THE TRAUMA NARRATIVE AS A PATIENT-CENTERED EMPOWERMENT TOOL | Michael Lowery Wilson
ABSTRACT
This paper offers an examination of how uninterrupted patient narratives, may provide insight into the nature and understanding of traumatic injury experience over the life course. I employ an interview method allowing for an in-depth narration of the importance of historical events, place and their meaning.
Keywords: Injury, life-course, Aboriginal, trauma.
INTRODUCTION
Ethnography as it relates to the examination of ill-health is concerned with understanding how individuals and groups make sense of illness given the cultural, social, historical and political environments in which they find themselves.Rarely are attempts made in the health sciences to go beyond causation to understand how individuals make sense of injury experiences given the complexities of experienced states that exist between objective biomedical interpretations of trauma and the subjective experiences of trauma sequelae such as suffering, pain and disability.
Uninterrupted patient narratives provide us with a symphony of data whose meaning can be orchestrated into understanding by bridging historical references into experience and suffering. The main idea behind any narrative is that the act of allowing an individual to speak - or write, legitimizes their experiences (Brown, 1990). The trauma narrative, can provide not only an useful adjunct to health care provision, but may also reveal important details about how people relativize their trauma experiences, cope and ultimately progress through various stages of recovery and healing.
Life course injury is a relatively rarely explored phenomenon in the clinical and public health sciences. While a focus on proximate factors and causal interpretations epitomizes the efficiency of modern epidemiological discourse (McMichael, 1999), this is done at the expense of providing meaningful answers to those whose suffering may be brought on by an array of social, cultural, physiological and contextual variables which may not capture subjective experiences of disability, pain and emotional trauma within the somatic experience. The established causal models allow for the exploration of subjectivities, which are integral to the human experience. Thus providing context and understanding of the lived experiences associated with a serious injury such as depression, anxiety, disassociation, and emotional trauma.
Cumulative in nature, life course injury necessitates the use of in depth approaches aimed at providing meaning to individualized injury experiences. Each account represents a personalized validity uniquely characterizing the sufferer and their understanding of the condition with which they are afflicted. Within this approach lies the trauma narrative, a patient-centered empowerment tool which provides meaning to somatic experiences of injury where modern medicine is less equipped to address in a holistically.
The Interview, Part I: The Injury Narrative
In order to examine the applicability of the trauma narrative, in 2008 I interviewed a Cree elder in Canada who suffered from a traumatic injury. I offer a contextual framework for interpretation of his narrative and briefly discuss how it might be relevant to the discourse on understanding injury.
An interview protocol for this effort was reviewed and approved by the University of Alberta Department of Anthropology ethics committee. Respecting his identity I refer to the participant as Mr. S throughout.
The experience of trauma is a complex process that transcends culture, community and place. This complexity is also interwoven into the fabric of location, identity and context. Of the themes raised above, exhibited in an abridged version below exists a commingling of these and other important themes which come into play as we tie the present to past occurrences and contextualize the present lived experience within the trajectory of events extending from the participant's youth to his present day struggle for equitable treatment in an authority-branded healthcare system.
A physician-colleague introduced me to Mr. S, a 70-year-old Canadian man of Cree descent who resided in the Province of Alberta in Canada. He characterized himself as "thoroughly Native" but also acknowledged a patrilineal link to southern Europe. Due to the geographical distance that existed between us, we decided mutually decided to conduct the interviews by telephone. The convenience of this method unfortunately came at the cost of not having the multitude of non-verbal cues and environmental context that would otherwise characterize a face-to-face account of his experiences.
During the first of two interviews, my impression was that of a sturdy, candid man who was very respectful. After providing an initial prelude to what I was interested in learning, I proceeded to ask him a series of short open-ended questions allowing him room to elaborate on his injury experience. His choice to participate in this interview with me was underscored by his urge to advocate for better healthcare services for Native peoples in Canada. He felt that he was doing his part to get the message out that not only were his current and past experiences with an authority-branded healthcare system detached and inadequate, but the extent to which his community faced structural impediments and inconsistent care was not only unacceptable but "inhumane" according to his interpretation:
"I want to do this, we have to try and get better service for Native people because right now that’s a big problem. I’ve been seeing my people waiting and sitting for 5-6 hours and a lot of times they [the doctors] say ‘there is nothing wrong with you, go home.’ We are human and I don’t think we deserve that kind of treatment."
The constraints ascribed to Mr. S’s own condition were debilitating. He was adamant that the pain not only affected his physical and psychological well-being but that it had castrating implications for his family and social life. Mr. S’s biomedical diagnosis was that of chronic pain from a herniated cervical spine disc, which did not improve with surgery. His experience not only included that of the chronic pain but physical impairment and psychosocial disengagement as result of a prior traumatic event, which he recounts:
"When my wife passed away I was in shock. She used to love houseplants and some of them were hanging plants. When I came home one day I climbed on a chair to water one of those hanging plants and I fell off the chair and landed on my right shoulder and my neck snapped. I laid there for maybe 45 minutes before I was able to crawl to the phone. I dialed 911 and they took me into Peace River where they flew me right straight to the university hospital and that’s where [Doctors] performed surgery."
The chronic pain and disability associated with his injury and subsequent surgeries, was enough to keep him in a persistent state of lethargy and lifeless torpidity. He was a vagabond in his own home where he spent his days lying and resting with little in the way of purpose or conviction. He stated that he had no interest in leaving his household anymore. Invitations from friends to join them in social gatherings often went unanswered.
In careful language, Mr. S described the pain resulting from the incident and how it had been compounded by successive corrective surgeries, which initially sought to replenish mobility and repair the damaged area cervical spine disc.
"The pain is on the left side of my body, but I’ve noticed that it has started to go to the right side too. Its not pain but it just goes numb. It’s the right side where I get most of my pain and in my neck it’s a burning sensation. Like it’s burning and my shoulder is numb and in my leg it’s a dull throbbing pain."
The Interview, Part II: The Life-Course Narrative
A part of the loss and suffering attributed to Mr. S’s injury was linked to two past trajectories; the loss of his mother and more recently of his wife approximately 3 years prior. Mr. S spoke very fondly of the memory of his mother, whom he reported suffered tremendous emotional pain and stress throughout her life as a result of being placed in a residential school during her childhood. His mother, while still in school, had been purchased by an Italian immigrant from her residential school when she was 17 years old.
This man would later become the father of Mr. S. His mother comforted much of her pain and suffering throughout her years by using alcohol. She continued to drink heavily until her death. Mr. S never really knew his father, who died when he was only 2 years old. He carries the surname of a father that he does not identify with emotionally or culturally.
"Yeah it was quite common because back then as there was no welfare and that and there were big families and a lot of them put their children in residential schools because they could not afford to feed them. My mother was in there until she was 17 and then one day she said that the sisters come in and said that you girls go and brush your hair and put on your best dress and get down here. So mom thought that her dad was finally coming to get her so they lined them up against the walls and the priests and a short white guy came in and he walked back and fourth and looked at the girls and he finally stopped in front of my mother and he said I’ll take this one and they left. My mom drank quite a lot until the day she died – she was 83 that’s how much emotional pain she had been subjected to. I tried to get to go to her father’s funeral when he died and she wouldn’t go. I love my mom so much. It wasn’t her fault that we ended up in a residential school.”
“My father passed away when I was 2 years old, she couldn’t support 5 of us so she had no choice. So yeah that’s why I have so much anger and emotional pain that, like I was saying this pain I feel in my neck and back is nothing compared to what I feel when I start thinking about you know like being alone now I get a lot of time to think and I start thinking you know, how our people have been treated all through the years and how families were separated. Like my sister in Halifax, I haven’t seen her for 43 years. They split up families and you know I don’t know, I guess I will die with all of this anger, cause I can’t get no answers from nobody. We are human you know. Then they wonder why Natives are always drunk I don’t think I have seen a happy Native. Every one of them has pain of some kind."
Being nearly always alone since the death of his wife and having a strained or dysfunctional relationship with his siblings add to his distress. His only living brother was more fond of his father as a child and in “acting white” according to Mr. S, his brother refuses to identify with or reconcile his Native heritage and this behavior in his view is hurtful and elevates the tension between the two of them at times.
Extending further into Mr. S’s lived trajectory was his own childhood experience of an 8-year stint in an Albertan residential school. At the age of two, Mr. S was taken to the St. Bernard Indian Residential School in Grourard, Alberta, where he remained for eight years until he ran 20 miles back home.
"Sexual abuse, physical abuse, they used to brain wash us to believe that the devil made the Indian people and it was their job to get the devil out of us, and there was a room that was about 12x12 [feet] and benches all the way around and about 56-60 of us kids were herded into that room and they would lock the door and turn up the heat, there were kids fainting and screaming and trying to claw at the walls you know, it was just so hot in there."
The residential schools were characterized by harsh treatment and substandard living conditions. Mr. S and his classmates were regularly subjected to torture as well as physical and sexual abuse. This according to Mr. S was all in the name of curing Native children of the devil from which they were believed to have been created. Today very little in the way of reconciliation has taken place.
"After 50 some years all of a sudden some high class lawyers called the Merchant Law Group found a way to make money so they started a lawsuit. They are the ones that handled our settlement. I spend 8 years in there and I got $31,000 as compensation. I don’t even use it, I don’t touch it. Because I feel like a prostitute, as if they are paying me for what they made me do. They can keep their damn money!"
The Interview, Part III: The Social Narrative
In a subsequent follow up with Mr. S, several snippets of a larger narrative began to emerge. He spoke briefly about how he wanted to do something for his community, a community that he stated was in certain decline.
"…they just buried an old guy that never does anything to anyone, someone kicked him in his head and crushed his brain or something and then kicked him in the ribs and crushed his lungs. They flew him out to Edmonton but he died on the way, they got the guy in jail now but he will probably be there for about 6 months because he killed a Native."
"There were two babies out in Saskatchewan, one was about 2 and the other was 18 months…just babies, it was 50 below and he was drunk and he took them out and he just left them and the next day they found them both frozen to death. Now they’re trying to bring him up in some healing circle, I said to hell with the healing circle hang the bastard!"
"You know the thing about 4 or 5 people run over on the road here? Nobody has ever been charged or nothing for it. Right away they say you were drunk that’s what I mean it’s not healthy to lay here and think about all these things but what can you do?"
The interplay between nature and culture was also captured in this narrative. In the course of his narrative, he made repeated reference to his prior “life in the bush” which was characterized by his being able to go out and hunt moose or trap rabbits. These were among the day-to-day activities of his active life, which were cut short due to the loss of his wife, who participated in the cleaning and preparation of hunted meat, as well as by the sudden collapse of his health due to the injury. As the rapid shift from a manual society to a mechanical one and from a mechanical to an electronic one began to unfold, slowly a more detached societal reality came to become a point of distress for him. As Jackson documents in his exegesis of the Swahili concept of ubuntu, captures the essence of Mr. S’s youth into his adulthood, where egalitarianism existed not only as a matter of social and cultural survival, but represented the lifeblood of community identity (Jackson, 2011). In Mr. S’s current life position, he sees a loss of not only ubuntu in terms of increased materialism and widening socioeconomic disparities, but a loss of what once existed as a shared communal response to pain and suffering. Mr. S deals with his pain alone, in a rapidly changing society characterized by having less respect for elders and an acquisitive nature of material possessions, which he characterizes as “whiteness.”
The commodification of authority, particularly in the provision of healthcare, but also in defining the reality of a once proud people, has left an entire community socially and culturally injured. It is this commodification that Mr. S speaks of with abhorrence. From accusations of being "devils" directed at Native peoples and abuse by clergy, to the shuffling and detachment of modern medicine men and harassment by other authority figures sworn to protect communities, Mr. S’s distrust of authority represents more than just an avoidance of risks incidental to past experiences it represents a core frustration of a community whose collective isolation, intra-community conflict and psychosocial dislocation represent outcomes of trauma (Kleinman, 1988). Injury experiences are complex and these abstracted vignettes demonstrate that this complexity is interwoven into a fabric of location, identity and context. One possible bridge beyond the veneer of the proximate is the narrative discourse that elevates the narrator and legitimizes their experiences. The trauma narrative is thus a method for exploring trauma experienced both in situ and over time.
Works cited
Brown, Mary Ellen. The colonization of prime time: Soaps and the question of pleasure. Diss. Murdoch University, 1990.
Jackson, Michael. Minima ethnographica: Intersubjectivity and the anthropological project. University of Chicago Press, 1998.
Kleinman, Arthur. "The illness narratives: Suffering, healing, and the human condition:[Excerpt]." Academic Medicine 92.10 (2017): 1406.
McMichael, Anthony J. "Prisoners of the proximate: loosening the constraints on epidemiology in an age of change." American Journal of Epidemiology 149.10 (1999): 887-897.
Michael Lowery Wilson is an Alexander von Humboldt Fellow at the Heidelberg Institute of Global Health, University of Heidelberg in Germany. He holds a PhD from the University of Turku in Finland which was awarded for research on pediatric traumatic brain injury. As a cross-discipline researcher in anthropology, epidemiology and global health, his work has focused on injuries as problems of public health importance. He has published widely in the public health literature on topics ranging from adolescent suicide, to pediatric burns and other external causes of mortality. His current research interests lie in the development and deployment of large scale experimental studies for injury and violence prevention in community-based settings.