Narratives and Post-traumatic stress

“I was walking down the road… I don’t know why the light didn’t go off… there it was, the screeching… and Amanda, she didn’t know what was happening…”

“That sounds upsetting. Let’s take a step back, and go back to the beginning. Which road were you walking down?”

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Trauma affects us in many ways. But what is trauma? There is no simple answer to that question. The reality is what may be traumatic to one person may not be traumatic to the next. Trauma cares about context. About who we are. About our past experiences. And importantly, trauma cares about how we react to it, and what we have the opportunity to do after a traumatic event.

The dialogue above might seem a little disjointed and confusing. Don’t worry, that was intentional! This is an example of poor narrative cohesion, a feature commonly seen in post-traumatic stress.

During a traumatic event, our senses are often overwhelmed and over-stimulated. Everything seems to happen so fast and take forever at the same time. In many ways, a traumatic event “shocks” the brain. Our memories of a traumatic event may seem sped-up, disjointed, or contain blanks. They can seem chaotic. As we think and reflect on a traumatic event, we piece together a cohesive narrative that makes sense to us, almost like a story.

This isn’t always as easy as it sounds. Traumatic memories are exactly that – traumatic! They’re not pleasant and can even be painful to think about. People may actively avoid thinking about a traumatic memory, or may avoid talking about it with friends, even if it’s all they can think about. This can contribute to the development of poor narrative cohesion, as seen in the dialogue above. Without the chance to think, talk, and reflect with our peers, we don’t fully get the chance to piece the story together for ourselves. It isn’t unusual that the first time someone has spoke about a trauma has been with me in my office, and it isn’t uncommon for their story to be disjointed at first.

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Discussing traumatic events with someone isn’t only important to string together your story. Speaking to someone about  trauma plays an important role in the prevention and treatment of post-traumatic stress disorder.

Whenever we recall a memory, that memory is overwritten and re-coded by our memory of the memory – wait, what? To simplify it, if we have a memory of an apple, and we remember the apple as being a little more red than it actually was, our memory would now be re-written as a little more red (and distorted!) than previous.

This phenomenon is why over time you might take a new perspective on a vacation you thought was bad, or change your thoughts on a movie. In post-traumatic stress, it allows us to continually expose ourselves to the traumatic memory, and re-code it into something more pragmatic and tolerable. This is why narrative therapy, a form of therapy which gives individuals an opportunity to explore their own experiences, and form them into a story that they can use to better understand themselves and their own story, is a key feature of any trauma-focused therapy.

I recently came across this article from HuffPost Canada that talks about a particular legal barrier some therapists may face in Canada if they wish to provide treatment to a Canadian juror. Apparently in Canada, section 649 of the Criminal Code prohibits jurors from discussing elements of their cases with anyone, including therapists, despite them being committed to confidentiality with their patients. As a physician, I wouldn’t have even thought about this legal scenario and I can promise you it wasn’t taught in medical school. That’s probably because it’s absolutely absurd.

Do you think it’s fair to vulnerable jurors at risk for PTSD that they cannot seek counselling?

Editor’s note: Narrative therapy is an important element of trauma-focused therapy but not the first element. Most trauma therapies first focus on building skills to manage distress before delving into traumatic memories. This can be important to prevent psychological distress from accessing memories that may be at first very difficult to recollect.

Dr. Travis Barron is a resident physician in Toronto, Canada.

He’s biting again

“Mr. V is biting again.”

“God, what are we going to do with him?”

“I don’t know, but he’s getting too much to manage…”

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Dementia is a debilitating disease. It creeps up slowly, crouches for attack, and seems to suddenly wipe our lives from right beneath our feet.

Many of us have had loved ones stricken by the disease, and have watched in muted horror while the person we knew vanishes, as we wonder, “if it’s this bad for us, what must it be like for them?”

I was working in an emergency department in Ontario, Canada, when a gentleman, Mr. V, was brought in from his place of residence when staff determined he was too agitated for their care. On arrival, he could not speak beyond muttering a few nonsensical words, and would randomly grab at staff as they walked by, seemingly on a completely random basis. The staff at his residence confirmed he had a history of dementia.

These sort of patients are difficult for a variety of reasons. The inability to communicate often results in subtle needs going unmet, leading to aggression. They require a high level of nursing resources to manage. And the fact is, our healthcare systems in Canada (particularly emergency rooms) are not equipped to properly care for people with dementia (in fact, in many ways they are perfectly equipped to exacerbate symptoms of aggression in dementia).

I began to work with Mr. V and I immediately noticed his age – he was in his late fifties. This is a fairly young age to develop dementia and immediately the differential changes. Could he have some rare form of genetic Alzheimer’s, which can affect people at  that age?

The second thing I noticed was has last name, changed for the purposes of this blog. The spelling on the name was immediately suspicious for someone of Sri Lankan descent. I phoned Mr. V’s emergency contact, and my suspicions were confirmed. Mr. V had a long history of alcohol abuse, and had subsequently developed a dementia. He had been various degrees of under-sheltered for the last number of years. He had immigrated to Canada some decades prior, as a refugee. Mr. V was Tamil and had been a victim of unnamed trauma during the Sri Lankan civil war.

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Credit: Alternative Press

I won’t go into details here, but the Sri Lankan civil war (1983-2009) was your typical civil war cocktail of genocide, torture, rape, and any number of unspeakable deeds. The effects of civil war and genocide on the human brain are well documented and not easily conceptualized. Obviously it has a tremendous impact on people, Mr. V being the latest example of a casualty of the war. The United Nations recently reported that one in five individuals in conflict zones suffer from a major mental illness, at any given time.

What struck me about this story was how succinct it was. The clear relationship between this man’s trauma, alcohol use, and dementia. The story isn’t always that clear. But there’s always a story. Next time you meet someone with an alcohol problem, dementia, or any other mental illness, stop and think, there’s more to the story.

 

Editor’s note: What happened to Mr. V? We uncovered an acute medical problem that was easily treated, superimposed on his dementia, and he returned to his baseline after a couple of days of treatment!

 

Dr. Travis Barron is a resident physician in the Department of Psychiatry at the University of Toronto in Toronto, Canada.