narrative vs visceral memory

A few years ago, I was working on a project through a site called "Storyworth." Every week they sent a writing prompt and I submitted a short piece in response, usually a brief memoir or autobiographical ditty. At the end of the year, I had 52 stories that they assembled into a book I gave to my children and grandchildren for Christmas. It included topics like "What was your favorite candy when you were a child," and "Did you have any pets when you were a child?" Nothing too deep.

One week, I tackled this one: "What Is One of Your Earliest Childhood Memories?"

I'd been avoiding the topic because my earliest memories date back to my hospitalization with rheumatic fever when I was three years old, not a happy tale to tell. I've written about it before. In fact, I published a brief memoir about the ordeal a couple of years ago. I have analyzed the experience in detail from every perspective over the years. I thought I was at peace with it.

I jotted down a few lines and then I went on-line to search for a couple of pictures. I found an image of The Children's Hospital of Buffalo, where I spent two weeks when I got sick. 

Then I found this:

www.ECMC.edu

This is a photograph from the Acute Scarlet Fever Ward at the hospital, and it made me catch my breath. It is exactly as I remember the ward I was in. Except that it was taken many years before my admission there, that little girl could be me. That was where my bed was in the ward. In the bed next to me was a boy about five years old. Back then the nurses wore stiff white uniforms, and they were proud to wear the official nursing caps they worked so hard to earn. I remember it all, but I did not expect the gut-punch I took when I saw this picture. It brought me to tears, it was so uncannily real to me. 

It made me wonder where that emotion has been hiding all these years, and why I felt it so viscerally when I saw this image.

It turns out we store memories in different ways. Narrative memory is the story we tell about what happened to us. Visceral memory expresses the sensory and emotional experience of the story without using words. It's what we feel, physically and emotionally, when the memory emerges. Fear. Sorrow. Anger. A racing heart. Sweaty palms. Nausea. 

"Trauma comes back as a reaction,

not as a memory."

~Bessel van der Kolk~

It's important for health care providers to understand the difference. I can describe the ward where I was hospitalized in great detail. I can tell you about the other children who were there with me. I remember the toys and books I kept at my bedside. I can tell you the whole story calmly and accurately, as though it were no big deal. In fact, I can narrate my entire medical history without blinking an eye. But there's more to it than that. Apparently, something else is still stored away inside, unwilling to be acknowledged and released. Something that still needs to heal.

When a patient presents with anxiety or depression that doesn't seem to fit the picture, or his symptoms don't respond to treatment, think about unresolved childhood trauma. When he senses a racing heart but his EKG is normal, or his headaches won't go away, go back in time with him. What triggers it? A certain song? The scent of his mother's cologne? The sight of a needle? Or like me, a random photograph I came across on-line? 

Narrative memory may be clear and accurate while visceral memory lurks in the shadows. Without warning, an innocent trigger can release a lifetime of unexpected emotion that can wreak havoc on the body. If you're a healthcare provider and things don't add up, go back. Try again.

"I may look peaceful,

but don't provoke the beast."

~Gautham Balaji~

jan

narrative medicine~not just for doctors

 

The program in narrative medicine that was conceived, developed, and implemented at Columbia University under the leadership of Rita Charon, M.D., PhD. teaches medical students and residents to reflect upon and to write about illness as it affects their patients.

 



 

This goes beyond traditional training which is satisfied with arriving at an accurate diagnosis and effective treatment plan. It involves much more than clicking the bullets on an EMR. Exploring the patient's narrative provides insight into the ways illness/injury changes every aspect and every relationship in their patients' lives. Their sense of self. Their ability/inability to fulfill their perceived role in the family and in society as a whole. Their fears and sorrows. Where they find strength. What gives them hope. This process enables doctors to see their patients as more than interesting or challenging cases. It empowers them to tend to the whole person--body, mind, and spirit.

 

"Stories are not material to be analyzed;

they are relationships to be entered."

~A.W. Frank~

 

This practice improves the physician's sense of engagement with his patients. It deepens empathy. It has been shown to improve physician satisfaction and to lessen the likelihood of burn-out.

 

"Writing improves clinicians' stores of

empathy, reflection, and courage."

~Rita Charon, MD, PhD~

 

But narrative medicine isn't just for doctors.

 

Everyone who works in a health care system carries untold stories with them. Nurses and aides, EMTs and first responders, and therapists in every field have important stories to tell. Even staffers such as receptionists, orderlies, and even maintenance and food service workers all have stories they could share with us.

 

"While medicine creates material

for writing, perhaps even more important

is that it also creates

a psychological and emotional

need to write."

~Daniel Mason~

 

But narrative medicine isn't just for them, either.

 

The book on narrative medicine begins with the patient's story...a story almost everyone can tell. If you have ever visited a doctor's office or an emergency room, or been admitted to the hospital, or been a caretaker for a friend or family member, reflecting on the experience can help you organize your thoughts about it. It encourages you to sort out and name your feelings about it. It clears away confusion, and that eases fear. When you tell your story and someone hears it, you both learn from it. When you write your story and someone reads it, you leave part of your burden on the page.

 

Storytelling applied to the practice of medicine is more than helpful. It is a healing process.

 

"Writing is medicine.

It is an appropriate antidote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

jan

 

 

a doctor's touch

Tanzania 2012

This week, I planned to provide a few prompts for physicians and healthcare providers who are blocked for whatever reason from telling their stories, perhaps because of constraints on time and energy, self-doubt, or lack of inspiration and support. I had planned to offer words of encouragement by Julia Cameron (http://www.theartistsway.com ).

"Writing is medicine.

It is an appropriate antidote to injury.

It is an appropriate companion

for any difficult change."

~Julia Cameron~

 

…and by mindfulness meditation leader Jon Kabat Zinn:

 

"Cultivate wisdom and equanimity

~not passive resignation~

in the face of the full catastrophe

of the human condition."

~Jon Kabat Zinn~

  

Then a friend of mine (she knows me too well...) sent me a link to a YouTube video by Abraham Verghese, titled "A Doctor's Touch.”

 

https://www.ted.com/talks/abraham_verghese_a_doctor_s_touch/transcript

 

"The most important innovation
in medicine to come along in the next ten years:
the power of the human hand."
~Abraham Verghese~
 

Suddenly a whole new set of questions arose. This video emphasizes the therapeutic effect of the laying on of hands by the physician...the healing roles of ritual and expectation...the importance of time spent with patients. It undermines the glorification of the ten-minute office visit…the game of "Beat the Clock" that doctors are required to play in order to meet productivity quotients. Don't get me started...

 

"The life sciences contain spiritual values
which can never be explained
by the materialistic attitude
of present day science."
~Sherwin B. Nuland~
 

These trends in the practice of "modern" medicine, among others, are what led me to bow out of practice because of fear of the inevitable: that the day would arrive when I would miss something important because there simply wasn't time to do the job well.

 

These are the questions I still can’t answer:

 

--Should I have taken a stand against the system and what I perceived to be the erosion of my wisdom and authority as a physician in the care of my patients?

 

--How could I have done it...without risking my job?

 

--Would it have made any difference?

 

--Is it too late now?

 

Thankfully, there are physicians like Abraham Verghese who are able to speak eloquently on our behalf while the rest of us scramble to collect our thoughts and yet fail to act on what we know to be true.
 

 "What moves men of genius,

or rather, what inspires their work

is not new ideas,

but their obsession with the idea

that what has already been said is still not enough."

~Eugene Delacroix~ 

 

 

Is there an issue you need to confront? What is holding you back? What kind of a difference can you make? When will you begin?

jan

 

the role of awareness and expression in recovery

This week I came across an article titled, "A New Psychotherapeutic 'Gold Standard' for Chronic Pain?". (The question mark suggests more study is needed...) It described a technique called emotional awareness and expression therapy (EAET) which, to me, sounds a lot like training in mindfulness and storytelling. In this study, it out-performed traditional CBT (Cognitive Behavioral Therapy) in reducing pain, depression, and anxiety in a group of injured and traumatized veterans.

"Awareness is the first step in healing."

~Dean Ornish~

In CBT, patients are taught to use guided imagery, relaxation techniques, and other techniques to change the way they think about pain.

In EAET, patients are asked to recall a difficult or traumatic memory, to re-experience how the related emotions felt in their body, to express those feelings in words, and how to release or let them go. They learn that the brain's perception of pain is influenced by their emotional reaction to it, the big culprits being grief, fear, anger, and shame. In this study, the researchers concluded that "the evocation and expression of emotions is superior to the mere cognitive discussion of these emotions in therapy..."       

Some time ago I listened to a program on NPR about the factors that influence the perception of, response to, and recovery from a painful or traumatic injury or condition. It focused on the differences in perception between persons who feel victimized by an injury, for example, a car crash, as opposed to soldiers who are hailed as heroes when they sustain injuries on the battlefield. 

In a futile attempt to revisit the program for the purposes of this blog, I reviewed a mountain of research and literature on the topic. It astounds me that so much academic effort is devoted to a topic that seems intuitive to me. We witness it all the time. Athletes who play through or continue to compete despite injuries that would sideline most of us. The fact that any woman would put herself through childbirth again, after the first ordeal. This is in contrast to the person who seizes on his injury or pain to excuse himself from work, or to gain sympathy.

"Pain is inevitable; suffering is optional."

~Haruki Murakami~

Many factors affect the way a patient responds to a painful injury or illness. In addition to gender and age, there is a role for:

• social and cultural norms and expectations
• past experience and conditioning
• the sense of victimization vs heroism
• the patient's motivational state
• his emotional state
• his spiritual inclination
• his social support system

"Often it isn't the initiating trauma

that creates seemingly insurmountable pain,
but the lack of support after."
~S. Kelley Harrell~

The easy part for the health care provider/therapist is to diagnose and treat the injury. The hard part is to understand the patient's attitude toward his pain, and how it affects his recovery:

• Is he angry, fearful, ashamed, or depressed?
• Who does he feel is to blame for his injury?
• Will he be able to work? Does he want to work?
• Where can he turn for support? Will he accept it?
• How will she take care of her children? Who can she turn to for help?
• Is he using his injury as an excuse or escape, or as a way to gain sympathy?
• Are his family and friends supportive or dismissive?

These dynamics suggest themselves when the patient fails to respond to treatment as expected, or is non-compliant with the treatment plan.

If you suspect this is happening, it may be time to put your laptop to sleep, look your patient in the eye, and sort through some of the other issues that complicate recovery from an injury, issues you won't find bulleted in the EMR. If you're the health care provider, you must explore the patient's whole story.

If, on the other hand, you're the patient, you must be honest and compassionate with yourself. It makes sense that awareness and storytelling can play a significant role in recovery.

"Self-care is a divine responsibility."

~Danielle LaPorte~

jan

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