Trauma Mastery

IMG_0253Note: This is an excerpt from my essay “The Body Remembers” in my book Soul Stories: Voices from the Margins (San Francisco: University of California Medical Humanities Press, 2018).

Early in my career as a nurse, I worked for a year in a “safe house” emergency shelter for women who were escaping intimate partner violence. Before my work there, I did not understand the concept of trauma mastery and how this plays out in the lives of women caught up in the cycle of abuse. I sided with the common misperception that the reason so many women return to their abusive partners is because the women are psychologically damaged and weak.

I learned that there is the not-insignificant role of addiction to the thrill of trauma and danger—to the effects of the very activating yet numbing fight-or-flight neurochemicals—which can bring at least temporary relief to the bouts of fatiguing depression that often accompany trauma. And there are also unconscious attempts to return to the previous trauma to “get it right this time”—to do what we wish we could have done the first time, to master our trauma.

Seattle social worker Laura van Dernoot Lipsky points out that these unconscious attempts to master our traumas often backfire and simply reinforce our old traumas. She says that many of us in health care and other helping professions are often using our work as a form of trauma mastery, and that by doing so, we may set expectations for ourselves and others that are “untenable and destructive.” (1) She advocates ongoing efforts aimed at self-discovery and self-empathy, and points to the many positive examples of “people who have been effective in repairing the world while still in the process of repairing their own hearts.” (2) Eve Ensler, with the combination of personal work and “world repair” work that she describes in her powerful book In the Body of the World, is one of my favorite examples of this sort of balanced approach. (3)

 

Sources:

1 and 2, Laura van Dernoot Lipsky with Connie Burk, Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others (San Francisco: Berrett-Koehler Publishers, 2009), page 159.

3, Eve Ensler, In the Body of the World (New York: Metropolitan Books, 2013).

 

Poetry Heals

IMG_4301 “come celebrate/with me that everyday/something has tried to kill me/and has failed.” Lucille Clifton, “won’t you celebrate with me” from Book of Light (Copper Canyon Press, 1993).

Poetry heals. Is it any surprise that at times of crisis, illness, grief—or joy and celebration—we turn to poetry to help express what straight word prose cannot?

I have been reminded of this over the past week while simultaneously holding the joy of a family milestone birthday with the sudden serious illness of a dear friend. I have been thrown into the arms of poetry.

Poetry heals. Our first responders are poets, as are artists of all kinds. Cherish our poets and artists. Their work is essential for our existence, for our survival. Listen up you curmudgeonly naysayers who proclaim that poet laureates of our cities, states, and nations are a waste of taxpayer dollars—that the money would be better spent on sweeping away our human waste, on filling the potholes in our roads. You too—but perhaps too late—will be thrown into the arms of poetry.

“There are times when people have experiences that don’t fit neatly into a storyline, a narrative of what happened. Especially within the context of trauma, suffering, and oppression, our ability to arrange bits together into a coherent narrative is overwhelmed. Yet these experiences, beyond the reach of narrative, can be formulated, conveyed, and communicated through metaphor, poetry, art, photography, and gesture.” (From my essay, “Witness: On Telling” in Intima: A Journal of Narrative Medicine, Fall 2017.)

I end this, as I began, with the words of Lucille Clifton. Here is a powerful video recording of her talking about and then reading her poem, “The Killing of the Trees.” In her opening statement, she says, “There seems to be very little reverence for life. I think there is a thing which bothers me about people not having reverence for life that doesn’t look like themselves. And I think that is a great mistake.” As a gifted poet, Clifton can “see it all with that one good eye.”

Poetry Saves

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“Pause there while the sea lights a candle” Josephine Ensign/2018

“…when people say that poetry is a luxury, or an option, or for the educated middle classes, or that it shouldn’t be read in school because it is irrelevant, or any of the strange and stupid things that are said about poetry and its place in our lives, I suspect that the people doing the saying have had things pretty easy. A tough life needs a tough language—and that is what poetry is. That is what literature offers—a language powerful enough to say how it is. It isn’t a hiding place. It is a finding place.” p.40

This is one of my favorite quotes from one of my favorite authors, Jeanette Winterson, from her memoir (with one of the best titles ever) Why Be Happy When You Could Be Normal? (New York: Grove Press, 2011). The book’s title comes from an admonishment her abusive, Fundamentalist Christian adoptive mother frequently gave her growing up. Jeanette was frequently locked in a coal cellar and then locked out of her house by her mother (for being “sinful and gay”) before she ran away from home permanently at age 16. In short, she had a tough life as a child. Poetry and literature saved her.

Towards the end of her memoir, Winterson writes eloquently of the complex relationship between madness and creativity. She admits that she often hears voices and realizes “…that drops me in the crazy category” but doesn’t much care. “If you believe, as I do, that the mind wants to heal itself, and that the psych seeks coherence not disintegration, then it isn’t hard to conclude that the mind will manifest whatever is necessary to work on the job.” Then she writes of the part of herself that acted out from her childhood trauma—the acting out in rage, self-harm (including suicidal ideation), social isolation, and “…sexual recklessness—not liberation.” She questions whether this madness could be the creative spirit. But she answers emphatically: “No. Creativity is on the side of health—it isn’t the thing that drives us mad; it is the capacity in us that tries to save us from madness.” pp. 170- 171.

April is National Poetry Month. Also, it is National Child Abuse Prevention Month as well as Sexual Assault Awareness Month—with this year’s theme (appropriately enough with the #MeToo movement) of Embrace Your Voice.

 

Field Notes on Witnessing

IMG_9363On this sunny Sunday in Seattle, I awake and find my essay, “Witness: On Telling” published in the Field Notes section of Intima: A Journal of Narrative Medicine. This is one of my most digging deep and making it real sorts of essays I have ever written. It is the second part of a two part bookended longer essay on the complicated role of witnessing to the traumas of others and of ourselves. The second essay is titled “Witness: On Seeing” and both are part of my forthcoming book collection of essays and poems, Soul Stories: Voices from the Margins.

In this essay I explore how and why and in what forms we tell (and listen to) stories of trauma and what Arthur Frank terms “deep illness.” I parse out the typology of illness stories as presented in his landmark book, The Wounded Storyteller. I challenge health care providers to increase our capacity to listen to—and to hear—different types of illness stories, including the more distressing (and closest to the reality of trauma) chaos stories.

And I look forward to being part of the upcoming (October 20-22) Northwest Narrative Medicine Conference in Portland, Oregon. I’ll be giving a Saturday keynote address titled “Endurance: The Limits of Resilience” and a Sunday writing workshop titled “Radical Self-Care for Social Justice and Health Equity.”

It’s Time to Read (and Write) Like You Give a Damn!

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Authors at the University of Washington Libraries’ 12th Annual Literary Voices event, May 2017.

“It’s time to read like you give a damn!” is the tagline admonishment to the University of Washington Health Sciences Common Book series, of which my book, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net, was this last academic year’s Common Book. I have added “write like you give a damn!” to remind me of why I write, why I read, and why I do the work that I do. It is the moral imperative of working towards a socially just world. As George Orwell stated so eloquently in his essay “Why I Write,” there are four great reasons to write:

  1. Sheer egoism
  2. Aesthetic enthusiasm
  3. Historical impulse
  4. Political purpose—”and political purpose in the widest possible sense. Desire to push the world in a certain direction, to alter other people’s idea of the kind of society that they should strive for.”

Catching Homelessness was published a year ago today. I am grateful for what the years of researching, writing—and living—the book have taught and continue to teach me. I think about the wise words of Sherman Alexie (as quoted by the wise woman author and teacher Pam Houston—whose 1992 book Cowboys Are My Weakness is partially responsible for my cross-county move to Seattle in 1994). This is from a reading Alexie gave in July at the Institute of American Indian Arts Low Rez program:

“How are you going to tell your story, so that people who don’t know anything about your story get something from it. And you are not in charge of what they get. Sure, you are vulnerable, but you are still a storyteller.”

Sherman Alexie was speaking about his new memoir You Don’t Have to Say You Love Me (New York: Little, Brown and Company, 2017), which is mainly the story of his complicated grief for his mother, Lillian Alexie, who died several years ago. And about the health effects of intergenerational trauma that he has experienced. In his memoir, Alexie writes about his childhood growing up in poverty on the Spokane Indian Reservation in Washington State—about his serious health issues and childhood sexual abuse—about his mother’s rape and discovering that she is the product of a rape. I am dismayed at the insensitive (and as I read it, racist and misogynistic—questioning, for instance, the veracity of his mother’s rape) June 13, 2017 NYT review by Dwight Garner “Sherman Alexie’s Complicated Grief for his Mother.

Alexie, in a recently published open letter, writes eloquently about the re-traumatizing and triggering effects on him that having his memoir out in the world has had. He states that he needs to “take a big step back and do most of my grieving in private.” While his memoir remains in the public domain, he has canceled the rest of his promotional tour events for the rest of the year in order to take care of his mental health—to tend to the ghosts of his mother and ancestors.

I applaud his letter and his honesty. I also understand what he means when he writes of ghosts and hauntings. Part of my motivation for writing Catching Homelessness was to deal with the presence of ghosts in my childhood and my life, which were and are marked by intergenerational trauma. One of the most frequent questions I have been asked by readers of my book is something along the lines of, “But tell me, did you really see the ghosts you write about?” As if a memoir, a book of non-fiction, cannot include something as unverifiable—as poetic— as a ghost? As if an educated, scientifically-grounded person cannot believe in, much less write about believing in, ghosts?  I imagine that the person asking me this question has had a fairly easy life. I’d like to think that they realize—at least at some level—their privilege in that regard and are genuinely attempting to reach for some level of empathy and understanding for what it is like to be haunted.  That is what “reading like you give a damn!” is all about: at the very least it is stepping outside your own comfort zone, finding the capacity for empathy leading to action.

And here I share the thought-provoking outreach packet for Catching Homelessness, put together by my social-justice-in-action colleagues at the University of Washington. 2016-2017 Outreach Packet copy

Catching Homelessness book launch and benefit for Mary's Place. Elliott Bay Book Company. August 2016. Photo credit: Karen Allman

The Role of Trauma-informed Care

IMG_1055Time to revisit and review trauma. Trauma-informed care is health care provided within the framework of an understanding of the various neurocognitive, psychological, physiological, and social effects of trauma on individuals. People who are homeless have particularly high rates of trauma—both before and during their experience of homelessness. And, of course, homelessness itself is a type of trauma, a type of deep illness, as sociologist Arthur Frank refers to an illness that casts a shadow over your life.

Trauma is an event that is life threatening or “self” threatening. Serious accidents and medical mishaps. Drug and alcohol addictions. Natural and manmade disasters. Wars. Rape. Intimate partner violence. Childhood neglect, physical, and sexual abuse. Complex trauma is trauma that occurs within key caretaker relationships and that is pervasive and enduring. Complex trauma is, well, more complex to live with and to treat.

We use the phrase scared speechless to describe fear that overwhelms and suppresses the speech and language area of our brain while we’re in the midst of a traumatic event. As Bessel Van Der Kolk, a physician and expert on trauma puts it, “All trauma is preverbal.” (p 43) Trauma bypasses these higher order areas of the brain and goes straight to the more primitive fight and flight fear area—the amygdala, two almond-shaped areas deep inside our brains in the primitive limbic system. Trauma is not stored as a storied memory with a clear-cut beginning, middle, and end, but rather as fragments of experience, images, smells, sounds, and other bodily sensations. That is why people who have survived a significant traumatic event—even years and decades after the trauma is over—struggle to tell the story of what happened. Yet their bodies bear witness to the event through terrors, flashbacks, numbing, and stress-mediated physical problems like migraines and auto-immune diseases—diseases in which the body turns on itself, as if in slow suicide. If the trauma happened to the person as a child before the firm development of a sense of self, that person’s memories of the event can remain visceral and largely inaccessible to verbal processing.

Van der Kolk states, “Almost every brain-imaging study of trauma patients finds abnormal activation of the insula. This part of the brain integrates and interprets the input from the internal organs—including our muscles, joints, and balance (proprioceptive) system—to generate the sense of being embodied.” (p 249) He points out that the flood of activating neurochemicals from the fight or flight response to trauma effectively cuts people off from the real origin of their bodily sensations; the fight or flight flood numbs people, and is the reason for dissociation and out-of-body experiences many trauma patients deal with. Van der Kolk goes on to declare, “In other words trauma makes people feel like some body else, or like no body. In order to overcome trauma, you need help to get back in touch with your body and your Self.” (p 249)

Art, music, and dance are often used as treatments for trauma patients because these expressive modalities do not depend on language. They do not depend on—indeed, they are better off without—the use of our rational minds both to create and to experience. As psychiatrist Laurence J. Kirmayer writes, “And if the text stands for a hard-won rational order, imposed on thought through the careful composition of writing, the body provides a structure to thought that is, in part, extra-rational and disorderly. This extra-rational dimension to thought carries important information about emotional, aesthetic, and moral value.” (pp. 324-325)

In the late 1990s, in a Seattle area community health clinic where I worked as a nurse practitioner, many of my patients were Bosnian and Ukrainian refugees. One of my more heart-wrenching patients was a 4-year old Bosnian girl whose teeth were rotted to the gum line because her mother had given her a sugar-soaked rag to suck to keep her silent as they tried to escape the civil war. The language interpreter told me that the child’s older brother had ben killed, and that her mother had been raped. I referred the child to our children’s hospital where they surgically removed all her baby teeth and then fitted her with child dentures until her adult teeth appeared. I was hoping to refer the mother for talk therapy to deal with her traumas, but soon realized it was best to refer her for massage therapy with a trauma-informed female therapist. I worked with our clinic social worker to petition the patient’s health insurance (which happened to be the state Medicaid office) to pay for this—what we typically consider slightly frivolous and self-indulgent treatment. Medicaid paid for the massage therapy and it seemed to lighten her depression. This wasn’t art, music, or dance therapy, but it was body-based therapy.

The body remembers. Maddy Coy, a UK-based researcher who works with survivors of prostitution, maintains that especially for women who experienced childhood sexual abuse (a startlingly high percentage of prostitutes worldwide), the use of appropriate body work such as yoga and massage is oftentimes crucial for recovery. Body work helps traumatized people reestablish a focus on what the body can do instead of what is done to the body.

Early in my career as a nurse I worked for a year in a safe house emergency shelter for women who were escaping intimate partner violence. Before my work there I did not understand the concept of trauma mastery and how this played out in the lives of women caught up in the cycle of abuse. I sided with the common misperception that the reason so many women return to their abusive partners is because they are psychologically damaged and weak. There is the not insignificant role of addiction to the thrill of trauma and danger—to the effects of the activating yet numbing fight or flight neurochemicals—which can bring at least temporary relief to the bouts of fatiguing depression that often accompany trauma. Then there is the unconscious attempt to return to the site of previous trauma to get it right this time, to do what we wish we could have done the first time, to master our trauma.

As social worker Laura van Dernoot Lipsky points out, these unconscious attempts to master our traumas often backfire and simply reinforce our old traumas. Lipsky goes on to say that many of us in health care and other helping professions often are using our work as a type of trauma mastery, and that by doing so we may set expectations for ourselves and others that are “untenable and destructive.” She advocates ongoing efforts aimed at self-discovery and self-empathy, and points to the many positive examples of “people who have been effective in repairing the world while still in the process of repairing their own hearts.“ (p 159) Eve Ensler and her personal, combined with world repair, work that she describes in her powerful book In the Body of the World, is one of my personal favorite role models for this sort of balanced approach.

Beyond Endurance Test

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Untitled, oil on canvas. Erika Kahn. Photo credit: Josephine Ensign/2017.

These dark, uncertain times demand our full attention, compassion, and capacity to endure beyond what we previously thought we could endure. And by this I do not mean passive suffering or some sick, masochistic hair-shirt sort of endurance. Nor do I mean resilience, the saccharine notion that the human body, the human psyche, and even entire communities (or countries) can be like heated metal—stressed and stretched but not broken—that they can bounce back, return to steady state, and perhaps be stronger and wiser for the experience?

Paul Farmer, physician and global health expert, reminds us that,  “The capacity to suffer is, clearly, part of being human. But not all suffering is equal, in spite of pernicious and often self-serving identity politics that suggest otherwise.” (1)

Trauma never happens in isolation. An individual trauma ripples outwards as well as inwards. Suffering from trauma is always a social process; recovering from trauma is always a social process.

Resilience, either from an individual or a community (or country as we are now facing), even if it were possible, would it be desirable? If most traumas, most disasters, are at least partially caused by and certainly compounded by social (in)justice issues, do we want to return to normal, to the status quo after our worlds, our bodies, our communities have been shaken to the foundations, have been seared by fire, have been permanently altered and scarred? Skirting close to the danger of glorifying trauma, of feeding an addiction to the pain and suffering so overly abundant in our world, is the recognition that individual and community healing “means repair but it also means transformation—transformation to a different moral state.” (2) And it means enduring, going on, doing what we can individually and collectively to transform the world for the better.

___

Adapted from my book manuscript for Soul Stories: Voices from the Margins.

Sources for quotes:

  1. Paul Farmer. “On suffering and structural violence: a view from below.” In: Violence in War and Peace. Edited by Nancy Scheper-Hughes and Philippe Bourgois. (New York: Blackwell Publishing, 2004). pp 281-289. Quote is from p. 288.

 

  1. Veena Das and Arthur Kleinman, “Introduction,” in Remaking a World: Violence, Social Suffering, and Recovery, ed., Veena Das, Arthur Kleinman, Margaret Lock, Mamphela Ramphele, and Pamela Reynolds (Berkeley: University of California Press, 2001), 23. (Quote is from “Introduction” pp. 1-30. Quote is from p. 23)

See also: Arthur Kleinman, “The art of medicine: how we endure” The Lancet. January 11, 2014. Vol 383. pp 119-120.