Hey, it happens to us all. I’m healthy as a horse, but a body part was bugging me, so at my annual check up I asked to see a specialist. I love my family doc, er I mean “primary care,” and I love this specialist. They’re the best there is. And they’re victims of the system as much as we. I’m grateful they’re here just when I need them, with all their years of training and miraculous skills. I don’t want to cause them trouble, so let’s call it “body part X.”
It took months to get authorization for the specialist, thanks to insurance lunacy. Meanwhile X got worse, but still I expected just a routine new prescription.
The new doc walked in, took one look, and said, “You’ve got [deleted] here, and also there. You can go on like that for a while, and I could just write you another prescription for Y [as it’s been handled before]. But you’ll be back in a year because it will get worse. It’s not for me to tell you what to do, but we can replace [body part X] with an implant…
“Outpatient surgery takes 20 minutes, insurance pays for it all because it’s legally classified as ‘medically necessary’ since otherwise you’re going to lose your Z [essential function]. Then you can forget about the problem, you’ll be done.” (And no, it wasn’t prostate cancer.)
“Outpatient surgery”? So professional. Me? I’ve just been told, “you’re getting a knife in a real scary place.”
The specialist (I do like him) told me later that at that first meeting, he then proceeded to outline my options for the different available types of inplants, and following surgery, what functional abilities each implant type would give me. I was with him less than 20 minutes. Next he sent me on to his medical assistant to be checked by one more machine, who sent me to their lady “surgery coordinator.” By which time I was hit by a barrage of panic from my belly.
I’ve never had more than a tooth pulled in my life, and OK, I’ve always been a “fraidy cat.” And all I could think of was “Surgery. Surgery? Surgery — there?”
From the first mention of “surgery,” clearly I was in trauma. But why did this occur to no one, with so many professionals there? They seemed so oblivious that anything upsetting could possibly have occured, I was afraid to show it.
“We’ve discovered in our work in trauma that going to the gynecologist, pediatrician, social worker at school, any of the helping professions, can be traumatic,” says trauma expert Dr. Mary Jo Barrett (below right). “People with prior trauma, especially, experience their attempts to get help from the medical system as traumatic – because they experience it as a threat to their bodies.” [FN1]
And according to the ACE Study, roughly 50% of us suffer one or more types of Adverse Childhood Experience (ACE) trauma. That means half of us are going to experience such a medical issue as trauma. Including clearly me.
But in fact any human who’s a mammal will experience something like this as trauma, science is just starting to show. And even the most well-meaning, kindly medical personnel have never gotten the memo on what is trauma and how their system contributes to it.
Not to mention the legions of pretty much heartless medical personnel who have had their humanity forcibly ripped out of them by their training. Psychiatric expert Dr. Daniel Siegel, MD, says he almost quit med school when he realized he was being deliberately trained to destroy his emotions and view patients as machinery to be fixed, in the name of better performance.
No Time to Think – Let Alone Feel
Not to mention the insurance companies who now force doctors to stay glued to a stop-watch while seeing patients. Docs are forced to spend no more than X (pardon the pun) minutes per patient, no matter what, or they won’t be paid, can’t pay their staff or their astronomical malpractise insurance premiums, and must close their doors.
Upset? Shove it. Suddenly there I was with the “surgery coordinator,” and I had no time to panic, feel any emotion, or even to think. Wham, she hit me with a barrage of wildly complex surgery insurance questions involving a five-way tangle between my HMO, the specialist, the primary doc, the doctors’ “medical group,” and the hospital– made more complex by the fact that my insurance was about to change radically in three months. Worse, she was the type who quickly rattles off a list of in-house acronyms that only an insurance exec could understand, then says “OK?”
No, it was most definitely not ok. In fact with all my experience handling insurance companies over many years, 15 years experience interviewing engineers about rocket science, a BS in Math and 3 foreign languages — I still couldn’t understand a word she said. Surely she’s good at what she does, but her ability to explain what she does to another human being was sub zero.
As I began to drown under her spiel, that internal voice just got louder: “Surgery. Surgery? Surgery — there?”
On she went with questions about my meds, vitamins, lifestyle, and complicated instructions about new meds they were going to give me before surgery, and when to take what in a detailed month-long schedule. The level of detail would have overwhelmed anyone who’d just been given good news. By the time she was done rattling, the office was about to close at 5 pm and I was ushered out.
No more than two minutes of the entire two hour ordeal had been allowed for discussion of, or even for me to think about, the real Square One decision at hand: Surgery? Go for surgery, or not?
“Surgery. Surgery? Surgery — there?” It seemed like a nightmare from which I’d soon wake up. As it turned out, that feeling lasted about ten days. I kept thinking, “Oh, this is just a bad dream. I’ll wake up any minute.” No such luck. Somehow I made it through an evening of appointments straight until 9 pm, drove home and collapsed at 11 pm.
Involuntary Reaction to Survival Threat
“Medical procedures send many of the cues to the nervous system that physical abuse has,” warns Dr. Stephen Porges (left). “We need to be very careful about how we deal with people and whether or not even medical practices trigger some of the features of PTSD…
“Our clothing is taken away. They remove your glasses. We’re left in a public place and all predictability is gone. Many of the features that our nervous system uses to regulate and feel safe are disrupted,” says Porges. [FN2]
“And one of the most potent triggers of neuroception un-safety, is low-frequency sounds which the neurological system interprets as ‘predator.’ In ‘Peter and the Wolf,’ friendly characters are always the violins, flute, and oboe. Predator is always conveyed via lower frequency sounds. Medical environments are dominated by low frequency sounds of ventilation systems and equipment. Our nervous system responds, without our awareness, to these acoustic features and shifts physiological state.”
Medical pronouncements about what’s going to happen to our bodies, and medical environments generally “trigger ‘neuroception’,” Porges explains, “the neural circuits regulating the autonomic nervous system” tell our bodies that we are under threat. The news goes straight to our brain stem which takes action, without ever involving our thinking brain. Something entirely involuntary happens.
“Neuroception is not perception. It does not require an awareness of what’s going on,” says Porges. “Throw away the word ‘perception.’ Neuroception is detection without awareness. It is a neural circuit that evaluates risk in the environment from a variety of cues. When our mammalian social engagement system is working and down-regulating defenses, we feel calm, we hug people, we look at them and we feel good. But in response to danger, our sympathetic nervous system takes control and supports metabolic motor activity for fight/flight. But next, if that doesn’t get us to safety, the ancient unmyelinated vagal circuit shuts us down,” says Porges, literally describing shock.
He gives an example: himself. “I had to get an MRI. Many of my colleagues conduct research using the MRI, and I thought, ‘This will be a very interesting experience.’ You have to lay down flat on a platform and the platform is moved into the magnet. I enthusiastically lay down on the platform for this new experience. I felt really good. I was not anxious…
“Slowly the platform moved into a very small opening of the MRI magnet. When it got up to my forehead, I said, “Could I get a glass of water?” They pushed me out and I took my glass of water. I lay down again and it moved until my nose was in the magnetic. I said, ‘I can’t do this.’ I could not deal with the confined space; it basically was putting me into a panic attack… And an MRI produces massive amounts of low-frequency sounds…
“My perceptions, my cognitions, were not compatible with my body’s response. I wanted to have the MRI. It wasn’t dangerous. But, something happened to my body when I entered the MRI. There were certain cues that my nervous system was detecting and those cues triggered a defensive of wanting to mobilize to get out of there. And I couldn’t do anything about it. I couldn’t think my way out of it. I couldn’t even close my eyes and visualize my way out of it. I had to get out of there! Now when I have a MRI, I take medication.”
I could go on. I could tell you how I dealt with the question “should I have this surgery” the very next day, by getting a second opinion in my area, and was told “Yes, and soon.”
I could tell you how after a few days, I realized that the next looming question was what type of implant to choose, how long it would take each type of implant to get approved through the insurance maze, and where each type would leave my body functions after surgery. So I put out queries to the second specialist, and to three personal friends in Maryland, New York, and Illinois who are doctors, who all polled their colleague specialists in body part X. All of them came back with conflicting advice.
I didn’t ask my first specialist because I’d been told by the surgery coordinator to wait for a packet by mail, believing it would tell me how to select implants. But when it came a week later, it didn’t mention implants.
As noted, the specialist said later that at our first meeting, he did outline my options for the different types of implants. I was with him less than 20 minutes, half of which was a physical exam with a lot of machines.
Perhaps he gave a good briefing, but I was in “Surgery!?!” trauma, and my brain was out to lunch — like Dr. Porges in the MRI. If so, didn’t he realize I might be too preoccupied by the word “Surgery” to hear all those critical complex details immediately?
Perhaps he just read me an incomprehensible list in under a minute. I’ll never know; I simply can not remember even a single mention that first day of this issue, which is still tying up many of my waking hours at this writing.
Because now, nine days later, I have his read-out, and read-outs from the other four specialists – and none of them agree on the implants. Some of them even imply that the type my specialist is recommending could be a health hazard long term. And none of them have the remotest idea there might be a bit of trauma after all this at my end.
It’s 1 am and time to post this blog — so I can get up tomorrow and try to get this straightened out in time to select the correct implants, in time to get them authorized by insurance, in time for — surgery.
——————
Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.
Footnotes
FN1 Barrett, Mary Jo, MSW, “Addressing PTSD: How to Treat the Patient without Further Trauma,”
NICABM Webinar, June 29, 2011. Dr. Barrett’s latest book is “Treating Complex Trauma: A Relational Blueprint for Collaboration and Change,” orders are here: http://goo.gl/SEiWVD and http://www.centerforcontextualchange.org/publishedworks.html
FN2 Porges, Stephen, PhD, “The Polyvagal Theory for Treating Trauma,” 2011, http://stephenporges.com/images/stephen%20porges%20interview%20nicabm.pdf
—“Body, Brain, Behavior: How Polyvagal Theory Expands Our Healing Paradigm,” 2013, http://stephenporges.com/images/NICABM%202013.pdf
—“Beyond the Brain: Vagal System Holds the Secret to Treating Trauma,” 2013, http://stephenporges.com/images/nicabm2.pdf
—”Polyvagal theory: phylogenetic substrates of a social nervous system,” International Journal of Psycho-physiology 42, 2001, Dept. of Psychiatry, Univ. Illinois Chicago, www.wisebrain.org/Polyvagal_Theory.pdf
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In my opinion traumatizing is due to lack of awareness among the masses and imbalance in the medical system overall. Surgery has pre and post processes which can add to the trauma. If correct information reaches the masses, the trauma of the complex process of pre and post hospitalization and discomfort can be avoided. Knowledge on Insurance (basics at least) needs to be foremost priority at the patients end. Financial imbalance also adds to the trauma to a huge extent. Lack of information on whether the surgery is beneficial or not is also one of the main reasons for post surgery trauma.
I’m writing to let you know what a outstanding encounter my cousin had reading your blog. She picked up so many issues, such as what it’s like to have a giving character, to let many people easily grasp selected grueling subject matter. You exceeded my expectations.
I hasten to add that I have also had excellent, compassionate care, especially from certain nurses, who held my hand in the most comforting way as I was going under anesthesia. There are doctors, and there are doctors; there are healthcare givers who are angels, and others who should choose another occupation. The prospect of getting too old and feeble to care for myself scare the daylights out of me at times, after having seen the attitudes of people in some of the care facilities in which relatives have spent their last days. I know volumes and volumes could be written about that topic alone.
One of my doctors, a head of staff at one hospital, described hospitals in general as glorified factories. He himself was very compassionate and expert at asking a series of questions about my well-being at our annual visit for my complete physical.
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I can’t say the same for every MD I have ever met. I have encountered the type that view their patients as “cases” rather than human beings with feelings. One such man was rejoicing about the success of a procedure he had just done on my husband’s eye, in my and my husband’s presence, despite the fact that it was not going to save my husband’s life. It made both of us feel insignificant and helpless. My husband succumbed to a long and complex illness, during which his retinas detached. This doctor and his team did a retinal reattachment procedure on one of my husband’s eyes, but did it without anesthesia! because of their fear that his medications and their anesthesia were not compatible. This was not a matter of life and death; it would have been better to not do the reattachment at all or to wait until treatment plans could be adjusted. All this was happening when my husband was probably not in the best position to give informed consent, and I was not advised of what was going on. My husband later told me the pain was so severe all he could do was lie there and take it. He described this experience to one of our sons, who to this day describes his father as having been tortured, and who to this day does not trust Western medicine.
Another thing that traumatizes anyone seeking medical care and dealing with certain hospitals is billing. While my husband was in his slow decline and I was completely occupied with his care, I would get telephone calls from billing asking for payments. Now we had full coverage for everything possible because each of us had platinum policies with family coverage. It would have been only a matter of time before the hospital would have received every last penny, but secondary insurance was/is? not obligated to pay within 30 days, so there were always bills that were partially delinquent. Furthermore, every time my husband saw anyone at that hospital for anything, a new account was created, making bookkeeping a nightmare for me. I finally wrote a letter to the chief of staff of that hospital telling them to make the billing department lay off, because they didn’t know who the %$@$&&$@^ they were dealing with and they would be sorry. He got them to stop. No wonder spouses of the deceased face the risk of dying not long after their loved ones!
I had up until that time had complete faith in Western medicine, having had a lot of training and work experience in it. I was traumatized with guilt for not being able to prevent this fiasco from happening.
I was fortunate when I had my open heart surgery at Boston University hospital 20+ years ago. The Anesthesiologist must have compared notes with Dr. van der Kolk, and agreed with my advance directive of having all post-op procedures announced aloud to me, by name, even while some of the effects of anesthesia still affected me, before the procedure was done [like slapping me on the back to clear fluid from my lungs]…I avoided becoming what some nurses refer to as a “management problem”, and it avoided a lot of Fight-Flight [&freeze] reactions on my part…
I just got my DVD of Dr. Bessel van der Kolk’s 25th annual Boston Trauma Conference. I am listening to differential gene expression in peer-reared versus mother-reared rhesus monkey studies. I as shocked as I was when I first learned of Harlow’s Monkey experiments in 2001.
Stephen J. Suomi, PhD, Comparative Behavior Genetics reports that genes that are thought to promote certain negative behaviors such as drinking too much as an adolescent, are protective if the monkey is mother-reared versus peer-reared. In fact 25% of the genome of the rhesus monkey is differentially expressed vs not expressed at age 8 in these monkeys depending on whether they are peer vs mother reared. Environment matters! This is astounding. So what many think may genetically be the problem gene is protective in the right environment.
Dr. Van Der Kolk said this about Suomi’s talk:
“I am really delighted that these presentations are being video taped because you all should get them, and you should show them to your clinic directors and to your state politicians and the mayor of your town and the heads of the board of directors. These things have profound implications for the welfare of our children. We know that the single most effective mental health intervention is early mother-child intervention. New York City Mayor Bill de Blasio, as some of you may have read, has a very horrendous childhood trauma history. Now he puts huge amounts of money into very early mother-child intervention in New York, trying to set the standard. Steve, did you talk to him? When I go to Norway or Holland or places like that, I often get calls from the local ministry of health; I bet you do also. And they ask me, “What’s the latest research on infant development?” The people in the ministries listen to the science. In Norway, there are 51/100.000 people in prison, in the US 951/100,000 — that’s because people listen to the science. People listen to SCIENCE and so this stuff has profound implications for the budgets of our countries because if you don’t pay attention to this, you waste your money on incarcerating people and having a huge percent of useless population. These things have huge implications. The issue is being seen deeply for who you are as a kid, being emotionally moved together
That is the implication of what we are talking about here, this is not just a cute story about monkies. This is really important. Thank you!”
http://www.pnas.org/content/ea…013/06/21/1305230110
http://cmbconference2012.org/b…riences-in-primates/
http://www.thefpr.org/private/pdf/BROWNC~1.pdf
http://annualreport.nichd.nih.gov/suomi.html
Very good blog! Kathy, could you also do a story about how uninformed psychiatry has a similar effect? It causes re-traumatization by putting us through the same trauma as when we were kids, but without the empathy to keep our attachment brains turned on. So it just rehearses the trauma, rather than heal it. I can give you lots of examples of this…Thank you for your blog.
Your story also relates to a little boy I saw in my pediatric practice, 6 yrs old. He has severe Developmental and Attachment Trauma. He goes from calm alert states to panic in a split second. His parents don’t know what to do. I have been trying to explain to them, as you did in your blog, about the way you were treated as a kid, which now gets echoed by the way the medical doctors treat you. They had no understanding that the shock of hearing the word “surgery” could put you in an alarm state. In that state, it is impossible to hear.
I am a medical doctor. Do you have any suggestions with the limitations we as physicians have, how we can help our patients better? First and foremost become aware! And what could be a second step?
Dear Dr. Hahn,
Thank for your comments about needing an article like this also to show how therapists and psychiatrists often end up re-traumatizing patients.
My “article” on how bad psychiatry causes
re-traumatization is right here on my website – in fact it’s taking me a whole book to document it. The article is my book, “Don’t Try This at Home,” at http://attachmentdisorderhealing.com/book/
What’s really scary is that this must happen to many people: I had so many re-traumatizing experiences by bad therapists, that I quit seeking help and “did it myself” at home. And that, was an even worse disaster, because it’s biologically impossible for us to do it alone.
See especially my book Chapter 11 at http://attachmentdisorderhealing.com/i-oughtta-have-my-head/ which says, “Out of the dating shark pool I stumbled, into the therapy jungle. That’s right, I took the plunge, despite the massive social condemnation, the incredible expense, and the huge time commitment. I threw myself into treatment heart and soul for seven months, out of genuine alarm at my own mental state…”
What medical doctors can do of course as you say first: be aware of the effect on patients of the impersonal med environment, and any bad news. Second, try to fight the insurance clock ticking, and budget 5 minutes to just sit with the patient as they absorb the news and let them know you care and you feel it with them. Third, do give them their options next: but rather than rattling it off and dismissing them, try to ask them if they’re ready to absorb it, and to give it to them slowly enough that they can grasp it. Or if no time, then make a second appointment, send them to your compassionate office nurse, give them something in writing or a website to check. Create time for them to put their thinking brain back on line.
Thanks again,
Kathy