Wary Book Review: Solving the Post-Traumatic Brain Injury Puzzle

Title: Solving the Post-Traumatic Brain Injury Puzzle 

Author: Linda Green

Date: 2018

Publisher: www.encouragegreen.com.

ISBN: 978-1724878816

Length: 395 pages

Quote: "Just started reading Bones on paper or whatever that book title is." 

This is a long review. Summarized in a sentence: This book does not solve the puzzle, and has as much potential to do harm for some people as it has to do good for others, but it's a valuable contribution toward solving the puzzle. 

If you're like some of my generation, what you don't understand about "post-traumatic stress disorder," PTSD, is why. Emergency care providers have come to expect that people who may have been "clinically dead" in the emergency room, combat veterans, victims of violent crimes, and survivors of traffic accidents and natural disasters, are likely to report nightmares or even waking "flashbacks," unpleasant feelings, aversions to things that remind them of the experience. Well, yes, but who hasn't had nightmares, bad feelings, and aversions to things that remind them of some unpleasant experience? People living with PTSD after falling forty feet may stiffen up and resist being touched. Yes, and so do people who've known even one or two people who liked to shove, pinch, trip, or sneak up and grab other people from behind. 

One would think that at least there'd be a consistent proportion between the severity of PTSD symptoms and the awfulness of the things people remember. There's not. One survivor of a plane crash feels overwhelmed and disabled by the memories, while another survivor who was on the same plane tells the story a few times and gets on with life. So the question arises: to what extent is disabling PTSD really just a bid for sympathy and/or handouts? Should even veterans get disability pensions for PTSD, or is "Suck it up, soldier!" the appropriate thing to say? 

I think most of our grandfathers knew someone who had "shell shock," and what most of them said was "Poor fellow." They could see that the poor fellow's reactions were physical, beyond his control, and interfering with his work. They might not have known a way to help him--getting him out of other people's way, in a locked ward in a hospital, didn't help him--and they may have held judgmental or fatalistic beliefs about why the poor fellow was so unfortunate. And sometimes what seemed to help was ridicule. Of a man I'll call John Doe my grandfather's friends used to tell, as a joke, how what brought him out of a state of nervous collapse was that someone roared, "Get up, Doe! You're not dead yet; if you were you'd see the flames." But they knew the "poor fellow" needed help, and if they were the praying type they probably prayed that he might someday receive it.

Today some people believe there's reason to hope that the "shell shocked" will be helped. Linda Green, a California fire fighter, has proved her fortitude enough to be willing to talk about her experience with the "weakness" of PTSD. Solving the Post-Traumatic Brain Injury Puzzle is her testimony, her account of the life pathway that led her through trauma to recovery. What has she learned?

Well, for one thing she's learned, from Natalie Goldberg's Writing Down the Bones, how to fill many journal pages with mostly one-line paragraphs, pages that look as if they were meant to be free-verse "poems" (and some passages really age). This is the raw material of a book. Goldberg's subsequent books discuss the need to revise these journals rather than publish them as books, at least as novels. As anecdotal evidence in the search for a useful understanding of PTSD, they are valuable. 

Although 395 pages sound like a lot, the word count per page is low; this book contains a lot of space intentionally left blank. The 395 pages span four years of self-observation. There's not a precise count of 100 pages per year, but it does seem convenient that Green's memories from 2015 really start in September (the big fire she was fighting when she felt something like a door closing in her mind), leaving space for introductory material, and she wrote the book in 2018, leaving space to transcribe a workshop-type discussion she does with traumatic stress survivors and include reference material. The sections from 2015 and 2018 have been polished into coherent narrative prose. The sections from 2016 and 2017 consist of journal pages. Much is left to the reader's imagination. There is that inevitable tendency to write in the journal when one feels relatively good, so Green's PTSD journal pages, like my own mononucleosis journal pages from the 1980s, seem deceptively optimistic. The reader has to compensate mentally, noticing the undescribed bad days between the sections of self-encouragement. I can say that my own reaction, when I read my mono diaries ten years later, was "It wasn't lying to myself, really, because I was not deceived, but it would be lying if I showed these pages to other people." I think it's valuable to observe the bias toward encouraging notes in disease journals rather than suppress it, actually. Read these pages and note how many more lines the encouraging notes get, as compared to the admissions that Green was drinking again.

Calling these notes raw data is not to say that Green has yet found a way to help you or someone you know. She tells her story and, because she has the sort of brain that's most comfortable being the "leader" or the center of attention, she outlines a way for other PTSD sufferers to tell their stories and look for points of resonance. However, her second career as a life/recovery "coach" is still very new. One might even say experimental. 

I believe one day people like Linda Green are going to start introducing themselves and their ideas with "I have extroversion," or even "I suffer from extroversion," and this is going to be a good thing, for them and for everyone else. Currently, and regrettably, Green writes as if she thinks she is normal. The neurological connections between thinking patterns and emotional mood are very different for introvert and extrovert brains. Green's description of her "normal" reads horribly like the way I would, and people I know well would, describe "the night before a major stress-related illness broke out." So naturally her advice seems to me not a great deal better than the advice she got from an "insensitive" man who, basically, said "Just have sex and sleep in and you'll feel fine." That advice works for some young men, at the level of traumatic stress they feel; Green's advice may work for people who are at the level she felt, though it would not do a great deal for me.

In no way does this devalue Green's work for people with whom it resonates. The only thing in her book that devalues it is her assumption that all or most people are like her. This sets up the possibility for this book to become an instrument of emotional abuse. And that's why, although I think it's valuable to science and can help some people in its intended audience, I want to be very wary about recommending Solving the Post-Traumatic Stress Brain Injury Puzzle.

Green completely loses me on page 287: "Try this experiment and note the difference. For two days, any time you purchase something...don’t make eye contact, no chit chat. Just pay your bill and move on...I’m pretty sure that impersonal exchange didn’t make you feel warm and fuzzy or add to your “I feel really good about myself” factor. Now, how do you think that made the clerk feel? Especially if that is all they get from every interaction for an entire shift, day after day? Now repeat the process, hopefully at the same places you just visited, and hopefully with the same sales clerks. This time, though, smile an honest-to-goodness smile. Use their name at least twice in the exchange. How about now? How did that make you feel? How do you think that made them feel? Most people probably don’t even have to conduct the experiment. They already know that a smile lights people up inside. They can feel the sound of music when they hear their name. If you don’t have a clue what I’m talking about, then you really need to do this experiment."

I think it's useful to unpick this passage. Has anybody not heard this exhortation before? And what happened when we did the experiment? What introverts learn from this experiment is that (1) when we just pay and move on, we feel fine, and (2) when we feed attention to the sales clerks, we feel bullied, and (3) there is no such thing as "enough" when we start feeding this monster. Extroverts are not wired to be our close friends. They can be valuable acquaintances but treating them like close friends usually spoils the acquaintance. 

Until extroverts have fully absorbed the reality that they are neurologically different from us, in a way that can fairly be described in terms like "deficiency," their control craving is likely to make them dispense actual punishment for that unearned reward of extra attention. Does anyone seriously believe that, today, that yappy sales clerk is going to say "Thank you for validating my deficient sense of my own identity as a human being"? That is not in her vocabulary. She's more likely to get into a little harmless, though tedious, empty chatter and then vap, "Say, why are you being nice to me for once?" And if we let one vap like that pass, there will be more. As long as any extrovert is allowed to believe that their way of socializing is "nicer" than ours, any close relationship with that person is all but guaranteed to be an abusive relationship. 

I actually have tried the experiment of dishing our unmerited attention to sales clerks. I've learned that, primarily, chatter gives the clerks more opportunity to cover up unethical practices. Let a cashier gabble while ringing up purchases, and you may occasionally find a mistake that you can believe was honest because it's in your favor, but nine times out of ten you will pay for more than you take home. For many chatty cashiers the payoff of periodically comparing what should be in the cash drawer with what is, and pocketing the difference, seems to be enough of a reward. Others, however, are addicted to that feeling of what they might call "being the leader"--social dominance, control of the conversation.

There is also the possibility that sales clerks are introverts, and in their subordinate position they have no defense against social bullying by extrovert customers, which is what "smiling and repeating their name" will inevitably bring to their mind even before it actually begins. Chattering at subordinates who don't crave chatter is cruel.

Introverts are generally less attached to that sense of hierarchy, unless and until it's been pounded into us that we need to protect ourselves by being the "leader" (or social bully). We can do that. We can reclaim the upper hand by making verbal abuse a way of life. That whole evil sexist "Karen White" stereotype can become our way of life, if we push ourselves to socialize with extroverts. Once convinced that "people" respect us only when we establish ourselves as the big boss bully, introverts can easily start to sound more like a real unpleasant person, e.g. the Ayatollah Ruhollah Khomeini.

Or we can just make it a policy that sales clerks get a kind word, maybe even a moment of eye contact (or, in my case, what looks like eye contact to them), if they earn that reward by adding up and writing/printing a bill with full attention on the numbers and saying the two (or optionally three) words that are really all the English a cashier really needs to know: "thank you," with the option of adding "Sir" or "Ma'am." Focus on task and a credible "thank you" deserve a gracious "you're welcome." Anything below that standard deserves either silence, a reprimand, or a complaint to the manager, depending on how far below the standard they fall.

Too many introvert readers have not (yet) invested some quality time in considering which people we really like best and how they interact socially, in learning that we are normal healthy humans and our way of social interaction can, and should, continue to be summarized as "having better manners than extroverts have." Good manners show respect for others, treating them as honored guests until they show that they're not, rather than grabbing for control. We try to impress others by showing how discreet, respectful, and non-intrusive we can be. Good manners include, among other things, an instinctive sense that it's wrong to distract cashiers and annoy people behind us in line, in a large store, with idle chatter. And the fact is that, whichever side of a store counter we find ourselves on, we feel better when sales transactions are not cluttered with any attempt to drag in slowing, distracting, inappropriate social interactions.

No, that doesn't mean we want to buy everything from machines. No, it doesn't mean we want all the cashiers and other sales clerks to be unemployed. It means that, instead of trying to tell ourselves that it's "nice" to chatter with people when they ought to be giving their attention to their jobs, we need to train sales clerks to recognize minimal chatter as the good thing it is.

This tangent leads us back to the question of who gets PTSD and why. While living through grief I've often observed that grief is much more traumatic for the family member whose grief is aggravated by guilt. This guilt may be exaggerated. The deceased knew the grief-racked relative loved her, but the last time they talked the relative who is now having a complete emotional breakdown didn't say it. I've made it a practice to avoid this. Some people want to save the words "I love you" for special moments; if so, family members need to recognize something else they can say as expressing love, and say that, at every opportunity.

Sure enough...Solving the Post-Traumatic Brain Injury Puzzle begins with a detailed, polished narrative of incidents Green obviously relived a hundred times. Fire fighting was her full-time career job; after thirty-two years she was already on the track toward retirement as having passed her physical peak, doing more management, coordinating teams of pilots and ground workers by radio, rather than the actual chopping wood and carrying water. So she felt responsible for keeping that year's big late-summer fire away from people and their homes. Human responsibility for managing the forces of nature is at best limited. She might have made some misjudgment, been blamed by some people. She did have to watch the fire growing out of control, read about lost lives, drive past burnt-out ruins, and she felt responsible for the damage. She describes having headaches, losing sleep to nightmares, drinking heavily. For some days she describes what she ate, though not in enough detail to be useful, and which symptom-suppressant medications she tried. 

For the first half of 2016 co-workers respected Green's seniority and hoped she'd snap out of her post-traumatic stress symptoms. She didn't. She read self-help books, talked to therapists, tried symptom suppressants. She doesn't describe any more big public failures, but does describe a few bursts of bad temper and episodes of heavy drinking. Late in the year she heard the dreaded words "You've become a liability." The end of 2016 was the end of her career. Green wrote down some bitter notes on the incidence of outright suicide among emergency responders after a situation got out of their control, and others who were also drinking heavily after the 2015 fire.

For 2017 there are fewer little prose poems of self-encouragement, more days when Green either didn't write or didn't choose to publish anything she wrote. She'd been pushed out of a position of "leadership," a life-threatening traumatic experience all by itself for her personality type. Her situation was dire. However, as the year goes by there are some early signs of improvement that may run deeper than Green's writing out the self-encouragement she took home from therapy sessions. For the first time she tells us that, before her traumatic stress, her husband had been ill, and her loss of interest in sex was making him feel worse. (PTSD often affects marital relations, and uninjured spouses may be delighted to read that the consensus seems to be that patients need to be in complete control of touching other people but, on the whole, they benefit from readjusting to touching and intimacy. Within marriage, sex can help) This is also the stage at which Green started thinking about the emotional feelings of sales clerks, even if what she thought about them was counterproductive. The ability to think about others is often a hopeful sign.

Late in 2017, without going into much detail, Green mentions accepting a diagnosis of "depression" as the stage she'd reached on her PTSD journey, and taking antidepressants. But, hello, this is California. While at a fairly dangerous stage of her own recovery Green found a way to get back into a position that felt like "leadership," eagerly teaching workshops and "coaching" others who aren't as far along as she is. Even in California some people laugh at the large number of "wounded healers" who lecture, teach workshops, and write books on mental health. Often these people are still visibly struggling with alcohol and/or other addictions. Sometimes their careers as counsellors break off abruptly when they are hospitalized or commit suicide. (I grew up hearing a psychologist-committed-suicide story, yes.) Even so, there are people who seek out guidance from the "wounded healers" and maintain that they've been helped by it. Twelve-step groups emphasize peer counselling and what Green is still offering, still marketing through this book, sounds like a kind of peer counselling that will at least help some people get through the first gruesome months of recovery, when anything that breaks up the mental cycle of "I feel bad, I reach for a drink" is probably good.

In 2018 Green seems to have done what some people cynically describe as "switching to a legal addiction" with the antidepressant meds. Traumatic stress can change the physical shape and chemical balance of our brains--though live brain studies are still statistically small, and there is some debate about the brain's ability to compensate for physical damage. (Alzheimer's Disease is associated with characteristic changes in autopsied brains, but autopsies also show that many old people with undamaged memories and moods undergo the same changes--their brains compensate.) Well, the antidepressants didn't drive Green insane, we know, because she's still here. Even best-case models of people who are being successfully treated with antidepressants are not models of good mental health. Even twelve-step groups have fissioned in response to disagreement about whether "days sober" count if the person is still taking pills. By 2018 Green is, however, editing her journal notes into coherent narrative again, in short expositions in between the questions she invites readers to answer. 

I hesitate to give unqualified endorsement to any book that encourages extroverts to thrust the burden of their chatter onto strangers--though many books still do. An aggressive outgoing style of "leadership" may be useful to emergency responders. Many of them have extroversion and are likely to relate to Green's story and workshops. That aggressive outgoing style is likely to do more harm than good when introverts seek help. There's a reason why people who want to vent their feelings about a fire or a violent crime traditionally don't seek counselling from fire fighters or police officers.

However, this book is a valuable resource for emergency responders, trainers, counsellors, and support groups. It's worth revising to be more inclusive of the introverts emergency responders meet every day; it's likely to be revised, because its target audience are already buying and using it. I've gone into detail about its shortcomings because people who are aware of what's wrong with the ideas "everybody needs to feed more attention to extroverts" and "antidepressant drugs are a safe effective cure for everyone" can work around those ideas, avoid using this book in harmful ways, and get the benefits it has to offer.