Straightening out the bends - aquaCORPS

I put this article up as it followed a discussion on a Facebook group about DCS and the 'deserved / undeserved bends' that some people get. All bends are deserved, we just don't know what caused them! To a certain extent the bend is the uninteresting part, like many of the outcomes diving accidents or incidents. What is interesting is the circumstances, conditions or context in which the event occurred. Only by recognising and addressing those factors can we have any hope in reducing future adverse events. However, for that to happen, we need to have a psychologically-safe environment. (Blog to follow but here is a quck link!)

Those factors can include mental shortcuts or rules of thumb (heuristics), cognitive biases such as attention blindness, anchoring or overconfidence. Or it might be because the information being perceived doesn't match the mental models and simulations which reside in our brains and thus lead to a poor decision (in hindsight). What we do know is that pretty much everyone has local rationality (makes sense) when it comes to the decisions made in real time, even if there is a risk to life.

Straighting Out The Bends - An aquaCORPS article from 1993

Part of an Ongoing Research Project on the Social Reaction and Stigma Surrounding Decompression Illness

by Jennifer C. Hunt

The experience of decompression illness is traumatic to the victim as a result of the physical nature of the injury and its link to deeper psychological issues. The strong negative social reaction and stigma surrounding DCI increases the trauma, and jeopardizes the healing process. In order to protect against the resulting feelings of anxiety, shame, humiliation, guilt, and incompetence, the diver may mobilize defenses and engage in behaviors that temporarily ease the psychological burden but ultimately have negative consequences for the individual, as well as the diving community as a whole.

The DCI experience

Decompression illness is potentially traumatic. The "hit," the chamber treatment and the rehabilitation period are all physically and psychologically painful. Analysis of DCI as a psychological phenomenon is complicated by the possible organic effects that the illness may have on the diver's mental functioning, particularly during the initial hit.

In severe cases, the onset and immediate aftermath of DCI are acutely painful. As in major surgery and long-term illness, rehabilitation can be excruciatingly slow. During the onset of DCI, thinking processes may be disturbed, and the diver automatically uses protective devices to keep from experiencing the terrifying anxiety that could occur with the realization that he or she could die.

For example, this diver knew that he would be bent when he made the decision to ascend but excluded conscious recognition of the possibility of permanent injury or death.

"I never let it enter my mind that I would be permanently crippled or dead. My thoughts were, ‘I have to get to the surface. I am in danger under water. I can't function anymore,’" he said. "I remember being in the boat. It was hard breathing. I knew I had really put my body through the ringer. I closed my eyes and everything went black. I saw stars and heard the chimes [over my child's] crib. My family needs me. The pain was so intense."

The immediate concern for the diver with DCI is the threat of death. Like the young athlete who sustains severe injury and must face the reality that he or she is not invincible, bend victims may suddenly become aware of their physical vulnerability and lack of control over their bodies.

One diver recalled the book "Titanic: the End of a Dream "while discussing his accident. He explained, "The Titanic represented the age of science. We were supposed to conquer everything with our knowledge of science, and it was deemed virtually unsinkable. When it sank, people were shocked. We can’t control things." The Titanic represented this diver’s fantasy that he could not be hurt. Its sinking symbolized his own vulnerability.

If the diver survives, the threat of other physical losses becomes paramount. These include the loss of bodily functions that have previously been taken for granted (urination, sexual response, walking, running etc.). Concerns about bodily damage are associated to fears of losing important professional and leisure activities and key relationships. One diver expressed the fear that she would be disabled and lose her job. Another was concerned that her fiance would abandon her.

If the victim survives the accident with minimal physical damage and is able to dive again, community reaction to the accident remains a concern. Divers fear that their identities will be spoiled and past accomplishments reinterpreted negatively. One diver commented, "All my work for naught. I guess I am worried that I won’t be taken seriously. Will my [diving] career be ruined?"

Diving is not only a social activity but also a deeply private one. A fundamental concern of any serious diver who "takes a hit" is the loss of diving itself, a deeply meaningful experience which lies at the core of the person’s being and defines him or her as fully alive. Here arises a fundamental contradiction of the sport. The very activity that allows some individuals to feel fully alive may also bring them closer to death. While sport divers all negotiate this contradiction, it is experienced most dramatically among the technical community, deep divers, cave divers, and wreck divers, as the following two accounts reveal. "Emotionally I was devastated. It was like being told a part of me was going to die. We have never lived more than a mile from the water. Water is a part of my life and I was losing that,"said one diver.

Said a victim who sustained serious damage and has been unable to dive since the accident, "I am a water person. I just love water and the beauty of the textures, colors, light all around me. I do miss it very much.

Every accident has internal echoes. The current meanings of DCI can become linked to a set of past experiences which may not be within the diver’s conscious awareness. This mobilization of past memories in the face of a traumatic event is routine and not necessarily "pathological." Only if the internal echoes haunt the diver to such a degree that he or she experiences inappropriate guilt, shame, sadness and rage or the echoes interfere with his or her resolution of the trauma in a way that precludes pleasure in work and play, can we assume unresolved conflict and so-called "pathology."

Typically divers associate DCI to past injuries, accidents or illnesses in which they also felt helpless, damaged and frightened. The events leading up to the DCI experience can also link to significant relationships from the past. One women whose father was an alcoholic became bent while diving with a male buddy with whom she had an erotic attachment. She went along passively with his wishes. Although she was afraid of sharks and not particularly interested in deep diving, she followed him to 172 feet to photograph sharks. She trusted him, omitting consideration of a three-day pattern of diving that embroiled her in one deeper dive after another. Her dependence on and obedience to an essentially untrustworthy buddy appeared to be, in part, a repetition of her early relationship with her father. Like most children who are physically or emotionally abused, she turned to the abuser for love and protection, only to find herself hurt again.

Another diver grew up in a family in which one parent was seriously ill. The diver saw her own childhood illnesses as insignificant compared to those of her father, who could suddenly die. Her father was distant and detached. In contrast, her mother was smothering. The mother was also a hypochondriac, who used her ailments to keep her daughter close. If the daughter was involved in some joyous activity, the mother would often become ill and spoil the occasion.

When the diver experienced DCI symptoms, she tried to ignore them despite mild, partial paralysis. She explained, "If you...can’t move your arm and leg, it’s obvious to everybody that you are bent. But if you just have some mild neurological symptoms, no one wants to hear about it."

The diver experienced her hit in a manner similar to childhood illness. Unless she were near death like her father, she could not take herself seriously and had to deny the importance of her symptoms. Recognition of mild DCI symptoms brought to mind her mother’s smothering attitude. It also reminded her of how the mother would manipulate her ailments to spoil good times. If the diver were to admit her illness to herself and others, she unconsciously feared that she would be like her mother, a hypochondriac and spoiler. Denial not only protected the diver against anxieties associated with DCI but also against an ambivalent identification with and entrapment by her mother.

In view of the multiple meanings of the decompression trauma, the diver mobilizes defenses against experiencing internal and external danger, unbearable anxiety, intolerable thoughts, memories and fantasies. In general, such protective devices constitute normal mechanisms of the mind and are constituted unconsciously and automatically. Under certain circumstances, such as some major traumas, the defenses mobilized may help the individual survive the immediate threat but at a considerable cost to future functioning.

The diving community is familiar with the term denial, coined "the first symptom of DCI." Unfortunately, however, diving literature reveals some confusion about the nature of the defense mechanism. Defenses are sometimes presented as unhealthy, intentional and/or irrational means to sabotage good medical treatment rather than occasionally costly efforts to manage psychological stress. One writer, for example, referred to one victim's near delusional denial of severe symptoms of DCI as "ludicrous." (Viders, 1991).

Denial is not the only defense divers use. Joking and excessive concern with a buddy provide other means of protection. Divers also try to minimize the guilt and shame associated with making mistakes by shifting the blame to something outside themselves. They may engage in attacks on the self in order to keep a lid on the rage they feel towards others. Admission of their own participation in an accident is particularly painful for some divers, because they recognize that there is a part of themselves they do not control which encourages them to take risks and suffer injury.

Social reaction

Dive communities tend to categorize victims as "good" or "bad." The definition of the "good" and "bad" victim varies depending on the diver’s community of affiliation. In general, "bad victims" include divers who exceed the limits of accepted no-decompression or decompression dive tables, whose dive profiles are deemed irresponsible, who run out of air or otherwise make mistakes viewed as unacceptable for a good diver. The "good victim," in contrast, includes the uneducated or inexperienced diver who couldn't possibly know his or her profile or dive related behavior was risky. For example, one diver was bent as a result of engaging in rigorous exercise after diving. He was not held morally responsible for the accident because he had been unaware of the dangers of post and pre-dive exercise. The "good" victim also includes the diver whose profile was within the limits of the relevant dive tables or who made an error deemed socially reasonable, such as the diver who is bent in the process of a rescuing a student or buddy. The definition of a "reasonable" and "unreasonable" mistake changes with the dive community

"Good victims" are not viewed as morally responsible for their illness and do not experience strong negative social reactions. "Bad victims," in contrast, are viewed as culpable and deserving punishment.

A recent article on computer dive accidents highlights this distinction. "Bends appear to fall into two distinct categories: 1) undeserved hits (mystery accidents), and 2) deserved hits (resulting from violations of safety procedures)." (Murphy, 1992). Categorization of the "bad" victim is subject to flux, depending on whether the diver admits a mistake and how he or she publicly handles the accident.

The diver with DCI can be compared to a woman who has been raped. In the minds of some communities, there is only one real rape victim, a young woman of limited sexual experience or a married woman who does not does not drink, take drugs, engage in extramarital sex, wear revealing clothes or take unnecessary risks like walking alone at night in environments deemed dangerous. Other victims of sexual abuse are often seen as morally responsible for their attacks and deserving of punishment as a result of their seeming flirtation with danger. One male diver compared the DCI experience to a rape scene in the film Cape Fear. The brutal jokes made by police officers about the victim were compared to colleagues’ reactions to a bends victim.

Many "good" victims receive support from family, friends, and medical personnel. Among "bad victims", however, there are numerous instances in which the reactions of significant people and organizations are negative. This includes stigmatization by important people and/or organizations including dive shops, medical personnel, dive operators, colleagues and buddies. The negative social reaction and stigmatization of "bad victims" has a number of consequences for the diver's identity and behavior as well as for the dive community as a whole.

In some respects, divers affiliated with cave and possibly technical communities may be less stigmatized than some recreational divers, as long as their practices obey informal rules governing skilled, decompression sport diving. One diver explained, "[If you are a cave diver], you know you can take a hit. A lot of people have lost friends, know people who have died or have been associated with a body recovery. Reef divers and wreck divers don’t have the same sense of community as cave divers." On the other hand, negative sanctions against divers who make "unreasonable" mistakes may be particularly severe in the cave diving community. This is because the cave diver who makes a mistake is likely to die.

Most divers are linked to more than one diving community and may experience different reactions from each. As a result, the injured technical or cave diver cannot always insulate him or herself from stigmatization, regardless of how the accident is viewed within "advanced" communities. Instructors, and would-be instructors may be particularly vulnerable as a result of multiple affiliations.

Dive shops: Dive shops involved in training and education may take a particularly hard line when they discover that employees are bent. This is partially economic. Many shops depend on training agencies for their ratings, which they fear will be compromised if too many instructors get DCI. The shop’s public image is also at stake, and managers fear losing customers. Managers assume that potential divers will be discouraged from diving if they are fully aware of the risks involved. Alternatively, students may interpret bend cases among the instructional staff as an indication of institutional weakness and seek training elsewhere. Finally, managers are concerned with their students’ welfare. They reason that students "do what instructors do and not what they say." If students learn that admired instructors dive below 130 feet, make mistakes or get bent, students may exceed the limits of their skills in the false belief it will make them "real divers."

As a result of these and other factors, managers tend to react punitively when instructors are bent, treating their accidents as a criminal, rather than a medical or psychological, matter. Managers may make quick decisions regarding punishment before the accident has been fully investigated to determine what, if any, sanctions are advisable. Instructors’ classes are likely to be canceled and future teaching opportunities denied until the diver is able to earn his or her way back to respectable status. Past accomplishments are sometimes seen in a new light, and the diver feels he or she must start from the beginning to prove him or herself.

Instructors who have DCI are not only often treated like criminals but also like children who must be punished for doing something bad. One diver explained, "We got reprimanded for getting bent in the first place. As if we hadn’t beaten ourselves enough, they are going to beat us up too."

The diver resents being treated like a criminal and a child and becomes increasingly alienated from management. Like the adolescent who is still dependent on his or her parents but is unwilling to submit totally to their restrictions, the instructor learns that lying about accidents is better than admitting mistakes. Instructors invent "cover stories" to avoid confrontations. This not only increases the distance between management and staff but may also compromise the instructor’s medical treatment. If he or she is bent in the future, treatment may be avoided or delayed in order to reduce the risk of discovery that could result in punishment.

When the DCI victim does resume teaching, managers may discourage discussion of the accident or other mistake with students, although some instructors informally violate this rule. One diver explained, "I got a lot of grief about it because I did something stupid and admitted it publicly. But two guys died in similar circumstances. I wanted to save someone's life. [A manager] said it made me look like an idiot. I guess they're afraid it will hurt their wallet. I just thought if you teach your people better about getting hurt then, they are less likely to get hurt."

The prohibition against sharing the DCI experience may be particularly problematic, because it interferes with the individual’s effort to heal psychological and physical damage. Sharing of the DCI experience can be reparative. By using his or her accident as an educational tool, the instructor attempts an early rescue of students, offering them the protection that he or she was not able to provide him or herself. Educational sharing of the DCI trauma is helpful to students as well as instructors. A diver explains, "I thought it would help someone, keep them from doing what I did. I felt good about talking. I didn’t know for sure that I would until I got up there. I think it did help, because people asked a lot of questions."

DCI victims who are prohibited from using their experience to save others may ultimately have more difficulty healing themselves. This is the case for one diver who was denied the opportunity to tell novice divers about her accident.

"All I ever have gotten back from them is criticism, that it was my fault. The holier-than-thou attitude which still angers me," she says. "Also I have offered to talk to novices about my situation and no one has ever asked me about it. If I could teach someone, have them learn from my experience, maybe I would get some good feelings about what happened. I would hate it if someone else got into the circumstance I did. I would like to serve as a personal example, so that people might take better care of themselves."

Medical and hyperbaric specialists: Some medical and hyperbaric organizations have taken a public stance advocating diving safety and discouraging practices they believe put divers at risk. It is certainly consistent with the goals of medicine to discourage activities that may lead to illness or injury. However, the politicalization of dive medicine and the moral stigma attached to decompression illness are not without costs to patient care and scientific research.

The public attitudes of admired representatives of the medical community structure opinion and behavior among a variety of persons engaged in the care of injured divers. Informal attitudes may be directly transmitted to hyperbaric personnel who work with and talk to respected physicians. This was the case during a professional conference for physicians and hyperbaric specialists. An X-ray was shown of a diver with air between his skull and brain. The presenting physician described the diver’s seemingly irrational, high risk profile and proceeded to call the patient an "airhead." This physician’s remarks inadvertently sanctioned ridicule of patients categorized as "bad victims" to an audience involved in patient care.

Divers suffering from DCI who seek advice and treatment from hyperbaric specialists are generally provided competent and professional help. Nevertheless, "bad victims" are sometimes targets of tactless comments by frustrated physicians who view "high-risk" diving as a challenge to their ability to rescue and heal. Stigmatizing reactions on the part of physicians are particularly potent in view of the inequality of the doctor-patient relationship and the patient’s vulnerability.

Patients are also in a position of physical and psychological vulnerability. First, they are sick and needy and do not have the ability to treat themselves. Second, they are willing to provide the physician knowledge about private and potentially embarrassing aspects of their lives in the interests of their care. The "bad DCI victim" may be especially vulnerable to abuse of the doctor-patient relationship, because he or she is already engaged in a critical self-assessment and may have experienced negative reactions from dive colleagues. Five out of six "bad victims" that were interviewed related interactions with medical professionals that they experienced as hurtful and even degrading.

Typically, "bad victims" call a dive medicine organization for advice regarding DCI symptoms and encounter unprofessional remarks about their diving practices. One diver revealed her profile and was told in what she perceived as a critical tone, "That’s way off the tables." A hospitalized diver with a severe case of DCI was repeatedly questioned by nurses and doctors regarding the depth of her dives, despite their irrelevance to ongoing treatment. Although medical personnel may just have been curious, the diver experienced these inquiries as intrusive accusations by incredulous listeners. In a confidential exchange between two doctors about a DCI patient, the referring doctor included in his letter a number of remarks that had nothing to do with diagnosis and treatment, reflecting instead his negative attitude about the patient and her "irresponsible," "dangerous" and "irrational" dive pattern. Upon discovering the letter, the patient was mortified.

Technical divers often avoid interactions with representatives of dive medicine organizations because they anticipate a negative response in view of the political positions such organizations take about deep diving. One diver explained, "Most of us don't call [the medical organization] because when you tell them your profile, you know what they're thinking: ‘You asshole’" In contrast to some recreational divers who do not have strong community affiliations, the technical diver is at an advantage. He or she has access to names of physicians who specialize in dive medicine and are less likely to infuse the examination with moral judgements. These physicians can consult with members of medical organizations regarding the divers health without putting the diver at risk of experiencing moral sanctions.

A number of problems result from the occasional tension between divers and doctors. Patient care may be compromised, because divers with mild DCI symptoms hesitate to consult with doctors who they fear will judge their diving practices and make them feel ashamed. Or divers may lie to doctors about their profiles or drug/alcohol consumption in order to protect themselves from moral judgements. They may omit some of the information needed for appropriate diagnosis and treatment.

The politicalization of diving and the moral stigma attached to decompression illness has compromised the ability of medical and other researchers to pursue objective research. Some "bad victims" refuse to fill out forms used for statistical and other purposes because of their discomfort with the attitudes of the medical organization sponsoring the studies. Divers also fear that researchers will compromise claims of confidentiality and reveal their accidents, subjecting them to further negative sanctions from non-medical members of the diving community.

One diver who planned to become an instructor expressed fear that participation in a study could ruin his diving career. He was concerned that dive shops might deny employment if they learned he had been bent. Divers also assume that all researchers have an axe to grind in the political arena and are not as neutral as they claim. Along these lines, a diver decided not to share her experience of decompression illness apparently because she did not believe the researcher's claim of neutrality and was concerned about her supposed allegiances.

Finally, dive shops and other may themselves discourage certain kinds of research. In one case a dive shop told its instructors to avoid participation in a study by an established scholar. Further data is needed to determine precisely why training managers are threatened by research. Many are unfamiliar with certain kinds of research and assume it could have negative effects on business. They may also associate some research with journalism and worry that compromising exposés will be written.

Dive Operators: There is great variation in policy and practices regarding diver safety. Warmwater dive operators in particular are more likely to serve a variety of unknown divers of varied skill and experience. Liveaboards tend to attract a class of divers who want to avoid the limitations of shore operations and maximize their underwater freedom. Many liveaboard operators are particularly concerned about diving safety because of the risks involved in repetitive diving among an unknown population of divers. Nevertheless, warmwater operators vary in how they view their responsibility and the precautions they are willing to take.

A number of operations appear to provide mixed messages to divers. For example, they may formally proclaim concern and informally practice neutrality. On one hand, dive briefings may limit dive depths and times. Captains and divemasters may require formal recording of dive profiles. Divemasters will make themselves available as guides and offer help if problems arise. Informally, however, there may be a "dive your heart out but don’t ruin the trip" attitude on the part of dive leaders. As a result, divers may have a false sense of security and/or be confused about what they really should do if a serious problem should arise.

In one case, a liveaboard dive operator requested the public recording of dive profiles. One group was making daily dives that disregarded known rules about computer use, depth, time and repetitive diving limitations. During the first three days, at least one diver in the "deep diving" group dutifully recorded her profiles. Although the dives were likely subject to private comment by crew and a group of "conservative" divers, no one took any of the deep divers aside to discuss their profiles. On the third day, the woman made a third dive below 165 feet. When her computer indicated that she had no more time at depth, she abandoned her buddy and began her ascent. She lost consciousness at 10 feet and sustained a serious hit.

She later explained, "I felt angry. I was angry at my own stupidity. Why hadn’t I paid attention to the fact that I was diving deeper? I looked at my profile and I was angry at the captain and I was angry at the divemaster. Had the divemaster said to me, ‘Do you realize what your profile looks like?’ I would have listened. I would have heard it as a criticism, but I would have listened. The cook told me later that the divemaster said that she thought we were all professionals. She didn't have the right to say anything to us because we were all professionals."

In pre-dive announcements, divemasters commonly express concern about safety and make clear that injured divers should report problems to crew. In the same briefings, divers are warned that if they get DCI, it will ruin everyone else’s trip, because the boat will have to go ashore.

Hearing these mixed messages, divers are likely to hesitate to confess their fears of illness lest they antagonize crew, buddies and friends. Social support is also provided for divers’ desires to deny injury. One diver explained, "If this had happened to me in the middle of the trip, I would not have considered telling anyone for a second. They would have had to turn the boat around and go back. They tell you that you better be careful, because if you have to turn around and go back, it will spoil everybody’s trip. You know that people just put down a thousand dollars for this trip and if they have to turn around and go back because of you, you aren't going to be a real popular person."

After the last dive of the trip, this same diver experienced symptoms of DCI and did not discuss them with the divemaster because she feared his reaction. She continued to conceal her fear that she had DCI when they arrived on shore, despite some mild symptoms of paralysis.

Dive colleagues and buddies: Dive buddies may also inadvertently collude with the injured diver’s desire to deny or minimize the seriousness of the injuries. One diver finally told her buddy about her concerns, and the buddy overtly displayed displeasure. As a result, the diver decided she would not further annoy her partner by telling him she wanted to go to the hospital. When the symptoms worsened on the plane ride home, the diver again mentioned her concern and discussed her desire for oxygen. The buddy remained firm in his insistence that the problem was not serious, claiming, "They will never give it to you because they need it for real emergencies." The diver did not ask for oxygen and delayed treatment until she returned home. The chamber bought little relief, and she suffered fatigue for many months. Mild DCI symptoms remain, perhaps as a result of delayed treatment.

A male diver was bent while attempting to rescue his inexperienced wife and buddy. He decided to go to the chamber when initial symptoms of nausea and vertigo persisted into the night. Prior to his decision to seek treatment, the diver expressed his fear that he was bent to his buddy, who denied the possibility and insisted that food was the culprit. Even after a chamber ride brought some relief, she insisted that, "If you had just slept it off instead of going to the chamber in the middle of the night, you’d be fine."

Joking and sarcastic remarks constitute another way that buddies often react to accidents. Some jokes are friendly; others are ambivalent or overtly hostile. Regardless of intent, jokes are not always welcomed by the DCI victim, who may experience them as attempts to cause pain and humiliation and/or minimize the seriousness of his or her illness.

Typical among divers are "bend presents" commemorating the accident. One diver who got DCI after making a 200-foot dive received a coffee mug stating "Divers Do It Deeper." Other victims typically receive T-shirts, some of which are illustrated with personal messages and cartoons. One diver graciously received his present in the hospital. Although he pretended to be pleased, his feelings were mixed. He explained, "At first I didn't like it. I felt like I was being discredited. I had a good reputation. Now I felt it was spoiled. After a while I realized that it was their way of handling it. It had as much to do with them as with me."

In contrast to jokes, which can be tolerated by most victims, tactless and sarcastic remarks are experienced as degradation ceremonies intended to shame and humiliate the injured diver. One diver was referred to as "Mr. Fizz" at a public forum. A colleague introduced a DCI victim to the colleague’s girlfriend at a party. After discovering that "this is the guy who got bent," she remarked to the victim, "stupid, stupid, stupid." A "friend" of one victim, herself just beginning to engage in decompression diving and apparently quite fearful, commented "So is fatigue still your excuse [for getting bent]?"

DCI victims handle such remarks differently, depending on their personality and the nature of outside support groups. However, few divers are able to isolate themselves from their feelings sufficiently to avoid feeling angered and humiliated regardless of how they publicly deal with stigmatization. One diver commented, "I felt like smacking him. I take the comments very personally. You read between the lines. ‘You are a bad diver.’ That is how I take it when people make these kinds of comments, and I don't like it. Some of these people will never shine a torch in the places I have been."

One diver was able to protect himself against the verbal assaults by trying to understand the aggressor’s motivations. Nevertheless, he still experienced the remarks as insulting and degrading. He explained, "You feel very vulnerable, and people exploit that vulnerability... because of their own fears. I was at a party and Jay comes up to me and starts making these jokes. ‘So Dan, where ya gonna be diving this year?’" Jay listed a series of novice dive sites. "Like this is so beneath a diver to be diving these things," the diver continued. "His attitude is that he wants to go deeper, longer, further than other people, to prove he is better, to out-macho everybody. Good way to get himself hurt."

As negative social reactions become more evident, divers may begin to read between the lines of any social interaction. They know that people are talking about them, because they hear about some of the conversations. Some discussion that goes on behind the diver’s back is well intended. However, the diver does not know the context of conversations and cannot know who is thinking what. Reality and fantasy are confused, and the more vulnerable divers are likely to find it difficult to face the world, anticipating and feeling shame wherever they go.

With time, a number of victims are able to resolve the trauma of DCI and subsequent social assault with relatively few disabling psychological scars. Others are not.

One woman , stigmatized as a "bad victim" and subjected to a severe social reaction, still lives in torment several years after her accident. She continues to vacillate between blaming herself and blaming others. Sometimes she attributes her accident and/or physical disabilities to her computer, an irresponsible dive operation and a catheter. At others, she becomes involved in endless attacks on herself. Her defensive fluctuations, which alternately protect her from shame and humiliation or intolerable rage, provide no relief. This diver cannot forgive herself for what happened and has little understanding of why she put herself at risk of injury. She often feels as though she was punished and sometimes she thinks she deserved it.

Indeed, the diver feels like a rape victim in a trial in which she becomes the criminal in the eyes of attorneys, judge, jury and even herself."I did talk to an attorney and I considered a lawsuit against the computer manufacturer," she says, "but the laws are based on what you do, and I didn't make my safety stops and was diving an irregular pattern. So it wouldn’t matter if the manufacturer hadn’t repaired the computer when I sent it in. It probably would have been thrown out of court. And also all the embarrassment of being dragged through all of this and being told that I was wrong. Rape. Yes it does feel like a rape. If you were to do it over again, you would do something different, in my case with depth and profile. But at the same time no one will even pat you on the back and say you must feel very bad. Instead, they all start asking questions and pointing fingers immediately, and all the fingers unfortunately tend to be pointed at me. I feel like I have been punished. Yes I deserved it. As I am speaking, I can realize that it’s ludicrous ,but I hear myself saying it as well."

Getting Straight On The Bends

Resolution of an illness involves coming to terms with feelings of bodily damage and fears of loss. It also involves a largely unconscious process of managing the complex web of images from the past which mediate the illness and its aftermath. In the face of social assault, divers are encouraged to maintain defenses such as externalization, denial and self-recrimination, which may minimize some immediate danger but can compromise their long-term psychological welfare.

Without this external assault, divers are far more likely to allow themselves to experience gradually the full range of feelings and thoughts that accompany DCI. In the process, "compromising" defenses can be substituted for others that are less costly to future functioning.

Some divers, feeling socially discredited and depressed after a prolonged illness, may go back to diving before they fully understand the dynamics of their accidents and resolved the trauma. In their minds, only diving can restore self esteem by proving to themselves and others that they are socially worthy members of the diving community. Some divers may also grow increasingly committed to high-risk diving subcultures, which are sometimes more willing to view DCI as an occupational hazard and accept the injured diver as one of their own.

Not only does the stigmatization of DCI increase psychological stress, it also has a deleterious effect on medical treatment. Fearing moral sanctions, divers are likely to delay seeking medical help and/or omit information about the accident which could be important for diagnosis and treatment. This can result in the diver sustaining permanent physical damage, as recompression treatments are only effective when they are instituted soon after the onset of illness.

Finally, the stigmatization of the DCI victim has negative effects on the diving community as well as on individual divers. It results in the alienation of certain groups of divers from dive shops and increases organizational conflicts. It also compromises the ability of researchers to pursue quality diving studies that could benefit the diving community.

DCI is not a moral disease and should not be treated as one. To do so damages the victim’s chance at full physical and psychological recovery and has a negative impact on the diving community. This recognition does not constitute an acceptance of practices that some segments of the dive community feel put divers at risk. It simply acknowledges that divers who are bent suffer a serious physical illness that can have far-reaching psychological consequences. Victims of decompression illness deserve understanding and treatment rather than social ridicule.

Jennifer C. Hunt, Ph.D., is a sociologist and a Clinical Instructor of Psychiatry at the New York University Medical Center, who is currently concluding a study of the social and psychological dimensions of DCI. She can be contacted at: 438 E 58 St., New York, NY 10022.


I am deeply indebted to the divers who have shared their experiences with me. They know who they are. I would like to thank Michael Menduno, Mike Emmerman, and Stephen K. Firestein M.D. for their ongoing encouragement. I am especially grateful to Bernie Chowdhury for his comments on parts of this manuscript and his continued support of my work.


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