This Thing of Darkness

We all walk the earth in egg-shell armour at the whim of Nature. There is little of any of us that will not break if chaos strikes, or heal without a scar. You’d think that, given our fragility, we would opt for conciliation or compromise, and yet more often we challenge those who are not us, and seek to conquer those we cannot otherwise convince to join. It has become a point of honour not to yield, and so we glorify those who suffer grievous injury for causes dear to us, and our stories magnify their deeds, and exploit their hardships. We call them heroes…

But not all who suffer are our heroes, even though they may also have demonstrated equal courage for their positions, or found themselves inadvertently damaged in the crossfire of our wrath. We call them victims -if we notice them at all -and often deny guilt, even if we do.

Despite Steven Pinker’s contention in his The Better Angels of Our Nature that violence has been diminishing ‘over long stretches of time’ and that ‘today we may be living in the most peaceable era in our species’ existence’, I am still troubled by the violence that continues around us. Of course he may be correct in pointing out a lack of current, or at least, local internecine wars that would affect our daily lives, and suggesting that our improved communication systems highlight and magnify our knowledge of more distant conflicts without our having to experience the trauma ourselves. So, is it our arguably decreasing experience of violence that makes something like domestic cruelty stand out? At any rate, when this form of abuse seems all too apparent around us, it is impossible to ignore. Immoral to accept.

And often hidden beneath the more obvious traumatic injuries are the long-term effects. Of course we have all read about the ramifications of continuing abuse, and about how difficult it is to know whether the injuries are purposefully inflicted or the accidents they are often claimed to be, but what about the often more subtle and cumulative effects of traumatic brain injury?

Two articles caught my eye when I was trying to learn more about the subject. The first was an op-ed in the Los Angeles Times of a few years ago: http://www.latimes.com/opinion/op-ed/la-oe-1012-garayserratos-tbi-domestic-abuse-20151012-story.html ‘In recent years, medical science has uncovered the high risk and devastating effects of traumatic brain injury, or TBI, among U.S. combat soldiers and athletes, especially football and hockey players. What if a vastly greater population were also suffering these effects: women and children living with the consequences of domestic violence?’

At that time, ‘There [were] few empirical studies on the prevalence of TBI among women and children affected by domestic violence. But evidence so far strongly indicates a silent epidemic, with major public health ramifications. A 2001 study found that 67% of women seeking emergency medical support for injuries stemming from domestic violence had symptoms related to TBI, and 30% reported loss of consciousness.’

A more recent article, with links to this op-ed was in the online Conversation: https://theconversation.com/traumatic-brain-injury-the-unseen-impact-of-domestic-violence-92730 ‘The statistics are terrifying: In Canada, one woman is killed every week by her partner, globally, one third of women will suffer violence at the hands of someone they love in their lifetime.’

The article was written by Paul van Donkelaar, a professor in the Faculty of Health and Social Development and a neuroscientist at the University of British Columbia. He goes on to ask, ‘But what if survivors […] are also dealing with the effects of a traumatic brain injury along with the fear and trauma of finally having escaped a long-term abusive relationship? […] the impacts of this injury can be devastating — ranging from headaches, double vision and nausea to difficulty concentrating, remembering things and completing simple tasks. It’s also clear the effects tend to be worse when the trauma occurs repeatedly over time, with symptoms lasting for months to years.’

And, ‘Unlike athletes who have suffered a sport-related concussion, survivors of intimate partner violence also quite often experience emotional difficulties such as post-traumatic stress disorder (PTSD), depression and anxiety.’

‘[…]the U.S. Centers for Disease Control and Prevention, reports each year, 2.3 per cent of women over the age of 18 experience severe physical violence including “being slammed against something” or “being hit with a fist or something hard.” Furthermore, up to 90 percent of survivors of intimate partner violence report head, neck and face injuries at least once and typically on multiple occasions.’

Although I’d like to hope that we live in somewhat different conditions from our neighbours to the south, ‘Assuming similar percentages in Canada, this translates into approximately 276,000 women per year who will suffer a traumatic brain injury as a result of intimate partner violence.’

One of the many disturbing things about this trauma is the possibility of subsequent cognitive deficits -some of which may be severe, and because they may have occurred years before, difficult to remedy, let alone reliably assign attribution. As the author of that op-ed in the L. A. Times, Maria Garay-Serratos, wrote of her mother: ‘For as long as I can remember, my mother took aspirin every day, complaining of unbearable headaches. Sometimes she locked herself in the bedroom with the lights off, asking me to take my siblings outside because she couldn’t tolerate the noise. As she got older, her naps grew longer and her sensitivity to light and noise intensified. By her 50s, her memory had begun to fail.

‘On the day she finally asked me to take her away from my father, I found her in a worse state than I had ever seen her. She could barely stand. She was crawling from room to room while my father ignored her. […] When all the tests were finished, the neurologist told us my mother was suffering from moderate to severe Alzheimer’s disease. The head trauma had been so great and so consistent that there was little they could do.’

Unfortunately, it’s all too easy to focus on simply treating the physical symptoms -and, of course, rescuing the victim from further harm. This is obviously important, and yet woefully insufficient; there is also a need to be alert to problems that seem temporally unrelated. The link to head trauma may be more evident with events like automobile and athletic or combat injuries, but less so in a woman who escaped from an abusive relationship years ago.

Maybe Pinker really has spotted an inexorable trend towards less violence in our society. In the meantime, however, I think ongoing surveillance and counselling for the effects of head trauma might help the abused victims to live a better life while we await an actual treatment for what we now call CTE (Chronic Traumatic Encephalopathy). Oh, and an effective prevention strategy, too -in case those better angels lose their jobs…

 

 

 

 

 

 

 

 

 

 

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Is What’s Past Really Prologue?

War has so many faces and wears so many different clothes that you might be forgiven for misunderstanding its refugees. Confusing cause and effect in their behaviour, their appearance, and perhaps, most obviously, in their adaptations to the stress of upheaval and migration. There is no universal pattern that obtains, and few things to offer as a template for relief except, perhaps, a welcoming succour. And when numbers become overwhelming, even compassion is strained in the melange of personalities and temperaments that inevitably occur in those fleeing danger. Not all victims may be to our liking, and when resources become limited and privileges are necessarily constrained, the reactions can be unpredictable on both sides. Empathy can mutate into grudging tolerance. Forbearance. Endurance.

But think of the effects on the refugees, first forced to flee intolerable conditions, often leaving behind members of their families, then subject to the hardships and exploitation of the journey,  finally being forced to trust themselves to the charity of strangers. It cannot be easy for adults to have their identity subsumed by that of victim, and everything they were, everything they had, everything for which they had worked no longer possible. No longer recognized, let alone appreciated, in a strange land with often stranger customs and language.

And what must it be like for their children who haven’t yet learned the curse of humiliation, or understood what the theft of identity may mean to their parents. They’re caught in the middle ground between witness and casualty, understanding neither. Lacking the tools to navigate the waters, some, I suppose, internalize it; others lash out. But none escape entirely.

I came across an unusual manifestation of trauma that seems unique to Sweden (so far), for some reason –the newly coined Resignation Syndrome: http://www.bbc.com/news/magazine-41748485  ‘[…] it affects only the children of asylum-seekers, who withdraw completely, ceasing to walk or talk, or open their eyes.’

‘The health professionals who treat these children agree that trauma is what has caused them to withdraw from the world. The children who are most vulnerable are those who have witnessed extreme violence – often against their parents – or whose families have fled a deeply insecure environment.’

‘As more Swedes began to worry about the consequences of immigration, these “apathetic children”, as they were known, became a huge political issue. There were reports the children were faking it, and that parents were poisoning their offspring to secure residence. None of those stories were proven.’ A not so hidden ‘blame the victim’ scenario that tends to surface under conditions of societal stress.

‘Numerous conditions resembling Resignation Syndrome have been reported before – among Nazi concentration camp inmates, for example. In the UK, a similar condition – Pervasive Refusal Syndrome – was identified in children in the early 1990s, but there have been only a tiny handful of cases, and none of them among asylum seekers. The most plausible explanation is that there are some sort of socio-cultural factors that are necessary in order for this condition to develop. A certain way of reacting or responding to traumatic events seems to be legitimised in a certain context’ writes Dr Karl Sallin, a paediatrician at the Astrid Lindgren Children’s Hospital, part of Karolinska University Hospital in Stockholm.

Theories abound, of course. There is a view ‘commonly held among doctors treating children with Resignation Syndrome, that recovery depends on them feeling secure and that it is a permanent residence permit that kick-starts that process.’ Unfortunately, with increasing numbers of refugees arriving, both the patience and the available resources are wearing thin, so stricter adherence to admission criteria do not always allow a family to stay. ‘Last year, a new temporary law came into force that limits all asylum seekers’ chances of being granted permanent residence. Applicants are granted either a three-year or 13-month visa.’

One treatment seems to be having some success, even with those not granted permanent visas, however. The thesis is that  sickness has to do with former trauma, not asylum. ‘When children witness violence or threats against a parent, their most significant connection in the world is ripped apart’ –the very connection on which the child has been dependent. ‘That family connection must be re-built, but first the child must begin to recover, so Solsidan’s [the treatment center’s] first step is to separate the children from their parents. “We keep the family informed about their progress, but we don’t let them talk because the child must depend on our staff. Once we have separated the child, it takes only a few days, until we see the first signs that, yes, she’s still there…” says Annica Carlshamre, a senior social worker for Gryning Health, a company that runs Solsidan, a home for all kinds of troubled children.

Even if effective, I would imagine that not every family would be willing to part with their child to strangers, nor would the number of treatment centers be equal to the task. Still, it may be a method worth exploring further.

Post-Traumatic Stress Disorder, Resignation Syndrome, Situational Adjustment Reactions, Panic Attacks… I am not alone in wondering what these may produce in the hundreds of thousands, if not millions, affected –either in childhood when coping mechanisms may not yet have been learned, or worse perhaps, in adulthood when the mechanisms may have been discarded. What can we expect from a generation torn from its customs, and rightful expectations of a peaceful family life? A generation often deprived of education, to say nothing of safety? What is normal to those who have never experienced it? And what are the obligations of the rest of us to them?

War, it is said, will be with us always, but we must not be fooled by its seeming inevitability. I suppose it is unbecomingly naïve in this time of terrorism and bellicose patriotism, but I still remember the words of Martin Luther King, Jr: “Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.”

An ounce of prevention is worth a pound of cure? It’s not an answer, perhaps -just a hope…

The Kingdom of the Blind

 

Sometimes, after waking up from a troubled sleep, it occurs to me that I live in a world to which I have become so accustomed that I wander down its streets like a horse with blinders. I see those things at which I am pointed and accept what I am told about the rest –even about the other horses… And they, like me, process their separate realities as if they were representative. Common grounds. All, no doubt convinced of the uniqueness -the appropriateness- of their own interpretations. Certain that what they see is what we all see –should see- otherwise we are mistaken and groping. Remember, in the kingdom of the blind, the one-eyed man is king.

But we miss a lot unless we stand back and consider what passes for reality. And why. The other day I was listening to an archival podcast from BBC 4 entitled Body Count Rising –a thought-provoking and insightful documentary about how we have come to watch- and accept- crime programs that seem to glorify violence against women. Rape, murder, abuse –all common themes that, had they no fascinated audience, no prurience, would never have gained the popularity they seem to enjoy: http://www.bbc.co.uk/programmes/b07wtggz

To me, only an occasional crime show adherent, the trend was largely invisible. And yet, as a man, maybe even a steady diet of such programs would have slipped past without a comment. Without a conscious recognition that perhaps the overly realistic depictions of female abuse, the preponderance of rape as an important component of the plot, and the salacious depiction of the female corpse was actually a not-so-covert titillation. A not-so-disguised form of necrophilia.

Another component of the podcast documentary that I had not considered until then –and one that I found powerfully compelling- was not so much the increasing demand for these kinds of stories, but rather the effects on the female actors who had to play the role of the victims. I suspect that most of us become so enmeshed in the storyline, so enveloped in the plot that we forget that to be convincing, the actor has to become the character she is playing. Those kinds of victim roles must be devastating -especially when the story purports to depict what is actually happening out there in real life to real women. And yet for the rest of us, we experience it vicariously and from the safety of our living rooms.

Where does the fault lie? The documentary makes an honest attempt to dissect it –from the writers who decide what species of story is saleable, to the networks and producers who pander to audience demand, and even to the actors who, despite their reluctance to glorify the ugliness they are asked to portray, dare not risk declining or criticizing the role for fear of subsequent unemployment… Sometimes I wonder if that isn’t another form of abuse. More subtle perhaps, more deniable, and yet one more gossamer-thin thread in a web of denigration so easily ignored in our society. So readily dismissed. So invisible…

We are all to blame, aren’t we? There are blind spots in each of our lives.

I walked into in a crowded restaurant for lunch the other day, and the only table left was uncomfortably close to one where a man and a woman sat arguing. To be fair, they were initially discreet about it, never raising their voices, nor gesturing suggestively with their cutlery, but nevertheless, I felt almost as if I was a guest in their kitchen and forced to witness a family squabble.

“… Whatever!” the woman hissed sotto voce, as she glanced at me sitting so close to them. She was young –maybe in her mid-twenties- and looked as if she had just come from work. Dressed in a grey skirt and a white now-creased blouse, her auburn hair once pinned on top of her head, escaped strand by strand as she tossed her eyes back and forth from the leftovers on her plate to her partner’s face.

He was probably in his forties, and dressed in a brown suit with a red tie loosened at the neck. Staring intently at the woman, a patient smile tattooed on his face, he was leaning forward on the table when I sat down. He made several desultory attempts to touch her arm, but she withdrew each time. “Sheila asks for it, though, Janice…”

Evidently, this was not the response Janice wanted to hear and she sat up stiffly on her chair and glared at him. “Asks for it! What kind of an animal are you, Jeff?”

“Come on, Jan. Get off your high horse!” he sat back on his chair and his facial tattoo expanded sardonically. Cruelly. “She flirts with every man in the office… Including me,” he added, as if this proved his point.

“Flirts?” Janice’s voice rose unintentionally, but she glanced my way and subdued the rest of her words. “Sheila is just friendly; that’s how she interacts with people.” She shook her head sadly, and several more strands of hair tumbled to her shoulder and danced as she spoke. “You’re so shallow!”

“Friendly is one thing –you’re friendly, but you don’t stand as close as she does when you talk. And you don’t start fondling people to make a point. Sheila bores into your face with her eyes, like she wants to peer inside, or something…”

“You mean she actually listens when you talk…?”

Jeff frowned at the remark and shook his head. “No… it’s more than just listening, Jan. It’s… seductive.”

The skin on Jan’s face tightened, and her eyes tore a strip off his face. “So that’s why Jason gropes her every chance he gets? Because she’s asking for it?”

“Gropes her?” His voice rose unpleasantly loud and people at the nearby tables turned to see who was yelling. He dropped his eyes to his plate again, and lowered his voice. “Janice you’re so bloody naïve! He’s just responding to her. Stimulus-response –it’s not groping! You make it sound so… so damned lewd.”

Janice’s eyes grew to the size of the plate in front of her and her face reddened as the veins on her neck grew fat and swollen. She took a deep breath and let it out slowly before answering. “Suppose Sheila kept grabbing his ass –what would you call that? Or his crotch…? I saw him trying to finger her in the corner, Jeffrey!!”

Jeff rolled his eyes and guffawed. “He’s just playing the game, Jan… And anyway, Jason wouldn’t do that unless she was okay with it.” He toyed with the bit of food left on his plate and then chose a large, dripping piece and put it in his mouth –but slowly and carefully. I could tell he thought he was being seductive.

From where I sat, I could see Jan’s fists opening and closing. She seemed momentarily speechless, although I suppose she was actually trying to calm herself down before she exploded. “Jeffrey, you’re missing the point!” The words came out between clenched teeth, her eyes locked on his. “Jason is her boss, for god’s sake! She feels she has to take it…” She tried to soften her face for a moment as she explained the obvious, but it was a losing battle. “Don’t you understand…?” she said quietly while shaking her head. I could tell she wasn’t far from tears.

But Jeff’s face stayed blank. It was as if Jan hadn’t explained anything. “Sheila could just tell him to stop, if she wanted to.” It was so obvious to him.

Jan glanced at her watch and stood up. “I’ve got to get back now, Jeffrey…” He smiled again and pointed to some food still left on his plate. “Wait till I finish this, Jan,” he said, and not kindly. It was an order, really, so she sat down again and leashed her eyes obediently.

But not before they strayed briefly to my face in apology –a silent recognition of the way things were. An invisible shrug.

 

Victim

One of the things about illness is that it seems unfair -especially if it involves pain or limitation. To some degree, I suspect we all give in to self-pity in the throes of the process; maybe it’s a coping mechanism: a world view that allows us center stage for a while, an excuse to treat ourselves to some unaccustomed luxury. And why not? It’s only a temporary aberration, limited not only in duration, but in magnitude as well. Tomorrow will undoubtedly be better – the flu will have diminished, the sprain begun to heal. Reality -Life- will peek around the corner and beckon us.

But suppose it’s not; suppose its the same -or worse? Suppose the pain and debility persist and we find ourselves powerless in the grip of something we cannot understand, let alone control? What then? What if you seek help and are told there’s nothing to be done, or that the treatment, even if successful, will come at a once-unacceptable price? At what point do you become someone else? Something else? At what point do you somehow become a victim –someone demeaned? Disempowered? At what point, in other words, do you give up? Assign blame -or assume guilt?

These are vexing questions to which I have no clever answers. But they are problems -dilemmas- that we all encounter as we travel through our days. Certainly the chronicity of pain is a problem in gynaecology. A problem in endometriosis in particular. Perhaps in some future blog I will discuss the condition more fully, but for now suffice it to say endometriosis has the potential for becoming a chronic source of on-going pain with treatment regimes that might include surgery and affect fertility. It is surrounded by myth and misinformation that adds to the burden; it has variable clinical presentations making diagnosis or even suspicion difficult. It can be over-diagnosed on the basis of inadequately investigated symptoms carrying with it the inevitable worry and concern about the future. It can be under-diagnosed leading to multiple unsuccessful treatments and distrust of the medical establishment and their lack of effective medication -a gold mine for alternative therapies.

All understandable I suppose, and yet treated or untreated, I have concerns for the person behind all this -the person experiencing the pain, the person who is experiencing this by herself, as we all must experience pain. I remember an ad in a medical journal years ago. It was an advertisement for a medication for endometriosis and it was a picture of a beautiful woman in an alluring nightie curled up in the fetal position on a rumpled bed. The caption read: “Trapped in her own body!” I was sufficiently disturbed by it to fire off a letter to the company. What it had assumed -indeed encouraged everyone to think- was that she was a victim, someone on whom a punishment, or at the very least an unfair condition, had been imposed.

Unfair? Of course it is unfair -but the word, the description, is inapplicable, really. Pain, diseases, injuries are not judgeable as fair or otherwise. Some are perhaps preventable, some avoidable, all undesirable but unfair..? I suppose I take issue more with the powerlessness of the woman implied in the ad, though. The message is to surrender, I think, like in one of those police shows where the criminal is surrounded with no chance of escape. For him, we are led to believe, the chances of anything he does that might result in his freedom are non-existent. He must give up, not only his freedom and perhaps how he would like to see his life unfold, but also hope.

The analogy is wearing thin here, for sure, but I’d like to think that hope is not what that woman in the ad has lost, that she does not think of herself as merely an undefended receptacle for pain, a defenseless body being assaulted and beaten on a bed somewhere. I’d like to think that she still sees herself as a person, a subject. Not an object: a thing acted upon, something incapable of acting on its own behalf -powerless. I realize that I say this from the  safety of my own health, as an unexperiencing voyager upon the surface of someone else’s disease. And yet despite the distance imposed I can still feel the suffering, however dilute. I can still encourage her to take some control, if only of very little. Any control, any sense of being able to influence direction is important. Even if the outcome, the destination, is unknown, walking along a path wherever it leads, is better than staying lost. It is hope renewed. It is the first step to recovery.