16 January 2019

The forensic fusillade unleashes its endless loss

Mental Health Psychiatry

As the hapless year of 2018 tumbled towards its conclusion, my appointment list had several cases that made my heart sink.

These were claims for what the lawyers call “nervous shock”. That is, close relatives of someone who has died in a motor accident, industrial accident, medical mishap or homicidal assault.

Such cases come up at intervals, but to have four over little more than a fortnight was confronting, to say the least.

Most forensic cases include their share of the standard emotions, in which indignation, disdain, frustration, resentment and entitlement predominate. The nervous shock cases, in contrast, are the rawest, most naked examples of human feeling one can encounter.

More often than not, it involves a child who has died suddenly and without any anticipation in a road accident. There may be others, also young, involved in the accident and, in some cases, an offender driver who was reckless, intoxicated or drug affected.

No parent, they often say, can imagine any greater loss than that of a child, and they are the living examples of this. Less often said, but difficult to ignore, is the difference between death from a severe illness, which often allows time to prepare oneself, and the sheer shock of receiving the news of the sudden and traumatic death of one’s child.

Such people come in with such an intense keening sense of loss it is like an invisible wall between them and their surroundings. Some, a surprisingly low number, may be so distressed they can barely talk; most impress by their determination to go through the story regardless of the pain.

The only comparison I can make is with those cases I saw in the late 1990s of refugee migrants who had survived the Serbian and Bosnian concentration camps. Their experiences were horrendous, as bad as anything known in World War II. Added to this was the loss of their homes and families. Now they had come to a safe life in a country on the other side of the world of which they knew little.

Their attitude was striking and consistent. They no longer had anything one could consider a sentient life. Their minds were a pulsing capsule of trauma, riddled with flashbacks; daily life was simply something to pass through with no hope of change in future. All they had to hold onto was that their children would experience something of a life they knew they could never again have.

Determining how the nervous shock patients are affected is the goal of the examination.

Such is one’s sensitivity for the distress that the account of the accident, learning of the death, viewing the body and the wrenching funeral is kept as short and to the point as possible. The patients often have numinous experiences: sensing the presence of the deceased; vivid dreams; believing, for an instant, that they can see or hear them. These are mostly consoling moments, especially when they learn that it is a normal reaction, neither psychotic nor something to be pathologized.

What can one say to console the wretched victim? – for victims they will be probably for the rest of their lives. They have by now heard every cliché in the book, and then some; anything one tries to say will come out as a pointless platitude. A silent acceptance is the only option, and then little at that.

James Joyce, in his acute way, described his reaction to the death of his mother in Ulysses, notably the first chapter:

Pain, that was not yet the pain of love, fretted his heart. Silently, in a dream she had come to him after her death, her wasted body within its loose brown grave-clothes giving off an odour of wax and rosewood, her breath, that had bent upon him, mute, reproachful, a faint odour of wetted ashes.  

Whatever joys or tribulations the holiday season brought, I could not escape the memory of the nervous shock parents for whom such a time is not one of happiness, relaxation and comfort, but a further twist of the terrible screw of their grief.

One can only remember the words of Japan’s World War II Emperor Hirohito on informing his people of the intention to surrender to the Allies: “We must endure the unendurable.” 

 A poignant comment on grief on a larger scale it was, but relevant nonetheless, asking the worse question: But how?

Robert M Kaplan is a forensic psychiatrist. His book, The King who Strangled his Psychiatrist and Other Dark Tales, is to be published this year