When the car stops she is disorientated. She tries to look around her but everything is white. Is she dead? She hears a buzzing or stillness in her head. As the whiteness clears she sees spots of rust in the grey railing from the traffic island a few feet away. Where is she? All around her is silence, deep deep silence. It feels like the end of the world.
Deep, deep silence.
She jumps as the silence is broken when someone bangs on the roof of the car. A man in a red jacket shouts to her through the broken windscreen asking if she is OK. She feels nothing. She says she doesn’t know and asks him what happened. She doesn't recognise the sound of her voice. He tells her a car jumped the lights and smashed into her, he was in the car behind her and saw it happen. He says his name is Mike. She tells him she is Tina. He says he has called an ambulance. She hears sirens in the distance.
She listens to Mike, he is an accountant on his way to work. He has a daughter called Chloe who is a similar age to Amy. She likes Mike. A woman’s voice tells her that she is Jo and she is a paramedic. Tina wonders why a paramedic is here. She notices her handbag in a tangle of plastic and material beside her, it is stained with blood. How did that happen? There are bits of blue plastic too, it comes to her it was once part of her pet carrier. What is it is doing in her car? Tina can smell petrol. She feels dazed.
She recognises police uniforms, she’s pleased to see them but doesn’t know why. She sees the letter. Something about insurance? She has no idea of time. Is she late to pick up Amy? She feels shaky inside. What will happen to Amy if she isn’t there? Jo the paramedic explains she is going to put a collar on her neck. She tries to fight her.…what about Amy? Don’t they realise she is only seven and needs picking up. Anything could happen? Jo explains to her that it is only 9:30, so Amy is safe at school. Tina tells herself that Amy is OK. Tina cannot believe this is happening to her.
Jo tells her that the fire brigade are coming to cut her out of her car. Does she remember what happened? She tells her she remembers dropping the cat off at the vet. Then listening to classical music and being behind a lorry but she can’t remember anything else. Mike told her she was in a car smash. Jo confirms that she has been in a road traffic accident. Her arm hurts. Tina can’t believe this is happening to her.
When the fire brigade cut her out it is very noisy. Jo protects her with her body from falling debris. Tina feels numb. As they lift her out of her car she sees a wrecked red car smashed up against a tree. She wonders how it got smashed like that. She can’t see Mike. She misses him. She can’t believe this is happening. Did she remember to insure her car? Is she in trouble now?
When she arrives at Accident and Emergency she is blinded by lights as she is wheeled down a corridor. She feels scared. Her arm hurts. She remembers she should be at work, where is her mobile phone? A nurse, June, says the paramedics probably brought it in, she will see if she can find her phone and ring work for her. Tina is worried her phone might be smashed as there is a game on it that Amy likes. Tina can’t believe this is happening to her. June asked her what happened. Tina said she wasn’t sure but Mike and the paramedics said she had been in a ‘road traffic accident.’ It feels like a dream to Tina.
A doctor examines her. She tells her she has a broken arm, a few cuts and lots of bruising. They are sending her for an MRI just to make sure she hasn’t hurt her neck. When the doctor tests her limbs she feels it and wonders why the doctor is hurting her. She can’t believe this is happening to her.
"lucky to be alive"
While she is waiting for the MRI her mother arrives looking very concerned and upset. She hugs her gently. Tina feels better. Mum says she can’t believe the accident has happened either. She has seen Tina’s car and it was ‘in a right state.’ Tina was ‘lucky to be alive’. The police were still at the scene. It didn’t look too good for the other driver. Tina feels angry, she loves her new car and has not finished paying for it yet. Surely, the other driver had hit her….what were they worried about him for? Tina rages about this.
After the MRI another doctor said it was safe to take her collar off. That feels more comfortable. He asks her what happened. She tells him she is ‘lucky to be alive,’ her car is ‘in a right state’ because she had been in a 'road traffic accident' she has no memory of. They want to keep her in hospital to repair her arm. While her arm is set in a temporary cast before her operation two more nurses ask her what happened. She tells her story, and again on the ward but she still can't believe it is happening to her.
"It hasn’t sunk in yet"
When the police come to see her she worries about her insurance, she knows she needed to do something to do with car insurance but can't remember what…was she insured or not? She keeps remembering the blood-stained letter on the passenger seat. She tells them what she remembers……waiting at red traffic lights behind a van listening to classical music but nothing after that. They tell her that the man driving the red car died at the scene. She feels numb. She asks if she is in trouble and they reassure her she is not. Her car was insured and several witnesses have told them the man jumped the red lights before he crashed into her. She feels guilty…the man is dead and she was upset about her car. She tells the police ‘it hadn’t sunk in yet.’ They say she should let them know if she remembers any more. She thinks about what she would be doing if she was at work and wishes she was. She still can't believe this is happening to her.
Tina dozes while she waits for her mother to return from collecting the cat and picking up Amy. She keeps flashing the red car in slow motion coming towards her. Every time she tries to drive out of the way but every time she gets hit. She can’t relax. She doesn’t feel safe so she watches people closely to see if they are a threat. She is sweating and shaking when her mother and Amy arrive but she pretends she is OK. Amy wants to know what happened so Tina tells her but it doesn’t feel like it happened to her.
Recovering from her operation Tina remembers being in the car as it slid across the road and seeing the pedestrian island. There was a poster on it advertising scrap metal. Her beautiful car was scrap metal now. Her arm hurt. She felt vulnerable and scared. She wants to go home. She feels angry with the man for jumping the light and is annoyed he's dead so he can’t be prosecuted, then she feels guilty, no one deserves to die like that. Why did this happen? If only she had left earlier/later/got a different job/driven a different route…….A nurse asks her if she was OK. She tells her it was starting to ‘sink in.’
Blame the other
The following day Tina goes home. The familiarity helps her feel safe. People from work have sent her some flowers but she feels disinterested. Every time she closes her eyes she sees a white thing coming towards her. She doesn’t understand what it is so she feels very scared. She feels scared a lot, jumping at the slightest noise. This isn’t like her. Over the next few days friends call in or ring to see how she is. They all want to hear about the accident. She is reluctant at first, board with saying the same stuff over and over but as she recalls more and more she realises she is lucky not to be more seriously injured or dead she cant stop telling people about it. Especially how angry she is with the other driver for jumping the lights and destroying her car. She could have died! She could have been paralysed! Then she feels bad, the man is dead. She remembers how much she loved her car and wants it back as it was. Why did this have to happen?
Tears start to flow
Tina can’t sleep at night and when she does she has nightmares about the red car coming towards her and a really thick fog pinning her down. Three days after the accident she goes to see her car. She thinks she will be angry, she saved up for it and now it was salvage. It's only when she sees the mangled mess of metal that her tears start to flow. She realises the ‘white’ coming towards her was actually the air bag that protected her from further injury. She finds out the other driver was called Paul, he was 35, he left a wife and three children. She thinks about Paul a lot, but when she thinks about him jumping the lights she doesn’t think of Paul, she thinks of him as ‘the man.’ She feels guilty that Paul died when she had survived. Why did it have to happen? She scours her memory- could she have done things differently? Is it her fault he’s dead? She knows this is unreasonable, the police and the insurance company said so, but they weren’t there, how would they know? Then she remembers the man destroyed her car and broke her arm and feels angry.
The accident, the pain in her arm, her bruising and the death of the man who hurt her occupy her thoughts to the exclusion of everything else. She feels sad for his children. Her mother comes to stay and look after Amy. Tina realises her house is dirty and cleans everything with bleach as best she can with her injuries. It’s not good enough so she does it again. She realises she is less upset by strange noises like the washing machine changing to spin when she is busy cleaning so she cleans some more. Tina still can’t sleep at night and when she does doze off she has nightmares. Tina is emotionally exhausted so she withdraws emotionally with a bottle of wine. She knows her mother is worried about her and wants her to rest but Tina can’t stop cleaning. Amy is really quiet around her especially since Tina shouted at her a couple of times for making a mess. She overhears her mother telling Amy that her mother is ‘not herself’ because she is ‘in shock.’ She feels guilty and helpless. Nobody understands what she’s been through.
A week after the accident Tina’s house is very clean. She has been shouting at Amy and her mother a lot for making a mess. She knows she is drinking too much. She feels bad about this, but she just can’t help it. She doesn’t want to go out but her mother insists on taking her back to the junction where the man died. She reads the tributes and adds their flowers to others. She starts thinking of ‘the man’ as Paul. She holds Amy. Her mother holds her and tells her how much she loves and that she would help her get well. She feels a little safer.
Telling the story
Tina’s injuries start to heal and her pain eases. Whenever people see her arm in the cast they ask what happened so she talks about the accident a lot. Every time she does it becomes more ‘real’ for her. Her flashes of memory get less, she has less nightmares and she starts to sleep normally again. She recovers her memory slowly and as she does she feels less helpless so she gets on with looking after Amy. Her mother goes home and life starts to return to normal. She learns that Paul’s car suffered catastrophic break failure and was unable to stop at the junction. She feels sad for him and very angry with the company that manufactured the car. She meets up with Mike after the report in the local newspaper and they talk about what happened. She thanks him for his help. Amy and Chloe play well together. This helps make the experience more ‘real’ for her.
Tina knows the accident has changed her and thinks about herself as ‘Tina before the accident’ and ‘Tina, after the accident.’ Sometimes she longs to become again the ‘Tina before the accident.’
After a month or so Tina has calmed down. She is sleeping normally, stopped cleaning, stopped being grumpy and jumping at sudden noises. Every now and then little reminders of the accident take Tina by surprise. Green logo’s like the one on the back of the lorry pop up from time to time. She realises she can’t avoid them so she reminds herself that she is safe now whenever she sees one. The flower Duet, is a bit trickier because it’s on an advert for an airline so it’s more difficult to avoid so she feels that sinking feeling often. She solves this by deciding to book a holiday with her injury money when her arm is healed so whenever she hears the music she anticipates the fun she will have with mum and Amy instead of the accident.
Getting over it
After few months she realises that she hardly ever thinks about the accident at all. She has forgiven herself and Paul for what happened. When the insurance money comes through she buys another car and when her cast is removed she starts driving again. The first time is hard, especially when going through the junction where it happened so she finds another route to work. She doesn’t think she will ever be entirely comfortable driving behind a lorry again but she feels confident driving.
A year later
On the first anniversary she goes to place flowers for Paul again. She thinks about Paul and how terrifying it must have been for him when his brakes failed, especially when he realised he was going to hit her. She is sad for him and his family but she is grateful to be alive herself. She knows she will always have the scars on her arm to remind her but even they will fade in time. She's sad for Paul, his wife and his children when she thinks about it but this isn't very often. She has been promoted at work and enrolled at college to get a degree. Amy is doing well at school. They are going to America on holiday. Tina has stopped thinking of herself as ‘Tina before and after the accident’ and is now just ‘Tina who had an accident.’
How Tina’s Psychological Health was affected
Before the accident Tina’s brain was processing normally through her Parasympathetic Nervous system (PNS) also known as ‘rest and digest’ system. As shown in the diagram 'Before the Accident' Tina has lots of free thinking space. Data from her senses was processed in her brain via synapses from her thalamus, which analysed it for threats, seeing none it passed to the sensory cortex which analyses it for potentially threatening visual stimuli and dangerous situations.
Detecting none the thalamus passed the sensory data to the hippocampus which stores and retrieves conscious memories in her neocortex. Deciding there was no threat, the hippocampus passed the data to the amygdala which performs primary roles in the formation and storage of memories associated with emotional events and then to the hypothalamus which controls body temperature, hunger, thirst, fatigue, sleep, and her body clock. There was no alarm. This is known as the 'high road' 1 as this involves higher brain functioning in the neocortex.
There were all sorts of things in her conscious awareness, She was thinking about things she had done and had to do that day, such as picking up her daughter from school and her cat from the vets after work. She was also aware that a tune on the radio was familiar but she hadn't remembered why yet. She was driving her car which was an automated response because she has been doing it so long she didn’t have to think about changing gears or applying breaks etc. As she had these thoughts they were processed through the hippocanthus which was in the process of linking the music to the advert. If this process was not interrupted the experience would have been processed again during rapid eye movement (REM) sleep and stored in the normal memory function in the neocortex of her brain. If nothing unusual occurred it would be just one of many uneventful journeys she wouldn't specifically remember.
Trauma processing during the accident
Unfortunately Tina’s processing is interrupted and her sympathetic (meaning self-regulating) Nervous System (SNS) also known as 'fight/flight' was activated. Her thalamus identified the threat from the car jumping the lights and alerted the amygdala and sensory cortex simultaneously. The amygdala analysed the threat, based on stored memories of previous frights, prior knowledge and emotional significance accessing the memory of the bumper car ride before alerting the hypothalamus. The hypothalamus issued the red alert by initiating the fight-or-flight response to give her body a greater chance of surviving the trauma. The fight flight response is known as the ‘low road’ 1 as this processing primarily involves the mammalian brain and primitive functioning essentially by possessing rational thinking allowing her to respond faster and increase her chances of survival.
When the hypothalamus signaled the alarm sequences of nerve cell firing occurred and chemicals such as adrenaline, noradrenaline and opiates were released into her bloodstream dramatically changing Tina's functioning. She became physically prepared to respond to danger immediately. Her eyes dilated to allow more light absorption and sharper sight so she saw the ‘bright red car.’ She actively sought a way to drive safety as her spatial awareness and her reaction time improved with increased adrenaline in her blood stream. She was aware of her breathing increasing and her heart beating as it increased pumping to improve oxygen supply. She had sinking feeling in her stomach and her body tensed as blood was diverted from her digestive system to her muscles to prepare her to fight or flee. She wasn’t aware that her skin broke out in goose bumps and went pale as blood was diverted, or that she broke into a sweat or that she didn’t feel the pain of her broken arm.
Psychologically she switched from a resting state to the fight/flight state where she actively looked for potential threats in order to defend herself. This state of alert exaggerated her fear and distorted her thinking
- She noticed the detail of the rust in the railing but not her location.
- When the man who was trying to help her banged on the car she jumped and perceived him as ‘shouting at her’.
- She thought she smelt petrol.
- She fought the paramedic when she tried to put a collar on her to protect her neck and didn’t acknowledge her help.
- She didn’t feel ‘safe’ in the hospital.
She struggled to make sense of what had happened because she didn’t have full access to higher functioning in the neocortex.
- Time slowed down and she had no idea what the time was because our internal ‘clock’ is in the higher cortex.
- She couldn’t comprehend what had happened and relied on others to explain it.
- She couldn’t identify her pet carrier, or make sense of the blood on her letter.
- She got confused about her insurance because she couldn’t remember what she needed to do with it.
- She felt relieved when she saw the police but couldn’t remember why.
- She didn’t realised the significance of being sent for a scan to check her spine.
- She couldn’t associate the crashed vehicle to her situation.
After the accident
An individual is considered to be traumatised when they experience a situation that is either life threatening or perceived as life threatening that completely overwhelms their mental capacity to cope with the event and/or their emotions. In this case Tina was overwhelmed when she recognised the red car was coming towards her at high speed and she could not get out of the way. She switched to flight fight processing and had little comprehension of the impact. When the motion stopped she couldn’t understand why she couldn’t move, why there was blood on her letter or why the cat carrier was destroyed even though she had just experienced an impact she had consciously bracing herself for. As the diagram 'After the Accident illustrates this is because Tina doesn't have enough energy available for free thinking.
Break in her normal consciousness.
The reality is that once she has been rescued from the vehicle the potential and actual immediate threat to her life was over- she was safe (well, as safe as any individual normally is). She has only actually experienced the physical trauma of a broken arm and some bruising which will recover and yet she continues to behave as if she is still in danger. It seems that her brain does not switch off flight or fight response and return to a resting state immediately and she remains on high alert, a break in her normal consciousness. Later, her mother described her as ‘in shock,’ others may have referred to her as ‘traumatised,’ what we actually mean is that someone who is not in danger continues to behave as if they are. This may be because the signal for the alarm is still running or that the body has to metabolise fear hormones before they can be removed. This process appears to follow a pattern, known as the Trauma Cycle, this is our take on it.
Tina does not develop PTSD even though she experiences symptoms of post traumatic shock (flashbacks, night terrors, sweating, avoidance, hyper arousal, emotional numbness, feeling detached and guilt) because it does not last longer than one month.
Looking at the trauma cycle you can see that recovery is not linear, ie moving smoothly from one stage of recovery to the next, she visits and re-visits various stages of recovery, while the general movement through emotional responses is upwards towards recovery, this is known as the ‘flight to health’ as the brain works through and processes split off trauma.
Numbing, Control and Disbelief
In the early stage of recovery she experienced feelings of numbness, disorientation and detachment which lead to confusion as her brain couldn't comprehend what was going on (stimuli). This lead to a need to take control creating an illusion of power over the situation. In Tina’s case it is was about her daughter, then work and later expressed in the need to clean and gets upset with her daughter for making a mess. Joseph LeDoux1 suggests in his work The Synaptic Self that the ‘high road’ and ‘low road’ are not mutually exclusive, it seems one process is more dominant over the other. This makes sense to us, Tina has awareness of the important things in her life but her understanding is fragmented so she creates an illusion of control which she protects aggressively. This feeling of confusion and powerlessness and fear of 'being found out' is common for multiples.
We were hurt in isolation – we recover together
It seems to us the most important factor in Tina’s recovery was that she had people around her in the immediate aftermath of the accident to help her comprehend what happened. Mike, the paramedic, and then her mother, gave her the words to express her experience- she’d had a ‘road traffic accident’, her car ‘was in a right state’ she was ‘lucky to be alive’. It was these constant interactions, Mike, Jo, the nurses and doctors, her mother, her friends and family, the newspaper article, even strangers, constant affirmation that she'd experienced trauma that allowed her to heal. She told her story, over and over again and as she did she found her own words and repeated them over and over again and other people responded. It was this process of telling her story that allowed her to accept what had happened, it made it '‘real'’ for her.
Tina could not relax and return to ‘rest and digest’ for some time because she didn’t feel safe even though in reality she was. She suffered hyper arousal, jumping when the washing machine changed cycle, even though she had heard it many times before and knew there was no danger. She suffered outbursts of anger expressed to her daughter and mother that were entirely out of character. She rationalised this was because of ‘mess’ but actually she didn’t know why she felt like that. She was fortunate to have a mother who understood trauma so it was allowed to pass. She didn’t start to feel safe until after she had seen her car and started to comprehend the seriousness of the accident. She went to the memorial site and made her own contribution of remembrance. Her mother was there for her so she received physical comfort. Until this point she was unable to process the memory of what happened due to her overriding disbelief so she suffered flash backs, nightmares and insomnia. As she got safe her brain linked her deeper intellectual understanding with the memory of the accident and processed it so it became a memory.
Tina got confused with ‘good’ and ‘bad,’, particularly thinking about Paul who was ‘bad’ for hurting her but ‘good’ for being a father and husband. This is so problematic for her she dehumanised him for a while only able to think about him as ‘the man.’ As she gets well she is able to hear more about Paul and the life he had lost, particularly when she learns that he had not deliberately tried to kill her. It took her a long time to reconcile the good and bad in Paul and herself which was fundamental to her recovery.
Guilt, Blame and Anger
She suffered irrational guilt and self-blame that she had survived and Paul had not. She tried to undo what had happened…’if only I’d……..’ blaming Paul, and ultimately the vehicle manufacturer and expressed her anger which was much healthier than blaming herself.
Mourning the lost and feeling safe
As she returned to a resting state (PNS) she was able to mourn for Paul and for the feelings of safety she has lost. She is aware of her avoidance issues and takes steps to manage stimuli that trigger memories of the accident such as the flower duet and tree logos to desensitising herself.
Re-establishing an Identity and existential anxiety.
She was aware of the fragility of life and felt happy to be alive, it didn't take long for her to work through this which manifested as a search for the meaning of life. She was able to reconcile Tina ‘before’ and ‘after’ the accident and become Tina after the accident.
Let’s explore how abused children manage trauma and how this can lead to PTSD.