Then we asked them about the traumas that had brought them into the study—many of them rapes. “Do you ever suddenly remember how your rapist smelled?” we asked, and, “Do you ever experience the same physical sensations you had when you were raped?” Such questions precipitated powerful emotional responses: “That is why I cannot go to parties anymore, because the smell of alcohol on somebody’s breath makes me feel like I am being raped all over again” or “I can no longer make love to my husband, because when he touches me in a particular way I feel like I am being raped again.”
There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events.
In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events or other vital details (the first person who arrived to help, whether an ambulance or a police car took them to the hospital).
We also asked the participants how they recalled their trauma at three points in time: right after it happened; when they were most troubled by their symptoms; and during the week before the study. All of our traumatized participants said that they had not been able to tell anybody precisely what had happened immediately following the event. (This will not surprise anyone who has worked in an emergency room or ambulance service: People brought in after a car accident in which a child or a friend has been killed sit in stunned silence, dumbfounded by terror.) Almost all had repeated flashbacks: They felt overwhelmed by images, sounds, sensations, and emotions. As time went on, even more sensory details and feelings were activated, but most participants also started to be able to make some sense out of them. They began to “know” what had happened and to be able to tell the story to other people, a story that we call “the memory of the trauma.”
Gradually the images and flashbacks decreased in frequency, but the greatest improvement was in the participants’ ability to piece together the details and sequence of the event. By the time of our study, 85 percent of them were able to tell a coherent story, with a beginning, a middle, and an end. Only a few were missing significant details. We noted that the five who said they had been abused as children had the most fragmented narratives—their memories still arrived as images, physical sensations, and intense emotions.
In essence, our study confirmed the dual memory system that Janet and his colleagues at the Salpêtrière had described more than a hundred years earlier: Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography.
Perhaps the most important finding in our study was that remembering the trauma with all its associated affects, does not, as Breuer and Freud claimed back in 1893, necessarily resolve it. Our research did not support the idea that language can substitute for action. Most of our study participants could tell a coherent story and also experience the pain associated with those stories, but they kept being haunted by unbearable images and physical sensations. Research in contemporary exposure treatment, a staple of cognitive behavioral therapy, has similarly disappointing results: The majority of patients treated with that method continue to have serious PTSD symptoms three months after the end of treatment.27 As we will see, finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries.
LISTENING TO SURVIVORS
Nobody wants to remember trauma. In that regard society is no different from the victims themselves. We all want to live in a world that is safe, manageable, and predictable, and victims remind us that this is not always the case. In order to understand trauma, we have to overcome our natural reluctance to confront that reality and cultivate the courage to listen to the testimonies of survivors.
In his book Holocaust Testimonies: The Ruins of Memory (1991), Lawrence Langer writes about his work in the Fortunoff Video Archive at Yale University: “Listening to accounts of Holocaust experience, we unearth a mosaic of evidence that constantly vanishes into bottomless layers of incompletion.28 We wrestle with the beginnings of a permanently unfinished tale, full of incomplete intervals, faced by the spectacle of a faltering witness often reduced to a distressed silence by the overwhelming solicitations of deep memory.” As one of his witnesses says: “If you were not there, it’s difficult to describe and say how it was. How men function under such stress is one thing, and then how you communicate and express that to somebody who never knew that such a degree of brutality exists seems like a fantasy.”
Another survivor, Charlotte Delbo, describes her dual existence after Auschwitz: “[T]he ‘self’ who was in the camp isn’t me, isn’t the person who is here, opposite you. No, it’s too unbelievable. And everything that happened to this other ‘self,’ the one from Auschwitz, doesn’t touch me now, me, doesn’t concern me, so distinct are deep memory and common memory. . . . Without this split, I wouldn’t have been able to come back to life.”29 She comments that even words have a dual meaning: “Otherwise, someone [in the camps] who has been tormented by thirst for weeks would never again be able to say: ‘I’m thirsty. Let’s make a cup of tea.’ Thirst [after the war] has once more become a currently used term. On the other hand, if I dream of the thirst I felt in Birkenau [the extermination facilities in Auschwitz], I see myself as I was then, haggard, bereft of reason, tottering.”30
Langer hauntingly concludes, “Who can find a proper grave for such damaged mosaics of the mind, where they may rest in pieces? Life goes on, but in two temporal directions at once, the future unable to escape the grip of a memory laden with grief.”31
The essence of trauma is that it is overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our sense of what is normal and accept that we are dealing with a dual reality: the reality of a relatively secure and predictable present that lives side by side with a ruinous, ever-present past.
NANCY’S STORY
Few patients have put that duality into words as vividly as Nancy, the director of nursing in a Midwestern hospital who came to Boston several times to consult with me. Shortly after the birth of her third child, Nancy underwent what is usually routine outpatient surgery, a laparoscopic tubal ligation in which the fallopian tubes are cauterized to prevent future pregnancies. However, because she was given insufficient anesthesia, she awakened after the operation began and remained aware nearly to the end, at times falling into what she called “a light sleep” or “dream,” at times experiencing the full horror of her situation. She was unable to alert the OR team by moving or crying out because she had been given a standard muscle relaxant to prevent muscle contractions during surgery.
Some degree of “anesthesia awareness” is now estimated to occur in approximately thirty thousand surgical patients in the United States every year,32 and I had previously testified on behalf of several people who were traumatized by the experience. Nancy, however, did not want to sue her surgeon or anesthetist. Her entire focus was on bringing the reality of her trauma to consciousness so that she could free herself from its intrusions into her everyday life. I’d like to end this chapter by sharing several passages from a remarkable series of e-mails in which she described her grueling journey to recovery.
Initially Nancy did not know what had happened to her. “When we went home I was still in a daze, doing the typical things of running a household, yet not really feeling that I was alive or that I was real.
I had trouble sleeping that night. For days, I remained in my own little disconnected world. I could not use a hair dryer, toaster, stove or anything that warmed up. I could not concentrate on what people were doing or telling me. I just didn’t care. I was increasingly anxious. I slept less and less. I knew I was behaving strangely and kept trying to understand what was frightening me so.
“On the fourth night after the surgery, around 3 AM, I started to realize that the dream I had been living all this time related to conversations I had heard in the operating room. I was suddenly transported back into the OR and could feel my paralyzed body being burned. I was engulfed in a world of terror and horror.” From then on, Nancy says, memories and flashbacks erupted into her life.
“It was as if the door was pushed open slightly, allowing the intrusion. There was a mixture of curiosity and avoidance. I continued to have irrational fears. I was deathly afraid of sleep; I experienced a sense of terror when seeing the color blue. My husband, unfortunately, was bearing the brunt of my illness. I would lash out at him when I truly did not intend to. I was sleeping at most 2 to 3 hours, and my daytime was filled with hours of flashbacks. I remained chronically hyperalert, feeling threatened by my own thoughts and wanting to escape them. I lost 23 pounds in 3 weeks. People kept commenting on how great I looked.
“I began to think about dying. I developed a very distorted view of my life in which all my successes diminished and old failures were amplified. I was hurting my husband and found that I could not protect my children from my rage.
“Three weeks after the surgery I went back to work at the hospital. The first time I saw somebody in a surgical scrubsuit was in the elevator. I wanted to get out immediately, but of course I could not. I then had this irrational urge to clobber him, which I contained with considerable effort. This episode triggered increasing flashbacks, terror and dissociation. I cried all the way home from work. After that, I became adept at avoidance. I never set foot in an elevator, I never went to the cafeteria, I avoided the surgical floors.”
Gradually Nancy was able to piece together her flashbacks and create an understandable, if horrifying, memory of her surgery. She recalled the reassurances of the OR nurses and a brief period of sleep after the anesthesia was started. Then she remembered how she began to awaken.
“The entire team was laughing about an affair one of the nurses was having. This coincided with the first surgical incision. I felt the stab of the scalpel, then the cutting, then the warm blood flowing over my skin. I tried desperately to move, to speak, but my body didn’t work. I couldn’t understand this. I felt a deeper pain as the layers of muscle pulled apart under their own tension. I knew I wasn’t supposed to feel this.”
Nancy next recalls someone “rummaging around” in her belly and identified this as the laparoscopic instruments being placed. She felt her left tube being clamped. “Then suddenly there was an intense searing, burning pain. I tried to escape, but the cautery tip pursued me, relentlessly burning through. There simply are no words to describe the terror of this experience. This pain was not in the same realm as other pain I had known and conquered, like a broken bone or natural childbirth. It begins as extreme pain, then continues relentlessly as it slowly burns through the tube. The pain of being cut with the scalpel pales beside this giant.”
“Then, abruptly, the right tube felt the initial impact of the burning tip. When I heard them laugh, I briefly lost track of where I was. I believed I was in a torture chamber, and I could not understand why they were torturing me without even asking for information. . . . My world narrowed to a small sphere around the operating table. There was no sense of time, no past, and no future. There was only pain, terror, and horror. I felt isolated from all humanity, profoundly alone in spite of the people surrounding me. The sphere was closing in on me.
“In my agony, I must have made some movement. I heard the nurse anesthetist tell the anesthesiologist that I was ‘light.’ He ordered more meds and then quietly said, ‘There is no need to put any of this in the chart.’ That is the last memory I recalled.”
In her later e-mails to me, Nancy struggled to capture the existential reality of trauma.
“I want to tell you what a flashback is like. It is as if time is folded or warped, so that the past and present merge, as if I were physically transported into the past. Symbols related to the original trauma, however benign in reality, are thoroughly contaminated and so become objects to be hated, feared, destroyed if possible, avoided if not. For example, an iron in any form—a toy, a clothes iron, a curling iron, came to be seen as an instrument of torture. Each encounter with a scrub suit left me disassociated, confused, physically ill and at times consciously angry.
“My marriage is slowly falling apart—my husband came to represent the heartless laughing people [the surgical team] who hurt me. I exist in a dual state. A pervasive numbness covers me with a blanket; and yet the touch of a small child pulls me back to the world. For a moment, I am present and a part of life, not just an observer.
“Interestingly, I function very well at work, and I am constantly given positive feedback. Life proceeds with its own sense of falsity.
“There is a strangeness, bizarreness to this dual existence. I tire of it. Yet I cannot give up on life, and I cannot delude myself into believing that if I ignore the beast it will go away. I’ve thought many times that I had recalled all the events around the surgery, only to find a new one.
“There are so many pieces of that 45 minutes of my life that remain unknown. My memories are still incomplete and fragmented, but I no longer think that I need to know everything in order to understand what happened.
“When the fear subsides I realize I can handle it, but a part of me doubts that I can. The pull to the past is strong; it is the dark side of my life; and I must dwell there from time to time. The struggle may also be a way to know that I survive—a re-playing of the fight to survive—which apparently I won, but cannot own.”
An early sign of recovery came when Nancy needed another, more extensive operation. She chose a Boston hospital for the surgery, asked for a preoperative meeting with the surgeons and the anesthesiologist specifically to discuss her prior experience, and requested that I be allowed to join them in the operating room. For the first time in many years I put on a surgical scrub suit and accompanied her into the OR while the anesthesia was induced. This time she woke up to a feeling of safety.
Two years later I wrote Nancy asking her permission to use her account of anesthesia awareness in this chapter. In her reply she updated me on the progress of her recovery: “I wish I could say that the surgery to which you were so kind to accompany me ended my suffering. That sadly was not the case. After about six more months I made two choices that proved provident. I left my CBT therapist to work with a psychodynamic psychiatrist and I joined a Pilates class.
“In our last month of therapy, I asked my psychiatrist why he did not try to fix me as all other therapists had attempted, yet had failed. He told me that he assumed, given what I had be able to accomplish with my children and career, that I had sufficient resiliency to heal myself, if he created a holding environment for me to do so. This was an hour each week that became a refuge where I could unravel the mystery of how I had become so damaged and then re-construct a sense of myself that was whole, not fragmented, peaceful, not tormented. Through Pilates, I found a stronger physical core, as well as a community of women who willingly gave acceptance and social support that had been distant in my life since the trauma. This combination of core strengthening—psychological, social, and physical—created a sense of personal safety and mastery, relegating my memories to the distant past, allowing the present and future to emerge.”
PART FIVE
PATHS TO RECOVERY
CHAPTER 13
HEALING FROM TRAUMA: OWNING YOUR SELF
I don’t go to therapy to find out if I’m a freak
I go and I
find the one and only answer every week
And when I talk about therapy, I know what people think
That it only makes you selfish and in love with your shrink
But, oh how I loved everybody else
When I finally got to talk so much about myself
—Dar Williams, What Do You Hear in These Sounds
Nobody can “treat” a war, or abuse, rape, molestation, or any other horrendous event, for that matter; what has happened cannot be undone. But what can be dealt with are the imprints of the trauma on body, mind, and soul: the crushing sensations in your chest that you may label as anxiety or depression; the fear of losing control; always being on alert for danger or rejection; the self-loathing; the nightmares and flashbacks; the fog that keeps you from staying on task and from engaging fully in what you are doing; being unable to fully open your heart to another human being.
Trauma robs you of the feeling that you are in charge of yourself, of what I will call self-leadership in the chapters to come.1 The challenge of recovery is to reestablish ownership of your body and your mind—of your self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed. For most people this involves (1) finding a way to become calm and focused, (2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) finding a way to be fully alive in the present and engaged with the people around you, (4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.
The Body Keeps the Score Page 25