Memory

Memory is a funny thing and is not always as reliable as we tend to assume.  And yet we DO rely on our memory and become deeply unsettled if it seems to fail us too frequently.  This is an observation I've made again and again in my work with patients.

For example, a lot of my patients complain about not being able to remember things.  They forget to complete tasks at work, they forget about appointments and meetings, they do not recall being told important information and often have no recollection of the conversation in which this information was given.  They may forget to pay bills or to pick the kids up from school.  One patient made plans with his wife for the following day.  When they got up the next morning he turned to her and asked, "So what do you want to do today?"  She looked at him aghast.  "We talked about this for a while yesterday," she told him.  "We made plans, remember?"  But he did not remember.  The patient is undeerstandably distressed.  "I'm losing my mind," he tells me.

Another patient was disturbed after realizing that the memory of an event he'd been reliving in his mind for years was completely inaccurate.  This particular patient works in the medical profession.  For years he has been plagued by memories of a patient he treated while overseas.  He clearly recalls his patient speaking to him, begging him to end his suffering.  The memory is so vivid he can hear the patient's voice in his mind.  When he (somewhat reluctantly) shared this memory with his psychiatrist he came to the sudden realization that his patient had been on a ventilator the entire time he'd been at the hospital.  "He couldn't have said what I remember him saying," he said.  "He was on a ventilator the whole time.  He wouldn't have been able to speak at all," my patient told me.  He told me that, upon coming to this realization, he left the psychiatrist's office in a hurry.  "I couldn't even drive home afterwards," he said.  "I sat in the parking lot for an hour trying to calm myself down."  He'd concluded that his memory of something that never happened was a sure sign of insanity.  He was shaken.

Of course, trouble with memory CAN signal a deeper problem - the onset of dementia, a brain tumor, or some other terrifying medical condition.  What most people don't realize is that psychological trauma can also cause changes in memory.  Memories of a traumatic experience can intrude in a person's thoughts, sometimes several times a day.  If your mind is filled with memories of the past it becomes difficult to focus on what's going on around you in the present.

Sometimes a traumatic experience can disupt a person's sense of security such that the person no longer feels safe anywhere.  Thus, he is always alert.  When he leaves his house he is continously on guard.  He spends a significant amount of time looking over his shoulder or scanning his surroundings, seeking to identify any potential threat.  Looking for danger consumes most of his attention; he has little left over for everything else.  He thinks he forgets what people tell him but perhapss he doesn't pay enough attention in the first place.  The information is never encoded into his memory, which is why it isn't there when he tries to retrieve it later.

And sometimes memory plays tricks on us.  If a trauma is particularly horrendous, a person might supress his or her memory of it.  Some people are consumed by their own role in the event - how they reacted or the choices they made - that they completely lose sight of the context in which the event occurred.  A woman might, for example, be angry at herself for not fighting back when someone attacked her.  She is so focused on this that she completely forgets that the attacker had a gun and threatened to kill her.  Memory is affected by perception; what we remember depends on what we think happened in the first place.  A person's recollection of an event can even be influenced by things that happen after the event.  There have been a number of studies about the reliability of crime witnesses.  What they remember seeing can be influenced by something as small as how the investigating officer phrases his questions.

We rely on our memories; it is necessary if we are going function as successful members of society.  I simply ask that we keep in mind that memory is falliable...

What patients don't say

A few weeks ago I had a session with a patient I've been working with off and on for over a year.  He's the kind of patient therapists love; he's introspective and insightful, he listens to feedback, he thinks about things in between sessions, and he attempts to use every technique we discuss at least once to see how it works for him.  He was a bit guarded when we first started working together.  Over time, however, he became more comfortable and talked more openly about things that bothered him.  I was surprised when he revealed to me a few weeks ago that he has been intentionally holding things back during our sessions.  When I asked him why he replied, "To protect you."  He explained that some of the things he's been through were so horrific that he did not want to subject anyone else to them.  He's tormented by memories of these events but has not shared his recollections because he fears they might be damaging to others.

His consideration for my feelings was touching and I told him so.  On the other hand, I wanted him to feel free to talk to me about anything.  I assured him I am capable of hearing his stories.  I explained that it is my job as a therapist to take care of myself emotionally so that I am able to listen to people's stories without becoming overwhelmed.  I told him I am diligent about self care.  I said some other things I can't recall.  Basically, I tried to persuade him that I can handle anything he decides to tell me.  I don't know whether or not I convinced him.

As a result of this incident, I realized I'd been taking for granted that most of my patients feel comfortable telling me anything.  Of course I know there are those who hold back but often these patients are upfront about that fact.  I've had plenty of patients tell me they don't know me well enough to tell me certain things. 

The thing that struck me most was the reason my patient had for holding back: he was afraid of damaging me with his thoughts, feelings, and memories. This in one way reveals something about the patient's character; he is genuinely concerned for the well being of others.  (Ironically, he claims to not like people very much).  Maybe that's the only thing it reveals.  I wonder though, if there's something about me that led my patient to decide to hold things back.  Is there something I said or did that drew him to his conclusion? 

I've searched my memory but can think of nothing.  If there is something I'm doing then it is something I am not aware of.  I am, however, paying more attention now.  Last week a different patient talked about how hard it is to cope with the horrible memories she has of her time in Afghanistan.  She doesn't talk to anyone about her memories because, in her words, "nobody wants to hear about this stuff.  Even I don't want to think about it and they're my memories!"  She went on to explain that the memories are her burden to bear.  I replied that hearing her memories is my burden to bear.  "That's why I'm here," I said. 

I'm not sure if spelling it out for people makes any difference.  I guess I'll have to wait and see.

Guilt and self condemnation

I often work with patients who have endured some sort of trauma and who have blamed themselves for these events.  In most cases, it would be obvious to any outside observer that my patient is not at fault for what happened.  In fact, many of my patients have been told on multiple occasions and by many people that they are not to blame.  Still, they continue to blame and then condemn themselves.  The most common example of this is sexual assault.  Patients often blame themselves for not screaming louder, fighting harder, or somehow resisting more vehemently.  Or they insist that they "should have known" the person was a rapist and stayed away from him. 

Then there are the patients I encounter whose actions did play some sort of role in the outcome of their traumatic experiences.  I have never had a case like this that was completely cut and dry, i.e., the patient's actions were the direct cause of a negative outcome.  Keep in mind that most of my patients are military service members.  So an example of this type of situation might be as follows: A patient is in charge of some team or unit of service members.  He plans some sort of mission or decides upon a particular course of action, which his team or unit then implements.  Someone in the team/unit gets hurt or killed during the mission.  The patient blames himself because he planned the mission and selected the people who participated in it.  Of course, the patient did not plant the bomb or fire the gun that killed his teammate.  Still, he feels responsible.

Self blame inevitably causes suffering.  A person's thoughts are often consumed by their traumatic experience/experiences.  They replay the event in their minds over and over again in an effort to identify what they could have done differently that would have led to a different outcome.  They initially condemn their actions but over time end up condemning themselves.  Often they begin to hate themselves.  As self-loathing grows, they withdraw socially and isolate themselves from others.  They frequently become depressed.

Self-blame also keeps a person stuck.  When a person blames himself for some traumatic event, everything about the event becomes frozen in time.  The person's memories of and feelings associated with the experience are stored in their mind and body in their original form.  When the person attempts to process the event he ends up condemning himself.  It doesn't take long before he decides to stop trying to process the event.  He tries to bury the emotions and memories.  This is, of course, impossible.  At some point, the emotions and memories rise to the surface (e.g., when the person sees something that reminds him of the event), as intense and as vivid as they were on the day the traumatic event occurred.  Most people respond by redoubling their efforts to suppress the thoughts and emotions, which may work in the short term but will eventually fail.  And thus a self-defeating cycle emerges.

If self-blame has such obvious negative consequences then why do it?  While the costs of self-blame are many, it also provides a certain benefit; it enables a person to maintain a sense of control.  If I accept that something bad happened that was completely beyond my ability to prevent or control then I must accept that something terrible could happen again at any minute and there is nothing I can do about it.  This is, of course, technically true.  It is, however, quite scary.  How do we live in a world where we cannot keep ourselves safe? 

If, however, something terrible happens and I blame myself for it then I can prevent the bad thing from happening again by changing my behavior in some way.  In other words, if it's my fault then I can fix it (or keep it from happening again).  I am in control.  Blaming myself allows me to maintain the illusion that I have control over my environment and that I can prevent bad things from happening to me (and am therefore able to keep myself safe). 

In future posts I will talk about ways to move past self blame...

Anxiety and ego strength

In my last post, I talked about what happens when a person reaches his or her "breaking point."  I have a particular interest in this topic because I think about it a lot when working with patients.  It is important for me to have at least some idea of how much anxiety a patient can tolerate; this is especially true with those patients who have experienced some sort of trauma. 

Even a single traumatic experience can leave a person feeling vulnerable and out of control.  It can shatter a person's sense of safety and cause him to view the world as a dangerous place.  This creates a significant amount of anxiety.  (In fact, Posttraumatic Stress Disorder is classified as an anxiety disorder).  The person becomes hypervigilant in an effort to identify and neutralize potential threats (which he believes are everywhere).  Maintaining this level of emotional arousal is exhausting.  His need to be ever alert and on guard, however, prevents him from relaxing to the degree necessary for truly restful sleep.  As a result, he becomes even more exhausted.  His functioning begins to deteriorate.  What little energy he has is directed towards trying to keep himself safe from threats, both real and imagined. 

This is often the state in which I first encounter a patient.  His symptoms have started to become overwhelming and he is doing everything he can to "keep it together."  Before I can even think about trying to help him I need to assess his "ego strength." 

According to Brown, et. al. (1979), ego strength refers to an individual's ability "to hold on to his own identity despite psychic pain, distress, [and] turmoil, [from] internal forces as well as the demands of reality."  In other words, how much distress can a person tolerate without falling apart?  In her "Nueroscience and Relationships" blog (http://blogs.psychcentral.com/relationships/), Dr. Athena Staik describes ego strength as "the resiliency or strength of your core sense of self, the extent to which you can face challenging events or persons, without feeling so overwhelmed that you take desperate action, perhaps with little or no thought to consequences." 

Exposure therapy (or prolonged exposure therapy) is one of the most effective treatment approaches for overcoming a traumatic experience.  The treatment requires a person to access his memories of the traumatic event and to allow himself to experience whatever feelings these memories evoke.  It also asks the patient to confront situations that now feel unsafe to him but that are, in reality, perfectly safe.

Exposure therapy can be pretty intense and would probably be overwhelming for someone with very low ego strength.  (There are plenty of other treatments that are beneficial for patients with low ego strength).  The problem is, it is not always easy to determine which patients have good ego strength and which do not.  I've had the unfortunate experience of believing a patient could handle exposure therapy only to have him decompensate a few sessions into it.  (This has happened on multiple occasions, actually, and not just to me.  Several of my coworkers have had simliar experiences). 

When I say a patient decompensates I mean that the therapy pushes him past his breaking point.  I've seen patients become suicidal.  One of my coworkers had a patient check herself into the psychiatric hospital because she couldn't guarantee she wouldn't try to kill herself.  Some patients start to have intrusive flashbacks or their nightmares get so bad that they become afraid to go to sleep.  A person who decompensates completely will become psychotic (and would probably have to be hospitalized), although this has never happened with any of my patients. 

So therein lies my dilemma.  How do I know when to "push" (i.e., encourage) a patient to stick with the treatment and when to back off?  Is it my job to say to a patient, "Look, I don't think you can handle this?"  And what if I'm wrong?  Then I'm depriving him of treatment that could really be helpful.  But what if I keep pushing and the patient decompensates?  Is it my fault?  Am I responsible for having pushed the patient "over the edge?"

There doesn't seem to be a clear cut answer to this.  My solution has been to put the ball in the patients' court.  I say something like this: "Only you know where your limit is.  My job is to push you to that limit, but not beyond it.  If you feel like you're close to going over the edge, please let me know.  We'll stop, regroup, and figure out where to go from there." 

Of course, the assumption here is that people know their own limits.  This may not always be true.  In fact, I cannot say for certain where my own breaking point lies.   I know there have been times when I felt so overwhelmed that I wished I would just fall apart completely; at least it would provide an escape from myself and my life.  In reallity though, I suspect I've never even come close to my breaking point.  I am fortunate enough never to have been faced with stressors so overwhelming that I was not able to cope with them.

What about you?  Where is your breaking point?  How do you know when you're too close for comfort?

Identity Loss

One thing I've noticed over and over when working with people who have experienced some sort of trauma is how depressed they often feel.  When we start talking about the factors that contribute to the depression people often describe feeling lost and unsure of what to do to move forward.  It became increasingly clear to me that whatever trauma they've experienced has fundamentally changed who they are as as people.

Most people realize they aren't the same as they were before the trauma occurred; actually, that's often why they come in to see me in the first place.  Maybe they've recognized it themselves or maybe their loved ones have said to them, "You're a completely different person now."

What most of my patients want is to be how they were before whatever happened took place.  Unfortunately, that's simply not possible.  "You can't un-do what's been done," I explain.  Events that bring a person face to face with death make them acutely aware of their mortality.  This in itself is a very frightening and yet very profound experience.  A close encounter with death or a severe illness or injury forces a person to reconsider his perception of himself as a competent individual who is able to handle threats and is capable of keeping himself safe.  He suddenly realizes that there are many threats from which he is unable to protect himself; this makes him feel very vulnerable and defenseless.

My patients are fundamentally changed as a result of their experiences; they cannot go back to being who they were before.  This is a difficult thing to accept; acceptance take place over time, not all at once.  A person must make a conscious decision to let go of who they were without first knowing who they are going to become instead.  They have to grieve the loss of their former selves.  "I really liked who I was before," one patient lamented early in his grief process.

After that there is a period of limbo.  Creating a new sense of identity takes a lot of hard work.  A person may have to re-examine deep seated beliefs about himself, other people, and the world.  He may need to find new activities that bring him joy and pleasure.  He may have to end some relationships with people with whom he is no longer able to relate.  He may have to seek out new relationships with different kinds of people.  All of this takes time.  Meanwhile, the person feels like he is no one, going nowhere.  He is lost.

For anyone reading this who has been through a trauma, did the experience change you as a person?  Did you go through a period of grieving the loss of who you were before?  How did you come out on the other side of it?