To Lose a Limb

Remember the song lyric, “When Johnny comes marching home again, hurrah, hurrah!”? Not all of the Johnnies and Janes will be marching when they come home again—some because of their physical injuries, others because of psychological scars, and many because of both. The staff of the department of psychiatry at Walter Reed Army Medical Center is dedicated to responding to this challenge. During a recent visit with Col. Steve Cozza, chair of the department, and his team at Walter Reed, I learned more about how they are working with the wounded returnees.

Initially, all returning wounded are seen by a member of the staff when they arrive at the hospital. Dr. Harold Wain, chief of the Walter Reed Psychiatry Consultation and Liaison Service, explained that the staff member is introduced to the soldier as a member of the “preventive medical psychiatry team.” The patients are all treated in the same way as an integral part of the medical team. This model assures that no patient has a sense of being singled out, stigmatized, or labeled. Patient contacts are not “debriefing” sessions, but instead provide the beginning stage of an ongoing supportive relationship. The intent is to create an openness for future communication. The soldiers see members of the team as their allies and often reach out for future contact as they see the need.

For amputees, many positive tools such as visualization, hypnosis, relaxation, and cognitive reframing are used to help them deal with their physical loss. For example, one soldier described how he had picked up his severed arm and carried it to the medevac team doctor in hopes that it could be reattached. “How did you think to do that? Where did such power and emotional strength come from?,” asked the member of the medical preventive psychiatry team. The question demonstrated to the soldier his inner emotional resources.

Twice-weekly group therapy, family support groups, and the best in prostheses are provided for the amputees. The intention is always to return these soldiers, as soon as possible, to their home base or civilian life.

Learning about all of these valuable interventions, I couldn’t help but reflect on what we know about the psychodynamics of body image and body loss. Freud wrote in his 1927 book The Ego and the Id: “The ego is first and foremost a body ego.” At birth infants reach out, touch themselves and others, and in turn are touched as they begin to form a picture of where they begin and end. Students of early child development speculate that in the beginning this is a fragmented and incomplete schema. As body boundaries begin to coalesce and the body image starts to conform more closely to reality, an awareness grows within infants that they are separate from their needed caretaker. With this realization comes the beginnings of separation anxiety. It has been postulated that the loss of a body part, years later, can trigger a resurfacing of this early and basic anxiety.

In the work I have done with 50 women who had mastectomies for breast cancer, many described experiencing a sense of vulnerability and insecurity psychologically different from their fears about the cancer itself. It was profound to see that following surgical breast reconstruction, this sense of vulnerability often dissolved as they, in their words, “felt whole again.”

In Michael Shaara’s fictionalized account of the Civil War, The Killer Angels, General Robert E. Lee describes one of his lieutenant generals after losing his leg in battle: “A man loses part of himself, an arm, a leg, and though he has been a fine soldier, he is never quite the same again; he has lost nothing else visible, but there is a certain softness in the man thereafter, a slowness, a caution. . . .I do not understand it. A man is in his spirit, and he has that in full no matter what part of his body dies. . . .But [Lee thought to himself] you may not understand. It had not happened to you, so you don’t understand it.”

As psychiatric professionals we do understand it. In so doing we can assist patients such that as they recover, they can free themselves from “a certain softness, a slowness, a caution” that goes beyond, and is different from, the painful and tragic physical obstacles they must overcome in adjusting to the realities of the loss of a limb and the use of a prosthesis. Cognitive reframing, group and family support, behavioral techniques, and visualization, as well as psychodynamic understanding and interpretation, can all play a part in the return of Johnnies and Janes to home even though they are no longer able to march in the same way as they once were. ▪