S1 Episode 2: An Eraser in My Brain, Part 2

New York Times journalist Alissa Rubin talks with Dr. Stieg about the cognitive and emotional effects of her injuries, and the treatments that helped get her back to work and to her life.

Dr. Stieg: Hello, I’m here again with Alissa Rubin and we were talking before about her trauma and the subsequent events that resulted in depression and post-traumatic stress disorder and I wanted to pick up from that area again. Did you recognize that you were depressed or did somebody have to tell you that?

Alissa Rubin: I recognized it but didn’t want to admit it to myself even, and I think many people are depressed and have different ways of dealing with it and some people retreat and some people work and I am someone who works for me. Work is a wonderful antidote to anytime that I feel down at all, you know, I start to do a project, I’m writing, I, I’m exercising, I’m maybe taking long walks and it dissipates. And none of those things, none of the remedies that I had recourse to in my daily life that have worked quite well for most of my life worked for me because I couldn’t physically do them. I could maybe walk, but I couldn’t do my work in the way that I used to.

Dr. Stieg: Was there a stigma for you about the concept of depression or was it just the fact that you’re just an a type A personality and gosh, I’m going to lick this?

Alissa Rubin: No, it was that it felt more profound than that I have to say because it had a physical origin and I had been very, very excited. I can’t tell you how excited when I got the visa to go to Baghdad and was able to help in this incredible story from a journalist standpoint, but also a moment when you can bear witness to atrocities. That’s, that’s the whole reason you do this kind of coverage. And that had been taken away from me. I felt very unfairly and then my body had betrayed me and my body had never betrayed me that way before where, you know, I was alive but I couldn’t do what I had set out to do. Usually mind over matter takes you a long ways and so I, I did understand what was happening. My, my father was a psychiatrist and I didn’t feel like depression was a terrible thing to admit to. I felt like most people should admit to it more and deal with it and then be able to have productive and happier lives. But I didn’t want to admit it because this time I felt like, I knew how to have a happier life and it involved running and working and thinking and I couldn’t do those things.

Dr. Stieg: Did going to see the psychologist and beginning the cognitive remediation — did that help you gain insight into this and how to deal with it?

Alissa Rubin:
Yes, it did. And it was something I really didn’t want to do at that point. I’d seen a lot of doctors. I’d had so many tests and MRIs and CT scans, and I remember when you wrote down her name, I just thought, Ugh, not another one. And I went to her and I remember the very first session she said, well, what exactly are you experiencing? And I said, well, I’m trying to work a few hours a day, which I had been told I could do. And after about two hours or so, I’m exhausted and I can’t keep going. And she looked at me quite sternly and said, “Well, you shouldn’t be trying to work for two hours. You can’t do that. You should work for about 40 minutes and then take a five minute break in which you do not do anything. You don’t look at websites on your computer, you don’t sleep, you don’t do anything.” And that was a revolutionary idea to me and I was extremely doubtful about it because I thought, how can you not do anything? I mean you could clean, or you could, there must be something I could do. And that the whole point was not to do anything.

Dr. Stieg: That’s something many Americans should learn is how to be bored and do nothing for a period of time in their life. Now did this, your initial reaction was obviously revolt, but obviously you came to terms with it.

Alissa Rubin: I did because I made a decision and I remember quite clearly making it and I thought, all right, I don’t know this time, what’s going to work. So I will do everything even if I don’t like it. And you had recommended this, you had recommended seeing a psychopharmacologist and seeing if you know some kind of antidepressant would help. Even a low dose, whatever would work. I do think it had some effect.

Dr. Stieg: I just, I feel compelled right now to, to make this pitch that people need to really understand the complexity of the brain and it isn’t solved by just one physician and that’s why, I as a neurosurgeon, started getting you involved with these neuropsychologists, the neuropsychopharmacologists and the physical therapists because they were working with your hands and helping you with your exercise and all of these emotional, physiologic and psychologic issues obviously come together in your brain and it was important to get you to work on each one of those individually. But having it done in a coordinated fashion to facilitate and expedite your care. You’re an example of how that worked.

Dr. Stieg: Where was your family in all of this?

Alissa Rubin: Well, I think my family was not particularly engaged. They supported whatever I wanted to do in a general way. My husband works in Europe and he was in Europe working. My mother was around, she’s in her eighties and so there’s a limit to what she could do, but that was actually probably fine because she’s a very, she was extremely consistent. She was no different than she has been my entire life, which is, you know, she’ll occasionally bring you a cup of tea and she’ll be happy to talk with you, but she’s not going to be terribly involved.

Dr. Stieg: What doesn’t kill you makes you stronger, huh? *laughs*

Alissa Rubin: I knew that it mattered to me to go and maybe more than anyone else in my family. She’s always respected that and always been very realistic about it and I am very grateful to her for that because lots of parents might not have understood that. My sister was working, so I didn’t have a real family support network, but I did have a couple of friends who were enormously supportive, and… I was tired every day. I was doing physical therapy five days a week because I had different parts of me that didn’t work and I had a terrible hematoma, which was totally benign, but it made it hard. It hurt and it made it hard to walk because it was where it was. But I was going to say the other thing that the cognitive therapist taught me was something that I really use every day. I’ve used it already today. It was that you tend, I think for whatever reason, when you’ve had this kind of brain injury to start to do several things at once, you’re very unfocused and I would be really interested to hear why that is because I still don’t understand it. So I would, I would start an email and then I would think something like, Oh, I need to write Dr. Stieg or I need to write Ann, or my cousin Prudence’s birthday is coming. And I would open another email and then another and I would soon have three, maybe three emails open, and something I was reading on the screen and get none of them finished and be exhausted.

Dr. Stieg: You’d never had attention deficit disorder.

Alissa Rubin: Not to my knowledge and I was puzzled and she said, well, when you feel the impulse to open a second email, have a notebook next to your desk and write down whatever the item is that you need to do. So you’re reassured that you have it anchored there. You will not forget it and then complete one task at a time. And I now do that and I now prioritize my emails in a somewhat obsessional fashion, but, but that continues to work and it’s, I think that’s a little bit leftover attention deficit disorder that I will have to discipline myself to work with for a long time or maybe everyone has that. I don’t know.

Dr. Stieg: You’re more complex because of the injury you sustained. It’s a little bit of attention deficit, but it’s also just a memory disorder and that has to do with the particular area of your brain that was injured.

Dr. Stieg: Was it during the cognitive remediation you were going through, you realized that you were also suffering from post-traumatic stress disorder?

Alissa Rubin: I would not have thought of it as that because I didn’t have a lot of what I’ve seen in post-traumatic stress because because of having been a Bureau Chief in war zones. I’ve seen symptoms, not necessarily in soldiers but even in our own journalists who are out with troops a lot. You see the effect of the stress and I, I wouldn’t have defined it that way. I think that what I had had was memory loss of the most upsetting moments of the accident.

Dr. Stieg: Which would be a stress and what, I actually learned something in preparing for this and that you went through something called EMDR, eye movement desensitization and reprocessing that you must have read about this, thought about it, and elected to do it. Or—

Alissa Rubin: Actually the friend of mine who encouraged me to listen to you on the question of, perhaps needing cognitive reconstruction and some kind of low-level antidepressant also recommended that I see someone for this. She said, you know, it’s very interesting. I know some people who do it in New York who do it very well. She’s a psychiatrist. She gave me a name and I called the person and I really liked the idea of it because it wasn’t a commitment to long-term therapy. It wasn’t what I thought of as something where, you know, I was going to go back to France or Baghdad or Afghanistan and you know, I’d be interrupting some process — my father had done, you know, everything from short term to psychoanalysis. I didn’t really want to do that. I didn’t want to go through that kind of thing. I wanted a quick fix.

Alissa Rubin: And so it appealed to me that it was something that you could do in a — you can’t say how many sessions, cause everybody’s different but three to six let’s say. And that it had been used quite effectively and you know, sort of the post-September 11th periods and it was remarkable. You retell what happened and something and I could not, I don’t know that the literature explains it, but something happens on the second or third retelling and things surface that didn’t surface the first time. And I had a memory that surface that was very, very helpful.

Dr. Stieg: You come to terms eventually with what happened?

Alissa Rubin: Yeah. And you don’t feel, I don’t know, you don’t feel upset afterwards.

Dr. Stieg: And what’s important for people to know is that the, it’s been espoused that this is about 80% successful in patients. So it seems to me one of the major hurdles for people like you or anybody with PTSD is just accepting the fact that they have this inner turmoil and seeking help. And there are very good ways of getting help.

Dr. Stieg: It’s remarkable to, to watch how the brain works because by retelling it, you see, you see how you’ve pushed something down.

Alissa Rubin: What the thing that I remembered was that after I had become conscious in that in the helicopter, I suddenly — everything went black and I couldn’t see. And I thought, “Oh my God, I’m blind and if I’m blind, what will happen?” I can’t do anything anymore. I, I would rather be deaf than blind. What a horrible thought, you know? And that was, it was so terrifying and I felt my whole life was sort of stopping before me. Yeah. I wasn’t dead, but so what, I couldn’t see anymore. Well, what had happened actually is I had a lot of blood and it had congealed over the eye and coagulated and, and somebody pulled it open after about an hour and a half and I must’ve started from the light and they said, “Oh, she can see.”

Dr. Stieg: I think it’s important also, to say that, that you’ve gone through the psychology, you’ve gone through the, the EMDR and you’ve gone through using some medications and physical therapy. All of these are exceedingly important and they all kind of come together in you as a person. You still have some symptoms and I was wondering whether you could describe — what are the workarounds that you’re using now to do what you’re doing and you’re working at the computer. You’ll write yourself little notes.

Alissa Rubin: I do. I use a lot of those cognitive disciplines. You know, keeping notes when you’re working. Keeping notes, really whenever you feel you might forget something and therefore you’re going to start something else. I also have tried when I’m not like when I do take a break, you know, if I’m feeling like I’m losing my focus when I’m writing, I’ll try to stop myself. Now what’s really hard is to not do something, you know, look at some article I’ve been wanting to read or spend that time buying some item I need to buy online or whatever. But I, I’m aware of the value of leaving blank space.

Dr. Stieg: Did you have to come to terms with these workarounds? Was there an emotional aspect to it or is it just you realize that it’s good for you so you’d do it?

Alissa Rubin: No, I think what helped me is that I, I actually feel, and I remember discussing this with you, that I think more sharply now than I used to, and it may be that I think a little slower and that has actually made me more precise because I’m not scattering myself so much. So I feel like when I write a sentence, I know more clearly what I want to say. And it may be because I’m not trying to do three things because I now acknowledge I can’t do three things at once. So it might be a skill that could be useful to people who haven’t had any, haven’t fallen out of a helicopter, um, uh, or had some other… But I mean it’s, I don’t know whether the brain can really multitask and maybe it, it actually wants to focus. You can answer that.

Dr. Stieg: it functions best if it focuses. And I think multitasking is, is an overused term. I think we can multitask doing simple things, but if it comes down to writing a Pulitzer Prize winning article, you can’t do that. Thinking about two or three other things, you’ve gotta be focused, you mentioned a little bit about your headaches. Those are persistent, controlled with medication, controlled with mindfulness, or how are you doing that?

Alissa Rubin: I have never found mindfulness really that helpful. I can barely do my five minute breaks when I need to. I’m, I’m not a very good person at the Zen level or which I, I wish I were. Lots of people seem to get a lot out of it, but that’s not, that’s not who I am. I really control it with, with medication taken. When I feel it happening, sometimes I’ll think it’s kind of on the edge and I’ll lie down for half an hour in the dark and it’ll subside and then I won’t need to take the medication. But it is something that is more frequent. I can’t say that it follows a pattern. I think like a lot of migraine sufferers, I know there are certain triggers for it. I avoid those triggers completely. Um, I know that wine for instance, is a trigger very sadly, and I just hardly drink at all anymore.

Dr. Stieg: I always appreciate it when you send me the bottle. *laughs*

Alissa Rubin: Well, so I think that’s the most important element is—

Dr. Stieg Are you going to do anything differently when you go back to Baghdad? No helicopters?

Alissa Rubin:
No helicopters. No, I haven’t. I have to say I’ve been in lots of planes since the accident. I haven’t been in any helicopters, but I am very careful not to promise my family that I’ll never go into a helicopter because I can envision situations where one might need one. But I do think that disciplining myself to follow all those cognitive rules is probably something I’ll need to do for the rest of my life and they’re not really burdensome. I think you can see them as actually helping your brain. I don’t know if I want to say, be healthy, but do what’s best.

Dr. Stieg: It’s been an absolute delight spending this time with Alissa Rubin. It’s a really, every traumatic brain injury is obviously a specific story, so we can’t, but your story is one of reconstruction and hope, and it also highlights the, for me and I hope for anybody with traumatic brain injury, the intensity with which one has to go at reconstruction, the levels that you went to in terms of the cognitive remediation and the EMDR and the psychotherapy and the medications and the physical therapy. All that comes together and for you who I would characterize as a type A, highly driven, motivated individual came to terms with the fact that you, you’ve got to accept your body’s limits and you’ve done beautifully with that. Thank you for spending time with us.

Alissa Rubin: Thank you for taking the time.