13. Trauma, Empathy and Counselling

(In the following story, names and minor details have been changed for confidentiality).

Steven Cohen CAMH Issakha.Me.block.2

Ahmed, one of the national staff pulled me aside today.  He hesitantly asked if he could speak with me about a member of his family who was “traumatized,” and specifically how he could help.  This is the story that was told to me.  Several weeks ago, Amane, his 32 year-old first cousin was fleeing violence in N’Djamena, the capital of Chad.  Fighting had escalated quickly and within 24 hours parts of the city were destroyed and looting and random violence were rampant.  Amane, her husband and their two children decided that it would be safer to flee at night, but she became separated from her husband and continued to the bridge to Cameroon with her two children, a 5 year-old daughter and a 9 year-old son.  Many people left N’Djamena for the villages outside the capital or fled to neighbouring Cameroon (UNHCR registered over 30,000 Chadian refugees).

I imagine that the 500 metre-long bridge was a welcomed sight.  There are three bridges across the Chari river, and the closest for Amane was single-laned, large enough for one truck and a few feet on either side.  Enterprising boat-owners were cashing in on the chaos, charging people up to 10,000 CFA (CAN $24) for passage across the short channel, but few could afford this and opted for the walk.  Stories tell of the flood of frantic people pushing to get by the abandoned vehicles to the other side.  The walk that normally takes fifteen minutes took up to three hours.  I’d like to think that it was to avoid the danger of her small children being trampled that Amane steered toward the side of the bridge, but it was probably bad luck and the madness of the crowd that pushed them against the rails.  And it was in this same madness that her children fell over the edge, into the water about 20 feet down.  There were no lights at all and when they fell, there was probably no way to see them in the dark water.  Ahmed tells me that Amane tried to jump in after them but people held her back, and she finished crossing the bridge not knowing whether her children were dead or alive.

It’s been over a month and they have not been found, and Amane has been taken to live with her husband’s extended family in a quiet village far from the capital.  I’m told that she sits with others at meal-times and looks as if she is “in a daze.”  She doesn’t talk, eat, or make any emotional contact most of the time, and when children are playing nearby, she often breaks into tears and has to get up and leave.  At night Amane is not able to sleep for longer than an hour; she wakes up crying, calling out the names of her children.  In the early morning she often informs her family that she needs to go to the market “to see her kids,” but given that loud sounds and sudden movements cause her great distress, a trip to the market would be quite difficult; she has not been able to leave the house for weeks.  Soon her sisters will visit, and the family hopes that this will help.

Steven Cohen CAMH door

Of course, one cannot make a diagnosis without a full in-person assessment.  But it does appear that Amane may suffer from a constellation of symptoms that is labeled in the Western psychiatry manual, the DSM-IV-TR, posttraumatic stress disorder (PTSD).  The label in-itself is not so helpful, and there have been other names of syndromes that collect and organize symptoms of re-experiencing, numbing, and hyper-arousal in other ways.  The diagnosis is a bit of a misnomer, too, as in many situations the threat and actuality of trauma continues, so there is nothing “post” about it.  But what is PTSD? And how does our understanding of its origins lead us to treat psychological trauma?

PTSD is a malady of memory.  To function well, we need the capacity to remember some things and to forget (or dull) others.  It is good to remember that touching a hot stove is dangerous, and in a near-literal way, this memory is seared into our minds by virtue of the pain—and emotional arousal—of the moment.  But we need to dull this memory allowing us to attempt to use the stove again, albeit more cautiously.  In PTSD, this natural dulling of the emotional tone of a bad incident is thrown off, and the smallest sound or sight takes you right back to the pain; in a real sense, every night since, Amane may be back on that bridge, with all the horror, helplessness, and loss.  The adaptive “high-alert” vigilance that helps her keep safe when cooking on hot stoves has turned against her, like a disease of adaptation, and now exhausts her resources.  Any loud sound or unexpected movement can be perceived as a threat, and it is this distorted threat-appraisal that must be unwound.  In a manner of speaking, our sense of who we are (our “self”) is bounded by the ability to remember and to forget, and if one is compromised, we lose who we are.

The question of what can be done to help Amane and so many other people who continue to suffer in this way, must be split up into two questions: 1) How can we prepare ourselves for this type of calling, and 2) What can we do to help?  The rest of this blog will answer the first question, and the second question will be the subject of the next entry.

1) Preparing to listen

In blog #11, I gave an account of the narratives of Fatna and Ibrahim, which were quite emotional for me.  A few days later, a friend from Montreal wrote a comment asking what we do in our mental health team to protect against “vicarious traumatization,” which means in this case a counsellor being themselves traumatized by hearing such difficult stories.  It’s a good question.  One has to balance empathy with self-preservation, while doing honour and justice to the integrity of the patient, his or her narrative, and the attendant empathic emotions that they evoke. A therapist needs to be able to withstand the brutal side of empathy to simply bear witness to it.  In psychiatric terms, the ability of a person to do this is their “negative capacity.”  In my opinion, the role of a good therapist is to facilitate a surface upon which meaningful communication can flow.  And we have to prepare ourselves for a torrent of words and emotions… whatever may come, a counsellor must be capable of simply letting the moment happen.

As you can imagine, discussion among our team of counsellors gets heavy at times.  We go from laughing about small things to presenting difficult cases to the group and getting support and counsel from each other.  We talk of our patients, and of our experience of being with them. Once a week, two hours are set aside for this exact purpose, and other “supervision” times are available, too.  (Of note, 24-hour psychological support is available for MSF staff.)

Steven Cohen CAMH woman_digging

It quickly becomes clear that fear and pity can be dangerous if they lead to a paralyzed empathy and inaction.  Through these discussions, in a number of ways, we become more familiar with the pain of suffering, so that we can contain the harshness of it, rather than have to dissociate, isolate, or destroy within us that which resonates with it.  This does not minimize the horror of the situations or stories that we witness and feel, but it increases our negative capacity, or ability to withstand it. And by doing so, we can attend more closely to our patients rather than to ourselves.

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