14. Trauma, Empathy and Counselling (Part 2)

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This entry has been hard to write. The fact is that while trauma is used as a medical term, it is deeply embedded in our social history, meaning that it has political, legal, economic, and moral components.This is fascinating stuff, and I can think of no better starting point than the concept of trauma to dive into how psychiatry itself, and the therapies it deploys, are themselves products of a rich social history.But after many starts, I’ve realized that this blog entry ain’t the place!  I want to write on what we say and do in Farchana or Arkoum when sitting with a person on a mat under a tree.The theory informs our practice greatly, but this is another discussion.  For people who want to track this down, I highly recommend reading the following two books:

What I want to address here is, in a sense, the first and last question that we need to ask ourselves as confidants, counsellors, caring friends and neighbours: what can we do to help someone who we think has been traumatized?  In the Farchana mental health services, we see many people who have lived through horrific events, and we talk a lot about what we can, should, and should not do to help them.About a week ago, we sat down for a few hours and explored this, and here I’ve amalgamated their words and experiences with some of the psychiatric lingo that is commonly used.

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In other words, what can a counselor say to Ahmed when told of Amane’s story?  He is waiting for a response that is useful.

Assume Resiliency: First, assume that the vast majority of people are going to get better without professional intervention. The counsellors in Farchana know this intuitively, whereas back home early intervention is more the norm.  I think an evolutionary perspective helps explain this phenomenon of resiliency: for literally millions of years, humans have lead lives that have been characterized as solitary, poor, nasty, brutish, and short.  Deaths were by infection rather than chronic diseases, mortality rates (especially in infancy and childhood) were high, and violence and food shortages were common. Whether you now wear a business suit, an animal skin or a tutu, you’ve got a brain that was baked in the Paleolithic period.  Even in the more recent ten-ish millennia since the invention of agriculture, these conditions have mostly persisted. Adaptation to stress was a necessary part of survival and often a source of individual strength and community bonding.Humans are survivors, and assuming that someone who suffers is a helpless victim is rude, crude, and wrong.

Listen and Follow: Listen to what a person says and feels and simply hear them out, using empathy and curiosity as guides. The counselors tell me that often they’ll spend up to three one-hour sessions just listening before they finally start asking anything specific. Statements like “How’re you doing now?” “Do you want to talk about it?” “Then what Happened?” and “Holy shit that sounds terrifying! What was it like?” strike me as good starters.  Sure, they’re campy, and even run the risk of being cliché, but that’s no big deal.  The most common form of an epiphany is when you get the deeper meaning of an otherwise throwaway statement.  Note that open questions are much more useful than directives; an open question would be like the ones above, whereas a “closed” question has a yes-or-no form, such as “were you sad when that happened?”

In most sources on this subject, there is both an encouragement to get someone to “tell their trauma story” in full detail and emotional tenor, and to let people know that they are having a “normal response to an abnormal event.”To me, it seems better to say something like “some people benefit from talking about it” rather than prescribing this path.  Likewise, I find the phrase “a normal response” troublesome.  In some senses, “normal” implies “expected,” and we don’t want to give anyone the impression that feeling better quickly, or not having any “traumatic reaction” is unexpected or in any way “abnormal.”  I think it is better to say something like “you’re not going crazy, what you are going through is an understandable response to what you’ve been through, and the vast majority of people feel much better in a few weeks to months.”  This is both true and encourages health rather than focuses on the sick role.  Of note, it is much more therapeutic for a person, if they are to tell their story, to have a high level of emotion as they go through it.You can say the words till the cows come home, but if there’s no emotion, there’s less benefit.

The final question at the end of our session is, of course, “would it be helpful for you to come back and see us again.”  If no, a smile, a well-wishing word, and a statement that our services are always available, are phrases commonly used by the staff.

Red Flags: A red flag is something that makes you think that professional help is likely necessary.  Things like suicidality, violence or escalating aggression, panic attacks, refusing to eat or drink, extended bizarre behaviour and confusion are the most common.  The formal intervention is to keep a person and those around them safe while in this state.  As well, if someone is not getting better and several weeks to a month has gone by, this may be time to ask for help, too.  Of course, some people may want to see a therapist without these red flags being present, and that’s fine, too. I just wouldn’t push for that.  Lots of studies have shown that one-off “debriefing” sessions after a difficult event can make things worse.

Encourage family and community support:  Healing is like learning to trust again… and trust means being comfortable with letting another take care of you. Family, close friends are the obvious choices, but it could be your ultimate Frisbee team-mate, rabbi, hiking buddy or flower vendor.  We’re all in this together.

Encourage meaningful activities: This could mean doing laundry or helping someone build a latrine or tukul. It could mean cleaning up after a meal or taking your half-hour walk everyday.  Something with a start, a finish, and a feeling of satisfaction that comes with the accomplishment.  As soon as someone is capable, going to school, a volunteer position, a job—whatever—is good.  Join the knitting bee, have tea with the regular group, or get back to the chess club… just get back into the world as fast as possible.  One study found that people who looked after children got better faster. Makes sense to me!

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