BURN TOPICS
A Guide to Burn Survival
Author's note
By removing damaged tissue, keeping wounds clean and protecting their patient from harm, burn specialists produce an environment favorable to recovery. The body's own built-in restoration processes take it from there. The principle: Caregivers create the conditions; nature heals. These little essays show how the same applies for mental and emotional trauma.
Clinton Tempereau MD
BURN TOPICS
Skin and Brain: A rapid-response team
Besides being the largest organ of the body, Skin is also remarkably versatile. As our main interface with the outside world, it sends frequent status reports to Brain, using specialized nerve fibers that carry information on pain, temperature, pressure, and touch. At the same time, it lets other persons know about various mental states, including embarrassment (we blush), anger (we flush), and horror (we shiver and shudder). Clearly, Skin operates as a double agent, informing us about the world, and the world about us.
Like any good informant, Skin adapts quickly to changing situations. For example, consider what happens with one of its functions, sexual arousal, after a major burn. The same touching/stroking/caressing, that might have been exciting before the trauma, now ushers in a sense of calm and quietude--more hypnotic than erotic. The end point is no longer sex, but bonding. And, as every sorrowing child and every suffering burn survivor knows, bonding heals. Only when healing is well under way, will sexual arousal be allowed to return. Here, then, we have evidence of a powerful therapeutic alliance between Skin, the informer, and Brain, the chief executive organ.
The close collaboration between Skin and Brain has a fascinating history. When you and I were mere embryos, the size of a grain of rice, a few of our pre-skin ("ectodermal") cells folded in and then closed over, to create a tiny tube. That tube eventually gave rise to the central nervous system: Brain and spinal cord. Considering their common heritage, it is entirely natural that Skin and Brain respond as a team when trauma strikes.
We now have a different way of looking at something that you, a burn survivor, already knew: Intimate physical contact means one thing when you’re active and healthy, quite another when you’ve been traumatized. The same goes for many other life processes. Remember this, as you engage with those you love, while you--and they--recover.
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BURN TOPICS
In any discussion of pain tolerance, those of you who have suffered life-threatening burns speak with the authority of experience. After all, for weeks, months, sometimes years, pain was your constant, unwelcome companion. We on the burn team look to you for insight into how interactions with other persons affect your response to on-going pain. A case in point: We know that pain usually eases off gradually as physical healing takes place. Usually, but not always! Once in a while it takes a perverse turn, growing and spreading, until it takes on a life of its own. Persons with this affliction, which clinicians call chronic pain syndrome, become captive to their own miseries. They always hurt somewhere; they lose friends; they suffer more than they live. Our experience with burn survivors in general, taken together with what we have gleaned from other studies, convinces us that if you find it easy to feel another person’s pain, if you have an empathetic nature, you are unlikely to develop a full-fledged chronic pain syndrome, no matter how serious your burn.
The vaguely religious notion that our own suffering becomes less acute, less disabling, when we take on the suffering of another, is hardly new. It bears on the whole question of pain tolerance, of course. As we empathize, we like ourselves better; we feel more genuine; we hurt less. Many of you, after leaving the burn center, come back from time to time to encourage newly burned patients during their acute distress. Perhaps there is a touch of Mother Teresa in all of us. Or perhaps, since this apparent selflessness buys us relief from our own distress, our deeper motivation may, in fact, be self-serving after all. It doesn’t really matter, does it? What counts is the reminder that when we warm up to a fellow sufferer, we are better able to give our own residual pain the inattention it deserves.
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BURN TOPICS
We use our hands to manipulate objects, our faces to control people. A smile, a frown, a smirk, a wink, a scowl, a stare: Just a few of the precision tools ("social skills") we carry with us all the time. And powerful tools they are. We learn very early how to wield them with devastating effect. Of course, a third degree facial burn changes all that. People stare at scars. When they do, we take it personally. After all, the way we judge ourselves depends heavily on what we see reflected in the eyes of others. In terms of control, we find ourselves at a competitive disadvantage: They have intact faces; we don’t. Burn surgeons and allied specialists will call on their prodigious talents to reduce scarring, reconstruct our features, and make us more presentable. But once they have finished, the rest is up to us.
Our new reality: Unable to use facial expressions the way we did before, feeling empty and unattractive, we find ourselves in a strange and unpredictable world, no longer "a familiar face". Grief, like that which accompanies the loss of a loved one, follows naturally. Entirely normal and even desirable--up to a point! But then, after a few sorrowful months, it’s time to "get on with life": A tall order!
Fortunately, there’s a strategy that’s been around for a few thousand years, going back at least as far as Moses and his Ten Commandants. Quite simply, this: Emphasize, not what to do, but what not to do. Using common sense as to what constitutes unacceptable, unattractive behavior, construct a personal list of "Thou shalt nots" (listing only what you know is realistic): Do not—whine..indulge in self pity.. provoke confrontations ..abuse caregivers ..lurk in the shadows, etc. The point is this: Once we rid ourselves of the bad stuff, what’s left is the good stuff. And it’s OUR good stuff. In the process, we become nicer, indeed better, more attractive persons. Our approval ratings go up, and we like ourselves more than ever. Bingo!
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BURN TOPICS
As you burn survivors know all too well, loss of the ability to move about freely, leaves you feeling sad. Sometimes that sadness deepens into depression. At other times, rather than getting depressed, one becomes despondent. Although depression and despondency are superficially similar, they come about in very different ways, and require entirely different handling. To understand this, let’s examine the two words, DEPRESSED and DESPONDENT, more carefully. Depressed means "pressed down". A depressed person feels heavy; burdened. Despondent means "without a sponsor". It derives from the Latin word spon-de’-re, which in fact means "to sponsor", or "to promise". A despondent person feels empty and alone. Now, do you see the difference? When we feel depressed, we need someone, anyone, to ease the burden, to help carry the load. When we feel despondent, we need the one right person--our primary caregiver, our personal "sponsor"--whose essential function is simply to be there. (Interestingly, that Latin word, spon-de’-re, also gives rise to our word, SPOUSE.) The moral of this story: Don’t view every sad mood as depression: Sometimes it’s despondency. Any one of several (often anonymous) caregivers can ease a depressed mood, but despondency cries out for individual attention from the primary caregiver. For most adults, that means the spouse or spouse-equivalent.
Correct treatment depends on a correct diagnosis. It’s quite easy to clarify whether the problem is depression or despondency, if you remember how the words are derived. Armed with that knowledge, you also know where to turn first for help: The caregiver network, when it’s depression; the primary caregiver, when it’s despondency. However, once in a while, even with the best efforts of many caregivers, depression may still spiral out of control. In that case, go to intensive psychiatric treatment, including anti-depressant medication. Conversely, if it’s despondency that’s getting out of hand, proceed instead to intensive training and step-by-step guidance, for the primary caregiver.
To all burn survivors and their caregivers: A depressed mood, if allowed to progress, opens the door to Major Depression. A despondent mood, if allowed to progress, opens the door to Post-traumatic Stress Disorder. Both are disabling illnesses. They don’t have to happen.
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BURN TOPICS
Many burn survivors go through a WHY ME? stage. Yet, strangely enough, no one seems to have a good answer to the "why me?" question. Why is that? Because it’s not really a question, that’s why! It’s a complaint; an embittered "woe is me" complaint. Infants, before they learn to talk, wail pitifully when they can’t get what they need. In their helpless state, they complain loudly if they are deprived of something important. Burn survivors, deprived of meaningful control over their lives and unable to do much about it, behave the same way. Babies wail. Grown-ups say "Why me?"
In reacting to a terrible trauma, Why me? is understandable and natural, but it doesn’t solve anything. Instead of addressing the situation, it merely reiterates the unfairness of it all, feeding one’s bitterness. The longer one indulges such an attitude, the more ingrained the bitterness becomes. Sooner or later, that gives rise to bigger problems: Social isolation (people avoid complainers); a self-centered approach to life ("From now on, no more Mr. Nice Guy"); paranoid thinking ("Someone’s out to get me"); depression ("What’s the use?).
To rid themselves of this malignant bitterness, some survivors have successfully reversed direction. Instead of complaining Why me?, they now ask, "Why NOT me? Am I so special that I should somehow be exempt from misfortune?" By using mental discipline and rational thought, they have learned to put their own misery into better perspective. "Easy to say, but when you’re alone in Hell, it’s not so easy to do!" True. Still, thought CAN override feelings and reason CAN change attitudes--especially when you let someone who loves you know what you’re doing. Once that primary caregiver (spouse, parent, best friend) shares your new perspective, once you accept that even in the worst of times you are not alone, your bitterness can relax its grip.
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BURN TOPICS
Do you think of yourself as (a) a burn survivor or (b) a burn victim? This is not a trivial question. A survivor views the burn as a learning experience. A victim sees it as punishment. Survivors recover more quickly because they concentrate (constructively) on what they can do to assure that it doesn’t happen again--to themselves or anyone else.
Victims concern themselves, not with HOW the burn came about, but WHY. For them, burns are not accidents. Instead they serve as graphic proof that somehow, justly or unjustly, judgment has been rendered and a penalty (the burn) imposed. Unlike survivors, victims expend energy, not on getting well, but on probing the depths of their wickedness.
Of course things are never quite that simple. Any burn survivor can drift into the victim mode once in a while. It goes with suffering. Perhaps all of us retain some lingering trace of the primitive notion that ANY burn represents a well-deserved punishment. But think about it. If that’s the way it works, how long before our bad deeds have piled up to where it’s time to be burned again? A worrisome prospect for those of us who are not saints! And that’s not the worst of it. Especially when the suffering goes on and on, it’s all too easy to treat it, not only as punishment, but even torture. Victims of torture dream of vengeance. Doctors know that vengeful patients don’t do well.
On the other hand, if one accepts that accidents do happen, then the task is clear: Check for any contributory carelessness, correct for error, treat it all as a learning experience and get on with life. There are many constructive ways of thinking about, and dealing with, one’s burn. Playing the victim is not one of them.
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BURN TOPICS
The first few weeks following a near fatal burn is a time most survivors would prefer to forget. These are days of crisis when one’s body must draw on all its reserves to contend with traumatic shock, unrelenting pain, multiple surgeries, daily dressing changes, infection, toxicity from burn breakdown products—the physical response of a body under siege. And then there’s the emotional side.
Mentally the first few weeks is a time of flashbacks and nightmares. Crazy images appear unbidden, racing through one’s mind--disrupting the brain’s chemistry and permanently reshaping its output. For every man, woman and child who has suffered through those weeks, life will never be the same. Still, their individual accounts, varied as they are, do have much in common: (1) Helplessness. A bad dream wherein one is paralyzed, unable to act; (2) Timelessness. Time has no meaning. An hour can fuzz into a minute or a week or forever; (3) Loss of identity. The concept of Self deteriorates: "Something is happening to me. Who, really, am I?" (4) Hyperawareness. A spooky sense that one knows too much, that one can see right through people. (5) Too much truth! Life and the burn can no longer be separated. BURN is everywhere, tainting everything and everybody.
This then is what the survivor’s inner world is like during those first few weeks. Four walls and a hospital bed. People morphing into monsters or angels, depending on what’s going on inside Brain at the moment. An unstructured nightmarish mindscape in which concepts of time, place and person lose their boundaries.
Since the acute burn experience is so bruising, so "psychotic", why do I as a trauma psychiatrist recommend that survivors preserve its memory? Simply this: Nothing else—no book—no philosophy—no psychoanalysis—no portrayal of heaven or hell—can clarify one’s priorities in quite the same way. For those who dare to listen, the wisdom of a lifetime, knowledge of what is important—and most of all WHO is important—declares itself most candidly during those first few weeks.
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BURN TOPICS
Recovery from emotional trauma relies on the same biological drives that encourage all healing. Of these, regression stands out from the rest. Regression entails a tactical retreat to some more primitive state. We see it in a wounded puppy whimpering at the roadside; a lost child wailing for its mother; a grown man or woman crying over the death of a friend. It shows up too in episodes of childlike behavior among persons rendered helpless and dependent by a major burn.
Unfortunately caregivers sometimes interpret crying and other forms of regression as evidence of inherent weakness. Nothing could be further from the truth.
Nature sees to it that the strong as well as the weak regress when they are traumatized-- and nature has her reasons. Why do certain burn survivors react to their injuries like teenagers while others behave like little children or even infants? Contrary to what one might expect, the depth of regression has little to do with the severity of the burn or its circumstances. Instead, it depends on residual damage from some earlier trauma. Adults whose teen-age years had been spoiled in one way or another will respond to their burns by regressing to adolescence. Or if serious damage occurred during early childhood, it is childhood that will be revisited. And if it happened during infancy, then it’s back to being a baby.
For most persons, there are certain life events of which they can truly say: " I’ve never been the same since." Nature in her wisdom keeps those moments on file in long-term memory. Then, when a new catastrophe comes along these persons revert to the very stage of development they had attained when their lives fell apart—even if it happened many years ago and is only dimly remembered.
We can now understand how burn trauma sometimes leaves survivors emotionally healthier than they were before it happened. Assuming that present-day caregivers—family, doctors, nurses, friends-- come through as they should, their support will of course ease the misery. But because in some important sense the regressed survivor also exists "back there", the benefits of today’s support can now be used to defuse the remote trauma as well as the current one.
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BURN TOPICS
A standard guideline for psychotherapy has long been Know thyself. A worldly-wise philosopher has taken it a step further: To know oneself one must first be tested! Any life-threatening burn provides just such a test; a made-to-order stress test capable of revealing details of a survivor’s basic nature. Because the burn is usually unplanned a scientist would call it a "natural experiment".
The slow pace of burn recovery, coupled with a realization that death could be imminent, gives survivors both the opportunity and the incentive to be especially honest with themselves. Doing so however means taking a mental journey into an uncompromising world of stark reality; a world where excuses and self-deception no longer work. For those who go the full distance it’s as though three years of psychoanalysis gets condensed into a few weeks—with no days off! We should take a sober look at just where that road can lead.
It turns out that the more honest people are in facing up to their own personality quirks and character flaws--the more starkly they reveal themselves before the non-distorting mirror of self-knowledge--the more they find they have in common with everyone else. What started as a "know thyself" project progresses into "know everyone". That means seeing the world through everyone’s eyes, not just one’s own. For better or for worse, one might then catch glimpses of human nature in the raw, a level at which liars and thieves become indistinguishable from virtuous citizens. Such clarity is not for everyone.
For the majority of burn survivors most of what we have described never rises to the level of consciousness and is never articulated. Instead their insights come directly from the burn experience itself, not by way of psychological interpretation. It is quite enough that their burn, the big stress test, has left them more tolerant, more sensitive to others’ suffering, more securely placed in the world as it is, than they had previously thought possible.
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BURN TOPICS
During the first few hours after a catastrophic burn, survival depends mostly on professionals—doctors, nurses and technicians. Not surprisingly survivors find themselves bonding quickly and strongly to those who have saved their lives. The model for human bonding is the mother/infant union, but any relationship between a helpless person and a helping "other" works the same way.
Ineffable means "incapable of being expressed in words". Human bonding is like that, working its little miracles quietly, without fanfare and with little danger of harmful side-effects. The mental serenity that comes with it supports homeostasis, a balanced physiological state in which bodily organs and their hormones operate in healthy harmony. In this, bonding differs radically from its more sensational cousin, love, which thrives on words and excitation. (The words, "I love you", spoken under the right --or wrong!-- circumstances, can change the course of history.) Love stimulates; bonding heals. There are good practical reasons for why every burn survivor should keep this distinction in mind.
Suppose that an important love relationship turns sour while one is still suffering burn trauma. Common reactions include anger, frustration, bitterness, depression, feelings of abandonment or betrayal, perhaps even vengeance. But remember, the opposite of love is not hate, but indifference. Eventually, when the emotions have run their course, one simply stops caring, leaving a residue of coldness.
By contrast, consider what happens when the partners in a bonded relationship are no longer "in touch"; when the other dies or moves away, or the situation changes. Think back to your favorite grade-school teacher, now long gone. You will notice that the bonding you had then has left a permanent residue of fondness. Similarly, when a parent, spouse, doctor, nurse, or fellow burn-survivor—in fact, anyone to whom you had bonded strongly-- is no longer part of your everyday life, you may nevertheless expect that residue of fondness to remain. Treasure it!
In its sensational and emotional form, love brings excitement and joy-- spiced with a bit of danger. (Of course it can also gently nurture and sustain both persons, but then we’re really talking about bonding.) Love makes the world go round. Bonding keeps it in balance.
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BURN TOPICS
From the very beginning burn survivors and their caregivers have different agendas. Survivors, operating from a position of helplessness, will do whatever they can to quickly regain control of their lives. Caregivers, on the other hand, emphasize protection and support, even if that sometimes means blocking the survivor’s wishes. Also, for each survivor there are several caregivers, each with a personal opinion as to "what is best for the patient". Thus the stage is set for disagreements and power struggles among well-intentioned people whose goal is not to defeat anyone but only to be helpful. Caregiving is not such a simple matter after all. A review of some simple truths might be helpful.
The primary caregiver is boss. Someone in the support network must step forward quickly to act as interface between the survivor and everyone else, taking ultimate responsibility for major decisions. Others may offer opinions and advice, but this primary caregiver (usually spouse or spouse-equivalent) has the last word.
Caregiving has a feminine face. In humans and other species as well, tenderness, sensitivity, protection, a readiness to touch and caress-- the universally recognized hallmarks of caregiving-- are typically female traits. Male caregivers are most effective when they augment their manliness with a touch of femininity.
Burn survivors need to be babied, then weaned. The weaker one’s position, the more tempting it is to misuse power. Survivors, as they struggle to get by one day at a time, will take advantage of any psychological leverage that’s available. At best they will do so in a sensitive and considerate manner, but sometimes they may try to manipulate their caregivers by creating guilt, making a scene or simply refusing to cooperate. The challenge for everyone, especially the primary caregiver, is to respond to the need but not to react to the misbehavior. Sometimes that requires "tough love".
A survivor who has no one, still needs someone. Not every trauma survivor has family or friends. Fortunately there is an invisible army of potential caregivers out there; kind and caring people, who will come forward once they are made aware of the solitary survivor’s plight. These are the people who understand the moral imperative that should apply to us all: With awareness comes responsibility.
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BURN TOPICS
Meet Laura. Laura is recovering from a major burn. Yes, her life history contains its share of wise and unwise choices, lucky and unlucky breaks and healthy as well as unhealthy habits. Taken together these choices, breaks and habits help define Laura, the individual. I have chosen her recovery story to illustrate how certain inborn trauma responses, present in her and all other seriously injured persons, can be turned to therapeutic advantage. We think of these genetically based responses as potential repair programs. The ones most important to mental recovery are (1) repetition, (2) regression and (3) bonding.
Repetition. Soon after arriving at our burn center Laura began having flashbacks. In between flashbacks "pictures" kept coming into her mind: Intrusive images. She dwelt obsessively on what went wrong, blaming herself, and agonizing about how she might have prevented the accident. Her brain insisted on replaying "the tape", sometimes inserting bits and pieces of other traumas. She had frightening dreams and wild nightmares. Not surprisingly Laura tried to suppress or deny these unpleasant reminders as best she could: But in so doing she was putting herself at risk for a very serious condition called posttraumatic stress disorder. Hence, rather than encouraging denial or trying to medicate it out of existence, a psychiatrist from our psychotrauma team chose to "tame" the symptoms by doing repeated debriefings—helping her gain mental control by reliving the event in a safe and supportive setting. After repeating the process several times with her husband and friends she now treats the "memories" as just another old war story.
Regression. For weeks Laura showed the emotional reactivity of a little child. She cried easily, overreacted to minor inconveniences, lashed out at caregivers. We reached an understanding: "We will cater to your childlike behavior as long as necessary. But when you abuse the privilege we will be ‘stern parents’ ". It worked.
Bonding. Laura bonded to her doctors, nurses and other caregivers as though her life depended on them--which in fact it sometimes did. The psychotrauma team encouraged and facilitated this bonding. Even now, months after leaving the hospital she maintains contact, stopping by the burn center, visiting recently burned patients, attending survivor meetings. This has added another dimension to her social life.
While this synopsis stresses nature’s contribution rather than Laura’s feelings, everything about her recovery pulses with emotion. For those of you who are musically inclined it can be likened to an opera: Laura wrote the words, Nature supplied the music.
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BURN TOPICS
In The Inferno, written more than 700 years ago, Dante Alighieri tells of his personal journey through Hell. Like those who have lived through a serious burn, Dante had suffered tremendous trauma—in his case political persecution and exile from home and community. Using memorable word-pictures, he portrays how major life-threatening trauma plays with the besieged mind, toying with its memories and recasting its thoughts and images. In so doing he highlights key elements of the recovery process. Burn survivors should benefit from seeing how he does it.
Hitting bottom. Hell symbolizes the human condition when it’s "as bad as it gets".
Dante’s descent into Hell meant hitting bottom, a necessary jolt if he was ever to rise to a better place. Most burn survivors find that their burn experience, their time in Hell, opens the way to a better, more real life back here on earth.
The wise guide. Needing a guide for his imaginary journey, Dante chose the poet Virgil. There were good reasons for his choice. Because Virgil had actually lived about 1300 years earlier, he played no part in the religious and political strife engulfing Dante, who was an intensely religious, politically partisan man. This allowed Virgil to be the non-judgmental voice of experience—warning, encouraging, explaining, consoling—as the two made way their into the depths of the inferno. Every burn survivor needs a personal guide. It could be one’s surgeon, one’s best friend, a psychologist or psychiatrist. The closer that guide comes to approaching Virgil’s example, the better.
The inspiration. Earlier in his life Dante had developed a deep and abiding love for a young woman named Beatrice. He envisioned her as the embodiment of all that was good, true and beautiful. Throughout his sojourn in Hell he felt her presence. She became his inspiration, his reason for struggling on, a beacon lighting the way to ultimate happiness. Every burn survivor needs a reason for going on. More often than not that reason comes together in one all-important person. Especially during the worst of times one may discern in that person, qualities reminiscent of Dante’s Beatrice.
Dante lends his voice to other less articulate trauma survivors who have made the same journey, who carry within themselves their own unwritten versions of The Inferno.
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BURN TOPICS
A rational basis for trauma counseling
In everyday life the mind and brain are inseparable. That insubstantial thing we call mind belongs to the brain just as surely as the fragrance of a rose belongs to the rose. Still, to understand how trauma works, we find it useful to treat them as separate entities. A stroke and a major burn both cause great mental distress but a stroke also damages the brain directly while a burn does not.
Trauma routinely activates three sets of responses, all of which are encoded in our genes. They are (1) repetition programs, which include flashbacks, intrusive images and obsessive thoughts, (2) regression programs, involving return to a less mature mental state, dominated by childlike or infantile behavior and (3) bonding programs, which draw on an instinctual drive to bond with important caregivers, just as newborn babies bond to their mothers. The brain assigns these responses to the mind which has the remarkable capacity to engage with other persons, something the brain on its own cannot do. (Again, consider the rose whose fragrance and color attract the pollinators needed to assure its survival as a species, something the bare flower could never do.) Here we have an instance of brain using mind to carry out special tasks. But suppose mind is too weakened, too depleted, to comply. In that case unproductive attitudes, dispositions and reaction patterns become fixed and permanent, quietly taking up residence at their appointed locations in the brain. Result? The infamous post-traumatic stress disorder. Enlightened trauma counseling will usually keep that from happening.
Over the course of untold generations, nature has evolved a sound biological basis for psychological healing. A rational treatment program must operate in accordance with her rules. During such therapy trauma survivors are guided through a series of carefully controlled "reliving" sessions designed to tame flashbacks and fearsome memories. Survivors learn that the uncomfortable reactions we call symptoms are simply by-products of nature’s blind drive to heal psychological, as well as physical, wounds. They come to view the first few weeks after injury as a narrow window of opportunity during which the closely linked responses of regression and bonding may be turned to therapeutic advantage. Medications are used to facilitate the counseling process, not to replace it. If counseling goes well the survivor becomes healthier, the counselor’s skills improve and both learn a bit more about human nature.
We live in a time when neuroscientists have access to sophisticated brain scans, advanced biochemical techniques and powerful computers. Aided by these tools they are now able to explore how our brains use mental and sensory inputs to shape human consciousness. To round out the picture they will surely benefit from the extraordinary humanistic insights that only trauma survivors and their counselors, working together, can provide.
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BURN TOPICS
Robert suffered a disfiguring burn because of a co-worker’s carelessness. They had formerly been on warm friendly terms but have not spoken since the accident. Robert was extremely angry at first. True, there were days when he was able to treat the event as one of those unfortunate accidents that could happen to anyone-- but whenever he looked at his scarred face in the mirror the anger surged more strongly than ever. Every operative procedure and every painful dressing change brought it all back. Now, two years down the road, the heat of anger has given way to icy coldness. He says he will never speak to his co-worker again. If they happen to meet he will refuse to greet the man, shake hands or in any other way acknowledge his existence. His stated position: "The guy damaged me for life. So far as I’m concerned he’s dead." Is this good for Robert? Knowing him as I do, I think not.
He had a choice. He could have continued seeing the co-worker, albeit at the risk of losing control of his anger at any moment. He chose instead to freeze all contacts. In so doing he followed the tradition of those feuding nations and ethnic groups that erect walls when they are unable to trust either themselves or their adversaries. The rationale of course is that a cold war is better than a hot one. Robert understands the concept full well. He cites it as a compelling reason for maintaining his wall of silence. His calculations, however, have not taken into account the hidden costs.
His devoted grandmother, drawing on her intuitions and the wisdom that occasionally comes with aging, alluded to one of those costs when she told him: "A grudge burns a hole in your brain." She was right. By freezing relations he simply switched off a bit of the brain circuitry that makes him human. Like other organs the brain operates on the "use it or lose it" principle. Far from neutralizing the co-worker, he has succeeded only in producing in himself the functional equivalent of a small stroke.
How this story will end remains to be seen. Robert must chart his own course. He may well decide to go on treating his erstwhile friend as a non-person. His grandmother, for her part, insists that the time has come for him to run a new cost-benefit analysis. She has a point.
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BURN TOPICS
Loss of control lies at the heart of all trauma. For adult burn survivors that means an abrupt change in virtually every aspect of life. For burned children it means they can no longer play. Children love to play. It helps them prepare for life's challenges. Of course being burned involves pain and scarring, but eventually pain goes away and scars become manageable. A child who is deprived of play for extended periods however, suffers in at least two critical ways: (1) Failure to thrive, due to lack of stimulation and (2) Failure to cope with traumatic memories, due to repression and denial.
Think of what life is like for a severely burned child. No more fun, only pain and fear, at least during the first few days when medical and surgical measures must take priority. When play does resume at some point during recovery, the world has become a different place. Relationships with playmates aren't the same. No more rough and tumble games on the playground. No more carefree running and jumping and climbing trees. Damaged skin remains fragile and sensitive for months, sometimes years. So it is that burned children of all ages feel safer when they're alone with their toys, even if that means shutting out the rest of the world. This is where play therapy comes in.
When they're alone with their toys little girls create scenarios in which their dolls are happy or tired or angry or hungry. Little boys do the same with robots and teddy bears. By projecting their own feelings, emotions and bodily states onto these "friends" they can invent all kinds of interesting situations. When play therapists join in the fun they are able to safely guide the children through dangerous territory. A sense of normalcy returns as the traumatized children regain control over their thoughts and memories.
Play therapists start with the premise that play is a universal need, an instinctual innate drive. Ordinarily a child's play looks to the future, building and honing skills for dealing with the world. After a serious burn however, playroom activity must look to the past for a while. Disruptive effects of the trauma must somehow be brought under control in a way the child can tolerate. Guided play, involving favorite toys and imaginative games, is the best way we know of undoing emotional damage, of taming the memories.
When A child is burned is written in collaboration with Norma A. Dolmo, Child Development Specialist at Grossman Burn Center. Ms. Dolmo's telephone: (818) 907-4518; Fax (818) 981-3865.Return to Table of
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BURN TOPICS
Bonding between people intensifies during and immediately after life-threatening trauma. It has biological roots.
When Glendale firefighter Bill J. left the Grossman Burn Center recently, he gave well-deserved credit to the many well wishers and caregivers who stood by him throughout his long and arduous struggle for survival. His message was simple and direct: "Without their support I would have died." I believe him.
Support comes in various forms. There is love, the emotion. Sometimes gentle, sometimes intense and passionate. There is care, the behavior. Gratuitous, compassionate, often anonymous. And then there is bonding, that elemental conjunction of parent and child, husband and wife, friend and friend, a boy and his dog. Bonding opens into a world where one plus one equals one; where energy is seemingly created anew. Unlike many interpersonal transactions it does not exhaust or weaken either participant but instead restores and strengthens both simultaneously. Bonding is a quiet thing. Lovers may rhapsodize and worshippers exult, usually with great expenditure of energy, but bonding silently sustains life. Without it infants fail to thrive and old folks stop taking care of themselves. Because it occurs throughout much of the animal kingdom, it must surely reflect an inborn biological imperative. "Thou shalt bond" is encoded in our genes.
When psychologist Jonathan Simons and I met with Bill and his family immediately after Bill entered the burn center, we found conjugal bonding already at work. Sue, his wife, was glued to his side and there she remained for the 104 days he was hospitalized. She suppressed her own anxiety while assuaging his. Both grew stronger in the process. Clearly, the biological imperative was at work. They were obeying nature's edict. So too, with Bill and his children. Nor was this phenomenon limited to family. Similar mutually restorative bonds developed spontaneously with his surgeon, Dr. Richard Grossman, with his primary nurse, Helena San Marco, with Jonathan, with me, and with several other members of the burn team.
Physical touch, the "laying on of hands", is an integral part of bonding, This has encouraged some practitioners to posit exotic, mystical sources from which healing energy is somehow generated in extracorporeal space. We favor a more sober, biological explanation. Here is how we believe it works. A severely traumatized person, Bill, for instance, inevitably reverts to a dependent state. There's no choice. Throughout most of his hospital stay Bill was helpless as a baby. As his needs were addressed, as he was fed, bathed, groomed, and generally looked after, he did what any well-tended child does; he latched on to the provider. In the process, his brain methodically dispensed its own brand of energizers, tranquilizers, and painkillers, including the opiate-like endorphins. But again, the provider, in this case Sue, was no inert bystander. Her need to provide, matching his need to be provided for, impelled her own brain to kick in with whatever was needed to do the job. At that point they were operating as though they shared a single central nervous system with a single output. Is it any surprise that Bill felt Sue's strength was now his as well? One plus one did indeed equal one. That's bonding!
We're talking biology, not traditional psychology, certainly not metaphysics. At no point did Sue become simply a "mother figure". At one time or another she performed mother functions, nurse functions, best friend functions, father functions, and more, but Bill did not bond to an abstraction. He bonded to Sue, his wife of 34 years. The psychological concept, transference, whereby an authority figure, usually a psychotherapist, becomes a surrogate parent for a time, can be useful when one seeks to revisit traumas of the past. But when we're dealing with current trauma, when our patient's reactions play out in real time, unembellished and unedited, the people in his or her world are who they are.
The story of Bill and his bonding is factual but also allegorical. His trip through hell is the story of Everyman's journey through this vale of tears. Big traumas happen all the time. When they do, a window of opportunity opens wide, but only briefly. The critical first few weeks of helplessness and regression is a time when new bonds form and old ones firm up. Given half a chance the need to bond will assert itself as it did with Bill. It's now highly unlikely that Bill will ever suffer posttraumatic stress disorder, a miserable condition that has left thousands of other trauma survivors damaged or disabled.
Bill is a good guy. He was injured on the fire line, fighting to protect others. The world responded. Now he's rewarding the world by doing good things, encouraging other burn victims, helping out wherever he can. Of course bad guys get hurt too. All too often they discover that just when their need for bonding is most intense no one shows up. That, however, is another story.
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BURN TOPICS
Finding peace of mind has special appeal to persons under stress-those who are in pain, mentally troubled, anxious, depressed, obsessed, in financial distress, or beset by domestic strife. If you're a burn survivor you have probably experienced all of the above. Of course some would have us believe there are many roads to relief. Drug companies offer tranquilizers, anti-depressants and a host of other "psychotropic" medications. Dealers in street drugs target the same market. Psychological counseling, prayer and meditation enjoy widespread support: Rabbi Liebman's book "Peace of Mind" has been around for 25 years. For their part philosophers have mused about angst and ennui for a long time without doing much about it. Of course there is always "the grape" but even alcohol has its drawbacks. And so the search goes on-and on.
A character in Chekhov's play The Cherry Orchard observed that when there are many remedies for a disease it means that it's incurable. Maybe he's right. Maybe there is no ultimate peace of mind to be found here on earth. Still there are many souls out there who do manage to eke out a few hours of true serenity from time to time. They may not have total and permanent peace of mind but by stringing together enough of their finest hours they come close. Among those resourceful people are some of your fellow burn survivors. Suppose we look at how they do it.
A lady I know, Lily, lost her face and some fingers in an auto accident. For weeks she lay helpless and near death. As often happens during recovery she bonded to those who saved her life--her beloved "caregivers". Little by little, as her strength came back, she looked deeply within herself. What did she find? She found intelligence she had never used. She found talents that she never knew were there. She found compassion that had lain dormant for years. She found courage. Lily is doing fine. Has she found true peace of mind? No, but I can assure you she's moving in that direction.
Next let's go to Bill, the hero of another of my Burn Topics, "When one plus one equals one". Bill's formula is quite simple: He focuses on doing good, leaving him little time for feeling bad. His days are filled with visits to burn patients, speaking to other burn survivors, and tending to the needs of his wife Sue and their children and grandchildren. If you think Bill is the exception look around the Burn Center. Why do you suppose overworked doctors and underpaid nurses stay on the job long after they need to? Ask them: They will tell you that seeing their patients happy and doing well is one of life's greatest satisfactions. It's Bill's formula all over again: Do good and you'll feel good.
Watch these folks closely--Lily, Bill, the burn team-- and every now and then you may catch a fleeting glimpse of what romantics used to call "The Bluebird of Happiness". Frankly I'm not exactly sure what that is but I think it has something to do with, you guessed it, PEACE OF MIND.
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BURN TOPICS
Friends hug when they meet and they hug when they say goodbye. They hug
when they celebrate and also when they grieve. A victory on the playing
field calls for hugs but so does a crushing defeat. Human beings hug a
lot! What does it all mean? How can it be that dozens of completely
different experiences all converge in the simple act of hugging? Notice
that these experiences do have one thing in common: they all involve some
form of stimulation or excitation. They include, for example, the joy of
meeting and the pain of parting, the thrill of winning and the agony of
losing. They also include every imaginable kind of trauma: anything that
excites or agitates, anything that gets the adrenaline flowing. But once
the stress begins to wind down the time is ripe for a soothing hug. (In
fact my dictionary tells me that "hug" is related to an old Scandinavian
word hugga, "to soothe".)
A hug's timing, intensity, and duration are determined by what feels
right! We don't talk things over first, we just do it. We don't calibrate
hug strength, the intensity adjusts itself. We don't keep hugging until
we get tired, we simply quit before soothing turns into something else. If
either person hugs too soon, too late, too hard or too long, the whole
experience becomes uncomfortable. That seldom happens. Our brains somehow
manage to fine tune the entire operation. Even more remarkable, while the
hug continues both persons' brains operate in unison. We don't know what
chemical changes occur during those fleeting moments, but they must be
significant. The embrace itself may last for only a few seconds, but its
effects can persist for hours. The memory could last a lifetime.
The mental miracle known as bonding finds physical expression in the act
of hugging. Experience tells us that hugging sometimes eases pain along
with other soothing effects. We have only the foggiest view of how it all
works but my best bet is that it goes something like this: When one's
brain receives a "hug message", a signal goes out to the appropriate
destination elsewhere in the brain. A signal goes to cells that dispense
natural pain-killers if one is in pain, natural tranquilizers if one is
agitated, natural sedatives if one is hyperalert, and so on.
Burn survivors take note. There is something about a burn that cries out
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BURN TOPICS
He thought of himself as a good person. Most of the people at work
agreed. If you asked them they would say he was definitely a good guy.
There were a few dissenters, people who called him names based on
below-the-waistline body parts. Over all, the good-guy votes
outnumbered the body-part votes by about four to one. Therefore we will
say that on balance he qualified as a good person.
One day he had an accident that left him with burn scars to his face, both arms,
both legs and some of the aforementioned body parts. Now all of the people
at work felt sorry for him. No one called him body-part names any more.
He didn't hear good-guy comments either. Everyone pitied him. He
hated that. Not that he hated the people, he just hated to be pitied.
It wasn't easy to think of himself as good when others thought of him as
pathetic.
When I first came to the Burn Center I thought my job was to help burn survivors
get back to feeling good about themselves. I would say things like
"You are a beautiful person inside" and "You are still the same
good person you were before". But since I hadn't known these
people before their accident I had no way of knowing whether I was speaking the
truth. Burn survivors have an uncanny way of knowing phoniness when they see it.
The more I repeated my platitudes the more their eyes would glaze over. I
decided to listen more carefully to my patients.
This is what I heard-over and over again: "I could never have made it
without my family and friends and the people at the Burn Center."
They were telling me that relationships can spell the difference between life
and death. That got my attention. I remembered a shocking statement
from one of my teachers: "A person is the sum total of his
relationships". In other words I can think of "me" as
"my wife's husband, my mother's son, my daughter's father, my friend's
friend, my doctor's patient" and so on. Of course when I complete the
list there is probably something left over, a shadowy something called "the
Inner Self"-but I'll leave that to the philosophers and theologians.
A burn survivor can rephrase the question "Am I still a good person?"
Instead he can ask "Am I now a good husband? A good son?
A good father? A good friend? A good patient?" In each case the
question can best be answered by the two persons themselves: The man and
his wife together can decide whether he is a good husband. He and his
parent together can answer whether he is a good son. He and I together can
determine whether he is a good patient (and whether I am a good doctor)…and so
on and on, taking every important relationship in turn. Notice that
we now have non-phony testimony. The two partners in a relationship know
better than any outsider whether a person is a good Whatever. The truth
begins with two!
Thus in the case of the burn survivor described above I no longer see my job as
"helping him get back to feeling good about himself". Instead I
work with him to create conditions in which he, with the help of his
relationship-partners, becomes a better husband, a better father, a better
friend….in short, a better person, than before he was injured.
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Einstein Visits Our Burn Center
One of the beauties of retirement is that I can imagine all sorts of exciting events that will never actually happen. Lately I've been reading a lot about Einstein. I got to wondering what he would think about the little "recovery miracles" that happen with burn survivors all the time. Well, Einstein is dead but just for fun let's suppose he had a granddaughter who was as smart as her grandfather. We'll call her Professor Allie Einstein. And then let's suppose she came to one of our burn survivor meetings. Here's how the meeting might go:Elaine Rojas: Well, this is certainly the largest turnout we have ever had. It's great to see so many burn survivors here, as well as all of you burn doctors and nurses and technicians. Tonight we are honored to have Professor Allie Einstein as our distinguished guest. As you know Allie is the granddaughter of Albert Einstein, one of the greatest scientists who ever lived. She is truly following in her granddad's footsteps. She is a top consultant at CERN, the world-famous atom-smashing facility in Europe. (Actually the term "atom-smasher" is a bit outdated. Now it's called a particle accelerator but we'll stick with the old-fashioned name.) When the project goes on line next year we can expect discoveries that will change the way we see the world. Please welcome Professor Allie Einstein. (Sustained applause)
Professor Einstein: It's nice to be here. You know, we scientists spend far too much time listening to each other and too little time listening to people from other walks of life. That's why I decided to attend this meeting. I'm here to listen. I want to learn more about trauma, especially burn trauma, from people like you. Frankly, I just can't imagine what it's like to be burned. In fact, I don't even know how I would define trauma. Is a divorce a trauma? Or the death of a parent? Or having your doctor announce that you have inoperable cancer?
Survivor Jenny: I would say trauma is when your world falls apart. When I had my accident it's like all of a sudden my whole life was out of control. I didn't know how any of my friends would react, especially my boy friend. I had been planning on going to college but now that might not happen. I didn't know if people would still like me. My parents hadn't been getting along and maybe this would really drive them crazy. In other words, all of my relationships were upside down and inside out.
Professor Einstein: You know I had always assumed that the worst thing about a burn would be the horrible pain and the ugly scars.
Survivor Jenny: That's what most people think but if you ask survivors they will say it's not the pain or the scars. It's the total confusion about what's going to happen to our relationships. The pain is terrible but when it's over it's over. Besides, there's always pain medication. So far as the scars are concerned, with each surgery things get a little better so we learn to concentrate on that. It's really all about our relationships with the people in our life.
Professor Einstein: Relationships! This is really interesting. We scientists tend to see all of reality in terms of relationships. When I think deeply about any relationship I think of it as a mathematical equation. Going back to my granddad's famous equation, E=MC 2, what he was really talking about was a relationship, the relationship between energy and mass.
Dr. Tempereau: Many years ago my mentor, Dr. J., suggested that maybe any person is simply the sum total of his or her relationships. In other words, I can think of myself as my wife's husband, my parents' son, my children's father, my friend's friend and so on. A whole big bundle of relationships. If you carry that thought to an extreme maybe every person is nothing more than one massive set of equations.
Professor Einstein: Thank you Dr. Tempereau, I don't think we want to go there. Anyone else?
Survivor Shannon: Well, backing up for a moment to what Dr. Tempereau just said. I was burned in a head-on collision. In the split second before the crash I just knew I was going to die. The only thought that came to me was "My poor daddy. He loves me so much. This will totally destroy him." Nowadays there are times when I think about suicide but then I remember what the doctor said: "Do you really want to murder your daddy's daughter? Could you really do that to him?" When I look at it that way the thought goes away.
Survivor Bill: So what we're saying is that relationships are what it's all about. Period. Come to think of it when the big surgeries are over and we go home from the Burn Center, most of us say pretty much the same thing: "Without the support of my family and friends and the wonderful people at the Burn Center I never would have made it." Of course being a married man, I give my wife Sue much of the credit.
Professor Einstein: Well, I'm not married but based on what you're saying, maybe it's time for me to get serious about finding a husband. The Tempereaus tell me that life begins the day you marry the right person.
Burn Surgeon Gene: Professor Einstein, I'm not married either. Are you taking applications?
Professor Einstein: Certainly doctor. Come up to my hotel room after the meeting and we'll talk about it.
(Laughter)
Elaine Rojas: On that note let's take a break for tea and cookies. When we come back Professor Einstein will have a few closing comments.
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Professor Einstein: During the break Lisa asked me if I believed in God. As you can imagine religion is a hot topic these days. Here's how I answered Lisa: "Of course I believe in God. I suspect that way down deep most scientists feel the same way. It's just that we all visualize God in our own way. Lisa, you tell me that God is black and has a bit of a temper. My little niece sees Him as a kindly gentleman with a long white beard. My friend Maria talks to Him in Spanish. For myself, when I think of God I visualize a stern old fellow who looks like Moses, wears a yamulka and sits under a banyan tree studying the Book of Nature."
Survivor Lily: That's all very interesting Allie, but seriously, do you really think you can learn anything important from talking to ordinary people like us? Let's face it, you're into atom-smashers and string theory and multiple universes and extra dimensions. We're into pressure garments and itch medicine.
Professor Einstein: The fact is, Lily, there's a lot I can learn from people like you. Let me tell you what I was thinking about on the plane coming to California. I was thinking about Grandpa Einstein, remembering when I was a teenager and he was telling me about how he arrived at his theory of relativity. He told me that he imagined himself as a little guy riding on a beam of light. While he was traveling at the speed of light the world looked completely different. Time was frozen. When I think of two particles smashing into each other in the atom-smasher I pretend that I'm a teeny girl riding on one of those little particles as it heads into the big collision, sort of like Shannon in her car just before the crash. When particles collide at high speed they fly apart. That allows us to see what they are made of. I think Shannon's story tells us that when people have a big trauma, when their world flies apart, they too may show what they are made of. In Shannon's case when she "knew" her life was over, when time stood still, she felt total love, nothing else. It's wonderful that she's here to tell us about it.
So thank you Shannon and Jenny and Lily and Bill and all you other burn survivors. You have shown me that when people have a big life-threatening trauma they behave very much like particles in the atom-smasher. Some crash head-on and are annihilated. Some manage to survive. And here's what I find so fascinating: All those strange thoughts and feelings, the insights, the flickers of truth, that come with the smash-up are known only to the survivor. No one but Shannon can ever know what she knows about what it was like when her world fell apart -- and what a challenge it was trying to put it back together.
It's really quite simple isn't it? Whether I'm at my lab in Europe or at the Grossman Burn Center in California, I'm learning about relationships in time of crisis. Listening to burn survivors here tonight is just like listening to my little particle-survivors at CERN telling their trauma stories. That is really cool!
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Most of us have brief moments when the world looks very bleak, when life hardly seems worth living. If the feeling persists we call it depression. There are many depressed people in the world. A few years ago this gave rise to an intellectual movement which said that the thing we call depression simply reflects reality-- that life itself is pointless, or as some philosophers put it, absurd. The idea was that since life contains so much struggle and misery and only fleeting moments of joy, and since we aren’t going to get out of it alive anyway, then what's the point? Wouldn’t it be logical to simply commit suicide right away and get it over with?
In today's purely fictional Burn Topic we meet a strange little guy who saw absurdity all around him at a very early age. He found himself thinking "Who cares?" Later when fate handed him a series of unbelievably harsh challenges, including a major burn, the "Who cares?" attitude remained stubbornly in place. In the end he survived the traumas, rejected the suicide option and managed to live a meaningful life after all. We don't know whether our guy could have adopted a more sociable attitude even if he wanted to. Perhaps. But then again maybe some genetic flaw left him little choice. In any case here's the story:
Once upon a time in a small town in California a child was born who was different from other children. Julius (that was his name) realized at an early age that much of what went on in the world didn't make sense. This was crystal clear to him even if other kids didn't get it. When he tried to explain they laughed at him. They said he had an "attitude". They nicknamed him Julie which is a girl's name. He soon decided to keep his opinions to himself. When something didn't make sense he kept quiet. But he would mutter to himself "Whatever!" or "Who cares?"
One day at breakfast he noticed that his mommy was sobbing. His daddy smirked and kept on reading the newspaper. That didn't make sense. Another time he and his parents were playing a bedroom game. His daddy or mommy would toss him in the air and let him land on the pillows. It was fun. Then for no reason they sent him to the den to watch TV. They locked the bedroom door and kept on laughing and having fun. That didn't make sense either. But Julius never whined or complained; he simply whispered to himself "Who cares?"
By age eighteen he had managed to adjust fairly well. He had a few casual friends. He played basketball. He excelled at computer games. He had strong opinions but never expressed them. The notion that maybe life itself is illogical intrigued him but he kept such thoughts strictly to himself. When he heard people carrying on about politics and religion in ways that didn't make sense he would shrug his shoulders and say under his breath "Who cares?"
On the way home from his nineteenth birthday party he and his cousin Susan were in an accident. The car caught fire. Susan died on the way to the hospital. Julius received third degree burns to most of his body surface. His face was badly scarred. He lost both legs and his right arm. There were many months of hospitalization, multiple surgeries. Years passed. He met a woman on the Internet. Eventually they married and had children. Being a husband and father seemed to change him in subtle ways. Then one day he noticed swelling and redness in his one remaining limb. After a series of tests the doctor delivered bad news: "Julius, you have osteomyelitis. We have to amputate the arm." As usual Julius said nothing. But this time he was no longer thinking "Who cares?" This time he couldn't wait to leave the hospital and get on with life. His attitude had changed--radically. Why?
I suggest that his attitude changed when his life changed. Somehow the series of traumas had activated an innate capacity for interpersonal bonding. Today he is firmly bonded to his wife, their three beautiful children and a few close friends. He operates his computer by using a pencil held in his mouth. He gets around well on his artificial legs. He loves music. Life is very good indeed. Deep within his brain the sterile idea that life is meaningless has been relocated to a storage area labeled "Abstract References".
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