PART FOUR THE IMPRINT OF TRAUMA
CHAPTER 11 UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY
It is a strange thing that all the memories have these two qualities. They are always full of quietness, that is the most striking thing about them; and even when things weren’t like that in reality, they still seem to have that quality. They are soundless apparitions, which speak to me by looks and gestures, wordless and silent—and their silence is precisely what disturbs me.
—Erich Maria Remarque, All Quiet on the Western Front
In the spring of 2002 I was asked to examine a young man who claimed to have been sexually abused while he was growing up by Paul Shanley a Catholic priest who had served in his parish in Newton, Massachusetts. Now twenty-five years old, he had apparently forgotten the abuse until he heard that the priest was currently under investigation for molesting young boys. The question posed to me was: Even though he had seemingly “repressed” the abuse for well over a decade after it ended, were his memories credible, and was I prepared to testify to that fact before a judge?
I will share what this man, whom I’ll call Julian, told me, drawing on my original case notes. (Even though his real name is in the public record, I’m using a pseudonym because I hope that he has regained some privacy and peace with the passage of time.1) His experiences illustrate the complexities of traumatic memory. The controversies over the case against Father Shanley are also typical of the passions that have swirled around this issue since psychiatrists first described the unusual nature of traumatic memories in the final decades of the nineteenth century.
1] FLOODED BY
SENSATIONS AND IMAGES
On February 11, 2001, Julian was serving as a military
policeman at an air force base. During his daily phone conversation with his
girlfriend, Rachel, she mentioned a lead article she’d read that morning in the
Boston Globe. A priest named Shanley was under suspicion for molesting
children. Hadn’t Julian once told her about a Father Shanley who had been his
parish priest back in Newton? “Did he ever do anything to you?” she asked.
Julian initially recalled Father Shanley as a kind man who’d been very supportive
after his parents got divorced. But as the conversation went on, he started to
go into a panic. He suddenly saw Shanley silhouetted in a doorframe, his hands
stretched out at forty-five degrees, staring at Julian as he urinated.
Overwhelmed by emotion, he told Rachel, “I’ve got to go.” He called his flight
chief, who came over accompanied by the first sergeant. After he met with the
two of them, they took him to the base chaplain. Julian recalls telling him:
“Do you know what is going on in Boston? It happened to me, too.” The moment he
heard himself say those words, he knew for certain that Shanley had molested
him—even though he did not remember the details. Julian felt extremely
embarrassed about being so emotional; he had always been a strong kid who kept
things to himself.
That night he sat on the corner
of his bed, hunched over, thinking he was losing his mind and terrified that he
would be locked up. Over the subsequent week images kept flooding into his
mind, and he was afraid of breaking down completely. He thought about taking a
knife and plunging it into his leg just to stop the mental pictures. Then the
panic attacks started to be accompanied by seizures, which he called “epileptic
fits.” He scratched his body until he bled. He constantly felt hot,
sweaty, and agitated. Between panic attacks he “felt like a zombie”; he was
observing himself from a distance, as if what he was experiencing were actually
happening to somebody else.
In April he received an
administrative discharge, just ten days short of being eligible to receive full
benefits.
When Julian entered my office
almost a year later, I saw a handsome, muscular guy who looked depressed and
defeated. He told me immediately that he felt terrible about having left the
air force. He had wanted to make it his
career, and he’d always received excellent
evaluations. He loved the challenges and the teamwork, and he missed the
structure of the military lifestyle.
Julian was born in a Boston
suburb, the second-oldest of five children. His father left the family when
Julian was about six because he could not tolerate living with Julian’s
emotionally labile mother. Julian and his father get along quite well, but he sometimes
reproaches his father for having worked too hard to support his family and for
abandoning him to the care of his unbalanced mother. Neither his parents nor
any of his siblings has ever received psychiatric care or been involved with
drugs.
Julian was a popular athlete in
high school. Although he had many friends, he felt pretty bad about himself and
covered up for being a poor student by drinking and partying. He feels ashamed
that he took advantage of his popularity and good looks by having sex with many
girls. He mentioned wanting to call several of them to apologize for how badly
he’d treated them.
He remembered always hating his
body. In high school he took steroids to pump himself up and smoked marijuana
almost every day. He did not go to college, and after graduating from high
school he was virtually homeless for almost a year because he could no longer
stand living with his mother. He enlisted to try to get his life back on track.
Julian met Father Shanley at age
six when he was taking a CCD (catechism) class at the parish church. He
remembered Father Shanley taking him out of the class for confession. Father
Shanley rarely wore a cassock, and Julian remembered the priest’s dark blue
corduroy pants. They would go to a big room with one chair facing another and a
bench to kneel on. The chairs were covered with red and there was a red velvet
cushion on the bench. They played cards, a game of war that turned into strip
poker. Then he remembered standing in front of a mirror in that room. Father Shanley
made him bend over. He remembered Father Shanley putting a finger into his
anus. He does not think Shanley ever penetrated him with his penis, but he
believes that the priest fingered him on numerous occasions.
Other than that, his memories
were quite incoherent and fragmentary. He had flashes of images of Shanley’s
face and of isolated incidents: Shanley standing in the door of the bathroom;
the priest going down on his knees and moving “it” around with his tongue. He
could not say how old he was when that happened. He remembered the priest
telling him how to perform oral sex, but he did not remember actually doing it.
He remembered passing out pamphlets in church and then Father Shanley sitting
next to him in a pew, fondling him with
one hand and holding Julian’s hand on himself with the
other. He remembered that, as he grew older, Father Shanley would pass close to
him and caress his penis. Paul did not like it but did not know what to do to
stop it. After all, he told me, “Father Shanley was the closest thing to God in
my neighborhood.”
In addition to these memory
fragments, traces of his sexual abuse were clearly being activated and
replayed. Sometimes when he was having sex with his girlfriend, the priest’s
image popped into his head, and, as he said, he would “lose it.” A week before
I interviewed him, his girlfriend had pushed a finger into his mouth and
playfully said: “You give good head.” Julian jumped up and screamed, “If you
ever say that again I’ll fucking kill you.” Then, terrified, they both started
to cry. This was followed by one of Julian’s “epileptic fits,” in which he
curled up in a fetal position, shaking and whimpering like a baby. While
telling me this Julian looked very small and very frightened.
Julian alternated between feeling
sorry for the old man that Father Shanley had become and simply wanting to
“take him into a room somewhere and kill him.” He also spoke repeatedly of how
ashamed he felt, how hard it was to admit that he could not protect himself:
“Nobody fucks with me, and now I have to tell you this.” His self-image was of
a big, tough Julian.
How do we make sense of a story
like Julian’s: years of apparent forgetting, followed by fragmented, disturbing
images, dramatic physical symptoms, and sudden reenactments? As a therapist
treating people with a legacy of trauma, my primary concern is not to determine
exactly what happened to them but to help them tolerate the sensations,
emotions, and reactions they experience without being constantly hijacked by
them. When the subject of blame arises, the central issue that needs to be
addressed is usually self-blame—accepting that the trauma was not their fault,
that it was not caused by some defect in themselves, and that no one could ever
have deserved what happened to them.
Once a legal case is involved,
however, determination of culpability becomes primary, and with it the
admissibility of evidence. I had previously examined twelve people who had been
sadistically abused as children in a Catholic orphanage in Burlington, Vermont.
They had come forward (with many other claimants) more than four decades later,
and although none had had any contact with the others until the first claim was
filed, their abuse memories were astonishingly similar: They all named the same
names and the particular abuses that each nun or priest had committed—in the
same rooms, with the same furniture, and as part of the same daily routines.
Most of them subsequently accepted an out-of-court settlement from the Vermont
diocese.
Before a case goes to trial, the
judge holds a so-called Daubert hearing to set the standards for expert
testimony to be presented to the jury. In a 1996 case I had convinced a federal
circuit court judge in Boston that it was common for traumatized people to lose
all memories of the event in question, only to regain access to them in bits
and pieces at a much later date. The same standards would apply in Julian’s
case. While my report to his lawyer remains confidential, it was based on
decades of clinical experience and research on traumatic memory, including the
work of some of the great pioneers of modern psychiatry.
2] NORMAL VERSUS
TRAUMATIC MEMORY
We all know how fickle memory is; our stories change
and are constantly revised and updated. When my brothers, sisters, and I talk
about events in our childhood, we always end up feeling that we grew up in
different families—so many of our memories simply do not match. Such
autobiographical memories are not precise reflections of reality; they are
stories we tell to convey our personal take on our experience.
The extraordinary capacity of the human mind to rewrite memory is illustrated in the Grant Study of Adult Development, which has systematically followed the psychological and physical health of more than two hundred Harvard men from their sophomore years of 1939–44 to the present.2 Of course, the designers of the study could not have anticipated that most of the participants would go off to fight in World War II, but we can now track the evolution of their wartime memories. The men were interviewed in detail about their war experiences in 1945/1946 and again in 1989/1990.
Four and a half decades later, the majority gave very
different accounts from the narratives recorded in their immediate postwar
interviews: With the passage of time, events had been bleached of their intense
horror. In contrast, those who had been traumatized and subsequently developed
PTSD did not modify their accounts; their memories were preserved essentially
intact forty-five years after the war ended.
Whether we remember a particular event at all, and how accurate our memories of it are, largely depends on how personally meaningful it was and how emotional we felt about it at the time. The key factor is our level of arousal. We all have memories associated with particular people, songs, smells, and places that stay with us for a long time. Most of us still have precise memories of where we were and what we saw on Tuesday, September 11, 2001, but only a fraction of us recall anything in particular about September 10.
Most day-to-day experience passes
immediately into oblivion. On ordinary days we don’t have much to report when
we come home in the evening. The mind works according to schemes or maps, and
incidents that fall outside the established pattern are most likely to capture
our attention. If we get a raise or a friend tells us some exciting news, we
will retain the details of the moment, at least for a while. We remember
insults and injuries best: The adrenaline that we secrete to defend against
potential threats helps to engrave those incidents into our minds. Even if the
content of the remark fades, our dislike for the person who made it usually
persists.
When something terrifying
happens, like seeing a child or a friend get hurt in an accident, we will retain
an intense and largely accurate memory of the event for a long time. As James
McGaugh and colleagues have shown, the more adrenaline you secrete, the more
precise your memory will be.3 But that is true only up to a certain
point. Confronted with horror—especially the horror of “inescapable shock”—this
system becomes overwhelmed and breaks down.
Of course, we cannot monitor what happens during a traumatic experience, but we can reactivate the trauma in the laboratory, as was done for the brain scans in chapters 3 and 4. When memory traces of the original sounds, images, and sensations are reactivated, the frontal lobe shuts down, including, as we’ve seen, the region necessary to put feelings into words,4 the region that creates our sense of location in time, and the thalamus, which integrates the raw data of incoming sensations. At this point the emotional brain, which is not under conscious control and cannot communicate in words, takes over. The emotional brain (the limbic area and the brain stem) expresses its altered activation through changes in emotional arousal, body physiology, and muscular action.
Under
ordinary conditions these two memory systems—rational and emotional—
collaborate to produce an integrated response. But high arousal not only
changes the balance between them but also disconnects other brain areas
necessary for the proper storage and integration of incoming information, such
as the hippocampus and the thalamus.5 As a result, the imprints of
traumatic experiences are organized not as coherent logical narratives but in
fragmented sensory and emotional traces: images, sounds, and physical
sensations.6 Julian saw a man with outstretched arms, a pew, a
staircase, a strip poker game; he felt a sensation in his penis, a panicked
sense of dread. But there was little or no story.
3] UNCOVERING THE
SECRETS OF TRAUMA
In the late nineteenth century, when medicine first
began the systematic study of mental problems, the nature of traumatic memory
was one of the central topics under discussion. In France and England a
prodigious number of articles were published on a syndrome known as “railway spine,”
a psychological aftermath of railroad accidents that included loss of memory.
The greatest advances, however,
came in the study of hysteria, a mental disorder characterized by emotional
outbursts, susceptibility to suggestion, and contractions and paralyses of the
muscles that could not be explained by simple anatomy.7 Once considered an affliction of unstable or malingering women (the
name comes from the Greek word for “womb”), hysteria now became a window into
the mysteries of mind and body. The names of some of the greatest pioneers in
neurology and psychiatry, such as Jean-Martin Charcot, Pierre Janet, and
Sigmund Freud, are associated with the discovery that trauma is at the root of
hysteria, particularly the trauma of childhood sexual abuse.8 These early researchers referred to traumatic memories as “pathogenic
secrets”9 or “mental parasites,”10 because as much as the sufferers wanted to forget whatever had
happened, their memories kept forcing themselves into consciousness, trapping
them in an ever-renewing present of existential horror.11
The interest in hysteria was
particularly strong in France, and, as so often happens, its roots lay in the
politics of the day. Jean-Martin Charcot, who is widely regarded as the father
of neurology and whose pupils, such as Gilles de la Tourette, lent their names
to numerous neurological diseases, was also active in politics. After Emperor
Napoleon III abdicated in 1870, there was a struggle between the monarchists
(the old order backed by the clergy), and the advocates of the fledgling French
Republic, who believed in science and in secular democracy. Charcot believed
that women would be a critical factor in this struggle, and his investigation
of hysteria “offered a scientific explanation for phenomena such as demonic
possession states, witchcraft, exorcism, and religious ecstasy.”12
Charcot conducted meticulous
studies of the physiological and neurological correlates of hysteria in both
men and women, all of which emphasized embodied memory and a lack of language.
For example, in 1889 he published the case of a patient named LeLog, who
developed paralysis of the legs after being involved in a traffic accident with
a horse-drawn cart. Although Lelog fell to the ground and lost consciousness,
his legs appeared unhurt, and there were
no neurological signs that would
indicate a physical cause for his paralysis. Charcot discovered that just
before Lelog passed out, he saw the wheels of the cart approaching him and
strongly believed he would be run over. He noted that “the patient. . . does
not preserve any recollection. . . . Questions addressed to him upon this point
are attended with no result. He knows nothing or almost nothing.”13 Like many other patients at the
Salpêtrière, Lelog expressed his experience physically: Instead of remembering
the accident, he developed paralysis of his legs.14
PAINTING BY ANDRE BROUILLET
Jean-Martin Charcot presents the
case of a patient with hysteria. Charcot transformed La Salpêtrière, an ancient asylum
for the poor of Paris, which he transformed into a modern hospital. Notice the
patient’s dramatic posture.
But for me the real hero of this story is Pierre Janet, who helped Charcot establish a research laboratory devoted to the study of hysteria at the Salpêtrière. In 1889, the same year that the Eiffel Tower was built, Janet published the first book-length scientific account of traumatic stress: L’automatisme psychologique.Psychological automatism15
Janet proposed that at the root of what we now call PTSD was the experience of “vehement emotions,” or intense emotional arousal.
This treatise explained that, after having been traumatized, people automatically keep repeating certain actions, emotions, and sensations related to the trauma. And unlike Charcot, who was primarily interested in measuring and documenting patients’ physical symptoms, Janet spent untold hours talking with them, trying to discover what was going on in their minds. Also in contrast to Charcot, whose research focused on understanding the phenomenon of hysteria, Janet was first and foremost a clinician whose goal was to treat his patients. That is why I studied his case reports in detail and why he became one of my most important teachers.16
4] AMNESIA,
DISSOCIATION, AND REENACTMENT
Janet was the first to point out the difference between
“narrative memory”—the stories people tell about trauma—and traumatic memory
itself. One of his case histories was the story of Irène, a young woman who was
hospitalized following her mother’s death from tuberculosis.17 Irène had nursed her mother for many months while continuing to work
outside the home to support her alcoholic father and pay for her mother’s
medical care. When her mother finally died, Irène—exhausted from stress and
lack of sleep—tried for several hours to revive the corpse, calling out to her
mother and trying to force medicine down her throat. At one point the lifeless
body dropped off the bed while Irène’s drunken father lay passed out nearby.
Even after an aunt arrived and started preparing for the burial, Irène’s denial
persisted. She had to be persuaded to attend the funeral, and she laughed
throughout the service. A few weeks later she was brought to the Salpêtrière,
where Janet took over her case.
In addition to amnesia for her
mother’s death, Irène suffered from another symptom: Several times a week she
would stare, trancelike, at an empty bed, ignore whatever was going on around
her, and begin to care for an imaginary person. She meticulously reproduced,
rather than remembered, the details of her mother’s death.
Traumatized people simultaneously remember too little and too much. On the one hand, Irène had no conscious memory of her mother’s death—she could not tell the story of what had happened.
On the other she was compelled to physically act out the events of her mother’s
death. Janet’s term “automatism” conveys the involuntary, unconscious nature of
her actions.
Janet treated Irène for several months, mainly with hypnosis. At the end he asked her again about her mother’s death. Irène started to cry and said, “Don’t remind me of those terrible things. . . . My mother was dead and my father was a complete drunk, as always. I had to take care of her dead body all night long. I did a lot of silly things in order to revive her. . . . In the morning I lost my mind.”
Not only was
Irène able tell the story, but she had also recovered her emotions: “I feel
very sad and abandoned.” Janet now called her memory “complete” because it now
was accompanied by the appropriate feelings.
Janet noted significant
differences between ordinary and traumatic memory. Traumatic memories are
precipitated by specific triggers. In Julian’s case the trigger was his
girlfriend’s seductive comments; in Irène’s it was a bed. When one element of a
traumatic experience is triggered, other elements are likely to automatically
follow.
Traumatic memory is not condensed: It took Irène three to four hours to reenact her story, but when she was finally able to tell what had happened it took less than a minute. The traumatic enactment serves no function.
In contrast, ordinary memory is adaptive; our stories are flexible and can be modified to fit the circumstances. Ordinary memory is essentially social; it’s a story that we tell for a purpose: in Irène’s case, to enlist her doctor’s help and comfort;
in Julian’s case, to recruit me to join his search for justice and revenge. But there is nothing social about traumatic memory. Julian’s rage at his girlfriend’s remark served no useful purpose. Reenactments are frozen in time, unchanging, and they are always lonely, humiliating, and alienating experiences.
Janet coined the term “dissociation” to describe the splitting off and isolation of memory imprints that he saw in his patients.
He was also prescient about the heavy cost of keeping these traumatic memories at bay. He later wrote that when patients dissociate their traumatic experience, they become “attached to an insurmountable obstacle”:18
“[U]nable to integrate their traumatic memories, they
seem to lose their capacity to assimilate new experiences as well. It is . . .
as if their personality has definitely stopped at a certain point, and cannot
enlarge any more by the addition or assimilation of new elements.”19 He predicted that unless they became aware of the split-off elements
and integrated them into a story that had happened in the past but was now
over, they would experience a slow decline in their personal and professional
functioning. This phenomenon has now been well documented in contemporary
research.20
Janet discovered that, while it is normal to change and distort one’s memories, people with PTSD are unable to put the actual event, the source of those memories, behind them.
Dissociation prevents the trauma from becoming integrated within the conglomerated, ever-shifting stores of autobiographical memory,
in essence creating a dual memory system.
Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association; think of a dense but flexible network where each element exerts a subtle influence on many others.
But in Julian’s case, the sensations, thoughts, and emotions of the trauma were stored separately as frozen, barely comprehensible fragments.
If the problem with PTSD is dissociation,
the goal of treatment would be association:
integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that “that was then, and this is now.”
5] THE ORIGINS OF
THE “TALKING CURE”
Psychoanalysis was born on the wards of the Salpêtrière. In 1885 Freud went to Paris to work with Charcot, and he later named his firstborn son Jean-Martin in Charcot’s honor. In 1893 Freud and his Viennese mentor, Josef Breuer, cited both Charcot and Janet in a brilliant paper on the cause of hysteria. “Hysterics suffer mainly from reminiscences,” they proclaim, and go on to note that these memories are not subject to the “wearing away process” of normal memories but “persist for a long time with astonishing freshness.”
Nor can traumatized people control when they will emerge: “We must.
. . mention another remarkable fact. . . namely, that these memories, unlike
other memories of their past lives, are not at the patients’ disposal. On the
contrary, these experiences are completely absent from the patients’ memory
when they are in a normal psychical state, or are only present in a highly
summary form.”21 (All italics in the quoted passages are Breuer
and Freud’s.)
Breuer and Freud believed that traumatic memories were lost to ordinary consciousness either because “circumstances made a reaction impossible,” or because they started during “severely paralyzing affects, such as fright.” In 1896 Freud boldly claimed that “the ultimate cause of hysteria is always the seduction of the child by an adult.”22
Then, faced with his own evidence of an epidemic of abuse in the best families of Vienna—one, he noted, that would implicate his own father—he quickly began to retreat.
Psychoanalysis shifted to an emphasis on unconscious wishes and fantasies, though Freud occasionally kept acknowledging the reality of sexual abuse.23
After the horrors of World War I confronted him with the reality of combat neuroses, Freud reaffirmed that lack of verbal memory is central in trauma and that,
if a person does not remember, he is likely to act out: “[H]e reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.”24
The lasting legacy of Breuer and Freud’s 1893 paper is what we now call the “talking cure”:
“[W]e found, to our great surprise, at first, that each individual hysterical symptom immediately and permanently disappeared
when we had succeeded in bringing clearly to light
1] the memory of the event by which it was provoked and in arousing its accompanying affect, and
2] when the patient had described that event in the greatest possible detail and had put the affect into words (all italics in original).
Recollection without affect almost invariably produces no result.”
They explain that unless there is an “energetic reaction” to the traumatic event, the affect “remains attached to the memory” and cannot be discharged. The reaction can be discharged by an action—“from tears to acts of revenge.” “But language serves as a substitute for action; by its help, an affect can be ‘abreacted’ almost as effectively.”
“It will now be understood,” they conclude, “how it is that the psychotherapeutic
procedure which we have described in these pages has a curative effect. It
brings to an end the operative force... which was not abreacted in the first
instance [i.e., at the time of the trauma], by allowing its strangulated
affect to find a way out through speech; and it subjects it to associative
correction by introducing it into normal consciousness.”
Even though psychoanalysis is today in eclipse, the “talking cure” has lived on, and psychologists have generally assumed that
telling the trauma story in great detail will help people to leave it behind. That is also a basic premise of cognitive behavioral therapy (CBT),
which today is taught in graduate psychology courses around the
world.
Although the diagnostic labels have changed, we continue to see patients similar to those described by Charcot, Janet, and Freud. In 1986 my colleagues and I wrote up the case of a woman who had been a cigarette girl at Boston’s Cocoanut Grove nightclub when it burned down in 1942.25 During the 1970s and 1980s she annually reenacted her escape on Newbury Street, a few blocks from the original location, which resulted in her being hospitalized with diagnoses like schizophrenia and bipolar disorder.
In 1989 I reported on a Vietnam veteran who yearly staged an “armed robbery” on the exact anniversary of a buddy’s death.26 He would put a finger in his pants pocket, claim that it was a pistol, and tell a shopkeeper to empty his cash register—giving him plenty of time to alert the police. This unconscious attempt to commit “suicide by cop” came to an end after a judge referred the veteran to me for treatment. Once we had dealt with his guilt about his friend’s death, there were no further reenactments.
Such incidents raise a critical question: How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remember?
How can patients themselves identify the source of their behavior? If
their history is not known, they are likely to be labeled as crazy or punished
as criminals rather than helped to integrate the past.
6] TRAUMATIC
MEMORY ON TRIAL
At least two dozen men had claimed they were molested
by Paul Shanley, and many of them reached civil settlements with the Boston
archdiocese. Julian was the only victim who was called to testify in Shanley’s
trial. In February 2005 the former priest was found guilty on two counts of
raping a child and two counts of assault and battery on a child. He was
sentenced to twelve to fifteen years in prison.
In 2007 Shanley’s attorney,
Robert F. Shaw Jr., filed a motion for a new trial, challenging Shanley’s convictions
as a miscarriage of justice. Shaw tried to make the case that “repressed
memories” were not generally accepted in the scientific community, that the
convictions were based on “junk science,” and that there had been insufficient
testimony about the scientific status of repressed memories before the trial.
The appeal was rejected by the original trial judge but two years later was
taken up by the Supreme Judicial Court of Massachusetts. Almost one hundred
leading psychiatrists and psychologists from around the United States and eight
foreign countries signed an amicus curiae brief stating that “repressed memory”
has never been shown to exist and that it should not have been admitted as
evidence. However, on January 10, 2010, the court unanimously upheld Shanley’s
conviction with this statement: “In sum, the judge’s finding that the lack of
scientific testing did not make unreliable the theory that an individual may
experience dissociative amnesia was supported in the record. . . . There was no
abuse of discretion in the admission of expert testimony on the subject of
dissociative amnesia.”
In the following chapter I’ll
talk more about memory and forgetting and about how the debate over repressed
memory, which started with Freud, continues to be played out today.
CHAPTER 12 THE UNBEARABLE HEAVINESS OF REMEMBERING
Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation.
Scientific interest in trauma has fluctuated wildly during the past 150 years. Charcot’s defenses, and instincts at the root of mental suffering were just part of mainstream medicine’s overall loss of interest in the subject.
This neglect lasted for only a few years, though, because the outbreak of World War in 1914 once again confronted medicine and psychology with hundreds of thousands of men with bizarre psychological symptoms, unexplained medical conditions, and memory loss.
The new technology of motion pictures made it possible to film these
soldiers, and today on YouTube we can observe their bizarre physical postures,
strange verbal utterances, terrified facial expressions, and tics—the physical,
embodied expression of trauma: “a memory that is inscribed simultaneously in
the mind, as interior images and words, and on the body.”1
Early in the war the British created the diagnosis of “shell shock,” which
Freud’s death in 1893 and shift in emphasis to inner conflicts, entitled combat veterans to treatment and a disability pension. The alternative, similar, diagnosis was “neurasthenia,” for which they received neither treatment nor a pension. It was up to the orientation of the treating physician which diagnosis a soldier received.2
More than a million British
soldiers served on the Western Front at any one time. In the first few hours of
July 1, 1916 alone, in the Battle of the Somme, the British army suffered
57,470 casualties, including 19,240 dead, the bloodiest day in its history. The
historian John Keegan says of their commander, Field Marshal Douglas Haig,
whose statue today dominates Whitehall in London, once the center of the
British Empire: “In his public manner and private diaries no concern for human
suffering was or is discernible.” At the Somme “he had sent the flower of
British youth to death or mutilation.”3
As the war wore on, shell shock increasingly compromised the efficiency of the fighting forces. Caught between taking the suffering of their soldiers seriously and pursuing victory over the Germans, the British General Staff issued General Routine Order Number 2384 in June of 1917, which stated, “In no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.”
All soldiers with
psychiatric problems were to be given a single diagnosis of “NYDN” (Not Yet
Diagnosed, Nervous).4 In November 1917 the General Staff denied
Charles Samuel Myers, who ran four field hospitals for wounded soldiers,
permission to submit a paper on shell shock to the British Medical Journal. The
Germans were even more punitive and treated shell shock as a character defect,
which they managed with a variety of painful treatments, including
electroshock.
In 1922 the British government issued the Southborough Report, whose goal was to prevent the diagnosis of shell shock in any future wars and to undermine any more claims for compensation.
It suggested the elimination of shell shock from all official nomenclature and insisted that these cases should no more be classified “as a battle casualty than sickness or disease is so regarded.”5
The
official view was that well-trained troops, properly led, would not suffer from
shell shock and that the servicemen who had succumbed to the disorder were
undisciplined and unwilling soldiers. While the political storm about the
legitimacy of shell shock continued to rage for several more years, reports on
how to best treat these cases disappeared from the scientific literature.6
In the United States the fate of
veterans was also fraught with problems. In 1918, when they returned home from
the battlefields of France and Flanders,
they had been welcomed as national heroes, just as the
soldiers returning from Iraq and Afghanistan are today. In 1924 Congress voted
to award them a bonus of $1.25 for each day they had served overseas, but
disbursement was postponed until 1945.
By 1932 the nation was in the
middle of the Great Depression, and in May of that year about fifteen thousand
unemployed and penniless veterans camped on the Mall in Washington DC to
petition for immediate payment of their bonuses. The Senate defeated the bill
to move up disbursement by a vote of sixty-two to eighteen. A month later
President Hoover ordered the army to clear out the veterans’ encampment. Army
chief of staff General Douglas MacArthur commanded the troops, supported by six
tanks. Major Dwight D. Eisenhower was the liaison with the Washington police,
and Major George Patton was in charge of the cavalry. Soldiers with fixed
bayonets charged, hurling tear gas into the crowd of veterans. The next morning
the Mall was deserted and the camp was in flames.7 The veterans
never received their pensions.
While politics and medicine turned their backs on the returning soldiers, the horrors of the war were memorialized in literature and art. In All Quiet on the Western Front,8 a novel about the war experiences of frontline soldiers by the German writer Erich Maria Remarque, the book’s protagonist, Paul Bäumer, spoke for an entire generation:
“I am aware that I, without realizing it, have lost my feelings
—I don’t belong here anymore, I live in an alien world. I prefer to be left alone, not disturbed by anybody.
They talk too much—I can’t relate to them —they are only busy with superficial things.”9
Published in 1929, the novel
instantly became an international best seller, with translations in twenty-five
languages. The 1930 Hollywood film version won the Academy Award for Best
Picture.
But when Hitler came to power a
few years later, All Quiet on the Western Front was one of the first
“degenerate” books the Nazis burned in the public square in front of Humboldt
University in Berlin.10 Apparently awareness of the devastating
effects of war on soldiers’ minds would have constituted a threat to the Nazis’
plunge into another round of insanity.
Denial of the consequences of trauma can wreak havoc with the social fabric of society. The refusal to face the damage caused by the war and the intolerance of “weakness” played an important role in the rise of fascism and militarism around the world in the 1930s. The extortionate war reparations of the Treaty of Versailles further humiliated an already disgraced Germany.
German society, in turn, dealt ruthlessly with its own traumatized war veterans, who were treated as inferior creatures. This cascade of humiliations of the powerless set the stage for the ultimate debasement of human rights under the Nazi regime: the moral justification for the strong to vanquish the inferior—the rationale for the ensuing war.
1] THE NEW FACE OF
TRAUMA
The outbreak of World War II prompted Charles Samuel
Myers and the American psychiatrist Abram Kardiner to publish the accounts of
their work with World War I soldiers and veterans. Shell Shock in France
1914–1918 (1940)11 and The
Traumatic Neuroses of War (1941)12 served as the principal guides for psychiatrists who were treating
soldiers in the new conflict who had “war neuroses.” The U.S. war effort was
prodigious, and the advances in frontline psychiatry reflected that commitment.
Again, YouTube offers a direct window on the past: Hollywood director John
Huston’s documentary Let There Be Light (1946) shows the predominant
treatment for war neuroses at that time: hypnosis.13
In Huston’s film, made while he was serving in the Army Signal Corps, the doctors are still patriarchal and the patients are still terrified young men. But they manifest their trauma differently:
While the World War I soldiers flail, have facial tics, and collapse with paralyzed bodies, the following generation talks and cringes.
Their bodies still keep the score:
Their stomachs are upset, their hearts race, and they are overwhelmed by panic.
But the trauma did not just affect their bodies.
The trance state induced by hypnosis allowed them to find words for the things they had been too afraid to remember: their terror, their survivor’s guilt, and their conflicting loyalties.
It also struck me that these soldiers
seemed to keep a much tighter lid on their anger and hostility than the younger
veterans I’d worked with. Culture shapes the expression of traumatic stress.
The feminist theorist Germaine Greer wrote about the treatment of her father’s PTSD after World War II: “When [the medical officers] examined men exhibiting severe disturbances they almost invariably found the root cause in pre-war experience: the sick men were not first-grade fighting material. . . . The military proposition is [that it is] not war which makes men sick, but that sick men can not fight wars.”14
It seems unlikely the doctors did her father any good, but Greer’s
efforts to come to grips with his suffering undoubtedly helped fuel
her exploration of sexual domination in all its ugly
manifestations of rape, incest, and domestic violence.
When I worked at the VA, I was puzzled that the vast majority of the patients we saw on the psychiatry service were young, recently discharged Vietnam veterans, while the corridors and elevators that led to the medical departments were filled by old men.
Curious about this disparity, I conducted a survey of the World War II veterans in the medical clinics in 1983. The vast majority of them scored positive for PTSD on the rating scales that I administered, but their treatment focused on medical rather than psychiatric complaints.
These vets communicated their distress via stomach cramps and chest pains rather than with nightmares and rage, from which, my research showed, they also suffered.
Doctors shape how their patients communicate their distress:
When a patient complains about terrifying nightmares and his doctor orders a chest X-ray, the patient realizes that he’ll get better care if he focuses on his physical problems.
Like my relatives who
fought in or were captured during World War II, most of these men were
extremely reluctant to share their experiences. My sense was that neither the
doctors nor their patients wanted to revisit the war.
However, military and civilian leaders came away from World War II with important lessons that the previous generation had failed to grasp.
After the defeat of Nazi Germany and imperial
Japan, the United States helped rebuild Europe by means of the Marshall Plan,
which formed the economic foundation of the next fifty years of relative peace.
At home, the GI Bill provided millions of veterans with educations and home
mortgages, which promoted general economic well-being and created a
broad-based, well-educated middle class. The armed forces led the nation in
racial integration and opportunity. The Veterans Administration built
facilities nationwide to help combat veterans with their health care.
Still, with all this thoughtful attention to the returning veterans, the psychological scars of war went unrecognized, and traumatic neuroses disappeared entirely from official psychiatric nomenclature. The last scientific writing on combat trauma after World War II appeared in 1947.15
2] TRAUMA
REDISCOVERED
As I noted earlier, when I
started to work with Vietnam veterans, there was not a
single book on war trauma in the library of the VA, but the Vietnam War inspired numerous studies, the formation of scholarly organizations, and the inclusion of a trauma diagnosis, PTSD, in the professional literature. At the same time, interest in trauma was exploding in the general public.
In 1974 Freedman and Kaplan’s Comprehensive
Textbook of Psychiatry stated that “incest is extremely rare, and does not
occur in more than 1 out of 1.1 million people.”16 As we have seen in chapter 2 this authoritative textbook then went on
to extol the possible benefits of incest: “Such incestuous activity diminishes
the subject’s chance of psychosis and allows for a better adjustment to the
external world. . . . The vast majority of them were none the worse for the
experience.”
How misguided those statements
were became obvious when the ascendant feminist movement, combined with
awareness of trauma in returning combat veterans, emboldened tens of thousands
of survivors of childhood sexual abuse, domestic abuse, and rape to come
forward. Consciousness-raising groups and survivor groups were formed, and
numerous popular books, including The Courage to Heal (1988), a
best-selling self-help book for survivors of incest, and Judith Herman’s book Trauma
and Recovery (1992), discussed the stages of treatment and recovery in
great detail.
Cautioned by history, I began to
wonder if we were headed toward another backlash like those of 1895, 1917, and
1947 against acknowledging the reality of trauma. That proved to be the case,
for by the early 1990s articles had started to appear in many leading
newspapers and magazines in United States and in Europe about a so-called False
Memory Syndrome in which psychiatric patients supposedly manufactured elaborate
false memories of sexual abuse, which they then claimed had lain dormant for
many years before being recovered.
What was striking about these
articles was the certainty with which they stated that there was no evidence
that people remember trauma any differently than they do ordinary events. I
vividly recall a phone call from a well-known newsweekly in London, telling me
that they planned to publish an article about traumatic memory in their next
issue and asking me whether I had any comments on the subject. I was quite
enthusiastic about their question and told them that memory loss for traumatic
events had first been studied in England well over a century earlier. I
mentioned John Eric Erichsen and Frederic Myers’s work on railway accidents in
the 1860s and 1870s and Charles Samuel Myers’s and W. H. R. Rivers’s extensive
studies of memory problems in combat soldiers of World War I. I also suggested
they look at an article published in The Lancet in 1944, which described
the aftermath of the rescue of the entire British army
from the beaches of Dunkirk in 1940. More than 10 percent of the soldiers who were studied had suffered from major memory loss after the evacuation.17
The following
week, the magazine told its readers that there was no evidence whatsoever that
people sometimes lose some or all memory for traumatic events.
The issue of delayed recall of
trauma was not particularly controversial when Myers and Kardiner first
described this phenomenon in their books on combat neuroses in World War I;
when major memory loss was observed after the evacuation from Dunkirk; or when
I wrote about Vietnam veterans and the survivor of the Cocoanut Grove nightclub
fire. However, during the 1980s and early 1990s, as similar memory problems
began to be documented in women and children in the context of domestic abuse,
the efforts of abuse victims to seek justice against their alleged perpetrators
moved the issue from science into politics and law. This, in turn, became the
context for the pedophile scandals in the Catholic Church, in which memory
experts were pitted against one another in courtrooms across the United States
and later in Europe and Australia.
Experts testifying on behalf of
the Church claimed that memories of childhood sexual abuse were unreliable at
best and that the claims being made by alleged victims more likely resulted
from false memories implanted in their minds by therapists who were
oversympathetic, credulous, or driven by their own agendas. During this period
I examined more than fifty adults who, like Julian, remembered having been
abused by priests. Their claims were denied in about half the cases.
3] THE SCIENCE OF
REPRESSED MEMORY
There have in fact been hundreds of scientific
publications spanning well over a century documenting how the memory of trauma
can be repressed, only to resurface years or decades later.18 Memory loss has been reported in people who have experienced natural
disasters, accidents, war trauma, kidnapping, torture, concentration camps, and
physical and sexual abuse. Total memory loss is most common in childhood sexual
abuse, with incidence ranging from 19 percent to 38 percent.19 This issue is not particularly controversial: As early as 1980 the
DSM-III recognized the existence of memory loss for traumatic events in the
diagnostic criteria for dissociative amnesia: “an inability to recall important
personal information, usually of a traumatic or stressful nature, that is too
extensive to be explained by normal forgetfulness.” Memory loss has been part
of the criteria for PTSD since that diagnosis was
first introduced.
One of the most interesting
studies of repressed memory was conducted by Dr. Linda Meyer Williams, which
began when she was a graduate student in sociology at the University of
Pennsylvania in the early 1970s. Williams interviewed 206 girls between the
ages of ten and twelve who had been admitted to a hospital emergency room
following sexual abuse. Their laboratory tests, as well as the interviews with
the children and their parents, were kept in the hospital’s medical records.
Seventeen years later Williams was able to track down 136 of the children, now
adults, with whom she conducted extensive follow-up interviews.20
More than a third of the women (38 percent) did not recall the abuse that was
documented in their medical records, while only fifteen women (12 percent) said
that they had never been abused as children. More than two-thirds (68 percent)
reported other incidents of childhood sexual abuse. Women who were younger at
the time of the incident and those who were molested by someone they knew were
more likely to have forgotten their abuse.
This study also examined the
reliability of recovered memories. One in ten women (16 percent of those who
recalled the abuse) reported that they had forgotten it at some time in the
past but later remembered that it had happened. In comparison with the women
who had always remembered their molestation, those with a prior period of
forgetting were younger at the time of their abuse and were less likely to have
received support from their mothers. Williams also determined that the recovered
memories were approximately as accurate as those that had never been lost: All
the women’s memories were accurate for the central facts of the incident, but
none of their stories precisely matched every detail documented in their
charts.21
Williams’s findings are supported
by recent neuroscience research that shows that memories that are retrieved
tend to return to the memory bank with modifications.22 As long as a
memory is inaccessible, the mind is unable to change it. But as soon as a story
starts being told, particularly if it is told repeatedly, it changes—the act of
telling itself changes the tale. The mind cannot help but make meaning out of
what it knows, and the meaning we make of our lives changes how and what we
remember.
Given the wealth of evidence that
trauma can be forgotten and resurface years later, why did nearly one hundred
reputable memory scientists from several different countries throw the weight
of their reputations behind the appeal to overturn Father Shanley’s conviction,
claiming that “repressed memories” were based on “junk science”? Because memory
loss and delayed
recall of traumatic experiences had never been
documented in the laboratory, some cognitive scientists adamantly denied that
these phenomena existed23 or that retrieved traumatic memories could
be accurate.24 However, what doctors encounter in emergency rooms,
on psychiatric wards, and on the battlefield is necessarily quite different
from what scientists observe in their safe and well-organized laboratories.
Consider what is known as the
“lost in the mall” experiment, for example. Academic researchers have shown
that it is relatively easy to implant memories of events that never took place,
such as having been lost in a shopping mall as a child.25 About 25
percent of subjects in these studies later “recall” that they were frightened
and even fill in missing details. But such recollections involve none of the
visceral terror that a lost child would actually experience.
Another line of research
documented the unreliability of eyewitness testimony. Subjects might be shown a
video of a car driving down a street and asked afterward if they saw a stop
sign or a traffic light; children might be asked to recall what a male visitor
to their classroom had been wearing. Other eyewitness experiments demonstrated
that the questions witnesses were asked could alter what they claimed to
remember. These studies were valuable in bringing many police and courtroom
practices into question, but they have little relevance to traumatic memory.
The fundamental problem is this:
Events that take place in the laboratory cannot be considered equivalent to the
conditions under which traumatic memories are created. The terror and
helplessness associated with PTSD simply can’t be induced de novo in such
a setting. We can study the effects of existing traumas in the lab, as in our
script-driven imaging studies of flashbacks, but the original imprint of trauma
cannot be laid down there. Dr. Roger Pitman conducted a study at Harvard in
which he showed college students a film called Faces of Death, which
contained newsreel footage of violent deaths and executions. This movie, now
widely banned, is as extreme as any institutional review board would allow, but
it did not cause Pitman’s normal volunteers to develop symptoms of PTSD. If you
want to study traumatic memory, you have to study the memories of people who
have actually been traumatized.
Interestingly, once the
excitement and profitability of courtroom testimony diminished, the
“scientific” controversy disappeared as well, and clinicians were left to deal
with the wreckage of traumatic memory.
4] NORMAL VERSUS
TRAUMATIC MEMORY
In 1994 I and my colleagues at Massachusetts General
Hospital decided to undertake a systematic study comparing how people recall
benign experiences and horrific ones. We placed advertisements in local
newspapers, in laundromats, and on student union bulletin boards that said:
“Has something terrible happened to you that you cannot get out of your mind?
Call 727-5500; we will pay you $10.00 for participating in this study.” In
response to our first ad seventy-six volunteers showed up.26
After we introduced ourselves, we
started off by asking each participant: “Can you tell us about an event in your
life that you think you will always remember but that is not traumatic?” One
participant lit up and said, “The day that my daughter was born”; others
mentioned their wedding day, playing on a winning sports team, or being
valedictorian at their high school graduation. Then we asked them to focus on
specific sensory details of those events, such as: “Are you ever somewhere and
suddenly have a vivid image of what your husband looked like on your wedding
day?” The answers were always negative. “How about what your husband’s body
felt like on your wedding night?” (We got some odd looks on that one.) We
continued: “Do you ever have a vivid, precise recollection of the speech you
gave as a valedictorian?” “Do you ever have intense sensations recalling the
birth of your first child?” The replies were all in the negative.
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.
5] 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.
6] 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 reconstruct 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.”
