The movie, The Railway Man, is set on two timelines, the current and in the 1940s during the World War II. In the movie, we meet young British soldiers who were held as war prisoners by the Japanese Military. Among the British soldiers is Eric Lomax, a signals engineer by profession is the main protagonist and he faces severe psychological effects in the modern day due to the severe conditions he was exposed to by the Japanese masters. Eric Lomax is excited and enthusiastic about being part of the team that is putting the railway system in Thailand, under the supervision and brutality of the Japanese. Lomax and his team however finds the situation in Thailand incredibly difficult and torturous. He finds some of the most important and respected generals from Britain in the camp having been overworked, malnourished, and mistreated. He will soon be in a situation worse than them. The men building the railway are forced to scribble through the wild jungle complete with rocks and harsh terrain often with high levels of unrelenting starvation.
It is such untold punishment that forces Lomax to put his profession and skills into practice to develop a rudimentary radio. He aims to raise the morale of his team by receiving radio transmissions about the happenings in the war zone where Hitler, Japan, and Americans are fighting it out. Using the radio, he is able to understand that Japan and her allies are on the verge of defeat. The success he achieves by building the radio turns against him when he is caught. He is isolated from his crew and severely tortured by limb breaking, beatings, and water boarding. It is this torture that becomes a psychological problem later in his modern life.
He survives the torture and is rescued by American soldiers and lives to tell the story. While at home, he blocks himself from the other world and he often gets nightmares of the Japanese officer who manhandled him. Many years after the war and the torturous ordeal, he meets a lady, Patti, on the train and falls in love immediately. They get married and soon Patti learns that Lomax has trouble with his past. Using her instincts and nursing training, she is able to follow up with Lomax’s friends and comrades about the issues Lomax faced in Thailand that are making him psychotic. Patti decides to hold on to Lomax but at the same time, working her way back in history. An ex-soldier and a comrade of Lomax realizes that their tormentor is still alive and works in a Museum displaying the same torture and heinous activities of the Japanese back in Thailand. Lomax gets wind of the information and decides to confront his tormentor. Instead of letting out his anger on the Japanese tormentor, he instead forgives him and a friendship between the two bosoms.
This paper will look at Lomax as a psychological patient. His characteristics as a psychological patient will be looked at from a social context in addition to an assessment. The paper will go ahead to detail therapeutic principles and best practice guidance that should be accorded to the patient. Evidence based treatment that is appropriate to the client will be described and towards the end of the paper, an analysis of ethical aspects of the case will be discussed.
Eric Lomax is a patient with deep psychological problems that are directly linked to the fact that he has been a soldier besides being tortured by his enemies. He is showing serious characteristics that are severely affecting his social life, more so, his relationship with his spouse. One of the major characteristics that he is displaying is emotional numbness. According to Monson, Price, Rodriguez, Ripley, and Warner (2004) a patient who experiences emotional numbness avoids activities, people and places that remind him of the trauma. This is a characteristic of Lomax. He avoids his fellow comrades since they might spark a discussion around the events that led to his trauma. He also avoids his wife when she brings about the discussion. Patti is in need of information that might help her assist her husband. In social places, Lomax prefers to sit alone.
Lomax is experiencing heightened levels of arousal. Shepherd and Wild (2014) explain that a patient with signs such as difficulty in sleeping and getting easily irritated or angered shows common arousal elements. Lomax at one time is seen dancing with his wife and he suddenly pushes her away and carries the music system away in anger like it has reminded him of some bad times in the past. In another instance, Lomax hears a commotion at his door between some strangers and his wife and he immediately gets angered and visualizes the men as his Japanese tormentor. He grabs a pocket knife and charges towards one of them with a clear intention of causing harm.
Lomax is re-experiencing the trauma. Ehlers, Hackmann, and Michael (2004) observe that experiences among patients might recur through intrusive recollections. The patient might flashback and even experience nightmares. Patti, in her first encounter with the traumatized Lomax finds him on the floor screaming and shielding herself from some imaginary attackers. This is a classic example of Lomax re-experiencing trauma. In many other times, he is re-experiencing trauma especially when there are triggers of the events that happened to him. Violent scenes are triggers of Lomax’s trauma.
Though not explicitly depicted, there are indicators by Brown, Curbishley, Paterson, and Teplitzky (2013) that Lomax has always been indifferent about relationships and the feelings they bring along. Since his time in Thailand, it has not been depicted whether Lomax had been in another romantic relationship and his comrade who confides to Patti about their experiences in Thailand, confesses that after Patti got into the life of Lomax, it was the first time he had been seen light-up. This indicates that Lomax has been having negative feelings towards other people and has been deliberately staying away from other people so as to avoid personal relationships.
In the assessment of Lomax, it is evident that he is suffering from Post-Traumatic Stress Disorder as it fits the Cognitive Behavioral Theory of PSTD as described by Taylor (2017). To assess him, properly, the American Psychological Association (2017) describes a list of 10 assessment techniques that can be used. I will review the most appropriate ones in this case. The first two are clinician administered while the last two are self administered. The first assessment is the Clinician-Administered PTSD Scale for DSM-5 or simply the CAPS-5. The interview has 30 structured items. It is relevant in the making of diagnosis and assessment of symptoms. I will apply it orally in interview sessions that will often last 45-60 minutes. In this assessment, it is uncovered that the patient is emotionally numb, has high levels of arousal, and is re-experiencing trauma through flashbacks and nightmares.
The second assessment method will involve the use of the PTSD Symptom Scale Interview (PSS-1 and PSS-1-5) which contains 17 items which are semi-structured for assessment and diagnosis. The assessment is appropriate to Lomax especially because it fits patients with a known trauma history and events leading to the trauma can be identified as expained by Foa and Tolin (2000). The assessment focuses on the the most current period and does not involve further probing beyond the questions in the assessment, something that Lomax will appreciate since it does not advocate for rekindling of traumatic memories.
The third assessment is the Davidson Trauma Scale (DTS) which according to Davidson et al. (1997), assesses two vital elements of PTSD, frequency and severity. The assessment is basically what I will use on Lomax to determine the level of anxiety, arousal or numbness at a personal level. With this assessment, it is evident that the most recurrent symptom is re-experiencing and increased arousal. It screens for the most prevalent symptoms and places the patient on a preliminary state of knowledge. As such, Lomax will be put in a state of knowledge where be in a position of identifying symptoms so as to be capable of exercising control.
Lastly, is the PTSD Checklist for DSM-5 (PCL-5) which is a 20-item report instrument which is useful in the development of a provisional diagnosis which can be confirmed using a clinician supported instrument. PCL-5 is important in that I will use it together with Lomax to monitor changes during and after my clinical intervention.
As described by Reisman (2016), the first line of treatment by a clinician handling a PTSD patient should be non-pharmacological treatment. As such, psychological interventions will be used as the first line of approach to handle the situation experienced by Lomax. Lomax has been diagnosed with PTSD with four main symptoms; is emotional numbness, high levels of arousal, re-experiencing trauma through flashbacks and nightmares, and negative feelings about people. The cognitive processing therapy and prolonged exposure therapy will be my strategies as opined by Reisman (2016).
With cognitive therapy, I will teach Lomax how to reframe negative thoughts about the trauma. According to the U.S. Department of Veterans Affairs (2017), cognitive behavioral therapy works through learning how to handle upsetting thoughts by appreciating that the forces or people that are to blame are not the ones. It is teaching Lomax how to be realistic. Just as his wife does, Lomax is able to think about Nagase (the Japanese tormentor) and finally confronting him. As a clinical practitioner, I will advice Lomax to think of Nagase as a servant and learn how to forgive him since he was executing the wishes of his masters. I will add to Lomax that being vengeful to the extent of harming Nagase will not alleviate his suffering but will instead make him suffer even more since he will be piling on his emotional burden.
The second approach, as recommended by Reisman (2016) is the use of prolonged exposure therapy. Besides teaching Lomax to reframe his thoughts, I will make Lomax to face his negative feelings. In this step, just as his wife does, I will encourage him to talk about the trauma without feeling ashamed of himself. I will reassure him that whatever happened was in the past and my interest in the issue is him getting better. With prolonged therapy, I will teach Lomax how to approach those feelings or situations that he has been avoiding which, according to Powers, Halpern, Ferenschak, Gillihan, and Foa (2010) make the symptoms keep on recovering. The culmination of this treatment will be searching for Nagase and confronting him with the intention to vent out the anger but not commiting more attrocities.
In the treatment of Lomax, a number of ethical issues need to be considered. To begin with, during the treatment, I will endeavor to acknowledge the selflessness Lomax and his comrades had and the sacrifice they made to make the world a better place. He should know it was not in vain. This is the courtesy part. The next part would be preparation. According to Hall, Prochazka, and Fink (2012), patients need time to adequately prepare and consent to the intervention of medical professionals. As such, to ensure that I get his informed consent, I will lay bare all the material facts about the treatment and possible effects, both desirable and undesirable.
I will explain to Lomax that I don’t intend to humiliate him or evoke his emotions and nasty memories. I will explain to him that if the same happens, it will be for the greater good and that we shall walk the recovery journey together. I will confide to both Lomax and his partner that it is not my intention to use medical drugs to control his condition but if the situation demands, if non-pharmacological interventions don’t work, I will be left with no alternative. I will go further to explain the working of such drugs and their potential side effects. I will ensure that Patti, Lomax’s wife is part and parcel of the process. She has come out to prove that she is the biggest support system Lomax has.
Lomax’s situation is delicate and needs a proven clinical approach to handle. After diagnosis of PTSD, non-pharmacological approach to treatment will be commenced. A leeway for pharmacological approach will be left in case the interventions will not work. Ethics will be considered during the entire period.
American Psychological Association. (2017, July 31). PTSD Assessment Instruments. Retrieved from American Psychological Association Website: http://www.apa.org/ptsd-guideline/assessment/index.aspx
Brown, C, Curbishley, B, Paterson, A (Producers) & Teplitzky, J (Director) (2013). The Railway Man [DVD]. UK and USA: Archer Street Productions, Latitude Media, Pictures in Paradise, Silver Reel & Thai Occidental Productions.
Davidson, J. R. T., Book, S. W., Colket, J. T., Tupler, L. A., Roth, S., & David, D., … Feldman, M. (1997). Assessment of a new self-rating scale for post-traumatic stress disorder. Psychological Medicine, 27, 153-160.
Ehlers, A., Hackmann, A., & Michael, T. (2004). Intrusive re‐experiencing in post‐traumatic stress disorder: Phenomenology, theory, and therapy. Memory, 12(4), 403-415.
Foa, E. & Tolin, D.F. (2000). Comparison of the PTSD Symptom Scale-Interview Version and the Clinician- Administered PTSD Scale. Journal of Traumatic Stress, 13, 181-191
Monson, C. M., Price, J. L., Rodriguez, B. F., Ripley, M. P., & Warner, R. A. (2004). Emotional deficits in military-related PTSD: An investigation of content and process disturbances. Journal of Traumatic Stress, 17(3), 275-279.
Hall, D. E., Prochazka, A. V., & Fink, A. S. (2012). Informed consent for clinical treatment. Canadian Medical Association Journal, 184(5), 533-540.
Reisman, M. (2016). PTSD treatment for veterans: What’s working, what’s new, and what’s next. Pharmacy and Therapeutics, 41(10), 623.
Taylor, S. (2017). Clinician’s guide to PTSD: A cognitive-behavioral approach. Guilford Publications.
Powers, M. B., Halpern, J. M., Ferenschak, M. P., Gillihan, S. J., & Foa, E. B. (2010). A meta-analytic review of prolonged exposure for posttraumatic stress disorder. Clinical psychology review, 30(6), 635-641.
Shepherd, L., & Wild, J. (2014). Emotion regulation, physiological arousal and PTSD symptoms in trauma-exposed individuals. Journal of behavior therapy and experimental psychiatry, 45(3), 360-367.
U.S. Department of Veterans Affairs. (2017). PTSD:Cognitive Processing Therapy for PTSD. Retrieved from U.S. Department of Veterans Affairs Website: https://www.ptsd.va.gov/public/treatment/therapy-med/cognitive_processing_therapy.asp
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