Abstract
Post-traumatic stress disorder (PTSD) is a condition characterised by recurrent intrusive distressing memories of a traumatic event(s) with recurrent dreams and flashbacks. Given the nature of standard forensic pathology practice which involves on-going assessments of violent crimes and their sequelae with autopsy dissections of victims and in detail study of injuries, it is surprising that more has not been written on this in the literature. Perhaps PTSD should be studied further in a forensic context with a recognition that years of intimate exposure to violence may lead to accumulated, ongoing and unresolved grief in practitioners.
The grief you keep inside you will whisper in your heart until it breaks. William Shakespeare (1564–1616), Macbeth Act IV, Scene III
Thus, it would not be surprising as a result of such exposure if many forensic pathologists have experienced features of PTSD such as ‘recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)’, ‘recurrent distressing dreams’ and ‘dissociative reactions’ such as flashbacks. 3 Occasionally, further psychological manifestations occur. An important point which may be pertinent to forensic practice is that partial PTSD has been recognised where the full manifestations of PTSD are not always present. Although this was first recognised in Vietnam veterans, it was later extended to civilians who had been exposed to trauma. 7 This has also been found to apply to mass fatality incidents 1 – events that usually involve intensive and prolonged involvement for many forensic pathology teams. In addition, the manifestations of PTSD may be delayed for months or even many years after a particular event 8 – a feature that forensic pathology managers should be very cognisant of. There has been, however, much more written on PTSD in a hospital rather than in a forensic environment.9,10
Given the nature of forensic work, the usefulness of psychological support is occasionally discussed, with variable responses. A more old-school approach is to follow the words of the American President Harry S. Truman: if you can’t stand the heat then you should get out of the kitchen. In other words, dealing with psychological trauma is part and parcel of a forensic job and should not be overly emphasised.
There are certainly differences among groups in their response to traumatic events, with a good example being the Snowtown serial killings in South Australia where nine bodies were dismembered and stored in large plastic drums – the so-called bodies in barrels case. 11 While a number of police officers took stress leave after being exposed to the details of the cases, which involved torture and cannibalism, none of the forensic pathology staff who decanted and examined the actual remains either requested counselling or required time away from work. Whether this reflects desensitisation/habituation – a need to be perceived as coping with the occupational challenge – or instead represents more highly attuned psychological coping mechanisms or resilience is uncertain, but the difference was striking. ‘Vicarious traumatisation; is a term which has been coined to perhaps explain the potential effects (psychological, physical, spiritual, cognitive and relational) of repetitive direct or indirect exposure to accounts of violent crimes.12,13 There has, however, been a trend in recent years not to expose police trainees and medical students to the autopsy room in an effort not to traumatise them, and so perhaps a shift in training philosophy may be responsible for a subsequent inability to deal with difficult cases. ‘Protecting’ police and doctors during their training from confronting cases certainly may not prepare them adequately for situations where they will encounter dead, dying and severely injured individuals, in vehicle accidents, explosions or fires, for example, or with childhood deaths.
Even when psychological care is available, the quality of institutional support is quite variable. After working in Thailand on hundreds of tsunami victims, counselling was provided for pathologists in the department that I was working in at the time. Ironically, the counsellor seemed more interested in the opportunity to discuss with a fellow professional the particular psychological difficulties that he was encountering rather than focussing on the issue at hand. In his defence, forensic pathologists with years of court training are often quite adept at deflecting probing and personal questions. Perhaps more solace is to be gained from debriefing amongst colleagues who have a shared experience.
The cases which break through the armour of professional detachment are quite varied and for me include a young girl dying of an acute asthma attack in her father’s arms on Christmas day; an elderly man strangled with wire by his granddaughter in front of his equally old and sole companion, his dog; young partying tourists dismembered and killed by explosives at a nightclub in Bali; newly-weds drowned in the Boxing Day tsunami in Khao Lak in Thailand; and a senior member of a biker gang who went to a beach on an isolated stretch of coastline where he grew up as a child and shot himself. Each carries with it its own unique characteristics and poignancy that for some reason still resurface at quite unexpected moments. Why these particular cases stand out in preference to one of the many thousands of others is difficult to understand.
I am often asked at public lectures how I can do my job. A particularly intense question that was put to me at the Dark MOFO festival in Hobart, Tasmania, raised the ‘visceral’ and ‘tactile’ aspect of the work that is seldom discussed. 14 Clearly, it is essential that forensic pathologists maintain a professional distance from their work – something that applies to all medical practitioners. We are there to assist in some extraordinarily difficult moments for individuals and their families, and to allow ourselves to be distracted or confused by emotions would be extremely counterproductive. Sometimes meeting with families at their request and discussing the case does provide some assistance in dealing with emotional issues. However, the defining feature of forensic work is that it is, by its very nature, always dealing with significant loss.
Finally, moving back to Shakespeare, does grief then sit within us all, albeit often not acknowledged until it inevitably surfaces? Perhaps we need as a professional group to acknowledge that once the dust has settled and case details have been resolved, this may be the case. Perhaps we also have a right and maybe a need ourselves to mourn the dead.
