July 11, 2017

Reading : Missoula - Rape & the Justice System in a College Town by Jon Krakauer

Our patients face different kinds of trauma in their lives, and the chronic stress leads to coping mechanisms and a way of interacting with the world that can be difficult to understand if you haven't experienced the same.  Very often, past physical abuse and emotional trauma emerge as severe anxiety, mistrust, and physical pain.  As providers caring for these patients, it's easy to find empathy for the former, but it can be really hard to treat the latter.  Sometimes the anxiety means that patients ask for a lot of tests that aren't needed for a diagnosis or won't change their treatment. Sometimes no matter how many tests come back with normal results, patients perseverate on what's wrong and why we can't find a reason.  Often, treating the pain means long, repeated conversations about how we don't have any immediate fixes, and there's disappointment and frustration for both patient and provider.

To be honest, these interactions can leave me really impatient and irritable.  As much as I concretely know about their lives, I can't really understand why patients have these feelings and pains that don't straightforwardly follow the cause-and-effect science of my medical training.  And so I don't always know what to offer them, which of course damages your ego as someone advertised as a source of help.  It's all around complicated and uncomfortable.

But this is also really what I love about primary care--that it's hard, that it requires patience and openness in order to be there for people who can be really different from us.  And that these are skills that take learning and training to really develop.  

Part of this learning that has been really helpful for me lately has been to read more about trauma in different forms.  I'll always rely on my favorite form of writing for a window into people--fiction.  Like this book that shared so much about how much history one person can contain.  Non-fiction has the benefit of a broader scope.  What I really appreciated about Jon Krakauer's account of rape culture in Missoula is that it captured this scope while remaining intensely personal.

Krakauer tells the story of five victims of rapes that occurred on college campuses in Missoula, Montana between 2008 and 2012.  Kaitlyn Kelly is raped by Calvin Smith in her dorm room.  When the police detective interviews Kelly and Smith, Kelly is asked why she didn't scream, while Calvin is reassured that he will not be prosecuted.  When Kerry Barrett tells the police she's been raped, one of their first questions to her is whether she has a boyfriend, because they've been taught that 50% of rape allegations are false and that the reason for this is often to cover up cheating on a significant other (the rate of false allegations per the FBI is closer to 8%).  Kelsey Belnap is gang-raped by four football players, and her best friend urges her not to say anything that would get the team in trouble. "Cecilia Washburn" is raped by quarterback Jordan Johnson, waking up to sheets and clothes covered in blood.  Allison Huguet is raped while asleep by her childhood friend and star member of the University of Montana football team, Beau Donaldson.  Despite a taped confession where he admits to assaulting Allison, he receives a sentence where he's eligible for parole after two years in prison.  Though all the others also try to prosecute, hers is the only one that's taken to court.

More than the men accused, the women face intense scrutiny.  And the same questions comes up over and over: why would a non-consenting woman act that way?  It just doesn't make sense, so her story must not be true.  

Krakauer does an amazing job of dissecting each step of the assault, eliciting not just the personal explanation of the victim but also drawing upon larger studies about the psychology and behavior of trauma victims.  Which are not the same as someone who is not a trauma victim.  This might seem obvious.  But I can see how it's a complex idea for people to accept, because we all like to think that we can empathize and judge other people's situations.  It's something I struggle with at work.  But there are some experiences are so impactful that they change our "natural" paths of thought and action, and so we just can't empathize unless we've been through it too; and often these experiences are the ones most removed from our everyday experience.

Olympic National Park, May 2017

Having had an experience of violation much, much less severe, I found myself relating to a very small degree to what Krakauer describes.  

During my first trip to Vietnam, the summer after my first year of medical school, I took an overnight bus.  The kind where your seat kind of reclines so you can kind of sleep.  As the drive started, a guy my age started aggressively talking to me and at some point asked for my phone number.  He made me really uncomfortable.  But because I didn't want to offend him or make the rest of the ride awkward, and I knew that we wouldn't see each other after the ride so it didn't really matter, I gave it to him.  In court, the question would be: if he made you that uncomfortable, why would you do that?  In life, I very much relate to what Krakauer researched: that women tend to want to be non-confrontational and accommodating.  In an uncomfortable or scary situation, they will often try to appease even if someone else is being inappropriate.  

I was able to ignore him after that, and a couple hours passed before it was time to sleep.  I knew it'd be hard for me to sleep on the bus and I wanted to have the energy to do things once we arrived in the morning.  So I took benadryl to help me sleep (I know, I know).  In retrospect and in court, there's the subconscious and direct judgment of putting yourself in a vulnerable position.  In life, we should be able to do what we want--I should be able to drug myself to sleep and college students should be able to drink at a party--and the onus should be on others to not take advantage of that.

The memory of this moment is hazy becuase of the benadryl.  I just remember being woken by a sensation of his face close to mine.  On it, but very briefly (or at least what I can remember of it was brief), because I shook my head, bothered and confused.  I opened my eyes and he was standing next to my seat looking back at me.  I didn't say anything, and covered my whole self with the blanket and hoped he would just go away.  Luckily for me, he did.  In court, the question would be: why didn't you say anything, ask for help among the many other passengers on the bus?  In life, there's paralyzing shock.

In the morning, I got off the bus as quickly as I could. I called the person I was dating at the time.  I gave him the facts, but I wasn't sure how to express how violated I felt.  In court, I'd be seen as not appropriately affected.  In life, I was really confused, and I was also tentatively seeking validation before making myself even more vulnerable by sharing.  And in life, I didn't get it.  My boyfriend seemed more annoyed at me than anything else, and it made me second guess what had happened (contributory to our dissolution as a couple soon thereafter).  In Krakauer's account, one victim asks her friend, "Was it something I did? Could I have prevented it?" In court this cast doubts on whether a crime had really been committed.  If it had really been a crime, why would you question your blamelessness as the victim?

So the main point I took away from the book, which I feel on some level every day at work, is that we can never fully understand how trauma affects people and we can't judge them based on our worldview.  Both in the moment and in the life after, trauma changes people.  It makes them less secure in their memories and feelings, more passive in their initiative and responses.  We can't judge the thought processes and behaviors of these people in terms of what we would feel or do in those situations, because we're not in those situations.  And it's not something in which you can pose a hypothetical--because a hypothetical assumes that you are the same person in that hypothetical situation as you are outside of it, and that just isn't true.

It's extremely helpful to be reminded that there are some things that make us very different from one another, and that we need to be humble about our ability to understand other people who have been hurt in ways we can't fully imagine.  The best we can do is to listen to the many people who have had this experience, and trust what they tell us, especially when there are repeated patterns among them.  Jon Krakauer does a really excellent job at giving voice to their experience.  And when you consider that 80% of rapes go unreported, it seems we owe it to these people to listen.

Olympic National Park, May 2017

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