Cultural Aspects of PTSD, Part II: Narrative and Healing
Posted by epfinley on June 22, 2008
Narrative and memory are interwoven in our consciousness, and thus explorations into trauma from both humanities and social science perspectives almost invariably discuss narrative in one form or another. An ongoing debate within psychological research, for example, ponders whether the coherence of trauma stories is correlated to the amount of emotional distress associated with a given traumatic memory. It is hypothesized that the greater the distress, the less organized the narrative. If this were the case, we might expect that the coherence with which an individual is able to talk about the trauma would increase as the memory is processed and resolved, a finding for which we have some evidence.
We do know – when it comes to Post-Traumatic Stress Disorder (PTSD) – that narrative matters. As I wrote in an earlier post, the most effective therapies yet proven for reducing PTSD symptoms are the exposure therapies, particularly Prolonged Exposure (PE) therapy. These therapies are more effective for reducing the full range of PTSD symptoms than any pharmaceutical yet identified. And the crux of these therapies rests on telling the story of the trauma, sometimes over and over again. This simple practice, this process of speaking, has been reliably demonstrated to result in an improvement of PTSD symptoms for many patients.
But for all its clinical benefit, this extraordinary observation tells us very little about the mechanisms of psychic healing after trauma. Instead, it points to a growing body of evidence that suggests it is not just narrative that matters in PTSD, but, more intriguingly, that it is the type of narrative that matters. Unstructured psychodynamic therapies, for example, have not been demonstrated to lessen the severity of PTSD, even among patients who continue in therapy for years. And yet certain ways of narrating memory do make a difference, and this phenomenon once again points to a role for anthropologists and other culturally-minded researchers in exploring the cultural-emotional-physiological-environmental interactions at play in post-traumatic processing.
Let me give an example. I recently attended a PE training workshop for VA and military mental health clinicians where specific instructions were given as to the essential structure of a patient’s ‘exposure narrative’, the trauma story that must be repeated until the patient becomes acclimated to the associated distress. One clinician raised his hand to ask the question, “So what’s the difference between this kind of talking about the trauma and the war stories a lot of these guys tell down at the bar?”
In this case, the answer the clinician received was strictly in line with the PE model of PTSD: namely, 1) that the types of stories veterans tell at the bar typically do not include the level of intimate and sensory detail that is necessary to process a disturbing memory; and 2) that the stories people tell at the bar are not typically the ones with which the greatest distress is associated (i.e., if they’re talking about the event that freely, it’s probably not that upsetting). Or, to paraphrase what one veteran told me, ‘We keep it superficial. And funny, not sad.’
But what makes the social worker’s question so intriguing is its resonance with work by anthropologist Theresa O’Nell. In a wonderful article , she explores two kinds of talking about the Vietnam war among Northern Plains veterans and the level of what she calls “psychological transformation” associated with each narrative style. She writes that, early on in her research, she was:
…puzzled by an apparent contradiction: on the one hand, it is said that Vietnam veterans have not “come home” from the war because they have not “talked about it.” On the other hand, friends and relatives of veterans know a great deal about the war experiences of veterans – experiences that could not be known unless the veterans had indeed “talked about it.” Moreover, despite their apparent disclosure of wartime experiences, many veterans seemed no closer to forgetting about Vietnam than if they had never “talked about it.” In other words, it seems to me that a lot of the disclosure done by veterans about their wartimes experiences was, at some level, lacking or ineffective, especially regarding the goals of disclosure and forgetting.
She set out to identify the different ways in which these veterans spoke about their wartime experiences, and came to recognize two distinct patterns, iglata (to “brag in excess”) and wagtoglaka (to “retell one’s heroism”). Informal iglata, for example, tends to occur while drinking and joking among peers, while the more formal wagtoglaka takes place in a ceremonial context, generally involving an intergenerational audience who listens in “respectful silence” to the veterans’ words. Thus her ethnography shows the two patterns of speech each have different discursive characteristics, social contexts, and manners of self-presentation.
O’Nell situates these forms of narrative in a way that reveals their meaning for those speaking and those listening, but she also links the experience of speaking in these ways to Northern Plains veterans’ ability to resolve their struggles with the war. She found that, among those who reported only talking about their war experiences while drinking (a context that would suggest iglata), self-reported PTSD symptoms were significantly higher than among those who denied only telling war stories while drinking (suggesting contexts not limited to iglata, although not necessarily indicating wagtoglaka).
O’Nell rightly points out that it is not just narrative that matters for these veterans, it is a specific form of narrative that appears to make the difference, as well as the social venue and the attitude of the listeners. In the context of a Western society in which going to see a therapist is a pretty mainstream response to many life problems, this emphasis on “talking things out” may seem a bit obvious. But what this example suggests is the possibility of cross-cultural variation in narrative forms that bear an essential commonality: they are in some way therapeutic for those struggling with the aftermath of trauma. This begs the comparative question, do narratives exist cross-culturally that may – despite different structures and content – similarly tap into the necessary processes for healing trauma?
In tackling this question, we yet again see how PTSD provides an opportunity for exploring the relationship between individual and environment, and in doing so demands that we consider the type of process Paul Mason writes of so infectiously in his recent post on neuroplasticity. We have had evidence for a while now that PTSD is associated with decreased hippocampal volume, but what will we learn about the structure of the brain through an exploration of the neural changes occurring alongside post-therapy symptom reductions in PTSD?
A study of eye movement desensitization and reprocessing (EMDR) – a therapy with mixed evidence for its efficacy, but which focuses on retelling traumatic memories in accompaniment with a series of eye motions intended to access key networks in the brain – found that, among 6 PTSD-diagnosed police officers who underwent SPECT imaging before and after their treatment, symptom reductions were associated with decreases in the left parietal lobe, left and right occipital lobes, and right precentral frontal lobe.
It’s just a beginning, but as our ability to conduct and comprehend neural imaging and other technologies increases, we will be able to observe the changes that accompany not only stress and PTSD but also the path to healing – that re-wiring of emotional and physiological responses that results in a reduced sense of suffering and distress. This research opens up the examination of narrative in a new way: as a focal point for understanding the practical interaction between communication and the brain, with very real consequences for healthy functioning. How incredible to think of being able to visualize such an internal, intimate relationship between words and illness, language and the body.
In considering the question of healing narratives, however, a series of other inquiries open up, most obviously: how does narrative-focused healing occur? What are the psychological and physiological processes providing the mechanisms for healing? We might also ask what characteristics define the appropriate type of narrative in a given cultural setting. Are there characteristics that appear to be common? And does variability in the nature of healing narratives occur in tandem with, or despite, differences in how closely local ideas of trauma resemble Western notions of PTSD?
Thinking in this way will also require that we navigate some rocky methodological questions. For example, it may be necessary to define traumatic aftereffects in a manner that considers cultural variation and the validity of comparison without limiting the field to PTSD per se. We must also distinguish between narratives that respond to long-term evidence of trauma, narratives that are intended to prevent acute aftereffects from becoming more chronic, and narratives that are useful in managing different types of traumatic events, from rape to war.
Despite its difficulties, such a path of inquiry has enormous potential for integrating neuroscience and some of the great questions of culture and experience.