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Invisible scars: what it’s like to survive a war

Too many outsiders to the world of war leap to make generalisations over those afflicted by PTSD.

Shot six times, blinded in one eye, his comrades lying dead around him, Lance Corporal Liam Culverhouse first gained a brief, unwitting fame in 2009 as the most badly wounded survivor of an attack by a rogue Afghan policeman who murdered five other British soldiers, shooting them repeatedly as they relaxed after a patrol in the Nad-e Ali district of Helmand. Given cursory treatment for mental health issues following the incident, the Grenadier Guardsman returned to the British public’s consciousness last year, this time under even more tragic circumstances, when he was jailed for causing the death of his 19-month-old daughter, Khloe, who died with brain damage and fractures to her skull, ribs and limbs after he assaulted her.

Both victim and perpetrator, Culverhouse epitomises the appalling potential consequences of post-traumatic stress disorder (PTSD), which the sentencing judge acknowledged as having contributed to his crime. Imprisoned, the war veteran now appears once more, this time as one of the principal case studies in Aftershock, Matthew Green’s outstanding study of the psychological wounds affecting British military personnel adapting to life at home after serving in the country’s most recent wars.

Green’s credibility in this field is hugely advantaged by his experience as a reporter for the Financial Times in Afghanistan, which bestowed him with both the cool, analytical eye of a field journalist and an instinctive, first-hand sympathy for his subjects. These skills are prerequisites for any navigator attempting to traverse a subject as complex as PTSD.

Riven with contradiction and paradox, the condition – its definition, prognosis and reaction to treatment – remains almost as contentious today as when “Case One”, an anonymous 20-year-old British private, was brought to the attention of Dr Charles Myers in 1914. The young soldier, who had endured a prolonged German artillery barrage, suffered trembling fits, sweats, nightmares and repeated intrusive thoughts – usually of shellfire – but was otherwise uninjured. The soldier was dubbed Case One in an article published in the Lancet the following year by Myers, a brilliant Cambridge psychologist and the man who first brought the phrase “shell shock” to public consciousness.

Back then, it was suspected that Case One suffered from a form of physical shock. By the time the condition was renamed PTSD in 1980, it was thought to be a mental reaction to the trauma of combat. Today, the circle of definition is turning once again, with various treatment therapies regarding the condition more in terms of an injurious trauma stored by the body rather than the mind. Small wonder, given the variations of PTSD’s definition, that among the myriad organisations offering treatment for the condition there is now suspicion that the two main methods currently used to counter it – eye movement desensitisation and reprocessing (EMDR) and cognitive behavioural therapy (CBT) – may be of limited effectiveness in many cases and, perhaps, even damaging.

The ongoing confusion around PTSD makes Green’s work all the more timely. He launches into his subject, its history and modern evolution, with confident elan, maintaining the attention of lay readers and specialists alike by illustrating his work with a series of poignant case studies, while engaging with the more complex evaluations of the affliction and the emerging therapies used to treat it. Throughout his pages, like a dark arterial chord, lurks “the Spiral”, down which the afflicted slide, usually accompanied by compounding conditions such as alcohol and drug abuse.

I confess to reading the book in bad company. After two decades spent reporting conflicts, a variety of shadows clustered over my shoulders as I turned the pages. Into my study walked a woman, quite unhinged by shellfire, who accosted me using her husband’s shrapnel-severed leg as a club in Grozny, back in 1995; a small choir of dead children I knew gathered around my desk; the walking corpse of a dead friend shot and left under the African sun lurched up to stare, beside a man who died bloodily as I tried to breathe life into him; while in the back of the room stood another who once shot me while my hands were tied. “Thanks a fucking bunch, Matthew,” I thought, as I read on. “You’ve just raised the whole ensemble at once.”

It is as well, then, that I am a journalist rather than a soldier and work in a profession in which individuality and expression protect practitioners from the worst depredations of war trauma far better than service personnel are guarded by the group-oriented dictates of theirs. I have “normalised” my visitors. They come but seldom stay.

Green never surrenders to cliché. Too many outsiders to the world of war leap to make generalisations over those afflicted by PTSD, an instinctive but naive sympathy for victims leading them to attribute every ill to the experience of conflict. Real life is never that simple and the erosions of war often magnify existing psychological traits rather than producing entirely new conditions. Green manages to describe the plight of Culverhouse, with whom he corresponded in prison, with gentle respect, while noting that his anger issues existed before the wounded man’s trauma in Afghanistan.

Likewise, rather than simplify his portrayal of Aaron Black – a traumatised 22-year-old Afghanistan veteran from the Royal Regiment of Scotland, whose experience in war and later suicide are central to the book’s narrative – Green admits that it is impossible to identify a single cause for his death. Confused by the sense of futureless isolation that accompanied his departure from the army, his depression compounded by alcohol abuse, Black could have been “equally a casualty of peace” as of war.

What is absolutely clear in the cases of Culverhouse, Black and every other traumatised veteran appearing in Aftershock is the systematic failure of the services to embrace the issue of PTSD, ensure effective treatment and hand treatment over to the civilian health sector once their time in the army was over. Culverhouse, for example, had explicitly warned that he could not handle crying children, yet despite his extreme trauma his chain of command had not been informed that he had missed appointments with mental health staff and, after leaving the army, he was not offered any follow-up care.

There is certainly no shortage of money available for the treatment of PTSD among today’s veterans. Combat Stress, Britain’s biggest mental health charity for former service personnel, received an income of £17.4m in 2014 – a combination of government funds and those provided by public and corporate donors. A horde of other smaller mental health charities have sprung up around the well of public sympathy shown to veterans returning from Iraq and Afghanistan.

Commensurate to the growth in this niche sector, however, is a lack of accreditation, registration and independent oversight. In 2012, a government study into veterans’ transition focused on 350 mental health organisations in the military charity sector with a combined annual income of £400m. The subsequent report highlighted a maze of competing organisations, the collective ill-use of funds and the ineffectiveness of many involved.

This overall muddle, extending from the definition of PTSD across its spectrum of treatment, ensures that the silent majority of unknown sufferers may never access help at all. As of 2014, there was neither a centralised 24-hour contact point for veterans in need of mental assistance, nor a register of accredited organisations to aid those in need.

Clearly the individual cost to anyone participating in war and killing – the most negative and damaging experiences of all – can never be fully erased. What Green describes equally well, however, is how the current standard of care for service personnel and veterans suffering from PTSD falls far short of what it should be at the precise moment when they are most in need.

Aftershock: The Untold Story of Surviving Peace by Matthew Green is published by Portobello (336pp, £20)

Anthony Loyd is a war correspondent for the Times. His book My War Gone By, I Miss It So has been republished (September Publishing, £9.99) with a new introduction

This article first appeared in the 10 December 2015 issue of the New Statesman, The clash of empires

Terry Notary's simian appearance as performance artist Oleg in The Square
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Ruben Östlund’s film The Square hammers home the point that we are all still animals

 Each thread and simian guest star shows how little distance there is between the civilised and the primitive.

Yasmina Reza’s play Art, about three friends whose closeness is threatened when one of them spends a fortune on an entirely white painting, offered audiences a series of packaged talking points (Does objective taste exist? What is art?) for their post-theatre meal. Ruben Östlund’s film The Square, which won the Palme d’Or at Cannes last year, serves the same function. Before the first scene is over, the Stockholm curator Christian (Claes Bang), a vision of metropolitan spiffiness in his red-framed glasses, has already wondered whether an ordinary bag placed in a gallery would qualify as art. In his current exhibition is a room filled with piles of gravel. A visitor pokes his head in, decides there’s nothing worth investigating, then leaves. We’ve all done it.

Like the canvas in Reza’s play, there is a catalyst for disorder here: the blue neon square set into the gallery’s courtyard. It is conceived as “a sanctuary of trust and caring” but its arrival throws everyone’s behaviour into sharp relief. A woman screams for help as she is pursued by an unseen aggressor, prompting everyone around her to become more than usually engrossed in their phones. Charity workers ask commuters whether they would like to save a human life, only to be given the brush-off. Christian’s relationship with poverty is squeamish. He buys a sandwich for a homeless woman. “No onions,” she says. “Pick them out yourself,” he snaps, incredulous to find that beggars can also be choosers.

His downfall, which starts after he hatches a cockamamie scheme to retrieve his stolen wallet and phone by leafleting the housing estate where he believes the thieves are hiding, is the thread on which the film’s provocative episodes are hung. Each one, such as the gallery chef flying into a rage because no one wants to hear about his balsamic reduction, shows how little distance there is between the civilised and the primitive. A series of simian guest stars, real and pretend, make cameo appearances to hammer home the point that we are all still animals, no matter how many private views we attend. These include the performance artist Oleg (Terry Notary), whose confrontational appearance imitating an ape at a black-tie dinner – not just scene-stealing but film-stealing – exposes the instincts of the herd to conform, even if that means ignoring violence taking place at the next table.

That sequence crystallises ideas that in other parts of the film feel distinctly wishy-washy. Jibes about pretentious artists (a cameo from Dominic West) or crass advertising executives smack of the contrived bugbears of clickbait columnists – what next, jokes about quinoa served on slates? And a section of the film about a bad-taste campaign to promote the neon square will seem penetrating only to viewers who have never considered that ad agencies might stir up controversy for publicity purposes.

Östlund is sharper when he focuses on the discord beneath everyday social interactions, using sound and camerawork to disrupt supposedly simple scenes. He prefers when shooting a conversation, for instance, to linger too long on one participant, rather than cutting back and forth between them, so that we begin to interrogate and mistrust the face we’re looking at. Stand-offs between Christian and the journalist Anne (Elisabeth Moss), including an excruciating argument over a condom, show this technique at its most blissfully torturous.

He is a director who is never more comfortable than when he is making audiences squirm, as he did in Force Majeure, in which a man neglects his family but not his phone when fleeing danger. But the situation in The Square, which escalates to the point where Christian must ignore a child’s suffering in order to safeguard his own existence, would have greater moral force if the film showed any interest in its poorer characters as something other than lightning rods for middle-class complacency.

The Square is undeniably entertaining, though its lasting use may be to demonstrate that movies can have the same effect as popping a coin in the collecting tin. Having seen the film, you can rest easy knowing you’ve already given. You’ve done your guilt for this week.

The Square (15)
dir: Ruben Östlund

Ryan Gilbey is the New Statesman's film critic. He is also the author of It Don't Worry Me (Faber), about 1970s US cinema, and a study of Groundhog Day in the "Modern Classics" series (BFI Publishing). He was named reviewer of the year in the 2007 Press Gazette awards.

This article first appeared in the 13 March 2018 issue of the New Statesman, Putin’s spy game