-view. From a psychodynamic point of view this constituted resorting to a defence-employing denial - a defence which was not so much a characteristic of the individual as of the movement to which the Club of the Repressed belonged, and the post Communist culture in general. From the point of view of interpersonal dynamics, this move invariably had the effect of placing the client in the position of power vis-à-vis the therapist and the health institution in general. The social power dimension emerged as by far the dominant dimension of human relating with which the political survivors in our cohort tended to be concerned. Within a world-view of this kind, there is hardly room for therapy.
This study was conducted in the context of social change: it was enabled by a political process which had been set free. At the time when it was done, major segments of the old system were still in place and functional, but they could now be viewed critically. The health-care segment - with all that it involved: attitudes to illness, delivery of care - was virtually untouched. This provided a rare opportunity to reveal how culturally determined health-care constructs were.
The notion of PTSD originated in a Western culture which assigns centrality to democratic values. It requires a health-care system consistent with these values to design programmes appropriate to the needs of the victims of organized violence, and to produce clients capable of making use of such programmes. The year-old democracy of Bulgaria did not live up to these expectations: the psychosocial outlook on health and illness and the type of service it entails were too much of a novelty for a project of this kind to thrive.
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Savov, R. (1988) 'Standardised Bulgarian version of GHQ' (dissertation, in Bulgarian). Sofia.
Tomov, T. (199l) 'The impact of political change in Eastern Europe on behavioural
sciences and psychiatry', British Journal of Psychiatry 159:
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study' (II)' (in Bulgarian). Savremena Medieina 9, Sofia.
Turner, S.W. (1991) Suruival of Torture Assessment Record (STAR).London: Medical
Foundation for the Care of Victims of Torture.
This article was published in Free Associations (no. 30) 4: 180-90, 1993.
Address for correspondence: WHO Collaborating Centre, Medical Academy, 15 Dimitar Nestorov Street, Sofia 1431, Bulgaria
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