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The meaning of intrusions in trauma recovery White, Valerie Marie 2001

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The Meaning of Intrusions in Trauma Recovery By VALERIE MARIE WHITE B.A., The University of Alberta, 1978 Diploma in Education, University of British Columbia, 1998 A THESIS IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS In THE FACULTY OF GRADUATE STUDIES (Department of Educational and Counselling Psychology and Special Education; Counselling Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 2001 © Valerie Marie White, 2001 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of toLu£JLhsX.a/ <W dfouU^y, ^eJ^USJtp ^ g ^ v ^ f f The University of British Columbia ^ ^ l A * ^ * . - C^-i^^^ /^£jL?i6r%(/ Vancouver, Canada ? / J7 $7 Date (yjtJbuJZlZOvi DE-6 (2/88) Abstract This narrative multiple-case study explored and described the meaning of intrusions to five individuals who had experienced trauma and the meaning of intrusions in their experience of trauma recovery. The participants included two men and three women, ranging in age from 26 to 71 years old. This was a cross-trauma investigation as the participants had experienced different traumatic stressors and the time elapsed posttrauma ranged from 2 1/2 to 25 years. Three had experienced chronic or prolonged traumatic exposure for an average of twenty years. Two had experienced sudden and unexpected events in which they were seriously injured and their lives were in danger. The chronic traumatic experiences included; childhood exposure to violence in the family home and foster care, childhood sexual abuse by a volunteer mentor and degenerative illness from beast implant silicone toxicity. The acute traumatic experiences included a serious motor vehicle accident and a direct lightning strike to a participant's body. Three types of intrusions were identified in the study; re-living phenomena, intrusions related to the practical issues and implications of the trauma and those involved in an existential search for meaning. The findings also showed that intrusions are related to unresolved issues of the person and that intrusions evolved. Specific intrusions ended when the issue that the intrusion illumined was resolved. The study illustrated the processes of meaning making that the participants engaged in. The involvement of intrusions in reschematization or the development of posttrauma assumptions has been proposed. Finally, the results of this study illustrated that intrusions have not been accurately defined and are more than re-experiencing phenomena. The identification of three types of intrusions challenges the validity of current assessment instruments and has implications for the practice of trauma therapy. TABLE OF CONTENTS Abstract ii Table of Contents . iii CHAPTER I Introduction 1 CHAPTER II Literature Review 6 2.1 The Impact of Intrusions . 12 2.2 Content of Intrusions 13 2.3 Intrusions and Reliving the Trauma 15 2.4 Meaning and Intrusions 17 CHAPTER TH Method ' 21 3.1 Approach 21 3.2 Inclusion Criteria 22 3.3 Recruitment and Screening of Participants 22 3.4 Interview Sites 23 3.5 The Research Interview 23 3.6 Working with the Information 25 3.7 Member Verification of Interview Material 27 3.8 Analysis 28 CHAPTER IV Case Studies 29 4.1 Little One 31 4.2 Groomed 47 4.3 Betrayed 63 4.4 It Could be Worse 76 4.5 It was bad Enough 89 iii CHAPTER V Results. 106 5.1 Types of Intrusions 106 5.2 Intrusions and Issues 110 5.3 Evolution of Intrusions I l l 5.4 Resolution of Intrusions I l l 5.5 Existential Search for Meaning 112 5.6 Shattered Assumptions 112 5.7 Changes in Assumptions 116 5.8 Common Themes of the Intrusions 116 5.9 Meaning Making Process 127 CHAPTER VI Discussion 142 6.1 Review of Findings 143 6.2 Theoretical Implications 144 6.3 Implications for Practice. . . 148 6.4 Future Research 151 CHAPTER V l l References. . 153 iv 1 CHAPTER I Introduction "Although the reality of extraordinary events is at the core of PTSD, the meaning that victims attach to these events is as fundamental as the trauma itself (van der Kolk, McFarlane & Weisaeth, 1996, p. 6). This study explored that meaning by describing how it is expressed in intrusive thoughts and an individual's response to those thoughts. Intrusions fall under the rubric of automatic thoughts and include; memories, images, flashbacks, nightmares, sensations, trauma related thoughts and somatic, behavioural and emotional responses to stimuli. Several definitions of intrusions can be found in the literature on intrusions. For the purpose of this study, the description provided in the American Psychological Association Diagnostic and Statistical Manual of Mental Disorders (1994) will be used as a basis for inquiry and discussion. This description has been chosen because it outlines the variety of phenomena that can be termed intrusions. In the DSM-IV (1994), all intrusions listed are considered re-experiencing phenomena. It should be noted that recurrent thoughts, dreams, images and perceptions about the event can also be related to the event in terms of it's implications in the individual's life over time, but do not necessarily cause the person to relive it. 2. The traumatic event is persistently re-experienced in one (or more) of the following ways: a. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed b. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content c. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening when intoxicated). Note: In young children, trauma-specific re-enactment may occur 2 d. intense psychological distress at exposure to internal and external cues that symbolize or resemble an aspect of the traumatic event e. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (DSM-IV, 1994) This study documented the participants' experiences with intrusions. Intrusions were described, interpretations of the meanings of the intrusions explored with the participants or co-researchers, and possible evolution or resolution of intrusions interpreted in relation to contexts of meaning, the participants' lives. The stories of how intrusions impacted or were effected by the plots of the participants' recovery narratives have been explored and described in this study. My interest in this topic is based in a curiosity about how people construct meaning after they have experienced a traumatic event. Horowittz (1999) outlined a model of response to trauma that involves phases of denial and intrusion followed by a working through phase, in which an individual assimilates traumatic information into old pretrauma schemas. Janoff - Bulman (1992) suggested that the individual must develop an integrated worldview through a process of assimilation and accommodation that integrates the information about the trauma and modifies pre- and posttrauma worldviews. Do intrusions have a role in meaning making or do they simply reflect those shattered beliefs and represent the individual's troubled thinking from traumatizatioh? These questions were salient to me when I was reading about posttrauma reactions. This interest arose after my own experience with intrusions and other symptoms of posttraumatic stress upon on the death of my husband Earl, by suicide in September 1994. I found that the literature on trauma largely classified intrusions as symptoms of traumatization, illogical and dysfunctional thinking. I was surprised that the persistence of symptoms for three months indicated chronic posttraumatic stress disorder (PTSD). 3 I questioned, how does one adjust to a traumatic event, within one to three months? Joseph Williams and Yule (1995) suggested that there are two major types of intrusions, flashbacks and ruminative behaviour. "In the early stages of processing, the survivor engages in ruminative behaviour in an attempt to make sense of their experience and integrate it within pre-existing models of the self and the world." (Joseph, Dalgleish, Thrasher, Yule, Williams & Hodgkinson, 1996). Early resolution of some of my intrusions led me to understand that intrusions were linked to meaning, and that once I got the message of an intrusion, it ended. The intrusions brought issues to the forefront of my attention and plagued me until I came to some insight or shift in thinking. The shift also occurred emotionally, in that I felt an unexpected sense of peace or acceptance in the understanding that came with the resolution of an intrusion. It was as if each intrusion was actually an internal therapist, albeit a therapist trained in the Ellis tradition, that probed my thoughts and confronted me with them. The intrusions that I remember clearly were the ones that were transformational for me in that they changed my understanding of the event, myself and fundamental beliefs I held about how to live and love. They included; visual representations or images of something I had not seen but was symbolic of a difficult issue I was struggling with, nightmares, thoughts and questions that provoked an internal dialogue for me. One major intrusion was a sentence starter, asked over and over, with my responsive thoughts changing over the years until I had apparently answered myself with an appropriate response. The last major intrusion was a question asked in various frequencies over four years, with my response once again changing until I responded with the most simplified and true answer, one stripped of complications and old meanings. In each case, I was 4 surprised when the intrusion stopped. Sometimes I did not have immediate awareness that I had finally confronted the intrusion or resolved the issue at hand. The intrusions made me struggle with the tacit beliefs I had about Earl's death, and what his choice meant to me. Perhaps the intrusions led me through my internal search for understanding, one that I would probably not have charted consciously. Although the theories of trauma adjustment aligned with my experience, particularly Janoff-Bullman's (1992) Theory of Assumptive Worlds and Horowitz's model of stress response, until recent publications the literature on post trauma reactions did not seem to acknowledge the link between intrusions and meaning making. Recent work has expanded the understanding of intrusions from symptoms of troubled thinking to speculation that intrusions relate to the meaning that an individual assigns to the trauma and it's implications. (Dunmore, Clarke & Ehlers, 1999; Ehlers & Steil, 1995; Foa & Rothbaum, 1998; Greenberg, 1995; Janoff-Bulman, 1992; Harvey & Bryant, 1998; Horowitz, 1999; McCann & Pearlman, 1990; Tedeschi, 1999; van der Kolk, 1996; Williams, 1983). I was surprised to see the short timelines given to people for the meaning making and recovery process. How does one resolve such fundamental breaks in the foundations on which they base their lives, within the short time frames given in the PTSD literature and the DSM IV? Weeks or a few months do not seem to allow for this process but those are the time frames given before the terms chronic PTSD are applied, and speculation that the person is stuck in fruitless rumination begins. Could it be that intrusions are part of the working through process and that initial re-experiencing phenomena are accompanied by those that relate to the implications, meanings and integration of the trauma? 5 Horowitz points out that reschematization in response to trauma is a formidable task. But the amount of information requiring changes in schemas is vast. Complete integration of new meanings into existing schemas is impossible in a short time. The emotional implications to identity, attachment, and safety are too overwhelming. Long-lasting information processing is set in motion and maybe essential to optimum adaptation. (Horowitz, 1999, p. 10) Horowitz' acknowledgement of the difficulty of meaningful integration and adjustment is further elaborated by van der Kolk. "The key element in the psychotherapy of people with PTSD is the integration of the alien, the unacceptable, the terrifying and the incomprehensible; the trauma must come to be "personalized" as an integrated aspect of one's personal history." (van der Kolk et al., 1996 p. xvi). The purpose of this research was to delve into the meaning of intrusive thoughts in the recovery process through the descriptions and reflections of individuals who experienced them in response to trauma. 6 CHAPTER II Literature Review This study described the experience with intrusions that five individuals had in response to a traumatic event and explored the roles and meanings of those intrusions in their recovery stories. The research question was "What do intrusions mean to individuals in their experience of trauma recovery?" This review includes material on what has been posited in the literature as the nature, content and roles of intrusive thoughts as well as theories of trauma response and adjustment. Literature related to the meaning of intrusions for individuals who have experienced trauma has been included, as has material on intrusions and the process of meaning making. For the purposes of this review, the word intrusions will be used to indicate all involuntary or automatic repetitive representations including; nightmares, flashbacks, images, thoughts or questions sometimes thought of as self-talk, as well as emotional, behavioural, somatic and sensory experiences related to the traumatic event. Theoretical Models of Adjustment to Trauma Several authours have proposed that intrusions play a part in an individual's search for meaning by exposing the person to the event and to issues arising as the event's implications develop. (Greenburg, 1995; Williams, 1983; Tedeschi, 1999). Various personality and trauma theorists have suggested that fundamental schemas about self and the world are challenged and altered by trauma. (Janoff-Bulman, 1992; Horowitz, 1976, 1999; Foa & Rothbaum, 1998 & Mcann & Pearlman, 1990). 7 Janoff-Bulman (1992) Assumptive Worlds Theory, a prominent theory of trauma response, suggested that a traumatic event throws the fundamental pretrauma schemas or basic assumptions that guide individuals in their daily lives into question. These core assumptions, which can be shattered by the event, include a person's belief that the world is benevolent and meaningful in that it is predictable and rational. This belief in a just and meaningful world holds that things happen to people because of their behaviour or the type of people they are. It follows that if one is a good individual who behaves or lives right, he or she will be protected from disastrous events. The third fundamental assumption is a belief that the person is a worthwhile human being. It is not that individuals do not understand that bad things happen, it is just that most people believe that they will not happen to them. Trauma exposes these fundamental guiding beliefs as naive and overly positive illusions. Although there is some truth to them, the fact that these beliefs are inadequate in the face of the new posttrauma reality becomes clear to the individual. This is a painful and devastating awareness when combined with the physiological impact of trauma. The foundation of the person's life, the theories that anchor their lives, no longer hold true arid they are adrift. (L. Cochran., personal communication, 1998). Janoff-Bulman's theory (1992) focused on the interpretations and re-definitions the individual makes over time as he or she adapts to the trauma and creates new meaningful assumptions about life. Janoff-Bulman and Frantz (1996) suggested that in the immediate aftermath of trauma, individuals have a choice between two extremes. They can adopt the new beliefs about a meaningless malevolent world in which they are worthless, which is frightening but rings of reality given the traumatic information, or the old theories that are appealing but no longer fit with the new reality. The authours proposed that initially the 8 individual is drawn to the first worldview and that is when one will find them exhibiting symptoms of posttraumatic stress. For Janoff-Bulman (1989), successful recovery occurs when intrusive re-experiencing of the event stops, and healthy adaptation occurs when the individual develops a new perspective that allows the person to account for the trauma, preserve his or her self worth and reconnect with others. She concurred with Horowitz' (1976) description of intrusion and avoidance as the primary automatic cognitive processing strategies involved in stress response. In Janoff-Bulman's theory (1992), the more positive and realistic perspective develops through the use of motivated conscious strategies, social comparison and talking with supportive others. If intrusions are the primary automatic cognitive processing strategies involved in traumatic stress response, how are they involved in the process of creating a meaningful foundation on which one builds their approach to life and their very identity? Do they reflect the turmoil, express the new negative worldview, or do they help individuals confront the issues of the disparity between the old and new views and contribute to re-schematization? In his Theory of Stress Response, Horowitz outlined a process in which two alternating responses to stress occur, intrusion and avoidance. "Intrusion was characterized by unbidden thoughts and images, troubled dreams, strong pangs and waves of feelings, and repetitive behaviour. Avoidance responses included ideational constriction, denial of the meanings and consequences of the event, blunted sensation, behavioral inhibition or counterphobic activity, and awareness of emotional numbness." (Horowitz, 1979, p. 210) The intrusion phase of the cycle serves to repeatedly expose the person to the trauma, while the avoidance phase allows the individual respite from the high emotional arousal of 9 those confrontations. These responses are also part of the working through phase of the model in which the person approaches and withdraws from the event in alternating cycles that gradually decrease in intensity as the individual works through information about the stressful event. Horowitz (1999) proposed that symptoms such as alarm reactions and the intrusive repetition of traumatic perceptions arise when new traumatic information does not match or fit with pretrauma schemas, which are cognitive maps that help individuals to define themselves in the world. "Completion involves the resolution of differences between new information and enduring schemata." (Horowitz, 1976, p. 95). According to Foa and Rothbaum (1998) Janoff-Bulman's theory (1992) did not account for the experience of those who have been previously or chronically traumatized in that positive pretrauma assumptions were proposed. Foa and Rothbaum suggested that individuals who have endured other traumas might hold extremely negative beliefs about themselves and the world. These extremely negative schemas seem to be similar to Janoff-Bulman's proposed early posttrauma worldview. Foa and Rothbaum did not acknowledge that in Janoff Bulman's theory, with integration and adjustment, the negative view is modified into a more realistic one. Foa and Rothbaum proposed that it is the rigidity of extremely positive or negative beliefs about the benevolence of the world and one's worth in terms of competence that effect emotional processing of traumatic information. In their view, pretrauma schemas affect what information will be recorded during the trauma and how it will be interpreted. Any extreme rigid belief about the self and the world, either positive or negative, will hinder processing and increase the likelihood of chronic PTSD. 10 The authours suggested that more moderate and realistic beliefs allow for integration of trauma and less disruption of basic schemas about self and the world. Epstein's (1991) Cognitive-Experiential Self Theory indicated that individuals have four "basic postulates in their personal theory of reality." (p. 278). Individuals have beliefs about how benign or malevolent the world is, whether it is meaningful (predictable, controllable or just), how threatening it is for them to relate to others and beliefs about their own self worth. Epstein posited that if any of these beliefs are invalidated, "the entire self system may be under pressure to disorganise." (p. 278). Traumatic events can cause a serious disruption of these beliefs. Epstein's suggested threat of disorganisation was supported by Janoff-Bulman (1992). "Psychologically, the shattering of fundamental assumptions produces a state of both loss and disintegration; the known, comforting old assumptive world is gone, and a new one must be constructed." (p. 71). McCann and Pearlman (1990) stated that their Constructive Self Development Theory (CSDT) includes notions from several authours and traditions. In the CSDT, cognitive schemas are conscious and unconscious beliefs and expectations through which individuals organize information about self and the world and interpret their experience. The schemas relate to or manifest seven basic psychological needs. "Trauma can disrupt any or all parts of the self, including capacities, resources, needs and schemas" (p. 14). McCann and Pearlman identified the need for safety, trust/dependency, esteem of and for others, independence, power and intimacy. They also determined a need for a frame of reference, or "a stable and coherent framework for understanding one's experience." (p.23). 11 The authours stated that the need for a frame of reference is the superordinate need in their theory, and that it is similar to the Epstein's postulate and Janoff-Bulman's assumption of a just, predictable and meaningful world. A disrupted frame of reference often results from trauma and individuals often search for the meaning of the event and why it happened to them. Ordinarily a need may or may not indicate a problem for the individual, but each need can become disrupted by trauma and general negative schemas related to that need can develop. Self-capacities such as the ability to soothe oneself emotionally, and ego resources such as the ability to moderate self-loathing will affect the response and adjustment to trauma (McCann and Pearlman, 1990). Harvey (1996) has proposed indicators of trauma recovery in her ecological view of trauma and trauma recovery. Her Person x Event x Environment Model provided a multidimensional definition of recovery with eight outcome criteria. These criteria include; authority over the remembering process, integration of memory and affect, affect tolerance, symptom mastery, self-esteem and self-cohesion, safe attachment, meaning making and the ability to give a continuous life narrative. In terms of intrusions, triggers are known and can be avoided or healthful coping routines adopted to reduce arousal and manage stress. The recovered individual can choose to recall or not recall events that previously intruded unbidden into awareness. In recovery, the person is able to call upon and review a relatively complete and continuous life narrative. (Harvey, 1996) 12 The Impact of Intrusions Herman referred to traumatized individuals as ill but also stated that those suffering from traumatic syndromes are undergoing a natural response to unusual circumstances (Herman, 1992). The literature on intrusive thoughts reflects a similar dichotomy. They are seen as part of a natural stress response and symptoms of disorder. Intrusions that initially force the person to relive or re-experience the event repeatedly seem to be accepted as normal symptoms of traumatization (Herman, 1992; Janoff-Bulman, 1989). Acute stress disorder is a diagnostic term applied when an individual experiences intrusion, avoidance and hyperarousal for up to one month after a stressor event. If these phenomena continue, they are regarded as the cardinal symptoms of Posttraumatic stress disorder or PTSD. (McFarlane, 1992; Herman, 1992; Barlow & Durand, 1993; Baum, Cohen & Hall, 1993). "Almost all persons who have been exposed to extreme stress develop intrusive symptoms, but only some of them also develop avoidance and hyperarousal. It is thought that the persistence of intrusive and repetitious thoughts, by means of the process of kindling, sets up a chronically disordered pattern of arousal (van der Kolk, et al. pg. 218). Creamer, Burgess and Pattison (1992) found that intrusive activity both helped and hindered emotional processing, with greater initial frequencies of intrusions predicting recovery. Joseph, Yule and Williams (1995) found that initial intrusion and avoidance levels were strongly associated with poorer general psychological outcome seven and nineteen months after the Jupiter Cruise Ship disaster. Initial intrusion levels predicted scores on the Beck Depression Inventory and the Spielberger State Anxiety Scale at nineteen months post accident, whereas avoidance levels did not. Baum and colleges, 13 (1993) found intrusions predictive of chronic distress, and MacFarlane (1992) indicated that they were part of normal trauma appraisal and coping as well as triggers in the onset of psychological disorder. Brewin, Dalgleish, & Joseph, (1995) and Shalev (1992), suggested that immediately after trauma, intrusions represent normal reaction, with ho predictive value in terms of recovery or outcome. Joseph and colleagues suggested, "After some weeks or months, however, continuing intrusive activity signals a failure to successfully emotionally process the experience and the longer the time elapsed since the trauma, the more likely it is that intrusive thoughts will predict poor outcome." ( Joseph, Dalgleish, Thrasher, Youle, Williams, Hodgkinson, 1996, p. 357). "The symptoms of PTSD emerge as part of a longitudinal process of adjustment to the effects of trauma." (van der Kolk et.al, 1996, p. xii). Content of Intrusions Quantitative studies have made some attempt to identify and categorize the content of intrusive thoughts. In a study designed to discover the content and emotional valence of intrusive thoughts in a "normal" population, Brewin, Christodoulides and Hutchinson (1996) asked 70 undergraduate volunteers to think about any thoughts and memories that commonly popped into their mind. They did not focus on stressful or traumatic events but all events and participants were asked not to include flashbacks. Despite the exclusion of flashbacks and the inclusion of pleasant intrusions such as those related to infatuation, subjects most often named fear as the emotion associated with their intrusive thoughts and sadness or happiness as the emotion accompanying their intrusive memories. Methodological problems were acknowledged by the authours in terms of conflicting 14 results on emotional intensity and frequency, but not on type of emotion which was given in a free response format. In their study of 92 victims of physical or sexual assault, Dunmore, Clark and Ehlers (1999) identified cognitive and behavioural factors that accounted for significant variance in the onset and persistence of PTSD. These factors were: appraisal of actions and emotions during the assault; negative perception of others' reactions to them after the assault; thoughts of permanent change in themselves or their lives, avoidance/safety behaviours, global beliefs before the assault and change in beliefs. In a case study of a woman in therapy for her unresolved grief, behavioural pattern analogues to patterns of intrusion and denial or avoidance were identified, and described "centrally important but currently unresolved topics." (Horowitz, Milbrath, Jordan, Stinson, Ewert, Redinton, Fridhandler, Reidbord, & Hartley, 1994, p. 527). Joseph and colleagues (1995) pointed to a need to identify the content of intrusive thoughts that may lead to symptoms. They suggested that such content may include cognitive distortions such as negative automatic thinking and pessimistic attributional styles and called for research to determine "at what point in time following an event, intrusion becomes a marker of a failure to emotionally process the experience." (p. 191) Qualitative inquiry will assist with the identification of thought content and help with the interpretation of intrusions. Are intrusions, which could be labelled as negative or dysfunctional, prolonging PTSD or an indication that the individual is actively involved in the working through process of resolving disparate schemas and assumptions? Steil and Ehlers (2000) suggest that a change in the negative meaning of intrusions could help the individual move towards recovery. An indication of change in intrusions may be the 15 marker that distinguishes progress from dysfunction, or disorder from recovery. Duration of symptoms seems to be implied as this distinguishing factor now. Intrusions and Reliving the Trauma Various theories of cognitive, cognitive behavioural and emotional processing describe intrusions as largely re-experiencing phenomena. Foa and colleagues (1989) proposed that a massive fear structure is encoded with the strongly imprinted traumatic memory so that as the individual begins to re-experience the event, the fear structure is only partially activated before avoidance mechanisms start. The inactivated portion is not experienced and cannot be habituated. The level of intrusion must be high enough to activate the total fear structure, and avoidance low enough to allow it to be experienced, for the fear response to be habituated. After thought suppression, a cognitive avoidance strategy, the stimulus is generalized to include all of the distracting items the person used during suppression. The re-experiencing response is then triggered by many different stimuli. This is known as the Rebound Effect (Werner & Schneider, 1989). Intrusions may increase after suppression, as Harvey and Bryant (1998) found in the first study of suppression in traumatized individuals, because of the cognitive load suppression places on individuals. Cognitive load causes reliance on more automatic processes and thereby enhances ironic effects. (Harvey & Bryant 1998, p. 589). Baum and colleagues (1993) note that epinephrine and blood glucose, which are known to aid memory encoding, are present at the time of the event so that the traumatic moment is vividly consolidated in memory. They found that these substances were also 16 present in individuals during states of high intrusion. This may further imprint the traumatic memory. Delahanty, Raimonde and Spoonster (2000) found lower levels of urinary Cortisol in motor vehicle accident victims who were subsequently diagnosed with acute Posttraumatic stress disorder, than in those who did not develop the disorder. Cortisol is considered an anti-stress hormone that is activated in times of acute stress. The authours concluded that initial Cortisol levels can predict subsequent PTSD symptomology. This evidence suggests a "downregulation of the hypothalamic-pituitary-adrenal axis in PTSD" (Delahany et. al. 2000). Traumatic memories, visual and sensory images that serve to have the individual relive the traumatic moment have been explained by various neuroanatomical findings. Decreased hippocampal volume has been found in PTSD suffers and not in matched controls. Positron emission tomography studies of individuals with PTSD who were read traumatic scripts showed almost no activity in the Broca's area, the area of the brain related to translating experience into language. There was heightened activity in the right hemisphere in what is called the worry circuit—the limbic system and amygdala areas that are involved in emotional arousal. Simultaneously, there was increased activity in the right visual cortex, which reflected the flashbacks and images reported by the patients, (van der Kolk, 1996). Metcalfe (1996) reviewed literature on traumatic memories and used these and similar findings as evidence of a hot/cool system. In this explanation of memory under stress, the cool system (contextual and narrative) becomes dysfunctional and the hot system (fear evoking) becomes hyperaroused. 17 Neuroanatomical studies explain re-experiencing intrusions, why they persist, and why intrusions are seen as symptoms of disorder and labelled dysfunctional. Are there two types of intrusions as Joseph and his colleagues (1995) suggested? Is there a difference between the initial re-experiencing intrusions such as flashbacks and traumatic memories and intrusions that do not cause the reliving of the trauma? Could these intrusions be part of the working through process of recovery and related to the issues that arise for individuals as they try to construct a reality that includes their experience of trauma? Why do intrusions persist? Meaning and Intrusions Ehlers and Steil (1995) suggested that the negative idiosyncratic meanings of intrusive symptoms contribute to the maintenance of PTSD and propose two pathways. The distress pathway leads to short term maintenance of arousal and re-experiencing symptoms. Physical arousal causes an internal trigger for the occurrence of intrusions, and distress and arousal may confirm the negative meaning the intrusion has for the individual. The avoidance pathway increases intrusions in the short and long term in that dysfunctional meaning and arousal from intrusions motivates the individual to engage in behavioural and cognitive avoidance strategies. The authours stated that avoidance mechanisms such as cognitive rumination, which avoids emotional processing or focuses on events surrounding the trauma while avoiding the event itself, as well as the paradoxical effects of thought suppression strategies, may actually cause the individual to experience more intrusions and become more distressed. "Avoidance of reminders of the trauma prevents reduction in distress/arousal (habituation). It prevents change in meaning of the intrusions and the trauma, and thus maintains the intrusions in the long run." (Steil & Ehlers, 2000, p. 540) 18 In two quantitative studies of 297 individuals involved in serious motor vehicle accidents, Steil & Ehlers, (2000) found that intrusion frequency was only moderately associated with PTSD severity, while intrusive recollections that were distressing to the individual were related to persistent PTSD symptoms. To the authours, the meaning the individual assigned to the symptoms determined whether the intrusion distressed them. If the occurrence or content of intrusions are interpreted as indicating (mental) insanity, incompetence, permanent negative change or future danger, the person experiences distress. If on the contrary intrusions are seen as a normal part of recovery and processing of the trauma, distress is less likely (Steil & Ehlers, 2000, p. 554). They report that the dysfunctional meaning of intrusions emerged as a significant predictor of PTSD severity when intrusion frequency, accident severity, and general anxiety-related cognitions were controlled for and explained additional variance beyond intrusion frequency and avoidance measures. The authors suggested that further research directly focusing on the meanings of intrusions is needed, and propose that treatment strategies aimed at identifying, restructuring and changing the negative idiosyncratic meaning of posttraumatic intrusions should be helpful (Steil & Ehlers, 2000). Joseph and colleagues (1996) also called for further research on the nature and content of intrusions and speculate that interventions should not seek to discourage intrusions but to modify the meaning of them. In her discussion paper on post-war adjustment, Williams notes that any unsettling important life event can illumine how incomplete or incorrect previous assumptions or beliefs have been. She sees, in most cases, intrusive thoughts and memories not as signs of illness, but "healthy and adaptive pathways in one's personal search for meaning" (Williams, 1983, p. 14). 19 In his article on posttraumatic growth in survivors of crime and violence, Tedeschi suggested four posttrauma growth domains; identity, goals, relationships with others and appreciation of life. Tedeschi maintained that it is not the event but "what it does to a person that sets the stage for growth. It is the struggle with the new reality in the aftermath of trauma that is crucial in determining the extent to which posttraumatic growth occurs. " (Tedeschi, 1999, p.321) Some successful coping must have allowed the survivor to relieve emotional distress and intrusive ruminations, and they must be engaged in the effortful aspects of the ruminative process, showing that they are actively searching for ways to conmprehend the trauma and its aftermath. This is fertile ground for growth. (Tedeschi, 1999, p. 334). Tedeschi suggested that high initial automatic intrusive rumination and re-experiencing phenomena could be conducive to growth because they result in greater coping efforts to reduce distress and allow "the possibility for a revision of schemas in a way that makes the perception of positive change more likely." (p. 329). The authour contends that continued automatic intrusive ruminations may indicate failure to manage emotional distress. The construction of revised schemas occurs through a more deliberate cognitive process that follows the early automatic ruminations (Tedeschi, 1999). Intrusions have been described in the literature as; symptoms, part of a natural process of stress response, playing both adaptive and hindering roles in cognitive processing, directing the search for meaning, predictive of chronic stress, both dysfunctional and functional, depending on the meaning assigned by the individual, and triggers in the onset of psychological disorder. (Herman, 1992, Horowitz, 1994, McFarlane, 1992a, Creamer, 1992, Foa, 1989, Williams, 1983, Baum, 1993 & Steil, 2000) It is possible that all of these descriptors are accurate. 20 Quantitative studies have provided information about intensity, duration and frequency of intrusions as well as correlational outcome data about intrusions and the development of disorders. Very little investigation has been done as to what intrusive cognitions mean from the perspective of individuals who have experienced them. It is difficult to understand the meaning of intrusive thoughts in trauma response and recovery without having a lived experience or context in which to place the intrusions, and an understanding of what intrusions are. Information on the nature, roles and meanings of intrusions in trauma recovery can come from exploration of the recovery narratives of individuals who have experienced trauma. The information will inform clinicians in terms of assessment, planning and therapy. Qualitative investigation is required to delve into the process each individual goes through in reconstructing their worldview after trauma and suggest how intrusions are involved in that process. 21 CHAPTER UI Method Approach This research followed a narrative multiple case study design. The research question was, What do intrusions mean to individuals in their experience of trauma recovery? Tedeschi (1999) described a process of traumatic change and the development of a narrative that has been supported by other authours as a sign of integration and recovery. (Harvey, 1996: & van der Kolk et al, 1996) A personal narrative is then produced that incorporates life before the trauma, the struggle with the ensuing changes, and the new way of living, and with this narrative comes changes in identity. This distressing process often involves transitory symptoms of anxiety, depression or posttraumatic stress disorder. (Tedeschi 1999 p. 322) What is the role of intrusions in the development of this narrative? Are they signs of anxious and depressive thinking, or are they mechanisms that cause the individual to confront the issues inherent in shattered fundamental beliefs? A narrative research design was selected to explore, describe and explain the content of trauma-induced intrusions within the context of the participants' lives. The temporal nature of narrative inquiry fostered description of the way the intrusions played themselves out within the recovery stories. The evolution and resolution of the intrusions, relationships of intrusions to events in the participants' lives post-trauma and how the intrusions effected the plots of the recovery narratives were explored in this research. 22 Inclusion Criteria Individuals were eligible to participate in the study if they met the criteria outlined below. 1. They had experienced a traumatic event that met the stressor criteria of the DSM-IV (1994) in that they had experienced a traumatic event which involved a threat to their life or bodily integrity, or had a close personal encounter with the same. 2. They felt or reported that they had largely recovered from the event. 3. They had experienced intrusions in response to the traumatic event. 4. They could remember their intrusions. 5. They could talk about their intrusions and the event without experiencing strong post trauma reactions. Recruitment and Screening of Participants Recruitment took place through snowball sampling. Individuals in and outside of the counselling field were asked if they knew of anyone who met the criteria and might be interested in participating in the study. They were given the researcher's phone number to provide to interested individuals. Professional counsellors were sent study posters, a letter of consent and description of the research interview for their information. Interested individuals were screened through telephone conversations in which the criteria were reviewed and the study procedures were explained. Interviews were arranged with those who met the criteria and wanted to proceed, based on the information that they were given. When there was time, the study poster and letter of consent were sent to the individuals in advance. 23 The first twenty minutes of the research interview was used by the researcher to establish safety and observe the participant for overt behavioural and verbal indicators of posttrauma reactions and the ability to talk about the study without becoming overtly distressed. The study procedures and letter of consent were read aloud and discussed before the individuals were asked if they wanted to proceed. The consent letter was then signed and a copy provided to the participant. Interview Sites The potential participants selected the place of the interview from the choice of their home, the researchers home or the closest counselling centre that the researcher had access to. Two participants chose to be interviewed in the researcher's home, two chose their own home, and one was interviewed in the counselling offices of the Y M C A in downtown Vancouver. Three participants were interviewed in Vancouver, British Columbia and two in Edmonton, Alberta, where they reside. The Research Interview One semi-structured research interview ranging from 2 to 3 1/2 hours was conducted with each of the chosen participants. The story of the participant's recovery was explored, beginning with the traumatic event. The researcher collaborated with the participants to describe their experience of intrusions in the context of their recovery narrative. The research interview outline follows. Through this conversation, I am hoping that we can work to describe your recovery or how you adjusted to life since the trauma. As we do so, I want to explore with you what you experienced in terms of intrusions. Intrusions are recurring, unbidden and uncontrollable thoughts, images, dreams, sensations, flashbacks and nightmares that people 24 often experience after traumatic events. These intrusions are accompanied by strong emotions. As we go through your story I will be trying to gain as much information as possible about the impact that the intrusions had on you, how they played themselves out overtime and how they affected your recovery. We will explore what the intrusions meant to you. 1. Please begin by telling me about the event, in as much or as little detail as you feel comfortable with. 2. Can you give to me a brief outline of your life since the event? Please continue the story from where you left off so that I get an idea of what you have done and what you have been going through. I am trying to get an understanding of the big picture or the story of your recovery and a context or background for our discussions about the intrusions. 3. Let's focus on the first few months after the trauma. During this time did you have memories of the event that made you feel like you were reliving it? Did you have intrusive thoughts, nightmares, or images? You may have had all, some or none of these. If you did experience any intrusions during this period, please describe them generally. As we go, I would like to sketch out a general picture of the way the intrusions occurred over time. 4. Now let's describe any further intrusions that you may have had. 5. I would like to now change from going through your recovery from beginning to end and concentrate now on how you experienced the intrusions. As we talk about the intrusions, I will be asking questions to guide the discussion, but these are only guides. I want you to feel free to say anything you wish about your experience. We are trying to describe your experience. I may not know all of the right questions to ask. 25 6. During this part of the discussion, the interviewer will be trying to elicit descriptions and information that address the following questions and research needs: - Description of the flashback, dream, nightmare, memory, sensation or visual image The verbatim content of intrusive thoughts or questions - When the intrusion began and if it was related to any event, change, person or decision in the person's life. - Any changes in the intrusion over time, particularly in terms of content and changes in the person's life. Whether the intrusion stopped occurring and if so why? Did the end of an intrusion relate to anything else in the participant's life at the time? Here the interviewer will be listening for events or actions, insights, decisions, new intrusions and emotions that the participant speaks of in relaying the story or explaining the end of an intrusion. - What meaning does the participant make of the intrusion? - In reflecting on the entire process, what does the participant think the role or purpose of intrusions was in that process. Why do intrusions occur? - Information about assumptions or interpretations the individuals once held or now make about themselves, the world and how to live. Working with the Information Two sets of audiotapes of the interviews were made. One set of tapes was sent to a professional transcriber for the sake of expediency. The researcher listened to each case once and then listened again while reading the transcript before beginning to write the case 26 from the transcript. A narrative of the recovery story of each participant was written and was based on the information from the tapes and transcripts. Intrusions were included in the narratives when it was possible to do so, in order to illustrate how they appeared throughout the recovery story and provide interpretations of the intrusions within a context. In many of the cases, all of the intrusions identified with the participants could not be included in the narrative because attempts to do so adversely affected the flow of the story and made it difficult to read. Al l of the intrusions that were identified in each research interview have been included with each case, in the section titled Meaning of the Intrusions. This is similar to the interview experience, in that the participants mentioned some of the intrusions as they told their story and others were identified within the conversation about the story. An effort was made to ensure that the each case represented the information from the research interviews. The explanation of what the intrusions meant to the individual was written to describe the participant's explanation of the intrusions during the research conversation. Al l of the information about the intrusion from the tapes and transcripts was incorporated into the description and interpretation of the intrusion. The goal of the researcher was to describe the meaning of the intrusions, as conveyed to her in the research interview by the participant. Member Verification of Interview Material The participants provided verification of the study findings. A second interview was conducted with three of the participants, those who live in Vancouver. Their input was recorded in writing by the researcher or written by the participant on the review draft of the case chapter. Their changes and additions were incorporated into this report. No one 27 wanted anything removed from the report. Two participants added an additional intrusion and offered more details about their story and one suggested that single words and phrases be changed to clarify the story. The three participants verified that the written work reflected their experience and interpretations. In the case of Little One, multiple layers of meaning became clear upon reading the transcripts, and the meaning of the intrusion was written to include that tacit meaning. The participant confirmed this interpretation, in that she seemed to gain that same insight. The description of the intrusion provided a new means of looking at the intrusion within the context of the story. She then verified the researcher's suggested interpretation when she read that part of the write-up. The two participants in Edmonton received their case studies through e-mail, in an effort to ensure that there would be a written record of their comments. One participant e-mailed her suggestions for changes to the length of time she was in hospital, and approved the meaning of the intrusions. One case, It Could Be Worse, has not been verified by the participant, as he did not respond to the e-mail or two telephone messages requesting his feedback. In a recent telephone conversation about the study, he said he would read and respond to the e-mail but has not yet done so. Analysis A cross case analysis was performed in areas related to the meaning of intrusions to the participants in terms of their experience of the process of trauma recovery. This analysis identified three categories of intrusions and the shattered assumptions that were revealed in the content or meaning of the intrusions. A general description suggesting each participant's process of meaning making has been provided in relation to the presence and role of intrusions in that process. Observations about similar content and themes that were 28 involved in most or all of the case studies were made. The participant's thoughts on the role of intrusions and their involvement in the research process has been reported in the results section of this report. 29 CHAPTER IV Case Studies Description of the Cases The names of the study participants have been kept confidential, in that different names have been assigned to them in the study material. One individual asked that her name not be disguised and this will be explained below. Each case study described a different traumatic event because traumatic intrusions are accepted as natural responses to trauma. Across trauma investigation allowed the focus to be the common experience of intrusions, and avoided a comparison of how the individuals coped with the same type of traumatic stressor. Little One Sharon is a 46-year-old single mother who suffered chronic trauma as a child. She has identified the trauma of her life, and the focus for this case study, as the 5 years that she spent in an abusive foster home. She has few early childhood memories and her first clear memory is of her first night in foster care, when she was 5 years old. She endured severe distress from trauma related nightmares from the age of 5 to 26. Groomed Sam was abused from the age of 7 to 21 by his volunteer Big Brother from Big Brothers Association. He then reported his abuse to the police and began an intense process of change. Sam is now 26 old. He is single and works security at a nightclub. 30 Betrayed In 1972, at the age of 42, Adella Matthew decided to get breast implants. She began to suffer the effects of silicone toxicity almost immediately. The trauma of that life threatening condition, as well as the struggle to have it acknowledged and treated, constitute the trauma described in this case study. She had the implants removed at the age of 62 and is now 71 years old. Adella is a founding member and the current president of the Implant Awareness Society of British Columbia. She requested that her and her husband's names and contact information be provided in this study, so that anyone who reads this study will be able to direct interested women to them for information, resources or support. Adella and Richard or the I. A. S can be contacted at (604) 572-8486. Email: matthew@radiant.net Web site: wwwinfo-implants.com/BC/index.html Could be worse Greg is a 34-year-old single male who suffered extensive and severe injuries in an automobile accident on May 31st' 1999. He spent six months in hospital, a year recuperating at his parents home, and has lived on his own and been able to work in his trade for about six months. It was bad enough Noreen is a 43-year-old married teacher who suffered a direct lightning strike to her torso in June of 1999. She was badly injured in the incident but her physical injuries are not debilitating and she was able to return to work with 17 months. She described her return to work as a psychological and emotional struggle, and stated "The lightning was kinder to me than my return to work." 31 Little One A little blond girl, 5 years of age, awakes in a soundless scream from the nightmare that haunts her every time she is able to fall asleep. She does not leave her bed. Her 6-year-old sister is there to comfort her, and holds her hand until she can go back to sleep. The girls have pushed their twin beds together so that this ritual can be performed again and again, every night. In the morning, the two little girls gather up the smaller girl's bedding and begin their anxious sojourn down the stairs to the washing machine in the basement, for she has wet the bed once again. As always the stairs creak and they do not make it. Their foster parents discover them. He is not a nice man and she is a harsh woman. They do not mean to be cruel, it is just that they do not understand or seem to like the littlest girl. She does not like them, and they know she will never accept them. She won't" put down her sword," for they are not her parents, and she does not understand why she lives with them. No one told her why she and her seven brothers and sisters were abducted from their home. Al l she knows is that everyone is gone and her mother is dead. Her mother must be dead. So as with every other morning, the little one is beaten for her crime of wetting the bed. She is beaten with a belt. She does not tell the worker who comes to the house about the beatings. She cannot tell her because the foster parents are sitting right there and she is afraid to tell on them. She is happy that they do not beat her sister. Her sister fits in better with that family of boys because she is a tomboy. The little one likes party dresses and tea parties. She only tells the social worker that she wants to go home and that she misses her mother. She cries and cries for her mother. For 3 years she cries for her mother. 32 The foster parents rearrange the girls' bedroom and separate the two beds. The girls are forbidden from moving them back together. Now when she awakes in speechless terror, the little one cannot call to her sister, no sound comes out of her mouth. She is too frightened to put her feet on the floor and go to her sister. The aliens and Indians with war paint and machetes, who crawl up her bed in her dreams, hide in the closet and under the bed. They will get her if she tries to leave her bed. One day, her mother and a man come to the foster home to visit the girls. She is alive! The visit lasts 15 minutes. The little girl stands with her face and hands pressed against her bedroom window as she watches her mother drive away with her new husband. She cries out for her. Her mother does not hear or answer her cries. The little one does not know why her mother is leaving with him and not taking her and her sister. For 2 more years she cries. When her mother telephones from her new home up North, the little girl cannot talk. She cannot tell her to come and get her. She can only cry. She bawls and bawls into the phone. She cries for years. When she is 10 years old, her cries are answered. Her mother, stepfather and all her brothers and sisters move into a house together. She is happy to be with her family and most of all her mother and her dear sister who protected and comforted her in the foster home. The nightmare has stopped. Still, one of her sisters always sits with her and holds her hand until she falls asleep. Within a short time, new nightmares come almost every night. They are not about her anymore. She is not in danger like in her other dreams; in these dreams her whole family is being slaughtered. She is hidden away, put in a safe place by her sister from the foster home. The little girl is the watcher; she sees the horror and hears the screams until 33 she can bear it no longer. She has to help. She cannot see the face of the man who is attacking her family with an axe, but she knows who he is. Her oldest brother is the one killing her family. The little one runs to save her family, but she can't. Her mother has already been killed, and she tries to save each brother and sister, but with each one she fails. As the little one runs to protect her sister, the axe slashes off her sister's arm, and she collapses into a pool of blood and dies. It is at this moment of excruciating pain and terror that the little girl wakes up. Night after night, for over 15 years, the family is slaughtered and the little girl is unable to help. She can only watch and fail in her attempts to save them. In the waking world, the family is together. The house is safe when Mother is home, but she'has-a lot of jobs and has to be gone a lot. When she is gone, the war starts. The boys attack the girls, who all band together to protect themselves and fight back. There is a lot of fighting. The little one does not know what will happen next. Sometimes people get thrown around the room. Anything can happen. She is frightened of her oldest brother. He is a criminal. She knows that because once when she was in the car with him he told her to get down on the floor because the cops were chasing them. He drove faster and faster and laughed and laughed as the police kept chasing them. He looked crazy. He is crazy and he is a criminal. By the time the young girl is 13, her oldest brother has been kicked out of the house. Some of the other brothers and her stepfather have left. There is less fighting going on. Her mother has just married her third husband, a nice man, and the family has moved into an old house in a different neighbourhood. She does not feel very safe in this neighbourhood and when she is in her bedroom she feels a sense of darkness and doom 34 descend upon her like a cloud. She has to check her entire room before she can try to sleep, and sometimes wakes up her sister so that they can check the house in the middle of the night. Her sisters still sit with her and hold her hand so that she can go to sleep. She is sure that she sees faces at her window, which means someone is in the yard. Sometimes the doorknob rattles, and she stiffens, waiting in case the intruder enters her room. No matter how long she waits, there is no guarantee that the person on the other side of the door will not outwait her. She cannot tell what is real and what is her imagination. She cannot tell. A lot of strange things happen in her family; you could be attacked at any moment. She just wishes she could decide if it is her imagination so that she could go to sleep. But when she sleeps, the nightmares come. As a teenager the girl lives a cautious life, leaving parties as soon as she feels that she has had a little too much to drink, that anything could go out of control or that she is vulnerable. She learns how to behave on the street to avoid being spoken to. She carries with her a feeling of insecurity. When the young woman is almost 20, she decides to see the world. She travels to Europe, and then takes up residence in a large American city. During this time, she learns that she is not the only one who has been hurt in childhood. She notes to herself that she has done okay. She has not been in abusive relationships and is doing better than some of the other people she has met. She gets the impression that she is actually quite strong. Yet so much bothers her about her past, and she is worried about her fearfulness and tendency to panic whenever anything unanticipated happens. She is embarrassed by her need to keep the lights on when she sleeps and ashamed when others notice her night 35 terrors. She feels very different from other people, a hidden part of her exists with the dream and she keeps her secret past from others. She cannot shake the fear inside her or her inability to trust people. She does not feel safe. She enters therapy in her early twenties and works on her childhood traumas on and off over the next decade. While working with her therapist, the young woman comes to the realisation that what was done to her in childhood was wrong, that it was not her fault, and that as a child she was powerless to stop it. As an adult, she has power and can protect herself. She thinks that she had heard this earlier but it didn't meant anything to her before. She can now accept and believe it. It is at this point that her nightmare, which plagued and terrified her from the age of 10 to 26 stops. Sharon later identified a career path based on her burning desire to help children. After 7 years in an unrewarding marriage and as a single mother of a preschooler, she went to university. She completed her undergraduate degree and a master's degree in Counselling Psychology. Sharon received no child support from her ex-husband but was determined to reach her goal of becoming a child therapist. "I have been so justly rewarded for all the pain . . . it's not about the paycheque, it's about the children." Sharon laughs and states that she is now a protector in that she "holds the hands of the children who are in foster care." She implements many of the things that she thinks should have been done for her and her siblings. She knows that children need to be told why they were apprehended and have their love for their families acknowledged and respected. She helps children who are silenced, by lending them her voice as an advocate and helping them to find their own through therapy. She can be a role model of someone who made it through the system and lives happily. "I felt so powerless before and now I can look with 36 kind hands and heart on where I was, and the new faces that are where I was in many ways." Sharon has successfully advocated for training for foster parents so that they can understand the needs and behaviours of traumatized children and help them to "put down their swords." The Meaning of the Intrusions Sharon has identified her apprehension into foster care as the traumatic event of her childhood, and the beginning of her story for this research. She has no clear autobiographical memory for events before the placement. Prior to the apprehension, her mother was her lifeline. "I remember things like my mother being very safe, always wanting to hold my mother's arm or the bottom of her skirt. She always felt safe for me. I remember feelings but not memories. Many times my mother was knocked out, stabbed, what have you, so obviously I was in a traumatized home, but I have no memories." I couldn't put one and one together. I had no idea. Al l I knew was I have my family and then all of a sudden I don't have my family. The most traumatic thing that happened to me in my life was being in that foster home. I don't care about all the trauma that happened in my house. To me the trauma was being taken away and then nobody for 3 years, like nobody." Sharon acknowledges that there was apparently "huge trauma going on in that house" and feels that the apprehension was justified. The children suffered and were re-traumatized because of the foster care system's lack of safety, support, communication and understanding of their needs. She found out later that her siblings also suffered abuse and humiliation. Apparently she was in the healthiest foster home. Her sister for example, was demeaned for being a chubby 13 year old. She was regularly given a dime to buy a bag of 37 chips for her dinner, and was made to eat them and all her other meals on the front porch, so that the family didn't have to watch her eat. Intrusions. 1. Nightmare in which little creatures crawl up her bed. In this dream little Indians in war paint carrying machetes approach the bed, climb up the bedding and come to attack her. She wakes up when they reach her shoulders, screams but no one hears her because it is a silent scream. This nightmare starts when the little girl begins living in her foster home. It occurs almost every night and lasts until the child is reunited with her family 5 years later. The nightmare changes when she is 8 or 9 years old. Two purple aliens who also try to attack her replace the Indians in the nightmare. The nightmare stops occurring when she is taken out of the home and re-united with her family. Sharon explains the intrusion. "Just the sense of powerlessness, the sense of fear, such horrible anxiety and fear to live with them and it came out in nightmares . . . I had no voice, I just had my tears." Sharon interprets the soundless scream as a measure of how frightened she was during the dream, in her life and in her foster home. The change in the dream from natives to aliens may be significant, as the two aliens may represent her foster parents or her mother and the man. The change in dream characters corresponds with her awareness at about the age of 8 that her mother is not dead but has left her with the foster parents. Sharon explains that when her mother abandoned her that day, she felt that the world became like an alien place to her. 38 2. Nightmare in which a man slaughters her family with an axe. In this dream the little one is the watcher, hidden away by the sister who always protected her. She hears and sees the brutal slaying of her mother and brothers and sisters by a faceless axe murderer, her oldest brother. She tries to save her family and her protective sister but fails. She wakes in terror. This nightmare begins shortly after she is reunited with her mother and siblings, when Sharon is 10 years old and occurs almost every night for 16 years. The nightmare stops occurring after the Sharon gained insight in therapy that while she was a powerless victim in childhood, she could protect herself as an adult. She had a sense that she was coming to the end of her turmoil and that she had started to heal. The dream seems to represent and parallel her life situation in that she is the witness in this dream and may have been the witness to the family violence before the age of 5 as well as after the age of 10. As the youngest child in the house, she may have hid, been hidden or simply been safe from direct assault because of her age, just as she was hidden in the dream. Her fear for her family members and inability to stop the violence in her home seem to be illustrated in the dream. After the dream, she was very aware of her powerlessness "I couldn't stop it, I couldn't believe that I couldn't stop the horror." Her fear and helplessness are the themes of her nightmares. For over 15 years, she relives her experience of being a terrified and helpless child, with no control over her environment. Sharon's dream portrays her protective sister's death in more detail than the rest, her arm is cut off and Sharon describes the moment of her protective sister's death as a moment of excruciating pain and terror. The arm may be a symbol of the protective stance the sister always took in Sharon's life, reaching out for her in bed and shielding her in life. 39 Sharon points out that "Where I always woke up, was not because my mother got slaughtered, it was when my sister did. It was when I couldn't save her that it was just too traumatic and I remember, like her arm being chopped off. . . her, always trying to protect . . . I guess it was such a deep, deep love, because I knew she loved me so unconditionally. My mother, I lost my mother in those years. My mother, I couldn't depend on my mother. So it was almost like she was vulnerable, or she was fragile, but my sister wasn't... she was always there at just the right time, constantly being my protector. She lost a lot of her youth protecting me because she was my surrogate mother. My whole family being slaughtered, but in the end, where I would wake up petrified would be when my sister was murdered." The little girl in the nightmare may have been terrified not only by her sister's death, but also by the meaning of it. She will no longer be protected and may become the next victim. We do hot know, because she wakes in terror at that time, but Sharon does not make that interpretation. Sharon gives her explanation of why the nightmares changed from danger to her to the slaughter of everyone else in the family. "Trauma happened in the home before I went to foster care. Trauma didn't really happen in the home after I was returned, except to other people—not to me." She clarifies, no, not to everyone. "No, just a few, so maybe it's not that parallel. Yeah. I'm just thinking of one particular sibling, you know she was raped by one of my brothers. She was 16 and she felt very angry with my siblings and me because we didn't come directly home from school that day... there was nobody to protect her. The abuse, the abuse, I had no idea what was going on." Sharon was not told of the rape until she was in her late twenties. She points out that this sister was a ready victim, more vulnerable than the rest of the older children. She was the only child of the family who was 40 placed in a foster home by herself. She was also the child who had to eat outside, away from the foster family. Sharon thinks that the brother who raped her sister may be the brother in the dream. "I think so, they had no face . . . I think that he was part of the early trauma. Like when I say craziness, I mean his behaviour was very crazy. He was the brother who had the effervescent smile on his face when we were being chased by the police car. He learned it all in our family system . . . and I had sisters that were . . . I was too young, that's why I say I wasn't part of that trauma in a sense. I guess I was too young, when I got placed in the foster home, but apparently it was huge trauma going on in that house." The children's biological father, her mother's first husband, promoted incest in the home. He did not molest the children directly. He encouraged the boys to have sex with their sisters, taught them that it was their right. That explains why the war Sharon described that occurred when her mother left the house involved the girls banding together to protect themselves against the boys. The battle lines were clearly drawn on the basis of gender rather than personality. "It didn't happen to me, I was very small. I was fortunate." Maybe that was why everyone else was being slaughtered in the dream, "Yeah, Maybe I was the eyes. I have no memory of seeing that horrible thing, I have no memory of seeing horrible things . . . but I heard horrible things . . . knowing but not seeing." As an adult Sharon felt that, "There was something hidden inside of me that the dream still owned in a sense. There was a dark side to me . . . this is what I felt and that is the shame part, that I felt my life was so out of control." She always felt that shame. As a girl she felt that it was important that no one find out what her home life was really like. As 41 an adult, she carried the painful secret about the horrific things her family members did to each other. She was different from others, for she came from that family. "I learned so much about myself when I travelled, and learned about other people. After my travels, when I started working on myself in therapy, I started realizing that it was really important how I looked at the traumatic event and learned from it that every child needs to be protected and that I was really unprotected, and it is not about me being a bad person." 3. Poor me. Poor me. Sharon thought this throughout her life, and as with the nightmares, this intrusive thought ended when she was about 26 years old with the insight that she did not have to stay a victim. Sharon explains this as an expression of her feelings and outlook as a victim. "It didn't leave until I was in my mid-twenties, the whole victimization, sort of that stocked woman idea. But it's learned. It's learned. I now notice when I am catastrophizing. That's no good. It's a marker for me. Don't go flying off the handle." She explains that when she worked through things in therapy, the "poor me thing" stopped. She also came to believe that her trauma gave her strength and compassion for others, instead of making her weak. 4. It's an unsafe world. I'm not safe. Don't trust anybody. Versions of these thoughts occurred throughout Sharon's life from the age of 5 until her shift in outlook when she was about 26. These phrases express her understanding of life as a child and a young woman. 42 Sharon still believes that the world is unsafe. "There are so many times that I was unsafe in the world so it's not my imagination. It's not just from my trauma. It's quite a realistic view . . . I have to say it made me more . . . protective, more scrutinizing the environment, discriminating in the environment. Looking around, thinking OK, where's the trouble? I'm still constantly making sure that I'm safe and that my child is safe. I also put ways to check that it's not me overreacting. I don't want to make my child afraid of the world but I want him to be conscious . . . I say to my son, "When you're afraid, turn on the lights and face your fears. Look at them." 5. An overpowering sense of doom and darkness that descends upon her while she is in her bed. This sense of doom is tangible to her. A dark sensation descends upon her like a cloud. Images of faces may appear fleetingly in the window and she thinks someone is waiting outside her door, trying the doorknob. These images and sensations begin when she is 13 years old after the family has moved to an old house in a different area. They continue until the family leaves the home 3 years later. The darkening force descends and indicates impending doom. An evil intruder is watching and preparing to attack her. She is being stalked in her own home. Her home is not safe and as with her first nightmare, the fear immobilizes her. She is too frightened to move off of her bed. Sharon explains that the intrusion expressed her fear of change and of her new neighbourhood. "I see my life in moves. Each time there was another move, another transition, many fears would come up again . . . new environment and whether you feel safe or not. I was so afraid of that house; it had too many dark corners. Moves were very 43 fxightening, everything was too unpredictable until the landscape became known and controlled. "I never thought about the fear of being unsafe, how prevalent it was really in my life. I actually think I was always worried about someone seeing and looking in and hurting me. Not the idea of in a sexual way, I don't mean like that, in a scary way. Like someone very unsavoury, someone not to be trusted, someone that was evil. Something so scary. " Although her older brothers have left the home and the eldest, whom she is most afraid of is gone, that sense of vigilance and impending assault remain. She struggles with the fact that she cannot tell whether she is imagining the sounds and clues that someone is there or not, because in the past this was a very real possibility. She could be imagining it, or unfortunately it could be real. Although Sharon explains that she had sense of being watched and stalked by someone evil is due to the fact that she found her new neighbourhood unsavoury, this intrusion may illumine tacit meanings and fears about her vulnerability to incest in the home. Sharon was safe as a young child from the horrific things that she did not see but heard and heard about. "I was too young, I was very fortunate, I was too young." Was she too young to be targeted for incest? This intrusion occurs when she is 13, of the age, a pubescent girl, not the baby any longer and possibly not safe from sexual assault any longer. She may know that she cannot be assured that her older brothers will not return. She also may be aware that other men could be interested in her now that she is becoming a woman. 44 6. Panic sensations when close relationships, especially with men, end. These sessions don't last long, usually one night. Sharon's reaction to the possibility that her friend or partner may end a relationship is panic. She paces quickly a lot and repeatedly says to herself, "Oh my god, I can't stand this, I can't handle this, I can't do this again. It's actually just the beginning, like the first night in the foster home." Sharon explains that many forms of rejection in personal relationships send her right back to the time of her separation from her mother. She relives it emotionally, "Just a chaos of anxiety inside me . . . almost like I was paralysed by this fear that was going around and around in my head that made me even more fearful and I couldn't settle myself down." To put words to the chaos, "I'm no good, I'm a failure, I'm not loved, I'm not worth it." These reactions pass within an evening usually. She will end the romantic relationship clearly and will not allow indecisive or protracted endings. In this way she takes control of a situation in which she was the recipient or "victim" of someone else's decision. 7. Anticipating the end of close relationships Sharon remembers wanting to find her soul mate and yearning for that love. "I would separate my yearning from reality and say, I can get lost in this fantasy. When are they going to leave, next week, or next month, and almost creating in many ways a self-fiilfilled collapse of the relationship. The horrific pain I would feel, because it would click right into loss in my childhood. It would go right back there . . .this huge abandonment issue . . . this sense of being a huge void." 45 8. Strong panic-like reactions to unanticipated events, such as being late. This panic reaction has occurred throughout Sharon's life and has been greatly reduced for the last decade. She explains that these emotions illustrate her belief that if someone is not where they are supposed to be something horrific has happened to them. Sharon thought for example, that her mother's disappearance from her life meant that she was dead. Sharon is equally distressed if she is late. She does not want others to worry that something disastrous had happened to her. She dealt with this panic reaction in therapy and has adopted many strategies to avoid creating such situations. Cognitive behavioural therapy was useful for her. She purchased a pager and cell phone, keeps her date book and address book organized, and talks herself down from anxiety when she is trying to get out of the house with her small son or is delayed in any way. "I use language to keep myself grounded." She has adopted a slogan, which helps her deal with life's contingencies and avoid overreacting, "There's no trauma, drama or crisis for me." Sharon re-frames situations by saying, "This is a nuisance" rather than a disaster. 9. Flashbacks while working. Sharon finds that not only the situations of the families and children she works with in the child protection system, but the places and sights where she visited her family as a child pull her back to her trauma many times. "It's where I started and now I really live my trauma, but as an adult I'm able to cope . . . I'm always in search. It's almost soothing for me because I'm always putting things back in place, like markers along the way. Only now, I'm here at a master's level, where I can make changes and my clinical impression 46 means something. This constant search to complete my childhood in a sense, to make a happier ending for somebody else. That's where the meaning comes in for me." 47 Groomed When Sam was 7 years old, about 2 years after his Mom and Dad broke up; he met Jim, his big brother from Big Brother's Association. Jim was supposed to spend about 4 hours a week with the little boy, for about a year. They spent more and more time together and Jim actions and influence consumed Sam's life for the next 20 years. At first it was great. They did so many things together and went to places like Playland and the PNE. About 18 months after they met, they spent the night at Jim's parent's house. His parents were away and Sam was told to sleep in their bed. "When I woke up, I was laying on top of him, and didn't know what had happened to me. I felt differently than when I went to sleep. I felt confused and very scared. I felt guilty, guilty about what I had no idea." Sam told his parents about waking up like that. They spoke to Jim, who swore that nothing happened that night. Sam had no memory of anything. They talked to Sam about sexual abuse, and he must have seemed OK to them, because the relationship was allowed to continue. Nothing happened for a while. They went to dude ranches, Whistler, and other places in and out of the province. It was in Whistler, when Sam was 9 or 10 years old, that things started to happen. "I would awake and find him masturbating me, caressing me, touching me in ways that just weren't right and didn't feel right. This went on until I was 21 years old." What happened to that little boy? Jim handed Sam his first drink at the age of 9 and he abused alcohol until he was 21 years old. He stopped going to Little League because he 48 felt bad about himself and just couldn't do it anymore. He dropped out of Boy Scouts, because Jim wanted to come along and to volunteer as a camp leader. If I was a part of those things, I would be putting so many other children at risk. By not doing it I'm protecting them and taking the brunt of the force myself... I gave up on all my activities as a child and that was that. I didn't want to be a part of any team, or anything I just wanted to be by myself. When he was with Jim he tried various things to avoid being touched like cinching up his belt or track pants so tight that he could hardly breath, staying awake all night, sleeping under beds or locking himself in the bathroom. At school he acted out, became the class clown and argued with teachers. He was placed in a learning disabilities class. He probably could have kept up with the other kids but felt so scared, angry, confused and had so much on his mind that he couldn't focus on a half hour television show, let alone school. He listened intently during abuse prevention talks and heard that there was nothing for him. What he heard most clearly was that girls were the ones abused, not boys. As a boy, he did not gain the confidence from those presentations to talk to someone. He felt more abhorrent and alone than before. Sam wished that someone would just come out and ask him if something was happening to him. As he went through his teens the boy hid. He hid behind baggy clothing. He hid his face. He wore a baseball cap pulled down so that no one could see his eyes. He wore that cap for years, and eventually slept with it on. To see my eyes was a very rare thing. It was that bad, that bad and that was my only way to hide and function in society. I could have hid in the house,.. but I needed people, unfortunately I found a negative group of people who were there for me. 49 He had no feelings for anyone else and he had no feelings for himself. He felt like a he was a video game, controlled and manipulated. He felt like just an empty body walking around, totally empty inside. He hid his pain in sex and aggression. He had sex with females as often as possible, it didn't matter who, where, when or how. He was forceful. Somewhere through their protests a switch would come on in the back of his head and he would feel disgusted with himself and leave. He was physically abusive to the general public and picked fights with other males whenever he could. He kept his distance. He was verbally abusive to those closest to him and tried to push them away. "The farther I kept them away the less they wanted to know about me, the less they wanted to pry into my past or into my secrets!" He had thought about telling someone but who would believe him? He was a punk from the Eastside, a gangbanger, and Jim was this successful businessman from a good wealthy family. People always said Jim was such a great guy. He thought of telling his Mom but was afraid that his family wouldn't accept him. He was too scared to talk to his family. They would know he let them down and he didn't know how to deal with that. He seemed to have very few options. One of them was to kill himself. I had told him on many different occasions that the things that were happening couldn't happen anymore, that I was not attracted to men, I'm attracted to women, that it didn't make me feel good, didn't feel comfortable or any of that. And while he was looking at me while I was saying this to him, he was looking right through me. He was empty. Sam had suicidal thought from the age of 15 to 20. He contemplated but did not attempt suicide. He was too scared to and could not inflict that kind of pain on his Mom. He also thought of his sister who is 2 years younger than Sam. Their father was not very involved in their lives and Sam had tried to be there for her. 50 If I was to have killed myself, where would she be? Would she be right behind me? Or would she go forward and be miserable. Would she be happy, as happy in life without me or with me? Would I be able to keep her happy and keep that smile on her face? Sam then found out that Jim had abused and provided drugs to two other teens, his best friends. They had been friends since childhood. It was bad enough that it was happening to him, but he was taking "that" away from his friends as well. The teens started backing each other up, not letting any of them be alone with Jim, especially for an overnighter. They fantasized about just outcomes for Jim. They thought of castration or having his legs cut off so that he would be totally dependant and know it. They thought of threatening to expose him so that he would get therapy. They decided he never would. From the age of 16 on, Sam made repeated attempts to sever the relationship but he would always get sucked back into it. Jim phoned Sam's home and talked with his mother as if everything was normal. He was thought of as a generous mentor for Sam. To expose Jim would be to expose himself, and the truth. When Sam was 21 and had not talked to Jim for 6 months, his mother told him that Jim would be phoning him soon. Jim was trying to adopt two boys, aged 14 and 16 and needed a reference letter. Sam reeled, "Here I am trying to get on with my life and here we go." When the call came Sam could only say one word, no. For 65 minutes Jim pleaded with Sam. He bribed him with a house, cars, and anything he wanted. Sam said no. "He knocked on my door and said, please send me to jail. Tell somebody. I don't know if that's his cry for help or what." Sam then contacted his two friends, and informed them that he was going to the police. He had hoped that they would join him, in order to have enough between the three of them "to take this guy down." His friends agreed. 51 The key fear that Sam had when going to the police was that he would not be believed. He was concerned that he and his friends were less credible than their abuser. The police officer never doubted him and Sam wrote a 15-page statement. When I walked out of that police station that day, I took my baseball hat off for the very first time and it hasn't been back on my head since that day. I've been able to look up, walk down the street with my head held high, look people in the eyes and talk to them face to face. Sam walked away from the drug scene and the gangbanger lifestyle, just walked out the back door of a pool hall and that was it. He did a complete 360. He left the destructive lifestyle and the negative people and decided he would go on with his life alone. He later discovered that there were positive people in the world who would support him. He didn't know people like that existed so he never went out looking for them. They came to him. They were there when he needed them. In preparation for the arrest Sam was interviewed again. There was one question that shocked him. "Did you ever feel like you were being groomed to be the perfect boyfriend, like you were in a relationship" Those were thoughts that went through his head so many times for so many years. The question sent shivers up his back, because he didn't think anybody else thought like that and because it was so true. Jim would take him out to dinner, to movies, hold his hand, drive down the street and put his hand on Sam's leg. He also spoiled Sam with gifts, cars, clothing, money and jobs. Sam agreed without hesitation to wear a wiretap for the police. Within minutes, Jim incriminated himself. Sam then took the opportunity to ask his own questions, what he need to know because he knew he would never have the chance to ask again "I got him to explain what he did to me, why he did it to me, and what it did to him." 52 At the preliminary hearing, a total of four young men testified for about 2 hours each. Sam was questioned for 2 days, and had to sit with his abuser less than an arm's length away from him while Jim's lawyer tried in vain to intimidate him. Jim squirmed, he sweated and he did everything but look at Sam. Sam wanted to look him in the eyes and let him know exactly where he was coming from. Jim pled guilty to all nine charges the day before the trail was to begin. Sam felt ripped off that Jim would not face a public accounting of what he had done but was allowed to read his victim impact statement at the sentencing hearing. When I walked through the gate in to read my impact statement to the courtroom, I was one person and when I finished reading that and walked back through that gate I was a different person. That was like the beginning of my new life. Sam spent a year and a half by himself, reading, watching TV programs and talk shows, watching people and examining life. "It's a scary thing. Coming from being a survivor to look at the big picture and go, here I am going to determine my own life and figure out when and how . . . or why do I even want to do it? Why do I want to change anything? I'm a tough guy. I can live with this. The question why is the big one, why do I want to do this?" He began to try to figure out, "why the happy people are happy, what makes them happy, how they stay happy, why the miserable people are miserable, why they won't come out of there." He worked on himself. "I had to find my own identity. I had to rip myself apart and I did it from one extreme to the next." He was very hard on myself, more self- critical than even during the abuse. He really pushed himself to face the abuse and his abuser in court. He examined his own behaviour as a victim and an aggressor. For the first 6 months after the police station, the abuse was always there. He never forgot about it. 53 He was always thinking about it. Sam was confused, upset, angry, ashamed, embarrassed and lost. He sought therapy because he didn't know up from down, left from right and what to expect next. His therapist's guidance through the process helped him a lot. Sam's main focus during this period of isolation was to make himself happy again. He learned that no one could possibly judge or criticize him more harshly than he had all his life. "That was a major factor in my unhappiness. I can't beat myself up now, I'm too up, I'm too aware, too in control. To get the control back of my own life, to be in control of the video game now is so much better than letting someone else be in control." On Nov. 30 1999, Jim was sentenced to 3 years for his abuse of Sam while being in a position of trust and 4 months for each of the three others. He was sentenced to 4 years and served 14 months. Sam believes that 14 months is not long enough for Jim to have to live with his thoughts and changed. Sam feels he can regain his self-esteem, self-respect,and self-love but he cannot regain his childhood, his innocence. Even my teen years were taken from me, from the time I was like 7 years old until the time I was 23/24 years old. Somewhere between 14 or 15 years are gone. I can't regain that. . . . Somebody decided that I wasn't able to have that anymore, made decisions for me, and took it all away. Sam requested that be notified of Jim's release. His only notification came when he saw him on the street months earlier than expected, as Jim was on a day pass. My first reaction was, "I'm going to kill you. My second reaction was, Who let me down?" Apparently the parole board did not receive the request letter in which Sam applied to be in attendance at the parole hearing. Jim refused to give his permission for Sam to hear the 54 record of the hearing, "Without being able to hear the parole tapes, and stuff like that, I will never believe that he will never do it again." He may be right. Sam recently noticed Jim parked outside the nightclub that he works security. He had gone outside during his break for some fresh air. "He was watching me, just staring me for the entire break. I wanted to run to the car and beat him but I am bigger than that now." He has learned by watching the other men he works with to be confidently strong and avoid being manipulated into loosing his self-control. Sam can never be sure that Jim will not re-offend and has done what he legally and morally can in that regard. He has decided that he can do more on a societal level to prevent child abuse. He has done two newspaper interviews about his experience and allowed his name, picture and e-mail address to be published. As a result, he was asked to be a team member on the CycleforAbuse cross Canada bicycle trip to increase awareness of child abuse. On September 4, he will begin that journey and has given a lot of thought to how he will talk to the school children along the way. "I think if I talk with them, not down or up to them it might help them. Sam is hoping he will be able to reach the boys in particular, in a way that he was not reached as a child. It's time that awareness of child abuse is more prominent. . . . awareness has to be different, it has to be more prominent, it has to he everywhere, not just posters, but verbal stuff. Kids need to hear verbally. I am so excited about this trip. I am hoping to be able to reach kids in a way that I was not reached. Sam feels that in the last 2 years he has had to face his demons. He describes them as the wiretap, the courtroom, writing his impact statement and reading it aloud to a courtroom full of people. "The fourth demon being life, the going forward and leaving that where it was. 'It was not easy, it was very difficult, but I survived and I made myself 55 happy. I've made my mom happy and I've made my sister happy, which is overwhelming." Sam has forgiven Jim, so that he can get on with my life, but he will never forget what he has done and what he has taken from him. "I can't forget because then I will forget who I am. . . . I don't like to remember too much of my past, but it made me who I am. I'll live with that, and be a better person for it." The Meaning of the Intrusions Triggers to Intrusions Sam identified the following triggers to the reliving intrusions that he experiences. 1. A certain smell, maybe a certain cologne like Jim's. "There's a certain shyness. Sometimes I clam up." 2. Being naked. He finds that he is ashamed to be naked around anybody, even himself. After a shower, he will run with a towel around him and get dressed as fast as he can. "I'm afraid somebody might come and somebody might try to do something, I know that." 3. Whistler. He finds that his body just will not allow him to sleep in Whistler. He can enjoy a day there but cannot sleep there. 4. Alcohol. Sam can work in a nightclub despite the fact that Jim was a nightclub owner and readily supplied what alcohol Sam didn't steal from the club. Other people's consumption or the smell of alcohol do not bother him, it is his own personal intake that brings back the meaning of a childhood spent drinking until he passed out, drinking excessively from the age of 11 on. 56 Most of the abuse but not all of it occurred when Jim was drinking or doing drugs. Alcohol scares Sam because of that association. He doesn't understand what kind of person Jim was when he drank. Sam likes to be in control and knows that when he drank he was never in control. He also knows what thoughts ran through his mind and body when he drank. These thoughts were with him while he was sober but he would act on them when he was drunk. Sam is referring to his anger, which he would take out on other males. He draws a link between his process and that of Jim's. Sam no longer drinks Intrusions. 1. Sleep Difficulties. Sleeping is a big problem for Sam. He will be unable to get more than a few hours of sleep for a few days and then he will burn out and sleep solidly. He sometimes wakes up sweaty, freaked out and feeling violated; but he does not remember any nightmare. "Thoughts, thoughts, thoughts, it wouldn't let me sleep, thoughts about the abuse." Thoughts about what was happening to him, what kind of person that made him, how to stop it, what would happen if he did and then thoughts about the court case. "They were repetitive, same old, same old; always turning over the same stone so to speak, different words but the same old conclusions." The sleep problems occurred throughout the years of the abuse and really came up when court was going on and during the first year of his recovery. Talking aloud about the issues in therapy and with supportive people helped. To let the conversation leave my head and share it with other people, so that it didn't just bounce back and forth in the canyon of my head." 57 2. Affectionate touching and sexual intimacy. He finds the sensations and flashbacks that occur during lovemaking take him back to the abuse and he has to remind himself that he is not with Jim. When he closes his eyes, he gets the feeling that he is with Jim. The flashbacks can be triggered by affectionate non-sexual touches and sexual acts, some of which he simply can not tolerate. He finds oral sex degrading. These flashbacks make being in a relationship with a woman difficult. Even though Sam may trust her, he cannot tolerate a lot of touching or certain signs of affection, such as "spooning." 3. Somatic, behavioural and emotional reactions in any situation in which Sam feels vulnerable. "I feel like I'm being overpowered and start to get intimidated. It's with some sort of authority figures. You know, like your boss, or just your peers in general, people who try to dominate. I have a hard time with that." He will leave the situation quietly if he can. He feels that he has become a watcher of people and an effective listener, not to judge them but to protect himself. He is trying to read them. He also finds that he looks to see where people's hands are in close or crowded situations. 4. Reaction to being given something such as a gift and being around people who don't expect anything from him. "I hate receiving gifts, even Christmas or birthday gifts. And I hate when people give me money... My mind and my heart won't let me because of my past experiences. I feel that somewhere along the line, they're going to want something back in return whether it be money, whether it be a present, whether it be a sexual favour. They want something, that's the first reaction." 58 "I also feel guilty because in my mind I do owe them something, I have to make it up to them. I don't want to feel that I owe anybody anything. The only person I owe anything to is myself, to be able to make a difference for myself. It's not that I haven't tried to shake i t , . . . I don't know if I'll ever be able to get rid of that." 5. I never really fought as hard as I should have. I never told anybody right away. Self-blame for allowing the abuse to occur and continue. Here Sam takes the responsibility for what happened to him rather than recognizing that the responsibility lies with Jim. These thoughts also expressed Sam's shame and occurred throughout the abuse. The intrusion became more prominent as Sam aged. This intrusion lost some of it's potency when Sam saw that he was a child and understood that breaking out of an abusive relationship is difficult because of the mentality of helplessness or victimization inherent in abuse. He felt he had few places to turn to and no way out. Now Sam has no reason to keep these and other thoughts to himself. He has worked to be open and to share his immediate feelings rather than to talk about them too late. "I'd rather say it too soon that too late." The concept of not having done enough is still with him, his self-blame has waned but he is still dealing with the intrusion and that issue. 6. Thoughts that deny and downplay the abuse. "It wasn't so bad, there was no penetration, so it can't be that bad." This is part of the struggle to accept what happened and these thoughts were very prominent and frequent during his years with Jim and his isolation period. He will still have these intrusions at times, it depends on the day he is having but they appear far less frequently than in the past. 59 7. Feelings and thoughts that he was being groomed to be Jim's ideal love mate. The violation of the abuse was one thing but to be molded into an image or an adult's fantasy was almost incomprehensible. Sam was dehumanized, an image or role rather than the young person that he should have been allowed to be. He was surprised at the officer's understanding of this. The officer's comment indicated to Sam that he was understood and that he was not alone. He became aware that this had happened to others. Perhaps the impact of this intrusion is that it also speaks to how abnormal Jim's thoughts were. Sam has in the past year come to understand that being groomed is often part of an abuse victim's experience. He has more of an understanding now, a whole new outlook or perspective on what it was about. He does not get as confused about it as a whole, and states that he is "sort of getting passed it." 8. What makes him do it? This is one of the biggest questions for Sam. "Why? Where does the molester fit in on the sexual orientation continuum, heterosexual—homosexual? Is one born with this need or does it happen to a person?" Sam understands that a majority of those that were abused are now abusers . . . "I'm not 100% confident that all of them were abused at one time. Without the trial and parole hearing, he has never given us a reason." Sam doubts that the motivation is sexual desire. "I was a child I don't know what it is that provoked my abuser to do those things to me. I couldn't have given the right sign or the wrong sign or any sign. I was a child. I had to figure that out for myself." Sam would like to someday meet an abuser who has decided to stop and talk to him about the motivation to abuse and the selection of the victims. He wants to understand what's going on with them. He is angry with his abuser for jamming out, for not giving 60 those explanations. He is angry with Jim and the parole board for not being allowed to listen to the hearing testimony. He feels that would have been helpful to him and the three other gentlemen who were involved. 9. Why me? Why did he choose me? What was it about me? In referring to the selection of a little brother, Sam remarks, "This must have been like a buffet to him." He does not hold Big Brothers responsible, he holds Jim responsible for the abuse. He does ask why more extensive background investigations aren't done. "You could be a hit man, and unless you had a record you won't come up as a problem." He refers to recent newspaper reports indicating that a Big Brother was a member of the Hell's Angels but did not have a record. "These are people's precious jewels, here's a single parent looking for a role model for her child and look who we are trusting these children with, alone one on one." Sam finds that he wonders about it, but finding out why Jim picked him is currently not a major focus of his recovery process. He has dealt with so many pressing matters since he went to the police and is now preparing for the CycleforAbuse trip. Jim did answer this question in the wiretapped conversation but Sam does not have an awareness of the answer. He thinks that he blocked Jim's answer and that it is not in his conscious mind. He does have the transcripts of the tape that he can refer to if he wishes. The why me question is no so prominent anymore, not bombarding him as it used to everyday. It is now on the back burner. He says he always wonders why but more from a personal perspective than during his intense working through process. He is not so worried about getting an answer, for he can't sit around waiting to find out why. Life goes on and 61 so must he. He feels that if he ever finds out why it will be like winning the lottery— a bonus. 10. Will my parents accept the things that happened to me? Will they accept me for who I am? I've let them down. These thoughts occurred throughout the years that Sam contemplated exposing Jim, from the age of 15 on. He also worried that society would not accept him. They reflect his fear of rejection and abandonment as well as the concern that his tough guy image would not hold up. What would that make him? "Wil l they accept me for who I am?" This intrusion relates to concerns about his identity, his sense of who he is and whether he is acceptable as he is. There is also an element of guilt and fear of public stigma and shame. These fears expressed in his intrusions kept him from disclosing. His concerns were alleviated when he received his mom's and sister's unwavering support. He learned that he did not let them down. He learned that the experience made him stronger not weaker. Those who were important to him did not reject him, only those who were with him for their own gains. The intrusion ended. 11. Questioning my own sexuality. Did it really excite me? Did it really do anything for me, or is that just my body reacting to the touch or to things that were happening to me? "I know I don't get turned on by it. I know that when it was happening I was never turned on. I was more afraid and my body was, I would try and fight and then I'd just give up and I would just become a sack and I would just lie there. It was like an out of body experience . . . leave my body and stand on the foot of the bed and sort of watch over, or sit in a chair, just not be there. This is the biggest thing for me. It's the only thing I can't get 62 to leave my head. I have the answers for it but I still can't kick it. It still just stays there and it haunts me day to day." 12. Acceptance Intrusions Sam described a struggle around acceptance of the abuse. He engaged in an internal dialogue that he could not keep just inside his head. "I can't talk in my head, because I would just argue with myself." He talked it out loud, while roller blading, running, and walking to burn the energy and frustration he felt. The denial intrusions mentioned earlier. "I didn't fight hard enough, I didn't tell anyone, There was no penetration, and It wasn't that bad," were part of the dialectic, as were thoughts about what Jim had done to him. Sam then had an insight. He told himself "You know, they happened to you and if you don't accept them, you're not going to get out of this. You are going to be stuck right here and that can be forever or as long as you want it to be. So it's either accept it now or you can wait to accept it later. And when I woke up the next day, it was different. Life was different." He stated that if anyone, his therapist or anyone else told him that he had to accept it, he would have laughed. He appreciates that his therapist did not do that, because he had to see it for himself. 63 Betrayed In 1972 Adella Matthew made the worst decision of her life. She decided to get breast implants. She was 42 years of age at the time. The decision was rooted in trauma and brought more trauma to her life. Adella had just left her abusive husband after 21 years of marriage. She carried with her a legacy from the marriage, a sense of inadequacy, particularly about her breasts. Her husband had convinced her that her breasts were ugly. "It was this constant battering on me" When he was mad and beat her, he would curse her for her small breasts. He was disappointed that her body had changed after childbirth and nursing the children. His insults would almost always focus on her breasts. His least abusive sentence was "You short titted bitch." I had to be fixed, I thought I was broken .. .so ingrained in me for so many years. I did want to have another home, with someone, have a decent marriage. . . some of my friends had really good marriages, very supportive husbands, loving husbands and I wanted that. I knew there are men out there that would give it if I could just find them, but it was a real mistake. I was trying to rescue myself, is what I was trying to do. I didn't know what else to do." Despite evidence that men did find her attractive, and her own awareness that she was pretty, thoughts of inadequacy rang through her mind again and again. "I am not good enough. I don't look good anymore. No man will find me attractive He had that ingrained in me. No man is going to want me. How will I ever find a home?" Her internal answer to those thoughts was that she needed to be fixed, and the words, " I need to be fixed" and 'I am broken and I need to fix this drove her to find and answer. Adella consulted a plastic surgeon who had worked to reshape her daughter's protruding ears. She trusted him. He reported that he had been doing implants for 10 years, with no problems. They decided to restore her breasts to their natural shape and 64 size. The implant surgery marked the beginning of her decline. Within weeks, Adella's beasts encapsulated. They were rock hard and very painful. The surgeon expressed surprise and told her that he had never seen this before. She was the only one he had seen like this. She would later learn that 50% of women encapsulate to some extent. He assured her that she would be fine. Adella started to have stomach problems, right away. She underwent gall bladder surgery, which was necessary and helped somewhat. The stomach pain continued. She was assured again that silicone was safe and that the implants had nothing to do with her pain. She continued to have health problems and these were attributed to stress. She could not identify significant sources of stress in her life. Adella loved her job as a realtor and found that for the first time in her life, she was financially secure and independent. She also enjoyed meeting so many people. However, the thought "I don't look good anymore" crossed her mind then and throughout her illness. She then started to have a lot of pain in her hands and toes. "Terrible, terrible pains, hot, stinging pains." She would awake in the night because her feet hurt so much it was if she was walking on crushed gravel or thorns. Her general practitioner tested her hands and toes and found a very lengthy delay in registering pain. The deterioration of the nerves in her feet progressed to the point where she could not tell where her feet were, even when she was standing on them. She regularly injured her feet and had to learn how to walk with feet that she could not feel. As Adella became sicker, she grew very tired. She sought medical help from many doctors over the years. She reported a fatigue that she could not understand, for she slept about 10 hours a night. She stated that she could not continue to struggle with such fatigue 65 and was rebuked by one doctor, "You think I am going to put you on disability. I won't be a party to that." Her problems were attributed again, to stress. Adele was very hurt and frustrated as it was not her intention to defraud anyone. Adele was in so much pain, but no doctor took her complaints seriously. She was often told to get out there and sell another house and that she would feel better. As time progressed, it became more and more difficult for her to follow this simple misguided directive. She was deteriorating mentally as well as physically. She relied on alarms, lists and large notes to herself to cope with daily tasks. She had spells of disorientation and experienced white outs while driving. Adella called them that because, "You know you are alive but you can't think . . . It's just a horrific feeling of emptiness." She lost co-ordination and would bump into doorways in her attempts to go through them. The doctors ruled out Alzheimer disease and assured her that she was just absent-minded. She was becoming desperate, and felt that the doctors dismissed her totally. So here you are trying to work and you are so incapacitated, you really are, and you have to go to support yourself, you have got to earn money. It doesn't matter how much you hurt, doesn't matter how much you love the job, doesn't matter about the fatigue, you have got to keep pushing and pushing and get it done. It was a constant battle, it never seemed to come to an end. It was an unseen, it was a war. You had all these unseen things happening to you that shouldn't be happening to you and you know they shouldn't be happening to you. And you know they never happened before. So why is it happening now? When is it going to end? Of course, it's not your implants, oh no silly, it (silicone) doesn't hurt anyone. She then began to lose her ability to speak clearly, and was unaware that she was talking in jumbled sentences. My daughter would say, "Oh for Christ sake mother, phone me back when you can talk! I thought I was." Adella was scared now. She kept thinking, "What will happen to me if I can't communicate? I can't think straight. What am I going to 66 do if I cannot be understood? What am I going to do?" Her daughter and son in law asked her to come live with them, for her own safety. Adella agreed but worried about getting worse and being a burden to them. Suicidal thoughts now plagued her. "What is the point? I can't go on, I can't. There is no help for me anywhere. And I am a drain on my kids." Adella thought of her father. He had always been an inspiration to her. As a girl, she worked beside him on the farm because he had no sons. He took the hardship of The Depression in stride and never gave up, even when they lost everything. Other men did give up; some committed suicide when they lost their farms. He helped others and did so much with so little. He taught her that she was responsible for her life and for helping herself. He was not an overtly religious man but she saw him say the Lord's Prayer every night. When she thought of him, she knew that she could not give up. She also had faith that God would send an answer. Through friends, she met Richard. He was the kind of man she dreamed of earlier in that he was kind, supportive and loving. Richard helped her keep her faith and would point out answers to her prayers before she saw them. They married in 1992. During the next year, her health spiralled downward rapidly. Thoughts of what a failure she was intruded into her consciousness over an over again. She could not get a meal on the table because she would at times collapse in the kitchen and have to crawl to the couch. Adella spent 12 to 15 hours a day lying on the couch. She could hardly lift her head because of severe headaches. The pain was excruciating, like a vice squeezing from all sides at once. Her liver became hard, misshapen and distended. Her husband offered her hope and assured her that she would not get worse. He was wrong. The unknown illness that she was succumbing to progressed. Richard and Adella 67 started using tonics and learning about natural medicine in the hope that something would help her. She feared that she was about to die. She was usually in bed all but 2 hours a day now. "I kept laying there, semicomatose thinking this isn't fair to Richard. This isn't fair, I am so sick. I was in total despair. God what a mess for him. I knew I would die." Other thoughts came to her all the time, "I have got to get better somehow. I have got to get better. It was the same thing, I have to rescue myself somehow, but I don't know how.'" Adella received a telephone request that she volunteer to take tickets at the Healtharama Show at the Hyatt. She decided to "drag herself down there" because of the natural health information available there. Dr. Keiv from Germany made a presentation. He ran overtime but went back to the podium and announced that he had an important health warning. He spoke of the toxic effects of breast implants and the need for women to have them removed immediately. Bang, I was sitting at the back of the room and I felt like I was sitting right in front, it seemed like he was talking only to me. He showed slides of women. They had that blank stare, you know, and I was seeing that when I looked in the mirror. I was seeing that same look . . . they didn't live very long after that look. Twenty-one years after her fateful implant operation, in 1993, Adella arranged for the removal of her implants. "Oh, it wasn't easy... They said, oh, you don't have to have them out. No, no, no." She insisted on a referral to a plastic surgeon. She helped arrange for her cousin's wife, Sharon to have her implants removed the same week. Sharon was also sick, so sick that "she was a walking graveyard." These operations gave the first glimpse of the negligence and indifference of the implant industry and medical community. 68 Adella's implants were examined and determined to have faulty seals around the fill holes. They would have looked and felt oily at the time of the surgery, and should have been identified as faulty by a surgeon with 10 years of implant experience. That explains why Adella became so ill and experienced such severe encapsulation. Her implants leaked from day one. They say... a woman has to be informed, but where does she get informed? Like I did with Dr. P., all those certificates all over the wall, the gold seals, how wonderful he is. How I trusted him because he is in a position of trust. Sharon was implanted with unsanctioned breast implants that were on the market only for a brief time, after Sharon was implanted. The surgeon performed the procedure in a surgical suite. He claims he performed it in a hospital, but there is no record of it in the hospital's files. Dr. Blais who investigated this case questioned how the surgeon obtained these implants. Although they were manufactured in Quebec, there is speculation that he got them in Europe for nothing and evidence that he charged the Alberta Government for them as Sharon's implant surgery was covered by the health care system. He is still practicing. So when I say they bury their mistakes, they do. The betrayal is just horrific. She is the only person alive that Dr. Blais knows of that had those breast implants. Yes, the rest are all dead. They are dead. The knowledge of what happened to her and Sharon marked the beginning of her realization of another trauma arising from implants surgery, the trauma of betrayal. With the removal of her implants, Adele began the recovery of her health. With the knowledge of the betrayal, she began her mission to save the lives of other women. Adele began "amassing literature" about implants. She found information that has led her to conclude that "the most heinous crime against women and children" has been and is still being 69 committed by the medical community, implant manufacturers and the governments that support them. While still very ill , Adella's inquiries put her in touch with others who are trying to stop the production of implants and help those who have them. Dr. Blais was one of four doctors fired from Health Canada for disagreeing with the approval of silicone implants. He now tests medical devices. The medical records of over 3000 women were examined, and Adella was one of 300 cases chosen for further study. Four patients, Adella and three other women, were flown to Texas in August of 1994 for evaluation and documentation purposes. Adella underwent extensive neuropsychological evaluation. She was diagnosed with "Toxic Encephalopathy, Severe." She was also given physical examinations and a muscle biopsy and was diagnosed with Polymyalgia, which indicates damage to the myelin sheath of the nerves. For the first time in my life, I was acknowledged that I was sick. I was acknowledged that I was sick because until I went down there, there was no doctor that would admit there was one darn thing wrong with me and this is the betrayal of all of this. Absolute betrayal. Adele's case was the most severe, probably because her implants leaked from the beginning. It was horrifying to learn that, "It was devastating to know that you are that compromised. I have to go through life like this. I knew I was sick but not to that extent. It's the same story for women with implants. Oh yeah, all of us" As President of the Implant Awareness Society of British Columbia, Adella is aware of several lawsuits against manufactures and governments. There are 4500 women involved in a claim against Health Canada. Adella is a claimant in a worldwide class action lawsuit against Dow Corning that involved 500,000 claimants. That lawsuit was started 8 years ago and settled 3 years ago, with no compensation to the claimants yet. Adella isn't doing this 70 for money and warns other women not to count on money from the lawsuit because of the huge costs involved in bringing it to court. She is frustrated with the lengthy delays and how long it is going to take to really make a difference. "It depresses me so." She presents information indicating that Dow Corning, the manufactures of her implants, conducted studies in 1975 that proved that they were aware that silicone is toxic and crosses the placental barrier. She points out that the Australian government has just approved an implant manufacturing plant and that the implant industry is now proposing silicone filled stomach implants for the morbidly obese. She assists Dr.Blais with documentation and has learned that the new silicone gel implants will liquefy if they rupture and come in contact with the pH level of the body. Saline implants putrefy at body temperature and have been black with fungus and bacteria upon explantation from women's bodies. Adella asks again, "When is it all going to end?" It just goes on and on . . . There is no goodness, all profit. Just greed driven. Look how many breast implants go the grave. Women died because they were sick from it. I feel just, you know, it's overwhelming, it's painful. Adella's return to health since the implant removal has been gradual. She notes that she still gets thoughts that she does not look good anymore, but knows now that she is not broken. It took about 3 years before she and Robert noticed improvement in her health. She has done everything she is aware of to detoxify herself and live a healthy natural lifestyle. She is now able to travel and Adella and Richard have been able to have some fun together. Adella has experienced disapproval and rejection from her sisters and some of her children because of her decision to have implants. She notes that there is a stigma and lack of sympathy for women who were implanted unless they were cancer patients. Her 71 family's lack of support is particularly painful because it exists even though they almost lost her. They disapprove of her despite her efforts to save other women. She is very thankful for the people who have come into her life; Richard, other women who understand, and those she works with through the implant society. Adella and Richard continue their mission to make the public aware of the dangers of silicone and saline implants, stop their production and to help those who have become ill from implant toxins. " Dr. Keiv, is responsible for saving my life and me in turn saving other women's lives." The Meaning of the Intrusions 1. I am not good enough. I don't look good anymore. No man will find me attractive. No man is going to want me. How will I ever have another home? These thoughts reflect and are accompanied by feelings of inadequacy. Adella stated that she became very insecure about her looks, body and particularly her breasts due to her first husband's continuous battering and verbal assaults about her appearance. These comments directly affected her self-concept as a woman and he targeted her breasts for his most common and hurtful insults. The previous trauma of abuse destroyed her self-esteem not as a person who could earn a living and take care of herself, but as a loveable person. She believed that she would not be able to find love, or build a home and a decent marriage as she was. 2. I need to be fixed. I am broken and need to fix this. This intrusion is actually her response to the first intrusion. These thoughts come automatically too. Adella feels a need to alleviate her thoughts and feelings of inadequacy and repeatedly thinks that she has to do something because she is damaged. She is driven 72 to solve this problem because there is a lot at stake, and her inadequate body represents a permanent obstacle to finding a supportive husband who will love her. She has a decision to make, fix the problem and find that positive future or continue to be unlovable. Her childhood role model never gave up and she learned from him that she was responsible for her life. This philosophy is reflected in her repetitive thought, " I have to fix this." She makes the decision to fix her breasts. 3. I don't look good anymore This intrusion plays itself throughout Adella's entire story. This thought arises during her first marriage and her decision to get implanted, and then dies away for a time. The relief from this belief is relatively short lived. She looked and felt attractive when she was healthy. After she becomes il l , she looks in the mirror and sees that she has lost vitality in her appearance and presentation. Her concern about her looks mirrors her physical and mental decline but as her health deteriorates, concerns about supporting herself and her eventual survival become the priority. This intrusion is replaced by others relating to those issues. After her life saving decision to have the implants removed, Adele experiences a gradual recovery. Despite being grateful for this, she notes that she still finds that the thought, " I don't look good anymore" enters her mind at least once a day. Her stomach is distended from the liver enlargement so she has no waistline. Although she does not consciously think that this is important any longer, the thought still comes from somewhere. "I don't look good . . . as good as I used to look. It doesn't matter now. I got over that, that I was broken." 4. Why is this happening? When is it going to end? When is it all going to end? 73 These questions express Adella's struggle to understand and find out what is wrong with her. She engages in a futile struggle to be taken seriously by doctors and to convey to them that something is seriously wrong. She is not able to find help or understanding of the severity of her problems. She is in an unseen war and her efforts to help herself seem futile. She is continually losing battles. Will she lose the war? Since her explant surgery and the return of her health, Adella has turned her efforts towards saving the lives of other women. This has been an emotionally costly choice as it mired her further into the depth of the betrayal surrounding implants. She has faced her ever increasing awareness of the breadth of the problem and the power and negligence of those who have committed this "heinous crime against women and children" and their loved ones. Her battle continues and so does the intrusion that asks, "When is it all going to end? When are they going to take their heads out of the sand?" 5. What will happen to me if I can't communicate? I can't think straight. What am I going to do if I can not be understood? Here there are layers of meaning for Adella. As a child she stuttered so badly that she rarely spoke or smiled. She withdrew and stayed silent. Her father offered her the rare opportunity to go to an agricultural college when she was 16 years old. He had sacrificed for this and arranged for clearance for a girl to attend the college. Adele saw this as a new start for her and could not bear the idea of going there as a person who stuttered or appeared stupid. She vowed that she would master her speech difficulties and did so. For Adella the thought of being silenced again<*in adulthood was almost intolerable and very frightening. This intrusion set represents her fears. She is also afraid of the loss of her mental 74 capacities for then she really will be helpless. She cannot find understanding now, what will happen if she cannot advocate for herself any longer? What will happen if she cannot help herself? Since childhood, Adella has known that it is up to her to be responsible for her life and help herself. These thoughts also reflect fear for her relationship with Richard. She finally has found that supportive and loving man and may not be able to communicate with him. The fear is about losing her health, independence and her ability to be part of good loving relationship. 6. What is the point? I can't go on, I can't. There is no help anywhere. I am drain on my kids. Adella's thoughts become suicidal. She is about to give up, "When no doctor will help you and you are so sick, how can you go on? What is the point?" There is no help to avoid a darkening future. 7. Thoughts of her father and that she can't give up. Here, the teachings and example of her father come to her mind. The virtue of never giving up and value of being responsible for one's life are exemplified by the intrusion. She has faith in God and believes that he will send an answer. She consciously thinks that she must keep going and that there must be a solution to her problems. "Well, my father was always an inspiration to me. I had seen him do the impossible. . . . When everything was so black for him, he still worked his way out of it and when things are black for me, no matter what it is, I work my way out of it. That is what he taught me. And I believe in prayer. At one time I would say, well I believe God is, I can say honestly now that I know that he is." 75 8. I'm a total failure. I can't even cook. I was always able to cook. The sense of inadequacy becomes more pervasive. This is another indication of her decline. This is important to her as that it relates again to her failure as a woman and her inability to fulfil the role of wife she wanted to be to Robert. Here the intrusion brings forth her tacit fears that she is a failure as a wife and a woman. 9. This isn't fair to Richard. This isn't fair, I am so sick. God, what a mess for him. At this time, Adella is bed all but about 2 hours a day. "I kept laying there, semicomatose, thinking this isn't fair to Richard. I knew I would die." Adella knows that she is close to death. Although she has not yet had medical confirmation that she is sick from the implants, she reports always suspecting that the implants were the start of her serious and inexplicable illness. She notes that Richard's last wife died at the age of 38 with breast cancer. "And here he ends up with another woman who has breast problems." He will lose two wives to breast related illnesses. This is so painful for him. 10.1 have got to get better somehow. I gave got to get better. Adella's determination to survive and help herself continues. She is desperate to do so, as she knows that she is running out of time. A resilient voice keeps being expressed. 76 It Could Be Worse On May 31st, 1999, suppertime, on a two lane rural highway, a van drifted over the centerline and hit the cab of a black semitrailer hauling a wide load. The vehicles approached each other at 100 km/hour. The impact caused the van to move backwards before it was thrown 20 yards. The truck driver was able to leave the semi and get away from it before it caught on fire. He was not injured. The van's passenger, who had been asleep at the time of the crash, suffered a cut on his knee and forehead. He and the driver had left the city at 7:00 am and travelled to their work assignment in a small town 90 miles from the city. They had worked all day and were driving back to the city in the company van. They were both pinned in the vehicle. Greg, the 32-year-old van driver was severely injured. He does not remember the pilot car, the black semi, or the accident. The truck driver saw that Greg's head was down as the van approached him, and witnesses suggested that he might have fallen asleep. Greg woke about 2 weeks later from a drug-induced coma, which was used to keep him still after the extensive surgery that was performed on him during the first few days. His family rallied together. "It was a bad thing, but it had some positive bonding." We weren't all that close before, my oldest sister is 20 years older than I am and my brother, the next closest in age to me, is 11 years older. Greg has always been very close to his parents, who are 73 and 80 years old. It meant a lot to him that his siblings came from all over to be with him. 77 Greg lists his injuries as he scans his body. A couple of bones in each foot, I have a pin in my right ankle, my tibia and by fibula I believe, below the knee were crushed. One knee joint was crushed. My kneecap is ruined. I have four screws in my knee. My femur, which is the largest bone in your body, was broken, punctured the skin. And my hip, there is a ball on the top of the femur which was broken, it is called the neck, it was broken. My pelvis was hurt, spleen was lacerated, cracked one of my vertebrae, three or four ribs, my collarbone, my chimeras, which is I believe my shoulder, upper arm, it has a pin in it, my lower arm, both bones were broken. I have plates in both bones and quite a bad head injury. Fifty stitches around my eye and from the centre of my forehead kind of over top of my skull to my ear. My ear was partly hanging. Initially everyone was concerned about brain injury. Friends and family members could not hide their fear from Greg when he would first talk to them. He could see it in their faces. Much of his repetitive speech and strange comments arose from a drugged state. He still monitors and compares himself a lot regarding his ability to remember and learn. Generally his long-term memory is excellent and short term is affected. He finds he has to remind himself not to write 1999 when he dates cheques and papers. I find repetition helps, whether it is vocal or internal I repeat things as a coping mechanism and it has helped my memory. In some ways my memory is better. It's hard to sort out how much permanent damage there is and I am hyper sensitive to it." Greg finds that he has a tendency to think repetitively anyway and has noticed that his parents repeat themselves a lot for emphasis. He thinks some of his rumination may be a learned behaviour and some of it is a natural part of his personality and notes that he is more aware of it since the accident. He copes with this tendency by distracting himself. "I can't decide whether it's a coping mechanism or just the way I am. I seem to jump 78 around. I don't dwell too long and when I do dwell on things it doesn't seem . . . it seems to bring me lower, almost a depressed state. And I am glad to get distracted . . . I am a willing participant in distraction" About one day a week, Greg gets depressed and suicidal thoughts come to mind. He has never planned to kill himself, but the intrusive thoughts of his inadequacies are there. He remembers having suicidal thoughts when he was in his teens, starting at the age of 12. In his late teens to mid-twenties he felt well adjusted, happy and self-confident. The moods returned about 6 years ago. He knows that they will pass, they always have. He has never figured out how he would commit suicide but he wonders why a 12 year old would think about killing himself and why he get these thoughts now. Greg has always been hard on himself and agrees that he is a perfectionist. He has high standards for himself and is his own worst critic. Greg notes that his negative self-talk and worry related ruminations are amplified, more frequent and more intense since the accident. He finds that he is aware that he is looking for his shortcomings more often now. When someone is telling me something positive about myself... like that I helped them in the hospital... I am looking at what I didn't do, what I should have done, what I did wrong . . . I am thinking of my shortcomings. Sure I helped you, but I could have helped you more. Sure I helped you, but like really I didn't even try. I keep saying awareness, awareness, but I am also looking. It's like a different focus . . . focus has shifted from my work and other people, more so to myself. I have always been self-critical but more so. I don't know if it is practice, having the time and doing it more, or if it was a need. He reports being more aware of it now, more aware of himself physically and mentally. "It has been a long time coming." He notes that the accident has brought him a lot of awareness about his surroundings, physical well-being and his reactions. 79 Greg has also found that he is more able to see the positive since the accident. Just as he seems to look for the negative, he is also much better now at finding the positive in situations and countering his negative thoughts with positive ones. "I can gain something positive from a negative experience . . . well, if we can gain something from nothing." Greg used and possibly developed that skill while he coped with the painful and frightening repercussions of the accident. He faced repeated surgeries; there were four for his hip alone. The first one failed because a bone graft did not take. The second one failed because the screws broke and his hip separated again. The next operation involved opening his leg with another two-foot gash and removing the broken "hardware." After a week in traction, with the wound open, he was told the fourth operation was cancelled while he was in pre-op because they had forgotten to order the right part, a blade. The blade is a titanium plate that was to fit into the neck of the hip and Greg did cringe upon hearing its name. He was sent home with his leg open and equipped with drains, to return for the operation a week later. Greg's emotional reaction to all of this was a learned calmness broken at times by strong feelings of fear or periods of anxiety. His fears related to the surgeries particularly; whether each one would be successful, whether he would need more operations, whether it was safe for him to go home, infection, rejection of the new parts, the risks of being anaesthetized, of pain and of certain procedures. These fears were often expressed in repetitive thoughts, questions and images that intruded into his mind. He coped with all of this with a variety of tactics. Greg learned to distract himself from his worrisome thoughts, and after months in bed, found that he could just shut his mind off or tune his thoughts out. He had a tendency 80 to fantasize various outcome scenarios, and in response decided he could not worry about what had not happened yet. He would distract himself by thinking of something positive and when he was able to use a wheelchair, he visited the other patients. There was always one person he was close with and they would willingly distract each other. He tried to establish a positive outcome by setting low expectations, thereby avoiding disappointment. He also used humour to help other people, including the staff members feel at ease with their situations, or his. You have got the capability of helping, you can make somebody's day better. Just control, it's having a little bit of control. You are dependant, and I didn't have a lot of control over much but I could make somebody's day better, I could distract them from their concerns. He was confronted with some very difficult situations. He has memories of lying in procedure rooms while radiologists, doctors and nurses talked about him with hushed voices. Fear would rush through his body and mind, "What's wrong? How bad is it?" He remembers hearing gasps when they saw his leg scars, and the x-rays of his hip. Greg sometimes had the same experience when he viewed his x-rays. On one occasion he saw the broken screws and a gap between bones that should have been held tightly together. This picture simply explained his pain and confirmed his suspicions that something had gone wrong after his hip operation. After the larger blade was inserted, and everything was screwed back in place, he saw something he didn't expect—a cable. Like a piece of steel cable around the bottom of the pin Below the screws right where the most force would be exerted. And to look at it on x-ray, I am like Wow, it doesn't, it's not me. I am used to looking at blue prints, machining, a lot of metalwork, and I am looking at this and I know what it is. But I try to avoid the thought that it is in me. And the way I talk about it, it's detached. I mean if I was fixing a piece of machinery, sure. This is me. It's my body... I try to keep it like, an object. Objective view.. . 81 I guess to face the fact that I have got all these spare parts in me. Hardware. His knee operation required the use of affixiators, which were rings attached to his left leg. He had nineteen pins inserted through the skin to hold the bone in place and threaded anchors that were screwed into the bone to hold the affixiators. He was in a Wheelchair for five months and in the hospital for six. When he lifted the rings fo move his leg. "Sure it's painful but relatively, as compared to the pain I felt before . . . it's amazing how you learn to cope. A lot of times when I am with somebody... and they ask how I am, I will say, I could be worse." The most painful and traumatic part of the whole experience was the removal of the affixiators. He had heard various versions of what would happen for about a month in advance. Some versions reassured him that he would be anaesthetized and others indicated no medication. He worried about it, a lot. He tried all his strategies to avoid thinking about it, especially between the first and second removal procedure. He would tell himself not to create something that hadn't happened yet. His fears were justified. I had these pins removed in two procedures a month apart and they didn't put me out and I was watching them, and you are on a metal stainless steel bed and they said, hang on, and I swear my handprints are in that bed. While they were removing, especially these threaded rods, they took a cordless drill and put it in reverse . . . During the removal was the pain, severe, and I mean my scales are quite high. By the third or fourth one, I was being restrained, I wasn't angry... more like an instinct, Get away! After his body was repaired Greg could be more active and prepare for life on the outside. He had learned to quantify his expectations. Rather than worrying about whether he would be able to bend his knee, it was to what degree will I be able to bend my knee? 82 He set small goals and felt good about accomplishing them. He couldn't wait to walk across the room, climb stairs without crutches and other steps as he savoured his progress. Greg stayed with his parents for almost 1 year while he continued to rebuild his independence. He has been working and living on his own for about 6 months. He returned to his old job as a fire alarm and sprinkler system installer. He knew his boss would not keep him on after the Workers Compensation Board funding ran out and he was right. He knew not to trust him before the accident so it wasn't a surprise. The surprise came when he was hired for a more physical and challenging job the day that he started his job search. He has a combination of qualifications that is rare in his field, which provides him with an edge. He now tests and inspects systems. Despite that evidence of his value and his employer's positive feedback, Greg is worried about his work security because he feels that he has limitations now. Greg is now embarking on the next phase of his adjustment, that of living well over the long term once the crisis has passed. He has concerns about the future, as he always had but they now include the realities of his new situation. He worries about the future. He is 34, single and does not want a physical relationship right now. He says that doesn't have the need for one unless he thinks about it. Greg would like to marry and have a family someday. He realizes he still has some time but knows that this is starting to become an issue for him. His reluctance to have a physical relationship is not so much about fear of hurting himself given his severe hip damage but more his fear of how someone would react to his deep and wide scars. "I have over 6 feet of scars on my body and they are deep." Greg is close to his elderly parents, and can see a time when he may be alone without them and without a family. 83 Has his worldview changed since the accident? "Precious, I am aware of that... It changed, I've always had fear but it has changed. It's more real now . . . I've always had a fear of tomorrow, the unknown . . . thinking the worst possible thing, but I didn't know things could be that bad. You know, like I never . . . No preparation at all for this" In his efforts to convey to people what the experience has been like for him, "the depth of it", he tells a story. When I woke up in the morning and had to take a leak I would have to ring the bell, three or four nurses would come trotting into my room, put me on a sliding board, a smooth board, slide my ass into a wheelchair, wheel me into the bathroom so I could go pee. I would ring the buzzer, three or four nurses would come back and wheel me up to my bed, lift me out of my wheelchair and into my bed, just to take a pee in the morning. And yet there are people worse off. There are always people worse off. When he thinks about it as a whole, Greg realizes that he is lucky to be alive and walking. "Mortality, realizing what I do have . . . most days I am more grateful. When his feet hit the floor in the morning, he is sometimes brought right back to the hospital. "When I get out of bed in the morning, I am grateful that I can get out of bed. I can get out of bed, and that is a good way to start a day." The Meaning of the Intrusions 1. Flashback of the accident Greg sees a vivid scene, it lasts only a second, like a single frame slide show. "There is nothing leading up to it, it's not moving and like boom it's there . . . I created this. Knowing from all the stories I have heard, picturing it was a sunny day, like all these different bits . . . Looking at it from the third person or looking at it from my vantage point, sitting in my van, what it would look like. It was a black truck. It was a sunny day, my 84 new truck. My van was only 4 months old. The air bags popped out, they were covered in blood, all these little pieces. I created something. It's not reality, but it's all for real." This intrusive image may appear while he is driving on the highway. The image may come when he sees a semi coming the other way, at the moment the van reaches the truck. It can also happen if he is describing the accident or watching a TV show or movie. This intrusion does not happen often, he can go weeks without seeing the image and it does not pre-occupy him. "There is a real jolt, not subtle. Like I am taking a real jolt. My heart jumps and it passes and then I reassure myself, Greg, you don't remember, like, this is something that you have created and that is a good feeling, it's a relief. Isn't it good that it's not real . . . I get the jolt, then I tell myself you don't remember it, that's a relief. And that's the loop." I need to analyze, why did it happen, how can I avoid it? He is referring to the flashback not the accident, for there is an acceptable answer for why the accident happened. "Something triggers it and whenever I find what triggers me, I try and avoid it. But there are multiple triggers. I haven't been able to pick them out and avoid them but luckily it doesn't happen often." When it does happen, he knows it's nothing new. He sees the intrusion as an instinctual reaction to various triggers or stimuli that are similar to the accident. 2. Flashback about being in the hospital when getting out of bed. The flashback, which occurs some mornings, occurs when he gets out of bed, and is possibly stimulated by his feet contacting the floor. A feeling reminds him of what it was like to be in the hospital. With this intrusion Greg contrasts his current independence with the long months of immobility, dependence and fears that he had while in hospital. Greg is 85 reminded of how fortunate he is and how far he has come. He is appreciative, aware of how lucky he is to be alive and independent. The flashback may be triggered when his feet touch the floor because of an accident he had at the hospital. He woke up and got up to go to the washroom. He couldn't walk, had a cast on each leg, as well as the affixiators. He hit the floor hard. He saw his feet in the air and remembers the sound of the hoops rattling on the floor. He lay there helpless, frightened and in pain for over an hour before he heard footsteps in the hall and called, "Help me. Help me." He was too worried about the nurses' reactions to cry for help earlier. 3. Memories of lying in rooms with radiologists and "all these other people discussing me around the corner in hushed voices." Through these memories, Greg relives the fear, uncertainty and vulnerability that he felt as a patient. In the months of assessment, planning and invasive treatments such as surgeries, life was very uncertain. He learned from experience not to expect success but to be prepared for the impending bad news that the hushed voices symbolized. While hearing them talk he would think, "What's wrong? How bad is it?" 4. Preoperative thoughts Greg was scared before the operations, "Anytime they put you under general anaesthetic, it's very traumatic. Screws me up for about a week, really throws me, the drugs for pain, inflammation, like the list goes on . . . I have had so many." He considers himself lucky to have never had a bad infection as he has had so many operations, so close together. 86 5. Postoperative thoughts Greg felt that most of his intrusive thoughts about the efficacy of the operations occurred after the surgeries rather than before them. He describes waiting and always wondering, "if I am going to heal or not and from past experience you know, will this one work or not? Will it heal? Hope for the best." Other questions developed about how much ability he would regain. In response Greg "tried to put a number on it. You know 25%, wow. Maybe I am being too optimistic. Why don't I cut it down and if it heals, great." He also tries to be realistic and accept his losses, such as having less range of motion or being pain free. He works on acceptance and being realistic. "That will never be and I face that." 6. X-ray images of his hip. Greg stated that his experience with the hip operations and seeing his x-rays has been traumatic as well as intrusive. He felt something was wrong, "it's moving around." The x-ray that had caused radiology technician to gasp and call over another person just to see it, revealed the broken screws and gap between the bones. Greg prepared himself for the worst and asked to see the x-ray. "It wasn't a relief, but at least I knew what was happening." The reaction of the staff once again brought up fears of more surgeries and the thought that maybe they wouldn't be able to help him. The second x-ray image that became intrusive was the one showing the cable wrapped around the pin in his femur. Greg was used to seeing plates and pins on his x-rays but the cable shocked him. The use of the cable seemed to dehumanize him, as if he was a machine, and that was shocking. Ironically, that is exactly how he made sense of the image. He eventually took an objective mechanical view of the need for and logical use of the "hardware." "When I look at it its like looking at a blueprint of a piece of machinery, I guess to face that fact that I have all of these spare parts in me." 7. Feelings and thoughts of being less than what he was and inferior to what he was before. He is more worried about the future, particularly in terms of job security. Greg finds he mentally punishes himself if he does something wrong such as being late for work. "Yes it's got deeper meaning because I have limitations. I should be grateful I even have a job. I don't know if I would say my self worth is lower, but I have defects. I have limits, more limits than what I had before and that is reality. Sometimes I tell myself that too much." 8.1 feel like a kid again. This isn't normal for a 33-year-old man. These thoughts occurred when he felt dependent "whether by need or by situation," such as when he was vacationing with his parents. Although he enjoyed a lot of it, he was aware of how different his vacation would have been without scooters, wheelchairs and the travel choices of senior citizens. His desire to and belief that he would "escape from the dependence" were also expressed in automatic repetitive thoughts, "I can't wait until I can . . . " Greg also entered the dialogue consciously, "I would think about it and tell myself, whatever, like that's the way it is, temporary, a necessary evil that will pass. It will get better." 9. Fears about future losses and being alone. Greg is more aware now than before the accident, how important it is to have someone who will provide unconditional support to him, especially since he has limitations now. He became even closer with his parents with the accident and appreciates them more than 88 ever. He is afraid of losing them and he is afraid that he won't be prepared. They are around 20 years older than most of his friends' parents and his dad has health problems. The fear of being alone is rising in him because of his awareness of how precious close relationships are to him, the probability of future losses, and the possibility of not being able to be in the kind of relationship he wants for the future. Greg also acknowledges that he has had a long-standing fear of intimacy, which has always hindered his ability to commit to a permanent relationship with a partner. 10. Awareness of how much he took for granted now that these things and people they are gone. Greg is thinking a lot about loss, both future losses and those of the past. He is thinking about a former girlfriend who he lived with. They were planning to get married but that ended. These thoughts have come to him in the last few months. 89 It Bas Bad Enough I have always had an intense fear of lightning but my fear was confined to a specific setting. I only felt the fear when I was on golf courses. It was almost like a panic attack. My friends now think that is so strange in light of my accident and consider my fear to be more like a premonition. I have no memory of being struck by lightning, of being at the golf course or arriving there. I do remember that it was a Sunday in June of 1999.1 have been told that when I was struck I collapsed and was on fire. John and my friends remained fairly calm. They put the fire out and John performed CPR on me while my girlfriend tried to phone 911. Poor John, it must have been terrible for him. He thought that I was dead. My heart had stopped beating. He said I looked like a zombie as my eyes were wide-open and bright red. Apparently people iri the apartments along the golf course called 911 and the lines were jammed. The CPR saved me from brain damage until help arrived. I woke 3 days later in intensive care and concluded that I was dying because everyone was there. Shortly thereafter, I was moved to the Burn Unit. I had received a direct hit and had third degree burns on my left side of my torso with feather burns running up my chest and face. The bottoms of my feet were also burnt. In the Burn Unit, I was very worried about making it through my upcoming skin graft surgery, and remember begging the doctors to let me use blood from my brothers rather than the regular blood supply. I was very frightened and actually begged for that. The doctors said there was no time for that. I was very frightened. They kept pouring liquid on my body and I thought they are getting ready to cut my arms off. I am told that right after 90 the accident, they had warned my husband of the possibility of amputation. I must have heard and remembered that at some level. I then had what I consider to be a spiritual visit by angels. It was very intense. It wasn't like they had faces or anything. They came and I felt this complete sense of joy, peace and love. It was as if they were giving me a message that the most important thing in the world or anywhere is love. And that's how I felt. I felt completely loved, totally and utterly loved. I felt that if I didn't make it through the surgery it didn't matter because I would be going to a better place. I found myself yearning for that place at times and the thoughts of having missed my chance to go have come to me quite often. " Gees, I had my chance to go, it would have been so easy. I wouldn't have suffered. I didn't get to go." Over the months those questions led to more, "Why didn't God want me? Why didn't I get to go" Despite these thoughts and feelings, I know what awaits us. "Yeah, I had my chance, but I'll get there, it's waiting." I was moved from the Burn Unit to Plastics and my medications were changed from morphine to Tylenol. Then reality hit me. It was very scary to have the reality of my situation sink in. I saw myself for the first time in a mirror and was shocked. I thought, "Oh my God, what happened to you. Is this you?" I saw this skinny emaciated looking person. It all hit me later over breakfast. Oh my God this is what happened to you . . . you . . .you. A janitor was working in my room. She said, " So sorry lady, so sorry lady". Her words helped, the human contact and sympathy helped. Three weeks later I was allowed to leave the hospital for my first day pass. As we approached the house, all I could do was cry. I was very happy and the release of my 91 worry about not ever being able to come home came out in my tears. I found myself thinking "Oh my God, I made it home." Often people don't ever get out of hospital. Due to a variety of injuries sustained in the accident, I had to go to a rehabilitation hospital. I agreed to go there for one week and one week only and was told that my stubbornness would assist me in my recovery. I felt lost. It was shocking to see the pain and obstacles faced by people who are hurt or ill , so many children and old people facing horrible things like amputations, strokes and burns. I saw so much courage and the compassion of the staff. The horror of losing my physical competence and independence hit me there, at a special event on the hospital grounds. I realized how helpless I was when I needed to go to the bathroom. I stubbornly had not learned to use the wheelchair because I did not plan to stay in it. What was I going to do? I had to depend on people for my most basic care. I felt totally helpless. That feeling is what motivated me to get better. "I thought I am going to make the best of this." I met a friend there, and we were able to distract each other from the pain and the fears we had. I also learned to shut it all out at times. I would "click" it off, as if I was operating a stereo remote control. Just Click. Lightning strikes damage the body's soft tissues. The myelin sheath of the nerves in my spinal chord was damaged. New muscle memory needed to be developed through physiotherapy, which I took on as an outpatient for 3 months. I had lost feeling and control in my feet and I had to learn to walk again. After physiotherapy ended, I started a regular gym workout program to improve my muscle memory and strength, and continued other therapy on my damaged hand. 92 The process of rehabilitation exposes the injured to a spectrum of approaches and personalities in their caregivers. There are some that take the time to work with you, not on you, and those who don't. The staff was for the most part caring, especially at the rehab hospital but there were distressing exceptions. I turned down an operation to implant a hearing aid in my skull, because I felt the procedure was too invasive and the permanent nature of having a hole drilled into my head was not something I wanted to pursue. I felt I had time to wait for newer developments in treating hearing loss. The specialist's reaction was nasty; he accused me of not wanting to rehabilitate myself. I thought, "You have no idea; you have no idea how hard I have worked to rehabilitate myself." I was told I had a spinal chord injury, no discussion, no explanation, and no comfort that I would be able to resume a normal life. I had to ask about all of that. When I hear of other lightning victims, I ask if they died. If they did die, I know that they are all right. I get more upset if I hear that they are injured. Each person's injuries are different, but I know the struggle that the injured face. "I don't have a death wish but I don't fear death either. I fear pain and the indignity of not being able to look after your own body." I feel it is very important for trauma survivors to have an advocate to support them as they deal with health professionals, insurance companies and employers. In September of 1999, as I watched the neighbourhood kids get on the school bus, I was overcome with sadness. This was the first September in 22 years that I could not go to work. Then I saw an inordinate number of squirrels and birds, even bluejays in my backyard. They seemed to be playing with each other. It seemed they were sent to me. I realized how beautiful life can be and to appreciate what is right in front of me. The next months were spent trying to regain my strength, skills and independence. I had the help of a lot of people. John and I became very close. He pushed me kindly and gently to keep progressing. I would often ask him if I was a burden to him and I cried, a lot. During these first months I often found myself saying, "God struck me down with lightning," It would just occur to me, he struck me down. It prompted me to question over and over again, "Was life too good? Was our life too good? Did something need to intervene to slap us in the face?" I asked these questions of John. He would tell me that no, God did not select you, it just happened. That didn't make sense, it wasn't enough. IT could have hit trees or buildings. Why did IT pick me? I often had nightmares in which I was literally being chased by lightning and I couldn't get away. It didn't get me, but chased me, zapping the ground as I ran though a large open area. IT picked me, and I need to found out why. Very close to the time of the accident, in September and October, I researched lightning. "You seek to learn all you can about the beast." The thing is that in part, lightning strikes are unpredictable. Lightning can for example, enter your home through a fireplace and sweep into the room. No one can be sure they are totally safe. I also found information and a support group on the Internet. My husband warned me not to get too wrapped up in the chat line. I agreed that people can "become their illness," I also knew that at the time, it was good for me to find someone to identify with, someone who understood. "You become a bit of a celebrity when you are struck by lightning." There was an outpouring of support, and I had received a lot of attention. I had been held up as this 94 inspirational person, a role model for recovery. I felt uncomfortable with these comments and would think, "I don't know any other way. Is there another way? I'm not trying to be this miraculous person, that is my way." Then came a time when I needed and wanted to withdraw from the social world which seemed trivial. "That's why I went into isolation. I don't think people had a clue how big my losses were . . . and I didn't care to continue to keep" doing things and trying to be understood. "I wasn't acknowledging my losses either." These were difficult months for me and I was quite depressed. I even felt I was letting people down, not living up to their expectations of the inspirational survivor. Thoughts such as, "They won't let me be weak, why can't I let me be weak," came to me. It was a difficult period of searching. "I needed to rebuild the real world." After a great deal of reading, soul searching, reflecting, and talking with those close to me, I resolved the questions of why It picked me, why God struck me down with lightning. "Basically, I came to the conclusion that it was meant to happen." As I began to go out into the world again, I was afraid of being hurt again in an accident. "I felt like a jinx." I repeatedly thought, T must be jinxed, I was struck by a bolt of lightning, the odds against that are quite high, so anything can happen." I was very afraid when we were in the car on the freeway, particularly if the roads were icy. It was a very intense fear, close to panic. I would cry. I kept thinking, "I'm going to be back in the hospital." A hurdle that John and my psychologist felt I should overcome was driving again. Didn't they understand that it would be dangerous for me to drive? I couldn't turn in the seat to shoulder check or back up because of my burns. I couldn't feel my feet well. I 95 could not stand the thought of not being safe and of ending up in an accident. I would be back in the hospital again. I waited until I could turn my body in the driver seat and started driving again in very small steps. I learned to control the gas and break pedals by going around the block, then the neighbourhood and beyond. Even so, I wouldn't go out alone in the evening, even to the mall. I worried that someone would sneak up behind me and because I couldn't hear them, "they would get me. They would hurt me." I had never had those kinds of fears or thoughts before the accident. I was vulnerable now. In order to have security and freedom, I had to rebuild my physical strength, rely on my eyesight more and think ahead. I became very aware, scanning the environment whenever I was outside my home. I still do. I tend to scan the sky a lot too, especially in cloudy or dark Weather and of course, on the golf course. I cannot hear thunder, so I have to scan and follow my instincts. If I feel uncomfortable or am warned of thunder, I will go inside. If I see lightning, I get frightened and scream a little. I can't help it, but I've got to stop that. Other things, such as the flash of a light bulb also startle me. I scream, my heart pounds, and I feel scared. I have gone back to the site of the accident and felt disbelief. "The only evidence I have that this actually happened to me are my injuries, the stories I have been told and my flashbacks." I've lost my creativity and can't find it in my life anymore. I used to spend days in the ravine doing photography, just "sucking up life." I loved creating a story about an animal or bird in pictures of their tracks and settings. It didn't matter if I missed the creature. The beauty was in their story. Now I am limited in how I can travel in the woods. My dog is stronger than I am, and can still pull me off balance while on the leash, but he will also be the key to my return there. He'll be my ears so that I am not frightened down there. I will 96 have to hold the camera in the other hand and focus with the other eye, because of a cataract from the lightning and the damage to my hand. The changes and losses are so big for me; "lots of losses but also a lot of gains." I fear I will not be able to have what I had before with my photography and that holds me back from trying again. I have found my return to work to be a painful experience. The school board had over a year to find me a part-time small group teaching assignment by September of 2000. I spent that year going from one untenable and isolating situation to another. Now its the summer of 2001 and soon I am to show up somewhere without a position to go to. I feel like they are seeing only my disabilities, not my needs, skills and proven track record of 20 years. "I don't want to be tolerated, or to be a sympathy case. I want to belong and to be given meaningful work, which I will do with excellence." The emotional impact of this struggle is hard to convey. People look at me and see the same person. I am glad that I have no obvious disfigurement for them to see but the internal struggle to get through is not seen and understood. I am frustrated by comments suggesting that I should be happy to work part-time in an easy setting and retain my old salary. When I am told that it could have been worse, aren't you grateful? I realize that they don't want to know about it. They want me to make them feel better by agreeing. I answer, "It was bad enough." . . . I saw it; I didn't need to hear that. I can truly say that the lightning was kinder to me than my return to work." Right now I feel that this problem with work is hindering my recovery, keeping me stuck in the past with the accident, as a victim. I also try to look for the good in what has happened, find the positive but my problems with work dominate and hinder that. I have fought so hard to return to work and rebuild my life and my employer sees me as a pain. "I 97 did live. I do want meaningful work. I want to go to work everyday and feel like I am part of a bigger picture, that I matter, that my contribution is just that, a contribution. Finding that place is critical to me, for my soul and my spirit." Noreen was injured in a bizarre and unexpected way and her view of the world has changed. She states, "I am in charge and in control of this life. I am the participant in the design of it. I never use to believe that as much as I do now and I have much more control than I thought. She demonstrated this agency again recently in that she called a meeting with representatives of her employer, professional association and WCB. She now has a new position with the school board. She will be teaching severely behaviour-disordered students in a small group setting. Although she is apprehensive about this challenging work, she has decided that this may be the opportunity she was looking for, a chance to make a real contribution to the lives of children who know trauma. The Meaning of the Intrusions 1. Nightmare in which Noreen is being chased by lightening, which is zapping the ground behind her as she runs through an open field. These are intense nightmares that initially occurred about one day a week. "I couldn't get away, the lightning kept chasing me, trying to get me again. They have returned with the summer. She thinks that she has had more nightmares this year than last and suggests that there may be more storms this year. 2. Flashbacks when she sees lightning or flashes of light. Noreen experiences a moment of intense fear when she sees lightning or flashes of light. Her heart pounds and she screams automatically. She mentions that she has no 98 memory of the event. She wonders about the purpose of flashbacks and nightmares. "Is that my subconscious trying to help me remember? No one explained that." 3. Oh my God, I made it home. Noreen was happy and relieved to be going home for her first day pass, a few months after the event. At the site of her home, her fears flood out of her in tears. She was afraid of never being able to get out of the hospital or of dying during or from the complications of surgery. 4. They won't let me be weak. Why can't I be weak? These thoughts express her frustration at not being understood in the social world. This intrusion was strong during her period of social isolation. She returned to work during that time, and would often be upset after a morning at work. She was confronted with the impact of her hearing loss again. Schools are busy noisy places and her inability to hear well was being evaluated as to how it would affect her role as a teacher. "I have tried to explain they don't want to hear it, how tough it is at work. I really did try to get people to try to understand, then gave up the fight. Then I decided it doesn't matter. How important is all of this anyway, if they understand." Noreen tried to tell her boss for example, that there was just no psychological preparation or help for her return to work and that she felt that she was struck down again and again. Her boss told her that it was hard for everyone, such as people coming off maternity leaves. Noreen can name several instances of this type of dismissal. She eventually silenced herself. "I hid my sadness from a lot of people" and questioned herself, as they did. "What's wrong with you, you're alive. What's wrong with me, I lived?" 99 5. They will be disappointed in me. I won't fit in. "I don't want people to know that I am not coping as well as I'd like to be . . . that would upset me. I will have disappointed them. "This strong person who could forge through a lightning bolt and everything else." I didn't want to be this person they wanted me to be. I had a horrible accident. I had a good attitude. I ended up having the best outcome I could." Noreen did not want to be put on a pedestal as an "amazing survivor," and felt the pressure to stay there. She worried that they would not accept her if she did not live up to their expectations. It was frightening to fall off of that pedestal. 6. What is wrong with me? I lived. With this intrusion Noreen asks herself the same question that others ask when they say, "It could have been worse, aren't you grateful? . . . I did not want to be seen as a person who is bitter." The questions reveal a misunderstanding of the impact of trauma. Noreen eventually decides that her feelings are legitimate and settles for a way to challenge the judgement of others, "It was bad enough." During her period of social withdrawal, she takes the time "to recognize and grieve my losses." She acknowledged that survival of the traumatic event is only the first step. "Oh you lived, but there are a whole lot of physical and a whole lot of life changes " to deal with. 7. I'm a jinx. I must be jinxed. I'm going to be back in the hospital again. These intrusions express the fear of being re-injured in an accident, and the awareness that accidents can happen to her. Noreen reasons that something rare and bizarre happened to her before, so there is a real possibility that she will be the target of other accidents. She feels so frightened that she cries. The underlying theme is the fear of being hurt, severely 100 injured and helpless or dependent again. As Noreen stated, she is not afraid of death, but of the indignity of being dependent, of not being able to look after her own body. 8. They will sneak up behind me. They will hurt me. They will get me. These thoughts occurred in rapid succession in anticipation of going out alone, especially at night. These express Noreen's fear and vulnerability because of her new physical limitations; loss of hearing, less physical strength, injury to her hand and loss of control and strength in her legs and feet. Those same feelings arise for her when she returns to the ravine. She knows that it is rational to feel more vulnerable given these changes, but the fears are probably heightened by her awareness that she could be hurt again. 9. I'm not earning my money. Noreen has always earned her own way. She cannot stand the thought of being dependent. She knows that class size is always seen as a marker for productivity in the school system and a source of professional jealousy among teachers. She has been the recipient of passive aggressive comments about her small group assignment. Her salary is partially paid through disability coverage, so that she is paid her former salary while working part-time. She notes that her perception of not earning her way is compounded by her feelings that the school board is looking at her only as a line item in the budget. 10. I'm not worth as much as I used to be. I have been reduced to the mighty dollar. These statements reflect the rejection and de-personalization that she experienced with her return to work and are related to the previous intrusions. "It's about money. My life has been reduced to the almighty dollar. People are making decisions about my life, I don't want to give up the control. . . . I was just a case file. The humanity wasn't there. 101 She once told someone in personnel, "You need to see Me. Me. I am a person." 11. I don't get to connect. What kind of life is it that I don't get to connect? Noreen feels excluded. She feels a sense of rejection by her principal, some colleagues and her school board. "Do they just want to push me out or do they just not have their act together?" Noreen knows that she has a need to belong and feels that this and other issues are keeping her from moving past the trauma. "I feel like my work problems are inhibiting that... I need to feel like I'm part of a bigger picture, that I matter, and that my contribution is just that, a contribution. She states that she needs to find her place, for her spirit and her soul." The fight to defend her rights has been difficult for Noreen. "I feel guilt in demanding this. Part of me thinks, Gee, I am this person with disabilities. Maybe I should just go along. Another part says, no don't just give in, you need this." 12. I am not doing meaningful work. How am I contributing? To Noreen, both belonging and permanence are required for her to do meaningful work with her students, to build a context in which their relationship and the children can develop. 13. I had my chance to go. It would have been so easy. I wouldn't have suffered. I didn't get to go. They wouldn't let me go. Noreen felt a complete sense of joy and peace with the spiritual visit and that she was utterly and complete loved. She feared the surgery and death no longer and began to yearn for that place, the place of the angels. She contrasts the ease of being in that place with her current suffering. 102 This yearning was strong while she struggled with her physical recovery and recently, through her uncle's struggle with cancer. One of the reasons that the frequency of this intrusion was reduced over the course of her adjustment is that she decided that she can wait, for she will inevitably get to that place. "Yeah, I had my chance, but I'll get there, its waiting." She feels that while she does not have a death wish, she no longer fears death. 14. Why didn't I get to go? Why didn't God want me? She started having these thoughts right away, right after her skin graft surgery. This intrusion was accompanied by feelings of sadness and rejection. The first question reflects her yearning for that perfect state after death and the second seems at first to have meant that she was not good enough, not yet ready to be rewarded. 15. I lived. Why? What am I supposed to do with my life? Why did I get to stay here? Why didn't I get taken? Noreen is challenged by any of these questions to determine the purpose of her life. She did not find this intrusion gave her any more comfort than the last. In fact this is the "biggest" intrusion for her. Her initial comment on this was, "I have no idea" She asked herself, "Am I supposed to do something profound?" This pressure was also put to words with admonition to her self; "You better not waste this life, because you got a second chance. But what does that mean?" As Noreen asked in her narrative, "What was I supposed to do with that?" In response, Noreen has concluded that she should live her life. "My attitude is that I'm not going to go down that road - why, why, why, and do miraculous things. I am going to do what I used to do and find my way in the world first, continue my life journey." Noreen appreciates that she and John have a chance to continue on together. 103 She feels that their relationship has been solidified by this experience, the caring and closeness has increased. She knows that her work is meaningful when she is allowed to do it. She has also helped other burn and lightning patients since her accident. Noreen recognizes the contribution that she can make by living as she always has and that she is still coping with the drastic changes from the event. 16. God struck me down with lightning. Most traumatic events that are not human induced are termed "acts of God." Here is an act of God that is actually interpreted as such by the victim. God has selected her for this devastation. Noreen explains this and similar intrusions by drawing upon the cultural meanings that are assigned to lightning. The common expression, God will strike you down with lightning expresses this culture's attribution of God's intention and power to correct or punish with a lightning strike. 17. Was life too good? Was our life too good? Noreen asked herself and John these questions in her attempt to figure out why the event happened. The rational explanation that it was just a random event did not suffice. Noreen reports that this intrusion came to her a lot. It was part of her search to find meaning in the event and examine the meaning of her life with her husband. Noreen found that she also had this intrusion in conjunction with others that related to her fear of accidents. She noticed it came to her when things were going well, and she felt anxiety that maybe she was jinxed. There was a link for her that implied that she might be experiencing a luck that couldn't last or perhaps even be punished for being happy. 104 18. The prominence of the number 13. The number thirteen took on unusual importance for Noreen during this time. Suddenly she noticed it in so many places and situations. Ordinarily she would have paid no attention at all to the number. This intrusion seems to give visual representation to her fears that she had been very unlucky with the lightning strike and that she was vulnerable again because she is a jinx. This intrusion frightened and confused her because she could not figure out why it was happening. The intrusion also reinforced her fear that she was a jinx. 19. IT picked me. Why did IT pick me? In this intrusion, Noreen has been selected not by God, but by lightning, which has become intentional and deified. Noreen explains that historically we have mythologized lightning. Here she speaks of culturally created and conveyed meanings about a natural phenomenon and myths of powerful gods garnishing lightning bolts. How did she resolve this classic post trauma question of why it happened? During her isolation period, she read and reflected a lot about the meaning of the traumatic event. Several books were meaningful to Noreen and a theme throughout them seemed to be that our soul returns to this life in order to learn something and then moves back in death to that place of the angels. As Sylvia Brown proposed, this is all planned. We design a blueprint with God to help our soul to grow. A veil of forgetfulness provides us no knowledge of this when we are on earth. This theory made sense to Noreen and explained why she seemed to have such a strong fear of being struck by lightning, but only on a golf course. Her friends considered this to be more than an intuition, but a 105 premonition, and would say, "It was as if you knew." The answer kind of came to her. Noreen decided that the lightning strike was meant to happen. 20. If you are going to get me, this time just kill me. This statement gives voice again to her fear of being hurt again and having to recover from severe injury and trauma. It expresses the aforementioned awareness of the fact that these things can happen to her, and a choice that she would prefer to die and reach that place, rather than endure another traumatic injury. 106 CHAPTER V Results In this chapter the common content of intrusions across the cases have been identified and the intrusions have been classified by type and shattered assumption (Janoff-Bulman, 1989). Findings in terms of the evolution and resolution of intrusions have been provided and the process that the study members went through in making meaning of their experiences will be described. Types of Intrusions Intrusions can be classified into three categories; Reliving intrusions, Implications Arising from the Trauma, and the Search for Meaning. Trauma reverberates through lives for the long term, and may have practical, physical, emotional, mental, social and spiritual implications for the person. In 1995, Joseph and colleagues called for research on the content and meaning of trauma related intrusions to confirm that there might be more than one type of intrusion. They suggested that there are re-experiencing intrusions and ruminations that relate to the implications of the trauma. (Joseph, et. al, 1995) In this study, Joseph's proposition has been supported and a third type of intrusion is proposed. The implication category of intrusions has been divided into two types. The first type involves the practical implications and issues arising from the trauma. The second involves an existential search for meaning that goes beyond an understanding of the event and extends to existential issues of responsibility, identity, the meaning and purpose of life and how to live it. The following list of intrusions from across the cases revealed the type of re-experiencing intrusions that the study members had and the content of their intrusions in 107 the latter two categories. Full explanations of the meaning that the participants assigned to these intrusions have been provided within each case. The categorization of intrusions into type and shattered assumption showed that some intrusions fit into more than one category, as some intrusions held multiple meanings for the individual. Those intrusions have been placed in the appropriate categories and the interpretation used for that categorization has been provided with the intrusion. Reliving Intrusions Reliving intrusions include experiences that cause the individual to relive the traumatic event or events, in that the person may believe or feel that the traumatic moment is happening again. These intrusions include memories, flashbacks, images or the same somatic reactions, sensations and emotional responses to various stimuli that the person felt at the time of the event. Little one. Nightmare of creatures crawling up the bed to attack her Nightmare of her family being slaughtered by a family member Powerful sense of doom, evil and darkness that descends upon the 13 year old girl at she goes to bed Panic reaction when close relationships end Flashbacks while working for the child protection system Groomed. Somatic and emotional reactions to the following triggers: a certain smell or cologne, being naked, Whistler, alcohol, nightmares that he doesn't remember, situations in which Sam feels vulnerable or dominated, affectionate touching and sexual intimacy (flashback) 108 Betrayed. What am I going to do if I can't communicate? I can't think straight. What am I going to do if I cannot be understood? (flashback to when Adella stuttered as a child) Could be worse. Flashbacks of the accident Flashbacks to his fall in the hospital It was bad enough. Nightmare of being chased by lightning Flashbacks to flashes of light or lightbulbs Implications Of The Trauma The implications of the trauma include practical implications such as injury, and issues that arise from the impact of the trauma, such as difficulty trusting others. Little one. Poor me. Poor me It's an unsafe world. I'm not safe. Don't trust anybody Anticipating the end of romantic relationships Groomed. Sleeping Difficulties Reaction to being given gifts, money or with people who do not have ulterior motives Betrayed. I am not good enough. I don't look good. No man will find me attractive. How will I ever find a home? (impact of previous trauma) I need to be fixed. I am broken and I need to fix this, (impact of previous trauma) I don't look good anymore Could be worse. What is wrong? How bad is it Preoperative thoughts and feelings of fear Postoperative thoughts. Will it heal? Did this one work Thoughts about the x-rays of his hip and leg (severe injury) I feel like a kid again. This isn't normal for a 33 year old man 109 It was bad enough. Oh my God I made it home They won't let me be weak. Why can't they let me be weak? (unseen struggle) They will be disappointed in me. I won't fit in I'm a jinx. I must be jinxed. I'm going to be back in the hospital again They will sneak up behind me. They will hurt me. They will get me I'm not earning my money If you are going to get me again, this time just kill me Search For Meaning Intrusions in this category include those that relate in some way to the following questions: What happened? Why? Why me? Who am I now? What kind of world is this? What is the purpose of my life? What is the meaning of life, or my life? How am I to live now? Little one. Panic reaction to the end of a relationship. I'm a failure. I'm not good enough. I am not loved Groomed. Suicidal ideation Thoughts of being groomed to be his abuser's ideal love mate I never really fought as hard as I should have. I never told anybody right away It wasn't so bad, there was no penetration, so it can't be that bad What makes him do it Why me? Why did he choose me Will my parents accept the things that happened to me? Will they accept me for who I am? I've let them down. Will society and my friends accept me Did it really excite me? Did it really do anything for me Betrayed. I am not good enough. I don't look good anymore. No man will find me attractive No man is going to want me. How will I ever find a home? (Identity) I need to be fixed. I am broken and need to fix this (responsible for her life) I have got to get better somehow. I have got to get better, (responsible for her life) I'm a total failure. I can't even cook. I was always able to cook, (identity) 110 This isn't fair to Richard. This isn't fair, I am so sick. God what a mess for him (meaning of losing two wives to breast problems) Why is this happening? When is it going to end What is the point? I can't go on, I can't. There is no help anywhere. And I am a drain on my kids - . Thoughts of her father and that she can't give up (Responsible for her life When is it all going to end? When are they going to take their heads out of the sand Could be worse. Thoughts about the x-rays of his hip and leg. (de-humanized) Thoughts about being less than what he was, inferior to what he was before Heightened self-criticism Fears about future losses and being alone Appreciation of what he took for granted It was bad enough. I don't get to connect. What kind of life is it that I don't get to connect What is wrong with me? I lived I'm not worth as much as I used to be. I have been reduced to the almighty dollar-I don't get to connect. What kind of life is it that I don't get to connect I am not doing meaningful work. How am I contributing I had my chance to go, it would have been so easy. I wouldn't have suffered. I didn't get to go. They wouldn't let me go - Why didn't I get to go? Why didn't God want me I lived. Why? What am I supposed to do with my life? Why did I get to stay here Why didn't I get taken God struck me down with lightning Was life too good? Was our life too good The prominence of the number 13 IT picked me. Why did IT pick me Intrusions and Issues Intrusions express issues that the person has not yet resolved. Issues of; employment and health, responsibility for the trauma, identity, safety, attachment, social support, having no way out of their situation, and the existential issues outlined in the search for meaning were evident in the intrusions. The resolution of an issue produced the end of the intrusion. I l l Evolution of Intrusions Events and issues in the person's life can affect the course of the intrusions. The plots of individual intrusions were affected by or reflected issues and changes in the participant's life story. As well separate intrusions illustrated this in that some intrusions seemed to subtly run through a story and others took precedence in response to different events, issues and pivotal points in the narrative. Adella's theme of inadequacy ran through her story with the intrusions, "I am a failure. I am not good enough" while her resilient intrusion occurred when this belief required action. The clearest example of the evolution of an intrusion in response to events and issues is the change in Sharon's nightmare, which began when she was placed in foster care. There was a character change in the dream at the age of 8, when she realized that her mother was alive but leaving her. That nightmare ended when Sharon was allowed to leave the foster home. A new nightmare started shortly after the family was reunited and ended 16 years later with her insight and acceptance of one concept from therapy. Resolution of Intrusions The resolution of issues resulted in the end of the intrusion that specifically voiced that issue. Issues were resolved through various means such as; a change in circumstance, the actions of others, insight or a change in the perspective that the individual took on the issue. The resolution of Sharon's nightmares appears to be from sudden insight, but it must be acknowledged that the insight occurred in a context of new lived experiences. The end of the nightmares seemed to be a result of the integration of new information. Sharon 112 learned that she was no longer a helpless victim who could not protect herself through her life experiences away from the family home and through her work in therapy Existential Search for Meaning Intrusions are involved in the search for meaning, and an examination of that type of intrusion category shows that a clear progression can occur to address classic posttrauma existential questions. What is usually described as the search for meaning of the event and it's implications, can be seen in this study as an existential search which generally begins the classic posttrauma questions, why and why me? The search may continue as the intrusions confront the individuals with issues about their identity, responsibility, and what meaning life has for them. Noreen's intrusion "Why didn't God want me?" is an illustration. This intrusion spurred her to ask herself consciously and through intrusions, if there was a reason or purpose to her survival. Intrusions are not the only way that the person grapples with these questions. Shattered Assumptions In the Assumptive Worlds Theory of trauma response, Janoff-Bulman proposes that there are foundational beliefs or schemas on which we base our worldview. These assumptions are that the world is benevolent, the world is meaningful, and I am a worthwhile person. Traumatic experiences can shatter those assumptions. In comparison to the terrible knowledge of trauma that the individual has, the assumptions are naive and regrettably, lost now. These shattered assumptions were evident in the intrusions of all of the participants in this study. (Janoff-Bulman, 1989) The intrusions about the self are particularly demonstrative of the different ways that shattered assumptions were expressed across the cases. The specific wording or feeling of 113 an intrusion illustrated or helped to identify the issue that lies under the shattered assumption. These issues may be related to attachment, identity and narcissistic wounds, practical issues an individual faces and aspects of the trauma, such as violation. The World Is Benevolent Little one. - Nightmares of being attacked by creatures. It's an unsafe world, I'm not safe, Don't trust anybody - Dark sense of doom and evil descending upon her, images of someone watching her. (Stalked by someone evil) Groomed. - Reliving intrusions that are triggered by the following stimuli; a certain smell, maybe a cologne like Jim's, being naked, spending a night in Whistler, consumption of alcohol, trying to sleep, affectionate touches, sexual intimacy, feelings of vulnerability Feelings that arise in situations in which Sam feels vulnerable, such as being in the presence of controlling or dominant people Reaction to being given a gift. "My mind and heart won't let me because of my past experiences" Sam cannot accept that someone would give him a gift without expecting some thing back from him. He also had difficulty being around someone who did not have ulterior motives for being with him - Difficulty sleeping (flashback sensations) Betrayed. There is no help anywhere What will happen to me if I can't communicate? I can't think straight. What am I going to do if I cannot be understood Could be worse. Preoperative thoughts Anticipatory thoughts about the removal of the affixiators It was bad enough. They will sneak up behind me. They will hurt me. They will get me I am not worth as much anymore. I have been reduced to the almighty dollar (mistreated by employer) Why can't I be weak? Why won't they let me be weak 114 The World Is Meaningful Little one. - Nightmare of family being slaughtered by another family member - Dark sense of doom and evil descending upon her, images of someone watching her (unpredictable and irrational world) Panic reactions to anything unpredictable or unexpected Groomed. - Why? "What makes him do it Why me? Why did he choose me? What was it about me Intrusive thoughts through which Sam is questioning is own sexuality, his identity Feelings about being groomed to be the ideal love mate for his abuser -. Sleep difficulties, (event review) Betrayed. What is the point? I can't go on, I can't. There is no help anywhere. I am a drain on my kids This isn't fair to Robert. This isn't fair. I am so sick. God, what a mess for him What is happening now? When is it all going to end When is it all going to end? When are they going to take their heads out of the sand Could be worse. Postoperative thoughts Flashbacks of the accident Flashback of his fall in the hospital when he got out of bed It was Bad Enough. I had my chance to go. It would have been so easy. Darn it, I had my chance to go to go Why didn't I get to go? Why didn't God want me God struck me down with lightning Was life too good? Was our life too good It picked me. Why did IT pick me I'm a jinx. I must me jinxed. I will end up in the hospital again The prominence of the number 13. If you get me again, this time just kill me Flashback reaction to flashes of lightning Nightmare of being chased through an open field by lightning I don't get to connect. What kind of life is it that I don't get to connect? (meaningful life) 115 I Am A Worthwhile Person Little one. - Panic reaction when close personal relationships end. "I'm no good, I'm a failure, I am not loved, I am not worth it Anticipating the end of close relationships Groomed. - Alcohol consumption Difficulty sleeping, (identity) - Will my parents accept the things that happened to me? Will they accept me for who I am? I've let them down. Will society and my friends accept me I didn't fight hard enough, I didn't tell anyone right away Betrayed. I am not good enough. I don't look good anymore. No man will find me attractive. No man will want me. How will I ever find a home I need to be fixed. I am broke and I need to fix this - I don't look good anymore I am a drain on my kids, which occurred when she was suicidal I'm a total failure, I can't even cook. I was always able to cook Could be worse. I have defects, more limits that I had before. I should be grateful I even have a job Increased self-criticism It was bad enough. - I am not earning my money I am not worth as much anymore. I have been reduced to the almighty dollar (devalued and rejected) I am not doing meaningful work. How am I contributing - I don't get to connect anymore. What kind of life is it that I don't get to connect (rejection) 116 The shattered assumptions appeared throughout the three types of intrusions. They appeared in the verbatim content, or in the meaning that the intrusion holds for the individuals. Statements such as I am no good, I didn't fight hard enough, and I am not safe are examples of the negative views of self and the world that arise post-trauma and are considered shattered assumptions. Changes in Assumptions Examination of trauma intrusions portrayed when all types were included, the negative post trauma view of self and the world that Janoff Bulman (1989) suggested develops in response to trauma. As the issues were resolved, the intrusions were as well. The negative post trauma view that reflects shattered assumptions may begin to change towards an integrated view of self and the world with the resolution of unresolved issues and ending of each intrusion. Common Themes of the Intrusions Identity and Sense of Self Little one. Sharon lived her life as a frightened person and re-lived her childhood terror and helplessness in her dreams. When she accepted that she was an unprotected child and that it was not her fault she realized that "It wasn't about me being a bad person." Sharon also carried shame until her mid twenties. "There was something hidden inside of me that the dream still owned in a sense. A dark side to me . . . the shame part, that I felt my life was so out of control." 117 Groomed. Sam downplayed the seriousness of the abuse and took responsibility for not stopping it. He also feared that his family, friends and society would reject him as he was. He asked through intrusions, why me? What was it about me that made Jim pick me? He also questioned his sexual orientation through intrusions. Sam's aversion to alcohol was related to the aggression he found in himself and his abuser when he drank, and the analogy that he drew between them affected his sense of self. Betrayed. Through her intrusions, Adella told herself that she was unattractive and broken and understood that this deprived her of the possibility of developing a home and life with a loving husband. She interpreted her physical and mental deterioration as an indicator that she was a failure and an unlovable person and this was expressed through intrusions. Her resilient sense of responsibility and self-efficacy was also expressed through intrusions at crucial points. It could be worse. Greg found he became more self-critical after the accident and reported that his focus moved from work and other people to himself. He wondered why and suggested he may have had a heed to do so. Greg also struggled with his thoughts and feelings that he was now less than what he was before he was injured. It was bad enough. Noreen was the victim of a natural phenomenon, but still wondered if there was some reason that she was selected for this. Her identity was threatened more directly by her 118 return to work. She found her professional identity changed. She felt personal rejection and that she was being seen more as a problem case than as an individual with strengths. Loved Ones Each participant talked about one or two people that helped him or her through the Experience. These were people that they could turn to for unwavering support. Surprisingly, these crucial relationships were the subject of intrusions. Little one. Sharon's nightmares from the age of 10 to 26 showed the importance to her of her protective sister. Her sisters protected her before the age of 5 and in many different situations outside the home and while the girls were in foster care. Groomed. One of Sam's intrusions literally expressed his fear that he had let his family down and they would not accept him if he disclosed the abuse. Suicidal thoughts were countered with thoughts about his mother and sister. He found that his commitment to them was reciprocated. They accepted him unconditionally and supported him through all of the court and personal challenges that he faced once he reported Jim to the police. Betrayed. One of Adella's intrusions expressed her father's teachings and helped her to personally reject suicide and resolve to keep on fighting to help herself. Another intrusion gave words to her concern for her husband's pain and how unfair it was that he would lose two wives to breast problems. Tacit meanings were revealed in her interpretations of her intrusions about not being able to communicate and cook any longer. She felt that she was a failure as a wife. 119 Could be worse. Greg was close to his parents and worried about losing them. His father is in his eighties and has several health problems. They were his closest supporters since his accident. He lived with them again for a year after his release from the hospital. His intrusion and worry expressed his fear about being alone and without them at some point. It was bad enough. Noreen and her husband became very close after her accident. She marvelled at his wisdom and gentleness. In an intrusion and in conversation with John, she asks, "Was our life too good? Was life too good?" Suicidal Ideation As stated above, Adella and Sam reported suicidal ideation in response to the trauma, as did Greg. No one had developed a plan or attempted to take their life. Groomed Sam thought of his mother and sister and the consequences to them. He decided could not inflict that pain on his mother and speculated that his sister's quality of life in the long term would be negatively effected if he killed himself, or that she might also take her life. Betrayed Adella's father was a role model of resilience for her, and his words reverberated through her head at that time and at other pivotal points in her narrative. 120 Could be worse. Greg was familiar with the experience of suicidal thinking, as he had experienced it in his early and mid teens. He used cognitive techniques to counter those thoughts and had faith that those moods would pass as they had in the past. It was bad enough. Noreen longed for the place of the angels and had intrusive thoughts regretting that she could not be there, particularly during difficult times. She stated that initially she wanted to go there but that was more of a yearning while she was in hospital and in her early recuperation stage rather than an intention to actively commit suicide. She did not have a death wish but would much rather die than endure severe injury and helplessness again. Tacit Meanings and Symbols The meaning that an intrusion holds for an individual may include tacit knowledge. The implicit meanings become intelligible when considered within the context of the participant's life. Little one. Sharon's nightmares were steeped in tacit meanings and symbolism and these symbols appeared throughout her narrative in the metaphors she used. In her nightmares, the weapons raised against her were machetes and an axe was used against her family. The little one rushed to her family's aid but awoke in terror after her protective sister's arm was cut off. In reality, Sharon's father had stabbed her mother, when Sharon was under the age of5. 121 In her narrative, she used the phrase that the little one could not "put down her sword" and accept the foster parents. The importance of arms and hands as symbols of protection, love and help were seen again in her narrative. Her sisters always held her hand when she tried to sleep, just as her protective sister comforted her after her nightmares when the two little girls were in the foster home. "I remember my mother being very safe, always wanting to hold my mother's arm." Sharon used several metaphors that alluded to the sense of love and protection the extended arm and hand mean to her. Sharon sees herself now as a protector, in that she "holds the hands of the children who are in foster care . . . now I can look with kind hands and heart on where I once was." It is of interest that when Sharon reviewed her story during the member check for validity, she complimented me on the eloquence of the phrase "put down her sword." When I pointed out that I had quoted her, she was taken aback. She commented that she didn't realize how prominent weapons such as knives and swords were in her dreams and her speech. The powerful sense of doom and darkness that descended upon Sharon as she went to bed brought tacit meanings to her consideration. She interpreted her intrusion as a representation of the fear that she felt in that house and neighbourhood. The family had just moved there and she didn't feel safe. This was one layer of meaning. A second layer of meaning was her tacit awareness that she had entered her teenaged years, the age that could make her a target for incest, just like her older sisters. The tacit meaning was not explicitly identified in the research interview, but was my own interpretation that I arrived at later when I worked with the tapes and transcripts. I had 122 noticed during the interview that there was something implied but not stated. When Sharon reviewed the written report with me, she stopped reading it before she came to my interpretation and confided, "There was rape going on in that house." She confirmed the interpretation that she was afraid of more than being physically beaten, and that she felt vulnerable to rape in that home. She had not fully realized the tacit meaning was being expressed in the intrusion until she reflected upon it. Groomed. Sam reaction to alcohol was complex. He was reminded of the destructive force alcohol had on his childhood, in that he abused alcohol from the age of 11 to adulthood. Alcohol reminded him of Jim "who was the worst alcoholic you could ever meet." Most but not all of the abuse happened after Jim drank or had taken drugs. These would be obvious reasons to have flashbacks and difficulties with alcohol. For Sam, the real aversive meaning of alcohol was the analogy he drew between his own aggressive thoughts that he acted upon when he drank, and Jim's behaviour. He found that deep down he was like his abuser. Sam no longer drinks and chose to work on his anger rather than continue down that road. Betrayed. Adella's interpretation that despite her severe illness, she was a failure as a wife because she could not communicate with and cook for her husband revealed her implicit fear that she was a failure as a woman and would lose the love that she had longed for. She once again viewed the situation from the stance of the inadequate woman who was not loveable. 123 It was bad enough. Noreen understood that the meaning she assigned to lightning and the lightning strike came not from a rational understanding of them as natural phenomena, but from cultural and mythological interpretations. Silenced Voices Little one. Sharon was so frightened as a little girl in the foster home that she woke in a silent scream from her nightmares. She could not tell her social worker about her abuse in the foster home, and her cries for her mother went unanswered. When she had the opportunity to talk to her mother on the telephone, no words would come, only her sobs. Groomed. Sam remained silent about his abuse as a child because his first efforts to report it to his parents failed to effect change. His abuser denied it and Sam had no memory of the actual event. He then silenced himself because he was frightened of Jim's response. He also feared the abandonment and rejection of his family, friends and society. Sam was afraid that he would not be believed because of he lacked credibility in comparison to Jim. Betrayed. Adele felt dismissed, misunderstood and silenced by the medical professionals who treated her over the 21-year decline in her health. She was very afraid of being silenced by the illness just as she had been silenced in childhood by her stutter. Her mission was to voice the dangers of implants and assist with lawsuits that expressed the collective voices of over 500,000 women and families. 124 It could have been worse. Greg used humour to help himself and others deal with his extraordinary injuries, failed operations, and the extensive and unique "hardware" implanted in him. Greg felt that he was more used to all of that than other people were, and even tried to make it easier for some of the medical staff to deal with. This is definitely part of his way of helping others and having control of his life, which is important to him. However, it may have prevented him from being able to seek comfort or express his vulnerability and needs at the time. When he would hear gasps as technologists viewed his x-rays, he would feel fear but try to make the staff feel better about what they saw. It was bad enough. Noreen felt extreme isolation and frustration at not being understood by her employer, some colleagues, and others. Although she realized that no one who had not been through such a trauma could truly understand it, she felt that these people did not want to know about it. They did not want to hear it. Participant Observations About The Research Why Intrusions Occur Little one. Sharon felt that nightmares "kept me victimized, re-living my horror and helplessness over and over again." Groomed. Sam thought they served to "remind me where I came from, what I'm fighting for." 125 Betrayed. Adella commented, "Negative thinking. I don't like to think negatively. I try to think positively." It could have been worse. Greg response was, "Primal. Like in medieval times, if a knight fell off his horse and broke his hip, it would be "What do I need to do, how will I get what I need, food, shelter." It was bad enough. Noreen wondered if flashbacks and nightmares were her mind's way of trying to help her to remember the event so that she could understand it. She commented on Other thoughts, "It's all about the journey, that search for meaning, helping you find your way through." Therapeutic Value of Narrative Inquiry Approach The participants stated that they found the interview helpful and therapeutic. They appreciated being given the opportunity to tell their story in detail to someone who valued and understood what they said. Little one. Sharon felt that she learned more about herself through the research process. She stated that before the interview, she was aware of the sense of helplessness, fear and victimization that she carried with her through childhood and early adulthood. She did not realize until she participated in this study how much of her life had been governed by fear and what a powerful a force that was in her life. She felt that telling the story, exploring it 126 with someone, and reading her case study helped her to see how frightened she was and how resilient she was as well. Groomed. Sam said that he did not hesitate to participate in the study because he trusted his therapist's judgement in referring him to the researcher. He found the interview very helpful because it helped him to prepare psychologically for his cross Canada CycleforAbuse tour, in which he would be making presentations to students, various audiences and the media. He felt that the narration of his story from early childhood to the present day was crucial in this preparation, because he had to reflect on the events and develop the story temporally and coherently. Betrayed. Adella felt betrayed by the helping profession, rejected by her sisters and children, and stigmatized by society. She appreciated the fact that someone valued and understood her story and that the research community cared about the personal traumatization of breast implant toxicity. It could be worse. Greg stated that he was motivated to do the interview because it would be therapeutic for him and commented during the interview, "This is therapeutic because I am analyzing myself. I am seeing good and bad." It was bad enough. Noreen appreciated being understood. She appreciated having her story heard and respected and talking with someone who clinically understood trauma. This was very important to her as the inability to find understanding had become an issue in her efforts to 127 reconnect with others. Noreen enjoyed sharing her wonder at the existential search for meaning that arose from the trauma and exploring her internal process and experience of that type of intrusion with someone else. In the telling of her story, Noreen realized how important it was for her to connect and belong in her workplace and have meaningful employment. Of key importance to Noreen was the information that she received in the interview that validated this awareness. She had doubted her right to fight for those needs because she had physical limitations that posed a problem to her employer. She felt that she was being placed in a position of needing to take a more assertive and confrontational stance than she was comfortable with and stated, "That is not who I am." When she discovered in the interview that reconnection was a major phase of recovery, (Herman, 1996) her belief that her return to work issues were hindering her recovery and preventing her from putting the trauma in the past was validated. She then read Trauma and Recovery and arranged a meeting with her employers, professional association and case manager to address those issues. Noreen used Herman's work as supporting evidence for her case. Noreen also mentioned that she had learned a great deal about herself during the research process and felt that one of the lessons to be learned from her trauma was that she needed to become more assertive in her attempt to meet her needs. Meaning Making Process The experience of trauma recovery was examined in terms of the way that the participants made meaning of the event and it's implications in their lives. A description of the process that each participant engaged in has been provided below and is followed by a comparison of those processes. 128 Little one. Sharon lived as a frightened and helpless little girl for the first 26 years of her life. Part of her was always depressed and ashamed and existed with the nightmare that forced her to relive the horror of the abuse that terrified her in her family and foster homes. She believed that she was helpless as a child, and carried her victimization inside her as a young woman. She gained some sense that she was strong through her life experiences away from her family home. She travelled and began to see that it might be possible for her to change her life. In hopes of learning how to deal with her pain and improve her life, she went for counselling. Sharon learned in therapy that she was helpless as a child, and that the abuse did not make her a bad person. She saw that as an adult she could protect herself and live differently. With this insight she no longer felt like a stalked victim and the nightmare that had victimized her in one form or another for 21 years ended. Sharon has learned to live differently. "It took me half my life to learn to love myself, and I do." Sharon takes good care of herself, and has learned strategies that help her with reliving intrusions related to her fears of being unsafe, rejected or abandoned. She found a passionate desire to help children in foster care and earned her M A in Counselling Psychology so that she could do so with credibility and insight. Sharon has made meaning of the event, in that she accepted that she had no control over her family system and that it was she who was let down. She began in her mid-twenties to see that she was not a bad person, and can now say that she is happy with herself. She has reshaped her identity. Sharon has also found her purpose, a way to contribute to the lives of hurt and traumatized children. In doing all of these things, she has 129 met her goal of learning how to live in way that was different from what she knew in childhood. Groomed. Sam indicated that he withdrew from the social world and went through an intense, depressing isolation period. Sam's lasted about 18 months. He first tried to determine if he should change and why. He then searched for explanations of what had happened to him, and why he did not stop it. He looked at himself. What did the abuse say about him? He faced his denial of the abuse and confronted himself with the consequences of not accepting it. "I had to find my own identity." He reported that he ripped himself apart from one extreme to the next. He also questioned how he was to live, specifically how he could make himself happy, which was a new experience for him given the duration of the abuse. Intrusions appear to have been part of that process. For the 6 months following his police report, Sam was always thinking about the abuse, he never forgot about it. He was very self-critical; he really "beat himself up." Sam described an internal dialogue and talked it out verbally, otherwise the thoughts would bounce back and forth in the canyons of his mind. These subtle descriptions seemed to describe intrusions. For more tangible evidence that intrusions were part of this intense work of understanding the event and it's implications, we look at the verbatim content of the intrusions. I never really fought as hard as I should have. I never told anybody right away. It wasn't so bad; there was no penetration so it can't be that bad. - Will my family accept me for who I am? I've let them down. Will society and my friends accept me? Why does he do it? 130 Why Me? Why did he choose me? What was it about me? - Did it really excite me? Did it really do anything for me Intrusions aren't the only thoughts involved in his search for meaning. Sam read, observed people, saw a therapist and attended a survivors group. He learned that many members lived with the repercussions of the abuse for decades before seeking help or confronting the issues involved. This realization can be seen as having provided a "transformative analogue" for him, as it helped him to confront his denial of his own abuse and build a more positive future for himself. (B.K. Bailey, personal communication, September, 2001) Sam had figured out why he wanted to change, which was the start of the process. The intrusions of the dialogue either provided inadequate answers that illumined his self-blame and denial, or posed questions to him. The dialogue is demonstrated in the way that Sam came to accept the fact that he was abused. Sam took the dialogue outside of his head and talked to himself while he moved; he walked, ran and roller bladed to deal with the energy and frustration that came with his thoughts. "I can't talk about it in my head, because I would just argue with myself." He confronted his intrusions of denial. At one point in the dialogue he told himself, "you know, they happened to you and if you don't accept them, you're not going to get out of this. You are going to be stuck, right here, and that can be forever or as long as you want it to be. So it's either accept it now, or you can wait to accept it later. And when I woke up the next day, it was different. Life was different." There was a shift in his thinking and his feelings; and he no longer had the repetitious thoughts of self-blame and denial. 131 Sam had fears about whether he was a worthwhile and lovable person. His concerns were reflected in intrusions "Will my family and friends accept me as I am? Will society accept me? He proceeded, and these intrusions eventually ended when he was given unconditional support by his family and walked away from his old life style. Sam himself quieted the fears and intrusions about stigma and rejection from society. He faced them by doing newspaper articles and adopting a mission to publicly fight abuse. Sam then struggled with the why and the why me questions that are posed by his intrusions. Why does Jim abuse boys? "Why did he pick me? What was it about me?" Through the wiretap Jim answered these questions but Sam reports that the answers are not in his conscious mind. He suggests that he blocked them out. This issue is still unresolved, and the intrusions continue, but don't plague him like they used to. He has decided that he must move on with his life and is focused on his mission of preventing abuse. Another concern about his identity was illumined by the intrusive thoughts that he had for years about being groomed, trained to play a role in a fantasy while being deprived of normal childhood development and experiences. Sam learned that the experience of being groomed is one that is common in abuse. He also decided to forgive Jim so that he can move on. He will not forget that loss and stated that he "can't forget because then I will forget who I am . . . I don't like to remember too much of my past, but it made me who I am. I'll live with that, and be a better person for it." His most salient identity intrusion involved questioning is sexual identity or orientation. He knows that he did not enjoy being molested; in fact, it was so disturbing and frightening that he dissociated. Despite this awareness, he has not found that 132 explanation enough to resolve the issue. He may also struggle with this because of the re-experiencing intrusions that he has that contribute to his inability to enjoy sexual intimacy. The issue remains unresolved and he still is confronted with it through his intrusions. Sam's process illustrates the involvement of intrusions in the search to find meaning in the event and its implications. The intrusions definitely illumined issues that required Sam's attention. The three shattered assumptions were evident, particularly in regards to the identity issues he faced and the loss of his childhood. That loss spoke of a lack of benevolence and meaning in his youthful world. The process to find meaning as an adult, to make sense of what happened to him, and what kind of person that made him, involved an inner dialogue. The intrusions represented one voice in the dialogue, posing questions and making statements that he would be forced to challenge. Sam resolved many of these issues, fears and intrusions through confrontation. He confronted his thoughts of denial with others that drew upon his observations of the prolonged suffering of other group members. He had to confront the fears of rejection and abandonment by his family, friends and society after Jim forced his hand and Sam turned him in to the police. With the support and acceptance of his mother and sister, he moved on to confront society with the reality that sexual abuse happens to men and boys. He did that through newspaper interviews in which he invited others to call or email him. Sam was then offered a chance to take this mission farther, to take his desire to increase awareness of abuse to a national level. He found the answer to the questions posed in the intrusions, whether he would be accepted as he was, by taking a personal risk for the greater good. 133 Sam's goal for his isolation period was to figure out how to make himself happy. He decided that his negative thoughts and self-criticism were preventing him from being happy, and that no one would be as harsh to him as he was to himself. He cannot longer "beat himself up," and reports that he is happy. He has his mother and sister, associates with positive people and he is having fim again. Before this I was lost. I was confused, I was upset and I was angry, ashamed, embarrassed. I'm not lost, I'm not scared. I'm not ashamed. I'm not embarrassed; I'm not anything. I'm happy with who I am. I'm not happy with what happened to me, but I'm happy with who I am and where I'm at and where I'm going. He asked himself how can I make myself happy when he started the search, and seems through his reflection and action, to have found the answer to other classic post-trauma questions of how he should live his life and how he can contribute to others. In Tedeschi's study of posttraumatic growth, he suggests a process that is very similar to Sam's. Sam's process also illustrates the theories of trauma response and adjustment in that Sam's words juxtapose the difference between his victimized mentality and his current more positive and happy view of life. He mentioned the abuse in the description as part of his past, which indicates integration, and it appears that he has achieved the development of new schemas and assumptions about life (Horowitz, 1999 & Janoff Bulman, 1996). Existing beliefs goals and behavior do now work very well after the trauma has changed things, producing in the trauma survivor a culling beliefs, goals and behavior. A cognitive and emotional disengagement from what has been culled must then be accomplished, with a development of replacements for what has been lost. A personal narrative is then produced that incorporates life before the trauma, the struggle with the ensuing changes, and the new way of living, and with this narrative comes changes in identity. This distressing process often involves transitory symptoms of anxiety, depression or posttraumatic stress disorder. (Tedeschi, pg. 322, 1999). 134 Betrayed. Adella's story is one that is focused on survival and physical recovery from the impact of the trauma. Her process can be expressed as the dialectic interplay of two life themes. One theme is of her inadequacy as a woman who can attract and be loved by a good supportive man. This theme expressed the shattered assumption that she was not a loveable person, and arose from 21 years in an abusive marriage. Her husband berated her breasts and ingrained in her that she would never find a man who would want her. The other theme can be expressed as her life theme in which she was competent, responsible for her life and a worthwhile person. This theme was developed from the values, virtues and teachings of her father, who was a role model of resilience for her. He taught her to never give up. These themes occurred to her as intrusions. These themes were woven throughout her recovery story, and influenced pivotal points in her story. The first theme influenced her after she left her first marriage. She came to the conclusion that she was seriously flawed or broken. At this point, her responsible life theme influenced her to take action, and she decided to get breast implants. The theme of inadequacy resurfaced within a few years and became stronger and stronger as her health declined. She repeatedly thought, "I don't look good. I am a failure." Her ill health, inadequacy and lack of ability to find help from doctors led her to contemplate suicide. Her resilient theme expressed itself again, and she knew she had to help herself and could not give up. Twenty years after her decision to become implanted and make herself lovable, she married the exact kind of man that she had longed to meet. About a year after their marriage, her health took a drastic decline and she was close to death. Once again her 135 resilient theme gave her the strength to go on. These themes were expressed through conscious thought and intrusions at these pivotal times in her story. The struggle for meaning in Adella's life juxtaposed the victimized worldview from one trauma with a life long theme of strength and resilience that helped her to survive another one. She learned with the support of her new husband to believe in herself. Although the first theme still whispers "I don't look good" in her ear, she knows now that she is not broken. Her strength and resilience allow her as president of the Implant Awareness Association of B. C , to try to prevent the use of implants and help women who are suffering from implant toxins. Adella has resolved a key issue about her identity, and devotes herself to living well with Richard and working with him on their mission. Could be worse. Like Sam, Greg also described a depressive process of self-examination. His natural habit of self-criticism and negative thinking was heightened "postaccident." He pointed out that he was not only more aware of his tendency to think negatively postaccident, but that the thoughts were also more intense, frequent and amplified. An alternate explanation for these thoughts was that he was depressed, rather than searching for answers. That may be true, but his reported increase in positive thinking provides evidence that he was not experiencing severe depression. He also employed cognitive strategies to counter his negative thoughts with positive ones, and reframed his views often to counter his negative self-talk, which is not indicative of a person with severe depression. "I keep saying awareness, awareness but I am also looking" for shortcomings. "It's like a different focus. The focus has shifted from my work and other people, more so to myself. I have always been self-critical but more so. 136 I don't know if it is practice, having the time and doing it more, or if it was a need." The need to be self-critical indicates a similarity to Sam's self-examination. This process of self-criticism may be part of the search for meaning. Did he experience the weight of being responsible for the accident and find that he questioned his worth as a human being? There is no direct evidence of intrusive thought content from the interview that supports that view. Greg's self-critical thoughts and intrusions reflect his view that he has defects and that these defects have implications for his future in terms of work and financial security. They also relate to his concerns that he could be alone one day and because of his defects and limitations, will not be as prepared as he should be for that eventuality. It is in these concerns that the shattered assumption related to his self-worth can be seen. Other intrusions that were identified with Greg are related to the physical impact of the accident and were about his injuries, the medical procedures and dependence on others. All that can be said is that Greg has gone through a period since the trauma of increased self-criticism, which built on his pre-trauma tendency to think that way and his perfectionism. This may indicate that he is actually processing the trauma. Greg employs a lot of cognitive techniques and other strategies to cope with pain and avoid dwelling on the negative. His flashback to his fall in the hospital that he sometimes gets when he gets out of bed spurs him to appreciate that he can do so. He has been struggling with severe and extensive injuries and now he is starting to face different implications as he resumes independent life outside the hospital. He has found that despite his apprehension about the future, his view of life has changed. He is aware of his mortality and grateful for his life. 137 It was bad enough. Noreen also found herself withdrawing from the social world. She found a lot of people's worries trivial and absurd compared to those she had seen people deal with at the rehabilitation hospital. She also was hurt, carrying the knowledge and experience of trauma and finding that most people did not understand what she was going through. In order to fully acknowledge and understand the event and its impact, she had to take herself out of the social loop. She felt depressed and was worried about not meeting the expectations of others who seemed to consider her as an inspirational and reassuring model of recovery. She felt that they could not see her battle scars and did not want to know or hear about the struggle she was in. While Noreen was in the hospital, she had a hint of what was to come in that she had intrusions that her expressed her regret about not being allowed to die and her desire to experience the presence of the angels again. Her intrusions asked her why God didn't want her and why she was allowed to stay. These intrusions were the start her intense search for meaning. "I needed to rebuild the real world." If we could find a starting point to her period of social withdrawal, it could be her awareness that what others expected of her was not realistic. She was expected to be, "this strong person who could forge through a lightning bolt and everything else." The culmination is difficult to precisely identify, but may have been the resolution of the why me question. She concluded that the traumatic event was meant to happen in her life. She made meaning of the event and that same theory helped her to determine why she was allowed to live. 138 During this period she read talked with those she trusted, and reflected about her experience and what it meant. The following intrusions were part of that process. They won't let me be weak. Why can't I be weak? They will be disappointed in me. I won't fit in. What is wrong with me, I lived? God struck me down with lightning. Was life too good? Was our life too good? I am not good enough. I'm not earning my money. Prominence of the number 13. IT picked me. Why did It pick me? Nightmare of being chased by lightning. As stated earlier the existential search began while Noreen was in the burn unit and continued with the exploration of why she was allowed to live and how she should do so. During her isolated withdrawal, Noreen was also struggling with the formidable return to work issues. Those issues affected her sense of self by excluding her from the group and questioning her competence. They reflected the narcissistic wounds of rejection and inadequacy in light of her changed situation and her employer's actions. Noreen acknowledges that the issues arising from her return to work, which has been harder on her than the lightning strike, are yet unresolved. She would like to be able to cope with these issues better emotionally and feels that she will have to advocate for herself in order to find her place again. Noreen describes her current status, which speaks to the post trauma 139 changes in identity that the theories of trauma response, and adjustment outline. (Janoff -Bulman, 1989 & Horowitz, 1999 & Tedeschi, 1999). I had a life prelightning strike and postlightning strike. The two lives are not the same. While I appear the same physically and emotionally to my close family, friends and colleagues, I am not the same. The accident has impacted my life on so many levels, I do not see myself whatsoever as the same person. There are parts of me that have remained constant but there are so many parts of me that have changed dramatically. . . If I remain the only person who can see this, then so be it. I cannot explain it to others . . . I have resigned myself to feel that yes, I do have a why to live so I guess the how is not as important as it used to be. The adjustments I have made to my new abilities are just that, adjustments and they do come with intense feelings about life. Summary The process of making meaning after trauma varies with the study participants but seems to have some common aspects. The first is that intrusions are part of that process, particularly in terms of the expression of issues and shattered assumptions. For those that went through an intense existential search, the intrusions seemed to follow a progression of logic. An internal dialogue seemed to occur, with individuals being asked questions or hearing their thoughts on issues. The intrusions seemed to follow a trail of inquiry and also brought practical implications of the trauma to the forefront. The degree to which the co-researchers explored the existential questions varied. Some were involved in prolonged struggles with victimization and helplessness, such as Adella, Sharon and Sam, whose traumas can be considered chronic. Greg and Noreen experienced a single and unexpected traumatic event in which there lives were at risk and they were badly injured less than two and a half years ago. In each category, chronic or acute trauma, we can find examples of extensive existential searches and cases where the process seemed to involve less internal examination and reflection. In each type there are 140 processes that focused more on the pressing practical implications of the traumatic event than the search for meaning. Al l of the participants' stories indicate shifts in perspective. Adella now knows that she is not "broken" and has regained enough of her health to enjoy life with Richard more. She takes action, and now works on her mission to stop the betrayal and the "heinous crime" being perpetrated upon women. She focuses now on the love of her life, and her purpose, rather than on the struggle for survival. Greg's perspective has changed towards a grateful appreciation of life and a stronger fear for the future. He now knows how bad it can get, and is facing a different future than the one he planned. This is unsettling for him. He has coped with injuries that almost shattered his entire body, and is aware now that he is facing the question of how he should live his life. Noreen described a pretrauma and posttrauma life. "The accident has impacted my life on so many levels, I do not see myself whatsoever as the same person." She is coping with changes on so many levels. Noreen is not mired in an extremely negative reality, but in one that is overwhelmingly different than before. Sharon and Sam had no pretrauma view, as Sharon was born into trauma and Sam's early memories only serve to emphasize his losses. Their lives could be considered the posttrauma reality, until they reached their twenties. Sam and Sharon each described in their narrations a new reality, a more positive one in which they are in control of their lives. Although they still have intrusions and issues that are implications of the traumas that they experienced, Sharon and Sam have been able to integrate their traumatic experiences 141 and develop more realistic and positive assumptions about themselves, the world and how to live their lives. This adapted worldview integrates and accounts for the terrifying and incomprehensible experiences that they described in their narratives. The challenge of trauma adjustment is to make meaning of the "alien, the unacceptable, the terrifying and the incomprehensible; the trauma must come to be "personalized" as an integrated aspect of one's personal history."(van der Kolk et. al., 1996. P. xvi). 142 CHAPTER VI Discussion What do intrusions mean to individuals in their experience of trauma recovery? The question is a layered one, which is appropriate for a study about meaning. The research design allowed for exploration of the meaning that individuals assigned to posttrauma intrusions, and the meaning of intrusions in their process of trauma recovery. A rich explanation of intrusions was possible because the recovery narrative provided a context for the exploration of the intrusions and their meanings. The recovery narrative also provided a description of the process that the individuals went through in their efforts to understand the event and it's implications. The presence of intrusions in that meaning making process was noticed as the participants told their stories. The description of the process allowed the researcher to suggest the meaning of intrusions in each participant's process of trauma recovery, which can be found in the previous section of this report. The research question allowed for two layers of inquiry and analysis. The first layer was the meaning of individual intrusions and the second was the meaning of intrusions in the process of each person's recovery story. An outline of the meaning making processes that the participants engaged in can also be seen through a quick perusal of the intrusions listed under the intrusion type, the search for meaning. The intrusions guided the person through the process of meaning making, as Williams (1983) suggested in her article that she appropriately titled "The Mental Foxhole: The Vietnam Veteran's Search for Meaning". A clear progression seemed to be evident in the search for meaning that both Sam and Noreen engaged in. The process was not linear, 143 but a trail of logic can be seen in the intrusions. Several intrusions of different topics or themes can occur at the same time. Noreen was confronted with return to work issues and intrusions related to her return to work occurred during her period of isolation in which she dealt with existential questions. Careful tracking of the plot of each intrusion was not carried out, due to the volume of intrusions identified as the participants narrated their stories about the traumatic events and their responses to them. While each intrusion was not tracked in detail, the course and possible evolution and resolution of some of them were identified. Review of Findings 1. Three types of intrusions have been identified in this study. They include; reliving phenomena, practical implications and issues arising from the trauma, and the search for meaning. 2. Intrusions express issues that are unresolved for the individual. 3. Intrusions evolve with events, changes of circumstance and issues in the individual's life. 4. Intrusions end with the resolution of the issues that they illumine. 5. Intrusions are involved in the search for meaning that an individual may go through posttrauma. An examination of the search for meaning type of intrusions revealed a logical but not necessarily linear progression through post trauma existential issues or questions. 6. The findings of this study confirm and illustrate Janoff-Bulman's Assumptive Worlds Theory. Intrusions expressed how the participants experiences shattered assumptions. The posttrauma worldview of an individual and the issues that the individual 144 faced were identified when the intrusions from across the three shattered assumptions were examined. 7: An internal dialectic dialogue has been observed in which intrusions represent the negative posttrauma perspective and confront individuals with unresolved issues. The dialogue has been documented clearly in two cases, and components of it have been found in all of the cases. A process has been suggested as to how the dialectic internal dialogue may be involved in updating posttrauma schemas or constructing new integrated assumptions. The process has been posited as a topic of future research rather than a finding that can be generalized to the broader population. Theoretical Implications Internal Dialogue and Post Trauma Assumptions. The findings of this research illustrated theory, by describing how Janoff-Bulman's shattered assumptions were expressed in intrusions. The intrusions put words to the new posttrauma beliefs. The intrusions expressed the issues that lay beneath the shattered assumptions. The shattered assumption, I am a worthwhile person was expressed in Adella's intrusion, "I am a failure. I can't even cook anymore." The underlying issue was her sense of inadequacy as a woman that was expressed in many ways throughout her story. The shattered assumptions ran throughout the vast majority of the person's intrusions and crossed all three types of intrusions. When all of one person's intrusions are examined together, they demonstrate collectively, the negative posttrauma view that Janoff-Bulman suggested is adopted in the wake of the trauma. She proposed that in adjustment, the 145 individual arrives at a new integrated view that accounts for the trauma but preserves his or her self worth and allows reconnection with others (Janoff-Bulman, 1996). In his theory of traumatic stress response, Horowitz (1999) stated that the new post-trauma reality must be compared to pretrauma mental models. A new view that integrates the traumatic information into the old needs to be developed. Horowitz acknowledged that reschematization is a long and difficult process. But the amount of information requiring changes in schemas is vast. Complete integration of new meanings into existing schemas is impossible in a short time. The emotional implications to identity, attachment, and safety are too overwhelming. Long-lasting information processing is set in motion and may be essential to optimum adaptation. (Horowitz, 1999, p. 10) Based on the reports of some of the individuals in this study, the way in which intrusions are involved in this process can be suggested. Intrusions represent the new posttrauma reality of the person. They challenge the individual with the unresolved issues that are represented by this view. An internal dialogue occurs in which the issues and posttrauma beliefs serve as the script for the intrusive side of the dialogue. This dialogue can be thought of as a dispute, but may be more like a dialectic exploration of the issues that occurs until the person finds an answer that is acceptable to them and resolves the issue, or until the issue is resolved by other means. In Sam's case, both types of resolution were illustrated. Some of the issues were resolved through the actions of others, and some by Sam's participation in the dialogue. The acceptance and support Sam received from his family resolved the issue expressed in the intrusive question, "Will my family accept me for who I am?" The issue was abandonment. His mother and sister proved that they would not reject him. A second issue illustrated in the intrusion, "Will my family accept me as I am," was the issue of identity. 146 That intrusion led to the next question, Who are you? Sam struggled with this question in various identity related intrusions such as those questioning his sexual orientation. In the trauma dialectic, the individual may find a way to answer appropriately, or that the issue has been resolved. The dialogue may move to a different intrusion, as illustrated above in the intrusion, "Will my family accept me as I am?" If not, the unresolved issue and the intrusion will continue, as with Sam's intrusions about his sexual orientation. Sam has often been asked by people, " Why did you let it go on so long? He has often asked himself that question as well. His inadequate answer was, it's my fault because, "I didn't tell anyone right away." In the internal dialogue an intrusive question was asked of a man who as a young boy, was so frightened and powerless that he dissociated during the abuse, "Did it really excite me?" He knew the rational and physiological answer to that question, but it wasn't enough. He had to keep searching for a more meaningful answer, one that rang true for him. An appropriate answer rings true because it addresses the issue at hand adequately. The intrusion may stop or evolve to give voice to another part of the dialogue on the same issue or a different issue that needs to be addressed Perhaps each resolution of an intrusion and its issue slowly erodes the harsh post-trauma analogue that the newly traumatized adopt. In the dialectic, if an intrusion asks a question, who is there to answer? If a posttrauma intrusion gives an unfair or inadequate answer, who is expected to deem it unacceptable and challenge it? The individual is the one who is challenged by the intrusion to represent the more positive part of the dialogue. 147 Assessment. The results of this study challenge the construct validity of current assessment instruments. We cannot accurately measure and interpret what we have not yet identified and defined. Three types of intrusions have been identified in this study, and it is evident from these results that intrusions are more than symptoms of traumatization. Assessment instruments measure traumatization and do not identify those intrusions that relate to the issues and implications arising from the trauma and the existential search for meaning. Several theorists have indicated that in response to trauma, individuals assign meanings to their experience, self and the world and that these meanings change during the recovery process. (Foa & Rothbaum, 1998; Harvey & Bryant, 1998; Horowitz, 1999; Janoff-Bulman 1992; Mc Cann & Pearlman, 1990; Tedeschi, 1999 & van der Kolk et al., 1996). This study demonstrated that intrusions are not only symptoms of traumatized thinking but contribute to meaning making. The present instruments only assess the presence of re-experiencing intrusions and identify them as symptoms of disorder. This study gives evidence that these instruments can incorrectly identify meaning making as disorder. Any objective assessment instruments should be used in combination with subjective assessment techniques. One effective way of identifying and interpreting intrusive activity post trauma would be with the use of a narrative approach such as the one used in this study. The nature of intrusions and the meaning that they held for the individuals became intelligible through the narration of the their trauma and response stories. Although this study focused on intrusions, considerable information was provided that relates to the broader experience of trauma response. 148 This technique allowed for identification of a participant's previous trauma history, life themes and narcissistic wounds. The stories also provided information on; social support, needs, developmental impact of the trauma, tacit influences and meanings, experiences of retraumatization, issues involved with reconnection and recovery, critical incidents that helped and hindered recovery, and existential exploration that helped the individual define his or her posttrauma identity and future. The narrative also provided key information on how the participants resolved issues illumined by intrusions, ended some of their intrusions and made meaning of the events and their lives. This information clearly indicates that the response to trauma is a process and recovery can understandably take time. Many of the issues and implications arising from the trauma do not develop within the first few weeks and months post trauma, but emerge as the individuals rebuild their lives. The process of culling of old beliefs, goals and behaviours and reschematization is formidable, involving vast amounts of information. (Tedeschi, 1999 & Horowitz, 1999). As intrusions have been found in this study to be involved in these processes, any interpretation that their presence shortly after trauma is indicative of chronic disorder or a lack of cognitive and emotional processing seems to be ill founded. Implications For Practice Attention should be paid to intrusions as more than symptoms of troubled and traumatized thinking. If intrusions are taken literally, one could imply dysfunctional and illogical thinking that should possibly be disputed. The elimination of intrusions used to be a therapeutic goal, as intrusions were seen as symptoms only and the lack of them as 149 recovery. This study suggests that people may have largely recovered and rebuilt their lives, and still experience some intrusions. Based on the findings of this study, it would be advisable to educate individuals and normalize intrusions not only as almost universal responses to trauma, but as mechanisms for meaning making and the resolution of issues. A goal should be the management of the client's emotional response to intrusions, rather than the elimination of them (Harvey, 1996). Cognitive behavioural therapy has been proven useful for the management of symptom distress and for dealing with some implications of trauma, such as fear and panic responses to triggering stimuli. Although the literal content of intrusions can be illuminating and make the therapist aware of shattered assumptions, it is the underlying issues that should be the focus of attention. Joseph and colleagues (1996) suggested that interventions should seek not to discourage intrusions but modify the meaning of them. Steil and Ehlers (2000) suggested that identifying and changing the negative idiosyncratic meaning of posttrauma intrusions should be helpful. As that meaning is concerned with the issues involved in the shattered assumptions, those issues need to be addressed in order to modify the meaning of the intrusion. We cannot just change the self-talk because initially at least, the very foundations of the belief system no longer support the logic we would use to do that. Intrusions represent shattered assumptions, and they often sound very illogical and dysfunctional. Under normal circumstances we would consider them to be so. However, in the case of posttrauma intrusions, the foundational beliefs that have guided the individual through life have been shattered. Intrusions reflect that new reality and those new beliefs are therefore logical. It may not be helpful to the client to focus on changing the beliefs by 150 disputing their content, as in cognitive therapy. Evidence has been provided in this study that the participants were aware of logical answers to their intrusive thoughts and questions. Rational answers were not enough to resolve the underlying issues that the person struggled with through intrusions and the emotions associated with them. It might be more helpful to address the issues from the perspective of the client, a person involved in a search for meaning. This is not to suggest that we ignore the beliefs as stated in the intrusions, but that we use them as a starting point, rather than a focus of therapy. They could be the starting points for entrance into the dialogue that the person is already engaged in internally. This dialogue should foster exploration and allow the debate of the dialectic of trauma to continue aloud in a safe container where it can be respected and understood, rather than silenced and considered dysfunctional and illogical self-talk. A narrative approach has been used in this study and suggested as an effective assessment technique because it provided extensive information for treatment planning. The participants in the study considered the research interview therapeutic; a narrative approach has promise in trauma therapy. The reflective telling and review of the clients' stories within a therapeutic relationship can provide them evidence of the strength and resilience that they demonstrated in the light of overwhelming circumstance. They can be helped to understand and forgive themselves for actions that they might feel ashamed of, such as the re-enactment of the trauma through unhealthy relationships. The examination of the way that clients resolved issues and ended intrusions can provide them with hope and a sense of control. The awareness that intrusions can help them to identify and resolve issues and make meaning of the trauma could ease their 151 concerns regarding their mental well-being and reduce the emotional arousal associated with intrusions. By reducing the emotional distress related to intrusions, hyperarousal and the frequency of reliving intrusions may also be reduced. (Brewin et al., 1993; Delhanty et al., 2000; van der Kolk & McFarlane, 1996). Theraputic interventions should encourage individuals to consider intrusions as healing mechanisms rather than indicators of deficits in their character or mental stability (Steil & Ehlers, 2000). A narrative approach could be of major benefit in that intrusions can clearly be understood when placed in the meaningful social and temporal context of a person's lived experience. Future Research Joseph and colleagues (1995) suggested that the evolution of intrusions might indicate that the person who is having intrusions after a length of time might not be progressing in their adjustment to trauma. The authours suggested that a lack of change in intrusions might be a marker that the person is indeed stuck. The findings of this study demonstrate that intrusions did evolve. They changed with events and issues in the person's life, such a change in social support, threats to the person's identity, changes in family situations or structure and the perspective of the individual. The marker may be the change or evolution of an intrusion, as Joseph and colleagues suggested, or it may lie in a change in the way the individual responds to the intrusion in the internal dialogue. The resolution of intrusions can also be seen in this study and seem to occur most clearly with the corresponding resolution of the underlying issues that the intrusion illumines. 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