Bessel Van Der Kolk

THE BODY KEEPS THE SCORE

Mind, Brain and
Body in the Transformation of Trauma

CONTENTS

PROLOGUE: FACING TRAUMA

PART ONE: THE REDISCOVERY OF TRAUMA

1. LESSONS FROM VIETNAM VETERANS

2. REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN

3. LOOKING INTO THE BRAIN: THE NEUROSCIENCE
REVOLUTION

PART TWO: THIS IS YOUR BRAIN ON TRAUMA

4. RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL

5. BODY-BRAIN CONNECTIONS

6. LOSING YOUR BODY, LOSING YOUR SELF

PART THREE: THE MINDS OF CHILDREN

7. GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND
ATTUNEMENT

8. TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND
NEGLECT

9. WHAT’S LOVE GOT TO DO WITH IT?

10. DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

PART FOUR: THE IMPRINT OF TRAUMA

11. UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC
MEMORY

12. THE UNBEARABLE HEAVINESS OF REMEMBERING

PART FIVE: PATHS TO RECOVERY

13. HEALING FROM TRAUMA: OWNING YOUR SELF

14. LANGUAGE: MIRACLE AND TYRANNY

15. LETTING GO OF THE PAST: EMDR

16. LEARNING TO INHABIT YOUR BODY: YOGA

17. PUTTING THE PIECES TOGETHER: SELF-LEADERSHIP

18. FILLING IN THE HOLES: CREATING STRUCTURES

19. REWIRING THE BRAIN: NEUROFEEDBACK

20. FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER

EPILOGUE: CHOICES TO BE MADE

APPENDIX: CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL
TRAUMA DISORDER

RESOURCES

FURTHER READING

NOTES

ACKNOWLEDGMENTS

FOLLOW PENGUIN

To my patients, who kept the score and were the textbook.

Prologue

Facing Trauma

One does not have be a combat soldier, or
visit a refugee camp in Syria or the Congo to encounter trauma. Trauma happens to
us, our friends, our families, and our neighbors. Research by the Centers for
Disease Control and Prevention has shown that one in five Americans was sexually
molested as a child; one in four was beaten by a parent to the point of a mark being
left on their body; and one in three couples engages in physical violence. A quarter
of us grew up with alcoholic relatives, and one out of eight witnessed their mother
being beaten or hit.[1]

As human beings we belong to an
extremely resilient species. Since time immemorial we have rebounded from our
relentless wars, countless disasters (both natural and man-made), and the violence
and betrayal in our own lives. But traumatic experiences do leave traces, whether on
a large scale (on our histories and cultures) or close to home, on our families,
with dark secrets being imperceptibly passed down through generations. They also
leave traces on our minds and emotions, on our capacity for joy and intimacy, and
even on our biology and immune systems.

Trauma affects not only those who are
directly exposed to it, but also those around them. Soldiers returning home from
combat may frighten their families with their rages and emotional absence. The wives
of men who suffer from PTSD tend to become depressed, and the children of depressed
mothers are at risk of growing up insecure and anxious. Having been exposed to
family violence as a child often makes it difficult to establish stable, trusting
relationships as an adult.

Trauma, by definition, is unbearable and
intolerable. Most rape victims, combat
soldiers, and children who have been molested become so upset when they think about
what they experienced that they try to push it out of their minds, trying to act as
if nothing happened, and move on. It takes tremendous energy to keep functioning
while carrying the memory of terror, and the shame of utter weakness and
vulnerability.

While we all want to move beyond trauma,
the part of our brain that is devoted to ensuring our survival (deep below our
rational brain) is not very good at denial. Long after a traumatic experience is
over, it may be reactivated at the slightest hint of danger and mobilize disturbed
brain circuits and secrete massive amounts of stress hormones. This precipitates
unpleasant emotions intense physical sensations, and impulsive and aggressive
actions. These posttraumatic reactions feel incomprehensible and overwhelming.
Feeling out of control, survivors of trauma often begin to fear that they are
damaged to the core and beyond redemption.

The first time I remember being drawn
to study medicine was at a summer camp when I was about fourteen years old. My
cousin Michael kept me up all night explaining the intricacies of how kidneys work,
how they secrete the body’s waste materials and then reabsorb the chemicals
that keep the system in balance. I was riveted by his account of the miraculous way
the body functions. Later, during every stage of my medical training, whether I was
studying surgery, cardiology, or pediatrics, it was obvious to me that the key to
healing was understanding how the human organism works. When I began my psychiatry
rotation, however, I was struck by the contrast between the incredible complexity of
the mind and the ways that we human beings are connected and attached to one
another, and how little psychiatrists knew about the origins of the problems they
were treating. Would it be possible one day to know as much about brains, minds, and
love as we do about the other systems that make up our organism?

We are obviously still years from
attaining that sort of detailed understanding, but the birth of three new branches
of science has led to an explosion of knowledge about the effects of psychological
trauma, abuse, and neglect. Those new disciplines are neuroscience, the study of how
the brain supports mental processes; developmental psychopathology, the study of the
impact of adverse experiences on the development of mind and brain; and
interpersonal neurobiology, the study of how our behavior influences the emotions,
biology, and mind-sets of those around us.

Research from these new disciplines has
revealed that trauma produces actual physiological changes, including a
recalibration of the brain’s alarm system, an increase in stress hormone activity, and
alterations in the system that filters relevant information from irrelevant. We now
know that trauma compromises the brain area that communicates the physical, embodied
feeling of being alive. These changes explain why traumatized individuals become
hypervigilant to threat at the expense of spontaneously engaging in their day-to-day
lives. They also help us understand why traumatized people so often keep repeating
the same problems and have such trouble learning from experience. We now know that
their behaviors are not the result of moral failings or signs of lack of willpower
or bad character—they are caused by actual changes in the brain.

This vast increase in our knowledge
about the basic processes that underlie trauma has also opened up new possibilities
to palliate or even reverse the damage. We can now develop methods and experiences
that utilize the brain’s own natural neuroplasticity to help survivors feel
fully alive in the present and move on with their lives. There are fundamentally
three avenues: 1) top down, by talking, (re-) connecting with others, and allowing
ourselves to know and understand what is going on with us, while processing the
memories of the trauma; 2) by taking medicines that shut down inappropriate alarm
reactions, or by utilizing other technologies that change the way the brain
organizes information, and 3) bottom up: by allowing the body to have experiences
that deeply and viscerally contradict the helplessness, rage, or collapse that
result from trauma. Which one of these is best for any particular survivor is an
empirical question. Most people I have worked with require a combination.

This has been my life’s work. In
this effort I have been supported by my colleagues and students at the Trauma
Center, which I founded thirty years ago. Together we have treated thousands of
traumatized children and adults: victims of child abuse, natural disasters, wars,
accidents, and human trafficking; people who have suffered assaults by intimates and
strangers. We have a long tradition of discussing all our patients in great depth at
weekly treatment team meetings and carefully tracking how well different forms of
treatment work for particular individuals.

Our principal mission has always been to
take care of the children and adults who have come to us for treatment, but from the
very beginning we also have dedicated ourselves to conducting research to explore
the effects of traumatic stress on different populations and to determine what
treatments work for whom. We have been supported by research grants from the
National Institute of Mental Health, the National Center for Complementary and
Alternative Medicine, the Centers for Disease Control, and a number of private foundations to study the efficacy
of many different forms of treatment, from medications to talking, yoga, EMDR,
theater, and neurofeedback.

The challenge is: How can people gain
control over the residues of past trauma and return to being masters of their own
ship? Talking, understanding, and human connections help, and drugs can dampen
hyperactive alarm systems. But we will also see that the imprints from the past can
be transformed by having physical experiences that directly contradict the
helplessness, rage, and collapse that are part of trauma, and thereby regaining
self-mastery. I have no preferred treatment modality, as no single approach fits
everybody, but I practice all the forms of treatment that I discuss in this book.
Each one of them can produce profound changes, depending on the nature of the
particular problem and the makeup of the individual person.

I wrote this book to serve as both a
guide and an invitation—an invitation to dedicate ourselves to facing the reality of
trauma, to explore how best to treat it, and to commit ourselves, as a society, to
using every means we have to prevent it.

Part One

THE REDISCOVERY OF TRAUMA

CHAPTER 1

Lessons from Vietnam Veterans

I became what I am today at the age of twelve,
on a frigid overcast day in the winter of 1975. … That was a long time
ago, but it’s wrong what they say about the past. … Looking back
now, I realize I have been peeking into that deserted alley for the last twenty-six
years.

—Khaled Hosseini, The Kite Runner

Some people’s lives seem to flow in a
narrative; mine had many stops and starts. That’s what trauma does. It
interrupts the plot. … It just happens, and then life goes on. No one
prepares you for it.

—Jessica Stern, Denial: A Memoir of Terror

The Tuesday after the Fourth of July
weekend, 1978, was my first day as a staff psychiatrist at the Boston Veterans
Administration Clinic. As I was hanging a reproduction of my favorite Breughel
painting, “The Blind Leading the Blind,” on the wall of my new office, I
heard a commotion in the reception area down the hall. A moment later a large,
disheveled man in a stained three-piece suit, carrying a copy of Soldier of
Fortune magazine under his arm, burst through my door. He was so agitated
and so clearly hungover that I wondered how I could possibly help this hulking man.
I asked him to take a seat, and tell me what I could do for him.

His name was Tom. Ten years earlier he
had been in the Marines, doing his service
in Vietnam. He had spent the holiday weekend holed up in his downtown-Boston law
office, drinking and looking at old photographs, rather than with his family. He
knew from previous years’ experience that the noise, the fireworks, the heat,
and the picnic in his sister’s backyard against the backdrop of dense
early-summer foliage, all of which reminded him of Vietnam, would drive him crazy.
When he got upset he was afraid to be around his family because he behaved like a
monster with his wife and two young boys. The noise of his kids made him so agitated
that he would storm out of the house to keep himself from hurting them. Only
drinking himself into oblivion or riding his Harley-Davidson at dangerously high
speeds helped him to calm down.

Nighttime offered no relief—his sleep
was constantly interrupted by nightmares about an ambush in a rice paddy back in
’Nam, in which all the members of his platoon were killed or wounded. He also
had terrifying flashbacks in which he saw dead Vietnamese children. The nightmares
were so horrible that he dreaded falling asleep and he often stayed up for most of
the night, drinking. In the morning his wife would find him passed out on the living
room couch, and she and the boys had to tiptoe around him while she made them
breakfast before taking them to school.

Filling me in on his background, Tom
said that he had graduated from high school in 1965, the valedictorian of his class.
In line with his family tradition of military service he enlisted in the Marine
Corps immediately after graduation. His father had served in World War II in General
Patton’s army, and Tom never questioned his father’s expectations.
Athletic, intelligent, and an obvious leader, Tom felt powerful and effective after
finishing basic training, a member of a team that was prepared for just about
anything. In Vietnam he quickly became a platoon leader, in charge of eight other
Marines. Surviving slogging through the mud while being strafed by machine-gun fire
can leave people feeling pretty good about themselves—and their comrades.

At the end of his tour of duty Tom was
honorably discharged, and all he wanted was to put Vietnam behind him. Outwardly
that’s exactly what he did. He attended college on the GI Bill, graduated from
law school, married his high school sweetheart, and had two sons. Tom was upset by
how difficult it was to feel any real affection for his wife, even though her
letters had kept him alive in the madness of the jungle. Tom went through the
motions of living a normal life, hoping that by faking it he would learn to become
his old self again. He now had a thriving law practice and a picture-perfect family,
but he sensed he wasn’t normal; he felt dead inside.

Although Tom was the first veteran I had
ever encountered on a professional basis,
many aspects of his story were familiar to me. I grew up in postwar Holland, playing
in bombed-out buildings, the son of a man who had been such an outspoken opponent of
the Nazis that he had been sent to an internment camp. My father never talked about
his war experiences, but he was given to outbursts of explosive rage that stunned me
as a little boy. How could the man I heard quietly going down the stairs every
morning to pray and read the Bible while the rest of the family slept have such a
terrifying temper? How could someone whose life was devoted to the pursuit of social
justice be so filled with anger? I witnessed the same puzzling behavior in my uncle,
who had been captured by the Japanese in the Dutch East Indies (now Indonesia) and
sent as a slave laborer to Burma, where he worked on the famous bridge over the
river Kwai. He also rarely mentioned the war, and he, too, often erupted into
uncontrollable rages.

As I listened to Tom, I wondered if my
uncle and my father had had nightmares and flashbacks—if they, too, had felt
disconnected from their loved ones and unable to find any real pleasure in their
lives. Somewhere in the back of my mind there must also have been my memories of my
frightened—and often frightening—mother, whose own childhood trauma was sometimes
alluded to and, I now believe, was frequently reenacted. She had the unnerving habit
of fainting when I asked her what her life was like as a little girl and then
blaming me for making her so upset.

Reassured by my obvious interest, Tom
settled down to tell me just how scared and confused he was. He was afraid that he
was becoming just like his father, who was always angry and rarely talked with his
children—except to compare them unfavorably with his comrades who had lost their
lives around Christmas 1944, during the Battle of the Bulge.

As the session was drawing to a close, I
did what doctors typically do: I focused on the one part of Tom’s story that I
thought I understood—his nightmares. As a medical student I had worked in a sleep
laboratory, observing people’s sleep/dream cycles, and had assisted in writing
some articles about nightmares. I had also participated in some early research on
the beneficial effects of the psychoactive drugs that were just coming into use in
the 1970s. So, while I lacked a true grasp of the scope of Tom’s problems, the
nightmares were something I could relate to, and as an enthusiastic believer in
better living through chemistry, I prescribed a drug that we had found to be
effective in reducing the incidence and severity of nightmares. I scheduled Tom for
a follow-up visit two weeks later.

When he returned for his appointment, I
eagerly asked Tom how the medicines had worked. He told me he hadn’t taken any
of the pills. Trying to conceal my
irritation, I asked him why. “I realized that if I take the pills and the
nightmares go away,” he replied, “I will have abandoned my friends, and
their deaths will have been in vain. I need to be a living memorial to my friends
who died in Vietnam.”

I was stunned: Tom’s loyalty to
the dead was keeping him from living his own life, just as his father’s
devotion to his friends had kept him from living. Both father’s and
son’s experiences on the battlefield had rendered the rest of their lives
irrelevant. How had that happened, and what could we do about it? That morning I
realized I would probably spend the rest of my professional life trying to unravel
the mysteries of trauma. How do horrific experiences cause people to become
hopelessly stuck in the past? What happens in people’s minds and brains that
keeps them frozen, trapped in a place they desperately wish to escape? Why did this
man’s war not come to an end in February 1969, when his parents embraced him
at Boston’s Logan International Airport after his long flight back from Da
Nang?

Tom’s need to live out his life as
a memorial to his comrades taught me that he was suffering from a condition much
more complex than simply having bad memories or damaged brain chemistry—or altered
fear circuits in the brain. Before the ambush in the rice paddy, Tom had been a
devoted and loyal friend, someone who enjoyed life, with many interests and
pleasures. In one terrifying moment, trauma had transformed everything.

During my time at the VA I got to know
many men who responded similarly. Faced with even minor frustrations, our veterans
often flew instantly into extreme rages. The public areas of the clinic were
pockmarked with the impacts of their fists on the drywall, and security was kept
constantly busy protecting claims agents and receptionists from enraged veterans. Of
course, their behavior scared us, but I also was intrigued.

At home my wife and I were coping with
similar problems in our toddlers, who regularly threw temper tantrums when told to
eat their spinach or to put on warm socks. Why was it, then, that I was utterly
unconcerned about my kids’ immature behavior but deeply worried by what was
going on with the vets (aside from their size, of course, which gave them the
potential to inflict much more harm than my two-footers at home)? The reason was
that I felt perfectly confident that, with proper care, my kids would gradually
learn to deal with frustrations and disappointments, but I was skeptical that I
would be able to help my veterans reacquire the skills of self-control and
self-regulation that they had lost in the war.

Unfortunately, nothing in my psychiatric
training had prepared me to deal with any of the challenges that Tom and his fellow
veterans presented. I went down to the
medical library to look for books on war neurosis, shell shock, battle fatigue, or
any other term or diagnosis I could think of that might shed light on my patients.
To my surprise the library at the VA didn’t have a single book about any of
these conditions. Five years after the last American soldier left Vietnam, the issue
of wartime trauma was still not on anybody’s agenda. Finally, in the Countway
Library at Harvard Medical School, I discovered The Traumatic Neuroses of
War, which had been published in 1941 by a psychiatrist named Abram
Kardiner. It described Kardiner’s observations of World War I veterans and had
been released in anticipation of the flood of shell-shocked soldiers expected to be
casualties of World War II.[1]

Kardiner reported the same phenomena I
was seeing: After the war his patients were overtaken by a sense of futility; they
became withdrawn and detached, even if they had functioned well before. What
Kardiner called “traumatic neuroses,” today we call posttraumatic stress
disorder—PTSD. Kardiner noted that sufferers from traumatic neuroses develop a
chronic vigilance for and sensitivity to threat. His summation especially caught my
eye: “The nucleus of the neurosis is a physioneurosis.”[2] In other words,
posttraumatic stress isn’t “all in one’s head,” as some
people supposed, but has a physiological basis. Kardiner understood even then that
the symptoms have their origin in the entire body’s response to the original
trauma.

Kardiner’s description
corroborated my own observations, which was reassuring, but it provided me with
little guidance on how to help the veterans. The lack of literature on the topic was
a handicap, but my great teacher, Elvin Semrad, had taught us to be skeptical about
textbooks. We had only one real textbook, he said: our patients. We should trust
only what we could learn from them—and from our own experience. This sounds so
simple, but even as Semrad pushed us to rely upon self-knowledge, he also warned us
how difficult that process really is, since human beings are experts in wishful
thinking and obscuring the truth. I remember him saying: “The greatest sources
of our suffering are the lies we tell ourselves.” Working at the VA I soon
discovered how excruciating it can be to face reality. This was true both for my
patients and for myself.

We don’t really want to know what
soldiers go through in combat. We do not really want to know how many children are
being molested and abused in our own society or how many couples—almost a third, as
it turns out—engage in violence at some point during their relationship. We want to
think of families as safe havens in a heartless world and of our own country as
populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places like Darfur
or the Congo. It is hard enough for observers to bear witness to pain. Is it any
wonder, then, that the traumatized individuals themselves cannot tolerate
remembering it and that they often resort to using drugs, alcohol, or
self-mutilation to block out their unbearable knowledge?

Tom and his fellow veterans became my
first teachers in my quest to understand how lives are shattered by overwhelming
experiences, and in figuring out how to enable them to feel fully alive again.

TRAUMA AND THE LOSS OF SELF

The first study I did at the VA started
with systematically asking veterans what had happened to them in Vietnam. I wanted
to know what had pushed them over the brink, and why some had broken down as a
result of that experience while others had been able to go on with their lives.[3] Most of the men I
interviewed had gone to war feeling well prepared, drawn close by the rigors of
basic training and the shared danger. They exchanged pictures of their families and
girlfriends; they put up with one another’s flaws. And they were prepared to
risk their lives for their friends. Most of them confided their dark secrets to a
buddy, and some went so far as to share each other’s shirts and socks.

Many of the men had friendships similar
to Tom’s with Alex. Tom met Alex, an Italian guy from Malden, Massachusetts,
on his first day in country, and they instantly became close friends. They drove
their jeep together, listened to the same music, and read each other’s letters
from home. They got drunk together and chased the same Vietnamese bar girls.

After about three months in country Tom
led his squad on a foot patrol through a rice paddy just before sunset. Suddenly a
hail of gunfire spurted from the green wall of the surrounding jungle, hitting the
men around him one by one. Tom told me how he had looked on in helpless horror as
all the members of his platoon were killed or wounded in a matter of seconds. He
would never get one image out of his mind: the back of Alex’s head as he lay
facedown in the rice paddy, his feet in the air. Tom wept as he recalled, “He
was the only real friend I ever had.” Afterward, at night, Tom continued to
hear the screams of his men and to see their bodies falling into the water. Any
sounds, smells, or images that reminded him of the ambush (like the popping of
firecrackers on the Fourth of July) made him feel just as paralyzed, terrified, and
enraged as he had the day the helicopter evacuated him from the rice paddy.

Maybe even worse for Tom than the recurrent
flashbacks of the ambush was the memory of what happened afterward. I could easily
imagine how Tom’s rage about his friend’s death had led to the calamity
that followed. It took him months of dealing with his paralyzing shame before he
could tell me about it. Since time immemorial veterans, like Achilles in
Homer’s Iliad, have responded to the death of their comrades with
unspeakable acts of revenge. The day after the ambush Tom went into a frenzy to a
neighboring village, killing children, shooting an innocent farmer, and raping a
Vietnamese woman. After that it became truly impossible for him to go home again in
any meaningful way. How can you face your sweetheart and tell her that you brutally
raped a woman just like her, or watch your son take his first step when you are
reminded of the child you murdered? Tom experienced the death of Alex as if part of
himself had been forever destroyed—the part that was good and honorable and
trustworthy. Trauma, whether it is the result of something done to you or something
you yourself have done, almost always makes it difficult to engage in intimate
relationships. After you have experienced something so unspeakable, how do you learn
to trust yourself or anyone else again? Or, conversely, how can you surrender to an
intimate relationship after you have been brutally violated?

Tom kept showing up faithfully for his
appointments, as I had become for him a lifeline—the father he’d never had, an
Alex who had survived the ambush. It takes enormous trust and courage to allow
yourself to remember. One of the hardest things for traumatized people is to
confront their shame about the way they behaved during a traumatic episode, whether
it is objectively warranted (as in the commission of atrocities) or not (as in the
case of a child who tries to placate her abuser). One of the first people to write
about this phenomenon was Sarah Haley, who occupied an office next to mine at the VA
Clinic. In an article entitled “When the Patient Reports
Atrocities,”[4] which became a major impetus for the ultimate creation of the PTSD
diagnosis, she discussed the well-nigh intolerable difficulty of talking about (and
listening to) the horrendous acts that are often committed by soldiers in the course
of their war experiences. It’s hard enough to face the suffering that has been
inflicted by others, but deep down many traumatized people are even more haunted by
the shame they feel about what they themselves did or did not do under the
circumstances. They despise themselves for how terrified, dependent, excited, or
enraged they felt.

In later years I encountered a similar
phenomenon in victims of child abuse: Most of them suffer from agonizing shame about
the actions they took to survive and maintain a connection with the person who
abused them. This was particularly true if
the abuser was someone close to the child, someone the child depended on, as is so
often the case. The result can be confusion about whether one was a victim or a
willing participant, which in turn leads to bewilderment about the difference
between love and terror; pain and pleasure. We will return to this dilemma
throughout this book.

NUMBING

Maybe the worst of Tom’s symptoms
was that he felt emotionally numb. He desperately wanted to love his family, but he
just couldn’t evoke any deep feelings for them. He felt emotionally distant
from everybody, as though his heart were frozen and he were living behind a glass
wall. That numbness extended to himself, as well. He could not really feel anything
except for his momentary rages and his shame. He described how he hardly recognized
himself when he looked in the mirror to shave. When he heard himself arguing a case
in court, he would observe himself from a distance and wonder how this guy, who
happened to look and talk like him, was able to make such cogent arguments. When he
won a case he pretended to be gratified, and when he lost it was as though he had
seen it coming and was resigned to the defeat even before it happened. Despite the
fact that he was a very effective lawyer, he always felt as though he were floating
in space, lacking any sense of purpose or direction.

The only thing that occasionally
relieved this feeling of aimlessness was intense involvement in a particular case.
During the course of our treatment Tom had to defend a mobster on a murder charge.
For the duration of that trial he was totally absorbed in devising a strategy for
winning the case, and there were many occasions on which he stayed up all night to
immerse himself in something that actually excited him. It was like being in combat,
he said—he felt fully alive, and nothing else mattered. The moment Tom won that
case, however, he lost his energy and sense of purpose. The nightmares returned, as
did his rage attacks—so intensely that he had to move into a motel to ensure that he
would not harm his wife or children. But being alone, too, was terrifying, because
the demons of the war returned in full force. Tom tried to stay busy, working,
drinking, and drugging—doing anything to avoid confronting his demons.

He kept thumbing through Soldier of
Fortune, fantasizing about enlisting as a mercenary in one of the many
regional wars then raging in Africa. That spring he took out his Harley and roared
up the Kancamagus Highway in New Hampshire. The vibrations, speed, and danger of
that ride helped him pull himself back
together, to the point that he was able to leave his motel room and return to his
family.

THE REORGANIZATION OF
PERCEPTION

Another study I conducted at the VA
started out as research about nightmares but ended up exploring how trauma changes
people’s perceptions and imagination. Bill, a former medic who had seen heavy
action in Vietnam a decade earlier, was the first person enrolled in my nightmare
study. After his discharge he had enrolled in a theological seminary and had been
assigned to his first parish in a Congregational church in a Boston suburb. He was
doing fine until he and his wife had their first child. Soon after the baby’s
birth, his wife, a nurse, had gone back to work while he remained at home, working
on his weekly sermon and other parish duties and taking care of their newborn. On
the very first day he was left alone with the baby, it began to cry, and he found
himself suddenly flooded with unbearable images of dying children in Vietnam.

Bill had to call his wife to take over
child care and came to the VA in a panic. He described how he kept hearing the
sounds of babies crying and seeing images of burned and bloody children’s
faces. My medical colleagues thought that he must surely be psychotic, because the
textbooks of the time said that auditory and visual hallucinations were symptoms of
paranoid schizophrenia. The same texts that provided this diagnosis also supplied a
cause: Bill’s psychosis was probably triggered by his feeling displaced in his
wife’s affections by their new baby.

As I arrived at the intake office that
day, I saw Bill surrounded by worried doctors who were preparing to inject him with
a powerful antipsychotic drug and ship him off to a locked ward. They described his
symptoms and asked my opinion. Having worked in a previous job on a ward
specializing in the treatment of schizophrenics, I was intrigued. Something about
the diagnosis didn’t sound right. I asked Bill if I could talk with him, and
after hearing his story, I unwittingly paraphrased something Sigmund Freud had said
about trauma in 1895: “I think this man is suffering from memories.” I
told Bill that I would try to help him and, after offering him some medications to
control his panic, asked if he would be willing to come back a few days later to
participate in my nightmare study.[5] He agreed.

As part of that study we gave our
participants a Rorschach test.[6] Unlike tests that require answers to
straightforward questions, responses to the Rorschach are almost impossible to fake.
The Rorschach provides us with a unique
way to observe how people construct a mental image from what is basically a
meaningless stimulus: a blot of ink. Because humans are meaning-making creatures, we
have a tendency to create some sort of image or story out of those inkblots, just as
we do when we lie in a meadow on a beautiful summer day and see images in the clouds
floating high above. What people make out of these blots can tell us a lot about how
their minds work.

On seeing the second card of the
Rorschach test, Bill exclaimed in horror, “This is that child that I saw being
blown up in Vietnam. In the middle, you see the charred flesh, the wounds, and the
blood is spurting out all over.” Panting and with sweat beading on his
forehead, he was in a panic similar to the one that had initially brought him to the
VA clinic. Although I had heard veterans describing their flashbacks, this was the
first time I actually witnessed one. In that very moment in my office, Bill was
obviously seeing the same images, smelling the same smells, and feeling the same
physical sensations he had felt during the original event. Ten years after
helplessly holding a dying baby in his arms, Bill was reliving the trauma in
response to an inkblot.

Experiencing Bill’s flashback
firsthand in my office helped me realize the agony that regularly visited the
veterans I was trying to treat and helped me appreciate again how critical it was to
find a solution. The traumatic event itself, however horrendous, had a beginning, a
middle, and an end, but I now saw that flashbacks could be even worse. You never
know when you will be assaulted by them again and you have no way of telling when
they will stop. It took me years to learn how to effectively treat flashbacks, and
in this process Bill turned out to be one of my most important mentors.

When we gave the Rorschach test to
twenty-one additional veterans, the response was consistent: Sixteen of them, on
seeing the second card, reacted as if they were experiencing a wartime trauma. The
second Rorschach card is the first card that contains color and often elicits
so-called color shock in response. The veterans interpreted this card with
descriptions like “These are the bowels of my friend Jim after a mortar shell
ripped him open” and “This is the neck of my friend Danny after his head
was blown off by a shell while we were eating lunch.” None of them mentioned
dancing monks, fluttering butterflies, men on motorcycles, or any of the other
ordinary, sometimes whimsical images that most people see.

While the majority of the veterans were
greatly upset by what they saw, the reactions of the remaining five were even more
alarming: They simply went blank. “This is nothing,” one observed,
“just a bunch of ink.” They were right, of course, but the normal human
response to ambiguous stimuli is to use our imagination to read something into
them.

We learned from these Rorschach tests that
traumatized people have a tendency to superimpose their trauma on everything around
them and have trouble deciphering whatever is going on around them. There appeared
to be little in between. We also learned that trauma affects the imagination. The
five men who saw nothing in the blots had lost the capacity to let their minds play.
But so, too, had the other sixteen men, for in viewing scenes from the past in those
blots they were not displaying the mental flexibility that is the hallmark of
imagination. They simply kept replaying an old reel.

Imagination is absolutely critical to
the quality of our lives. Our imagination enables us to leave our routine everyday
existence by fantasizing about travel, food, sex, falling in love, or having the
last word—all the things that make life interesting. Imagination gives us the
opportunity to envision new possibilities—it is an essential launchpad for making
our hopes come true. It fires our creativity, relieves our boredom, alleviates our
pain, enhances our pleasure, and enriches our most intimate relationships. When
people are compulsively and constantly pulled back into the past, to the last time
they felt intense involvement and deep emotions, they suffer from a failure of
imagination, a loss of the mental flexibility. Without imagination there is no hope,
no chance to envision a better future, no place to go, no goal to reach.

The Rorschach tests also taught us that
traumatized people look at the world in a fundamentally different way from other
people. For most of us a man coming down the street is just someone taking a walk. A
rape victim, however, may see a person who is about to molest her and go into a
panic. A stern schoolteacher may be an intimidating presence to an average kid, but
for a child whose stepfather beats him up, she may represent a torturer and
precipitate a rage attack or a terrified cowering in the corner.

STUCK IN TRAUMA

Our clinic was inundated with veterans
seeking psychiatric help. However, because of an acute shortage of qualified
doctors, all we could do was put most of them on a waiting list, even as they
continued brutalizing themselves and their families. We began seeing a sharp
increase in arrests of veterans for violent offenses and drunken brawls—as well as
an alarming number of suicides. I received permission to start a group for young
Vietnam veterans to serve as a sort of holding tank until “real” therapy
could start.

At the opening session for a group of
former Marines, the first man to speak
flatly declared, “I do not want to talk about the war.” I replied that
the members could discuss anything they wanted. After half an hour of excruciating
silence, one veteran finally started to talk about his helicopter crash. To my
amazement the rest immediately came to life, speaking with great intensity about
their traumatic experiences. All of them returned the following week and the week
after. In the group they found resonance and meaning in what had previously been
only sensations of terror and emptiness. They felt a renewed sense of the
comradeship that had been so vital to their war experience. They insisted that I had
to be part of their newfound unit and gave me a Marine captain’s uniform for
my birthday. In retrospect that gesture revealed part of the problem: You were
either in or out—you either belonged to the unit or you were nobody. After trauma
the world becomes sharply divided between those who know and those who don’t.
People who have not shared the traumatic experience cannot be trusted, because they
can’t understand it. Sadly, this often includes spouses, children, and
co-workers.

Later I led another group, this time for
veterans of Patton’s army—men now well into their seventies, all old enough to
be my father. We met on Monday mornings at eight o’clock. In Boston winter
snowstorms occasionally paralyze the public transit system, but to my amazement all
of them showed up even during blizzards, some of them trudging several miles through
the snow to reach the VA Clinic. For Christmas they gave me a 1940s GI-issue
wristwatch. As had been the case with my group of Marines, I could not be their
doctor unless they made me one of them.

Moving as these experiences were, the
limits of group therapy became clear when I urged the men to talk about the issues
they confronted in their daily lives: their relationships with their wives,
children, girlfriends, and family; dealing with their bosses and finding
satisfaction in their work; their heavy use of alcohol. Their typical response was
to balk and resist and instead recount yet again how they had plunged a dagger
through the heart of a German soldier in the Hürtgen Forest or how their helicopter
had been shot down in the jungles of Vietnam.

Whether the trauma had occurred ten
years in the past or more than forty, my patients could not bridge the gap between
their wartime experiences and their current lives. Somehow the very event that
caused them so much pain had also become their sole source of meaning. They felt
fully alive only when they were revisiting their traumatic past.

DIAGNOSING POSTTRAUMATIC STRESS

In those early days at the VA, we labeled
our veterans with all sorts of diagnoses—alcoholism, substance abuse, depression,
mood disorder, even schizophrenia—and we tried every treatment in our textbooks. But
for all our efforts it became clear that we were actually accomplishing very little.
The powerful drugs we prescribed often left the men in such a fog that they could
barely function. When we encouraged them to talk about the precise details of a
traumatic event, we often inadvertently triggered a full-blown flashback, rather
than helping them resolve the issue. Many of them dropped out of treatment because
we were not only failing to help but also sometimes making things worse.

A turning point arrived in 1980, when a
group of Vietnam veterans, aided by the New York psychoanalysts Chaim Shatan and
Robert J. Lifton, successfully lobbied the American Psychiatric Association to
create a new diagnosis: posttraumatic stress disorder (PTSD), which described a
cluster of symptoms that was common, to a greater or lesser extent, to all of our
veterans. Systematically identifying the symptoms and grouping them together into a
disorder finally gave a name to the suffering of people who were overwhelmed by
horror and helplessness. With the conceptual framework of PTSD in place, the stage
was set for a radical change in our understanding of our patients. This eventually
led to an explosion of research and attempts at finding effective treatments.

Inspired by the possibilities presented
by this new diagnosis, I proposed a study on the biology of traumatic memories to
the VA. Did the memories of those suffering from PTSD differ from those of others?
For most people the memory of an unpleasant event eventually fades or is transformed
into something more benign. But most of our patients were unable to make their past
into a story that happened long ago.[7]

The opening line of the grant rejection
read: “It has never been shown that PTSD is relevant to the mission of the
Veterans Administration.” Since then, of course, the mission of the VA has
become organized around the diagnosis of PTSD and brain injury, and considerable
resources are dedicated to applying “evidence-based treatments” to
traumatized war veterans. But at the time things were different and, unwilling to
keep working in an organization whose view of reality was so at odds with my own, I
handed in my resignation; in 1982 I took a position at the Massachusetts Mental
Health Center, the Harvard teaching hospital where I had trained to become a
psychiatrist. My new responsibility was to
teach a fledgling area of study: psychopharmacology, the administration of drugs to
alleviate mental illness.

In my new job I was confronted on an
almost daily basis with issues I thought I had left behind at the VA. My experience
with combat veterans had so sensitized me to the impact of trauma that I now
listened with a very different ear when depressed and anxious patients told me
stories of molestation and family violence. I was particularly struck by how many
female patients spoke of being sexually abused as children. This was puzzling, as
the standard textbook of psychiatry at the time stated that incest was extremely
rare in the United States, occurring about once in every million women.[8] Given that there
were then only about one hundred million women living in the United States, I
wondered how forty seven, almost half of them, had found their way to my office in
the basement of the hospital.

Furthermore, the textbook said,
“There is little agreement about the role of father-daughter incest as a
source of serious subsequent psychopathology.” My patients with incest
histories were hardly free of “subsequent psychopathology”—they were
profoundly depressed, confused, and often engaged in bizarrely self-harmful
behaviors, such as cutting themselves with razor blades. The textbook went on to
practically endorse incest, explaining that “such incestuous activity
diminishes the subject’s chance of psychosis and allows for a better
adjustment to the external world.”[9] In fact, as it turned out, incest had
devastating effects on women’s well-being.

In many ways these patients were not so
different from the veterans I had just left behind at the VA. They also had
nightmares and flashbacks. They also alternated between occasional bouts of
explosive rage and long periods of being emotionally shut down. Most of them had
great difficulty getting along with other people and had trouble maintaining
meaningful relationships.

As we now know, war is not the only
calamity that leaves human lives in ruins. While about a quarter of the soldiers who
serve in war zones are expected to develop serious posttraumatic problems,[10] the majority
of Americans experience a violent crime at some time during their lives, and more
accurate reporting has revealed that twelve million women in the United States have
been victims of rape. More than half of all rapes occur in girls below age
fifteen.[11]
For many people the war begins at home: Each year about three million children in
the United States are reported as victims of child abuse and neglect. One million of
these cases are serious and credible enough to force local child protective services
or the courts to take action.[12] In other words, for every soldier who
serves in a war zone abroad, there are ten
children who are endangered in their own homes. This is particularly tragic, since
it is very difficult for growing children to recover when the source of terror and
pain is not enemy combatants but their own caretakers.

A NEW UNDERSTANDING

In the three decades since I met Tom, we
have learned an enormous amount not only about the impact and manifestations of
trauma but also about ways to help traumatized people find their way back. Since the
early 1990s brain-imaging tools have started to show us what actually happens inside
the brains of traumatized people. This has proven essential to understanding the
damage inflicted by trauma and has guided us to formulate entirely new avenues of
repair.

We have also begun to understand how
overwhelming experiences affect our innermost sensations and our relationship to our
physical reality—the core of who we are. We have learned that trauma is not just an
event that took place sometime in the past; it is also the imprint left by that
experience on mind, brain, and body. This imprint has ongoing consequences for how
the human organism manages to survive in the present.

Trauma results in a fundamental
reorganization of the way mind and brain manage perceptions. It changes not only how
we think and what we think about, but also our very capacity to think. We have
discovered that helping victims of trauma find the words to describe what has
happened to them is profoundly meaningful, but usually it is not enough. The act of
telling the story doesn’t necessarily alter the automatic physical and
hormonal responses of bodies that remain hypervigilant, prepared to be assaulted or
violated at any time. For real change to take place, the body needs to learn that
the danger has passed and to live in the reality of the present. Our search to
understand trauma has led us to think differently not only about the structure of
the mind but also about the processes by which it heals.

CHAPTER 2

Revolutions in Understanding Mind
and Brain

The greater the doubt, the greater the
awakening; the smaller the doubt, the smaller the awakening. No doubt, no
awakening.

—C.-C. Chang, The Practice of Zen

You live through that little piece of time that
is yours, but that piece of time is not only your own life, it is the summing-up of
all the other lives that are simultaneous with yours. … What you are is an
expression of History.

—Robert Penn Warren, World Enough and Time

In the late 1960s, during a year off
between my first and second years of medical school, I became an accidental witness
to a profound transition in the medical approach to mental suffering. I had landed a
plum job as an attendant on a research ward at the Massachusetts Mental Health
Center, where I was in charge of organizing recreational activities for the
patients. MMHC had long been considered one of the finest psychiatric hospitals in
the country, a jewel in the crown of the Harvard Medical School teaching empire. The
goal of the research on my ward was to determine whether psychotherapy or medication
was the best way to treat young people who had suffered a first mental breakdown
diagnosed as schizophrenia.

The talking cure, an offshoot of
Freudian psychoanalysis, was still the primary treatment for mental illness at MMHC.
However, in the early 1950s a group of
French scientists had discovered a new compound, chlorpromazine (sold under the
brand name Thorazine), that could “tranquilize” patients and make them
less agitated and delusional. That inspired hope that drugs could be developed to
treat serious mental problems such as depression, panic, anxiety, and mania, as well
as to manage some of the most disturbing symptoms of schizophrenia.

As an attendant I had nothing to do with
the research aspect of the ward and was never told what treatment any of the
patients was receiving. They were all close to my age—college students from Harvard,
MIT, and Boston University. Some had tried to kill themselves; others cut themselves
with knives or razor blades; several had attacked their roommates or had otherwise
terrified their parents or friends with their unpredictable, irrational behavior. My
job was to keep them involved in normal activities for college students, such as
eating at the local pizza parlor, camping in a nearby state forest, attending Red
Sox games, and sailing on the Charles River.

Totally new to the field, I sat in rapt
attention during ward meetings, trying to decipher the patients’ complicated
speech and logic. I also had to learn to deal with their irrational outbursts and
terrified withdrawal. One morning I found a patient standing like a statue in her
bedroom with one arm raised in a defensive gesture, her face frozen in fear. She
remained there, immobile, for at least twelve hours. The doctors gave me the name
for her condition, catatonia, but even the textbooks I consulted didn’t tell
me what could be done about it. We just let it run its course.

TRAUMA BEFORE DAWN

I spent many nights and weekends on the
unit, which exposed me to things the doctors never saw during their brief visits.
When patients could not sleep, they often wandered in their tightly wrapped
bathrobes into the darkened nursing station to talk. The quiet of the night seemed
to help them open up, and they told me stories about having been hit, assaulted, or
molested, often by their own parents, sometimes by relatives, classmates, or
neighbors. They shared memories of lying in bed at night, helpless and terrified,
hearing their mother being beaten by their father or a boyfriend, hearing their
parents yell horrible threats at each other, hearing the sounds of furniture
breaking. Others told me about fathers who came home drunk—hearing their footsteps
on the landing and how they waited for them to come in, pull them out of bed, and
punish them for some imagined offense. Several of the women recalled lying awake,
motionless, waiting for the inevitable—a brother or father coming in to molest
them.

During morning rounds the young doctors
presented their cases to their supervisors, a ritual that the ward attendants were
allowed to observe in silence. They rarely mentioned stories like the ones I’d
heard. However, many later studies have confirmed the relevance of those midnight
confessions: We now know that more than half the people who seek psychiatric care
have been assaulted, abandoned, neglected, or even raped as children, or have
witnessed violence in their families.[1] But such experiences seemed to be off
the table during rounds. I was often surprised by the dispassionate way
patients’ symptoms were discussed and by how much time was spent on trying to
manage their suicidal thoughts and self-destructive behaviors, rather than on
understanding the possible causes of their despair and helplessness. I was also
struck by how little attention was paid to their accomplishments and aspirations;
whom they cared for, loved, or hated; what motivated and engaged them, what kept
them stuck, and what made them feel at peace—the ecology of their lives.

A few years later, as a young doctor, I
was confronted with an especially stark example of the medical model in action. I
was then moonlighting at a Catholic hospital, doing physical examinations on women
who’d been admitted to receive electroshock treatment for depression. Being my
curious immigrant self, I’d look up from their charts to ask them about their
lives. Many of them spilled out stories about painful marriages, difficult children,
and guilt over abortions. As they spoke, they visibly brightened and often thanked
me effusively for listening to them. Some of them wondered if they really still
needed electroshock after having gotten so much off their chests. I always felt sad
at the end of these meetings, knowing that the treatments that would be administered
the following morning would erase all memory of our conversation. I did not last
long in that job.

On my days off from the ward at MMHC, I
often went to the Countway Library of Medicine to learn more about the patients I
was supposed to help. One Saturday afternoon I came across a treatise that is still
revered today: Eugen Bleuler’s 1911 textbook Dementia Praecox.
Bleuler’s observations were fascinating:

Among schizophrenic body
hallucinations, the sexual ones are by far the most frequent and the most
important. All the raptures and joys of normal and abnormal sexual satisfaction
are experienced by these patients, but even more frequently every obscene and
disgusting practice which the most extravagant fantasy can conjure up. Male
patients have their semen drawn off; painful erections are stimulated. The women patients are raped and injured
in the most devilish ways. … In spite of the symbolic meaning of many
such hallucinations, the majority of them correspond to real sensations.[2]

This made me wonder: Our patients had
hallucinations—the doctors routinely asked about them and noted them as signs of how
disturbed the patients were. But if the stories I’d heard in the wee hours
were true, could it be that these “hallucinations” were in fact the
fragmented memories of real experiences? Were hallucinations just the concoctions of
sick brains? Could people make up physical sensations they had never experienced?
Was there a clear line between creativity and pathological imagination? Between
memory and imagination? These questions remain unanswered to this day, but research
has shown that people who’ve been abused as children often feel sensations
(such as abdominal pain) that have no obvious physical cause; they hear voices
warning of danger or accusing them of heinous crimes.

There was no question that many patients
on the ward engaged in violent, bizarre, and self-destructive behaviors,
particularly when they felt frustrated, thwarted, or misunderstood. They threw
temper tantrums, hurled plates, smashed windows, and cut themselves with shards of
glass. At that time I had no idea why someone might react to a simple request
(“Let me clean that goop out of your hair”) with rage or terror. I
usually followed the lead of the experienced nurses, who signaled when to back off
or, if that did not work, to restrain a patient. I was surprised and alarmed by the
satisfaction I sometimes felt after I’d wrestled a patient to the floor so a
nurse could give an injection, and I gradually realized how much of our professional
training was geared to helping us stay in control in the face of terrifying and
confusing realities.

Sylvia was a gorgeous nineteen-year-old
Boston University student who usually sat alone in the corner of the ward, looking
frightened to death and virtually mute, but whose reputation as the girlfriend of an
important Boston mafioso gave her an aura of mystery. After she refused to eat for
more than a week and rapidly started to lose weight, the doctors decided to
force-feed her. It took three of us to hold her down, another to push the rubber
feeding tube down her throat, and a nurse to pour the liquid nutrients into her
stomach. Later, during a midnight confession, Sylvia spoke timidly and hesitantly
about her childhood sexual abuse by her brother and uncle. I realized then our
display of “caring” must have felt to her much like a gang rape. This
experience, and others like it, helped me formulate this rule for my students: If
you do something to a patient that you would not do to your friends or children, consider whether you are
unwittingly replicating a trauma from the patient’s past.

In my role as recreation leader I
noticed other things: As a group the patients were strikingly clumsy and physically
uncoordinated. When we went camping, most of them stood helplessly by as I pitched
the tents. We almost capsized once in a squall on the Charles River because they
huddled rigidly in the lee, unable to grasp that they needed to shift position to
balance the boat. In volleyball games the staff members invariably were much better
coordinated than the patients. Another characteristic they shared was that even
their most relaxed conversations seemed stilted, lacking the natural flow of
gestures and facial expressions that are typical among friends. The relevance of
these observations became clear only after I’d met the body-based therapists
Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about
how trauma is held in people’s bodies.

MAKING SENSE OF SUFFERING

After my year on the research ward I
resumed medical school and then, as a newly minted MD, returned to MMHC to be
trained as a psychiatrist, a program to which I was thrilled to be accepted. Many
famous psychiatrists had trained there, including Eric Kandel, who later won the
Nobel Prize in Physiology and Medicine. Allan Hobson discovered the brain cells
responsible for the generation of dreams in a lab in the hospital basement while I
trained there, and the first studies on the chemical underpinnings of depression
were also conducted at MMHC. But for many of us residents, the greatest draw was the
patients. We spent six hours each day with them and then met as a group with senior
psychiatrists to share our observations, pose our questions, and compete to make the
wittiest remarks.

Our great teacher, Elvin Semrad,
actively discouraged us from reading psychiatry textbooks during our first year.
(This intellectual starvation diet may account for the fact that most of us later
became voracious readers and prolific writers.) Semrad did not want our perceptions
of reality to become obscured by the pseudocertainties of psychiatric diagnoses. I
remember asking him once: “What would you call this patient—schizophrenic or
schizoaffective?” He paused and stroked his chin, apparently in deep thought.
“I think I’d call him Michael McIntyre,” he replied.

Semrad taught us that most human
suffering is related to love and loss and that the job of therapists is to help
people “acknowledge, experience, and bear” the reality of life—with all
its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell
ourselves,” he’d say, urging us to be honest with ourselves about every
facet of our experience. He often said that people can never get better without
knowing what they know and feeling what they feel.

I remember being surprised to hear this
distinguished old Harvard professor confess how comforted he was to feel his
wife’s bum against him as he fell asleep at night. By disclosing such simple
human needs in himself he helped us recognize how basic they were to our lives.
Failure to attend to them results in a stunted existence, no matter how lofty our
thoughts and worldly accomplishments. Healing, he told us, depends on experiential
knowledge: You can be fully in charge of your life only if you can acknowledge the
reality of your body, in all its visceral dimensions.

Our profession, however, was moving in a
different direction. In 1968 the American Journal of Psychiatry had
published the results of the study from the ward where I’d been an attendant.
They showed unequivocally that schizophrenic patients who received drugs alone had a
better outcome than those who talked three times a week with the best therapists in
Boston.[3]
This study was one of many milestones on a road that gradually changed how medicine
and psychiatry approached psychological problems: from infinitely variable
expressions of intolerable feelings and relationships to a brain-disease model of
discrete “disorders.”

The way medicine approaches human
suffering has always been determined by the technology available at any given time.
Before the Enlightenment aberrations in behavior were ascribed to God, sin, magic,
witches, and evil spirits. It was only in the nineteenth century that scientists in
France and Germany began to investigate behavior as an adaptation to the
complexities of the world. Now a new paradigm was emerging: Anger, lust, pride,
greed, avarice, and sloth—as well as all the other problems we humans have always
struggled to manage—were recast as “disorders” that could be fixed by
the administration of appropriate chemicals.[4] Many psychiatrists were relieved and
delighted to become “real scientists,” just like their med school
classmates who had laboratories, animal experiments, expensive equipment, and
complicated diagnostic tests, and set aside the wooly-headed theories of
philosophers like Freud and Jung. A major textbook of psychiatry went so far as to
state: “The cause of mental illness is now considered an aberration of the
brain, a chemical imbalance.”[5]

Like my colleagues, I eagerly embraced
the pharmacological revolution. In 1973 I became the first chief resident in
psychopharmacology at MMHC. I may also have been the first psychiatrist in Boston to
administer lithium to a manic-depressive
patient. (I’d read about John Cade’s work with lithium in Australia, and
I received permission from a hospital committee to try it.) On lithium a woman who
had been manic every May for the past thirty-five years, and suicidally depressed
every November, stopped cycling and remained stable for the three years she was
under my care. I was also part of the first U.S. research team to test the
antipsychotic Clozaril on chronic patients who were warehoused in the back wards of
the old insane asylums.[6] Some of their responses were miraculous: People who had spent
much of their lives locked in their own separate, terrifying realities were now able
to return to their families and communities; patients mired in darkness and despair
started to respond to the beauty of human contact and the pleasures of work and
play. These amazing results made us optimistic that we could finally conquer human
misery.

Antipsychotic drugs were a major factor
in reducing the number of people living in mental hospitals in the United States,
from over 500,000 in 1955 to fewer than 100,000 in 1996.[7] For people today who did not
know the world before the advent of these treatments, the change is almost
unimaginable. As a first-year medical student I visited Kankakee State Hospital in
Illinois and saw a burly ward attendant hose down dozens of filthy, naked,
incoherent patients in an unfurnished dayroom supplied with gutters for the runoff
water. This memory now seems more like a nightmare than like something I witnessed
with my own eyes. My first job after finishing my residency in 1974 was as the
second-to-last director of a once-venerable institution, the Boston State Hospital,
which had formerly housed thousands of patients and been spread over hundreds of
acres with dozens of buildings, including greenhouses, gardens, and workshops—most
of them by then in ruins. During my time there patients were gradually dispersed
into “the community,” the blanket term for the anonymous shelters and
nursing homes where most of them ended up. (Ironically, the hospital was started as
an “asylum,” a word meaning “sanctuary” that gradually took
on a sinister connotation. It actually did offer a sheltered community where
everybody knew the patients’ names and idiosyncrasies.) In 1979, shortly after
I went to work at the VA, the Boston State Hospital’s gates were permanently
locked, and it became a ghost town.

During my time at Boston State I
continued to work in the MMHC psychopharmacology lab, which was now focusing on
another direction for research. In the 1960s scientists at the National Institutes
of Health had begun to develop techniques for isolating and measuring hormones and
neurotransmitters in blood and the brain. Neurotransmitters are chemical messengers that carry information from
neuron to neuron, enabling us to engage effectively with the world.

Now that scientists were finding
evidence that abnormal levels of norepinephrine were associated with depression, and
of dopamine with schizophrenia, there was hope that we could develop drugs that
target specific brain abnormalities. That hope was never fully realized, but our
efforts to measure how drugs could affect mental symptoms led to another profound
change in the profession. Researchers’ need for a precise and systematic way
to communicate their findings resulted in the development of the so-called Research
Diagnostic Criteria, to which I contributed as a lowly research assistant. These
eventually became the basis for the first systematic system to diagnose psychiatric
problems, the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM), which is commonly referred to
as the “bible of psychiatry.” The foreword to the landmark 1980 DSM-III
was appropriately modest and acknowledged that this diagnostic system was
imprecise—so imprecise that it never should be used for forensic or insurance
purposes.[8]
As we will see, that modesty was tragically short-lived.

INESCAPABLE SHOCK

Preoccupied with so many lingering
questions about traumatic stress, I became intrigued with the idea that the nascent
field of neuroscience could provide some answers and started to attend the meetings
of the American College of Neuropsychopharmacology (ACNP). In 1984 the ACNP offered
many fascinating lectures about drug development, but it was not until a few hours
before my scheduled flight back to Boston that I heard a presentation by Steven
Maier of the University of Colorado, who had collaborated with Martin Seligman of
the University of Pennsylvania. His topic was learned helplessness in animals. Maier
and Seligman had repeatedly administered painful electric shocks to dogs who were
trapped in locked cages. They called this condition “inescapable
shock.”[9] Being a dog lover, I realized that I could never have done such
research myself, but I was curious about how this cruelty would affect the
animals.

After administering several courses of
electric shock, the researchers opened the doors of the cages and then shocked the
dogs again. A group of control dogs who had never been shocked before immediately
ran away, but the dogs who had earlier been subjected to inescapable shock made no
attempt to flee, even when the door was wide open—they just lay there, whimpering and defecating. The mere
opportunity to escape does not necessarily make traumatized animals, or people, take
the road to freedom. Like Maier and Seligman’s dogs, many traumatized people
simply give up. Rather than risk experimenting with new options they stay stuck in
the fear they know.

I was riveted by Maier’s account.
What they had done to these poor dogs was exactly what had happened to my
traumatized human patients. They, too, had been exposed to somebody (or something)
who had inflicted terrible harm on them—harm they had no way of escaping. I made a
rapid mental review of the patients I had treated. Almost all had in some way been
trapped or immobilized, unable to take action to stave off the inevitable. Their
fight/flight response had been thwarted, and the result was either extreme agitation
or collapse.

Maier and Seligman also found that
traumatized dogs secreted much larger amounts of stress hormones than was normal.
This supported what we were beginning to learn about the biological underpinnings of
traumatic stress. A group of young researchers, among them Steve Southwick and John
Krystal at Yale, Arieh Shalev at Hadassah Medical School in Jerusalem, Frank Putnam
at the National Institute of Mental Health (NIMH), and Roger Pitman, later at
Harvard, were all finding that traumatized people keep secreting large amounts of
stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount
Sinai in New York confronted us with her seemingly paradoxical findings that the
levels of the stress hormone cortisol are low in PTSD. Her discoveries only started
to make sense when her research clarified that cortisol puts an end to the stress
response by sending an all-safe signal, and that, in PTSD, the body’s stress
hormones do, in fact, not return to baseline after the threat has passed.

Ideally our stress hormone system should
provide a lightning-fast response to threat, but then quickly return us to
equilibrium. In PTSD patients, however, the stress hormone system fails at this
balancing act. Fight/flight/freeze signals continue after the danger is over, and,
as in the case of the dogs, do not return to normal. Instead, the continued
secretion of stress hormones is expressed as agitation and panic and, in the long
term, wreaks havoc with their health.

I missed my plane that day because I had
to talk with Steve Maier. His workshop offered clues not only about the underlying
problems of my patients but also potential keys to their resolution. For example, he
and Seligman had found that the only way to teach the traumatized dogs to get off
the electric grids when the doors were open was to repeatedly drag them out of their
cages so they could physically
experience how they could get away. I wondered if we also could help my patients
with their fundamental orientation that there was nothing they could do to defend
themselves? Did my patients also need to have physical experiences to
restore a visceral sense of control? What if they could be taught to physically move
to escape a potentially threatening situation that was similar to the trauma in
which they had been trapped and immobilized? As I will discuss in the treatment part
5 of this book, that was one of the conclusions I eventually reached.

Further animal studies involving mice,
rats, cats, monkeys, and elephants brought more intriguing data.[10] For example, when
researchers played a loud, intrusive sound, mice that had been raised in a warm nest
with plenty of food scurried home immediately. But another group, raised in a noisy
nest with scarce food supplies, also ran for home, even after spending time in more
pleasant surroundings.[11]

Scared animals return home, regardless
of whether home is safe or frightening. I thought about my patients with abusive
families who kept going back to be hurt again. Are traumatized people condemned to
seek refuge in what is familiar? If so, why, and is it possible to help them become
attached to places and activities that are safe and pleasurable?[12]

ADDICTED TO TRAUMA: THE PAIN OF
PLEASURE AND THE PLEASURE OF PAIN

One of the things that struck my
colleague Mark Greenberg and me when we ran therapy groups for Vietnam combat
veterans was how, despite their feelings of horror and grief, many of them seemed to
come to life when they talked about their helicopter crashes and their dying
comrades. (Former New York Times correspondent Chris Hedges, who covered a
number of brutal conflicts, entitled his book War Is a Force That Gives Us
Meaning.[13]) Many traumatized people seem to seek out experiences that would
repel most of us,[14] and patients often complain about a vague sense of emptiness and
boredom when they are not angry, under duress, or involved in some dangerous
activity.

My patient Julia was brutally raped at
gunpoint in a hotel room at age sixteen. Shortly thereafter she got involved with a
violent pimp who prostituted her. He regularly beat her up. She was repeatedly
jailed for prostitution, but she always went back to her pimp. Finally her
grandparents intervened and paid for an intense rehab program. After she
successfully completed inpatient treatment, she started working as a receptionist
and taking courses at a local college. In
her sociology class she wrote a term paper about the liberating possibilities of
prostitution, for which she read the memoirs of several famous prostitutes. She
gradually dropped all her other courses. A brief relationship with a classmate
quickly went sour—he bored her to tears, she said, and she was repelled by his boxer
shorts. She then picked up an addict on the subway who first beat her up and then
started to stalk her. She finally became motivated to return to treatment when she
was once again severely beaten.

Freud had a term for such traumatic
reenactments: “the compulsion to repeat.” He and many of his followers
believed that reenactments were an unconscious attempt to get control over a painful
situation and that they eventually could lead to mastery and resolution. There is no
evidence for that theory—repetition leads only to further pain and self-hatred. In
fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and
fixation.

Mark Greenberg and I decided to learn
more about attractors—the things that draw us, motivate us, and make us feel alive.
Normally attractors are meant to make us feel better. So, why are so many people
attracted to dangerous or painful situations? We eventually found a study that
explained how activities that cause fear or pain can later become thrilling
experiences.[15] In the 1970s Richard Solomon of the University of Pennsylvania had
shown that the body learns to adjust to all sorts of stimuli. We may get hooked on
recreational drugs because they right away make us feel so good, but activities like
sauna bathing, marathon running, or parachute jumping, which initially cause
discomfort and even terror, can ultimately become very enjoyable. This gradual
adjustment signals that a new chemical balance has been established within the body,
so that marathon runners, say, get a sense of well-being and exhilaration from
pushing their bodies to the limit.

At this point, just as with drug
addiction, we start to crave the activity and experience withdrawal when it’s
not available. In the long run people become more preoccupied with the pain of
withdrawal than the activity itself. This theory could explain why some people hire
someone to beat them, or burn themselves with cigarettes, or why they are only
attracted to people who hurt them. Fear and aversion, in some perverse way, can be
transformed into pleasure.

Solomon hypothesized that endorphins—the
morphinelike chemicals that the brain secretes in response to stress—play a role in
the paradoxical addictions he described. I thought of his theory again when my
library habit led me to a paper titled “Pain in Men Wounded in Battle,”
published in 1946. Having observed that 75
percent of severely wounded soldiers on the Italian front did not request morphine,
a surgeon by the name of Henry K. Beecher speculated that “strong emotions can
block pain.”[16]

Were Beecher’s observations
relevant to people with PTSD? Mark Greenberg, Roger Pitman, Scott Orr, and I decided
to ask eight Vietnam combat veterans if they would be willing to take a standard
pain test while they watched scenes from a number of movies. The first clip we
showed was from Oliver Stone’s graphically violent Platoon
(1986), and while it ran we measured how long the veterans could keep
their right hands in a bucket of ice water. We then repeated this process with a
peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their
hands in the painfully cold water 30 percent longer during Platoon. We then
calculated that the amount of analgesia produced by watching fifteen minutes of a
combat movie was equivalent to that produced by being injected with eight milligrams
of morphine, about the same dose a person would receive in an emergency room for
crushing chest pain.

We concluded that Beecher’s
speculation that “strong emotions can block pain” was the result of the
release of morphinelike substances manufactured in the brain. This suggested that
for many traumatized people, reexposure to stress might provide a similar relief
from anxiety.[17]
It was an interesting experiment, but it did not fully explain why Julia kept going
back to her violent pimp.

SOOTHING THE BRAIN

The 1985 ACNP meeting was, if possible,
even more thought provoking than the previous year’s session. Kings College
professor Jeffrey Gray gave a talk about the amygdala, a cluster of brain cells that
determines whether a sound, image, or body sensation is perceived as a threat.
Gray’s data showed that the sensitivity of the amygdala depended, at least in
part, on the amount of the neurotransmitter serotonin in that part of the brain.
Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud
sounds), while higher levels of serotonin dampened their fear system, making them
less likely to become aggressive or frozen in response to potential threats.[18]

That struck me as an important finding:
My patients were always blowing up in response to small provocations and felt
devastated by the slightest rejection. I became fascinated by the possible role of
serotonin in PTSD. Other researchers had shown that dominant male monkeys had much
higher levels of brain serotonin than lower-ranking animals but that their serotonin
levels dropped when they were
prevented from maintaining eye contact with the monkeys they had once lorded over.
In contrast, low-ranking monkeys who were given serotonin supplements emerged from
the pack to assume leadership.[19] The social environment interacts with
brain chemistry. Manipulating a monkey into a lower position in the dominance
hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the
rank of former subordinates.

The implications for traumatized people
were obvious. Like Gray’s low-serotonin animals, they were hyperreactive, and
their ability to cope socially was often compromised. If we could find ways to
increase brain serotonin levels, perhaps we could address both problems
simultaneously. At that same 1985 meeting I learned that drug companies were
developing two new products to do precisely that, but since neither was yet
available, I experimented briefly with the health-food-store supplement
L-tryptophan, which is a chemical precursor of serotonin in the body. (The results
were disappointing.) One of the drugs under investigation never made it to the
market. The other was fluoxetine, which, under the brand name Prozac, became one of
the most successful psychoactive drugs ever created.

On Monday, February 8, 1988, Prozac was
released by the drug company Eli Lilly. The first patient I saw that day was a young
woman with a horrendous history of childhood abuse who was now struggling with
bulimia—she basically spent much of her life bingeing and purging. I gave her a
prescription for this brand-new drug, and when she returned on Thursday she said,
“I’ve had a very different last few days: I ate when I was hungry, and
the rest of the time I did my schoolwork.” This was one of the most dramatic
statements I had ever heard in my office.

On Friday I saw another patient to whom
I’d given Prozac the previous Monday. She was a chronically depressed mother
of two school-aged children, preoccupied with her failures as a mother and wife and
overwhelmed by demands from the parents who had badly mistreated her as a child.
After four days on Prozac she asked me if she could skip her appointment the
following Monday, which was Presidents’ Day. “After all,” she
explained, “I’ve never taken my kids skiing—my husband always does—and
they are off that day. It would really be nice for them to have some good memories
of us having fun together.”

This was a patient who had always
struggled merely to get through the day. After her appointment I called someone I
knew at Eli Lilly and said, “You have a drug that helps people to be in the
present, instead of being locked in the
past.” Lilly later gave me a small grant to study the effects of Prozac on
PTSD in sixty-four people—twenty-two women and forty-two men—the first study of the
effects of this new class of drugs on PTSD. Our Trauma Clinic team enrolled
thirty-three nonveterans and my collaborators, former colleagues at the VA, enrolled
thirty-one combat veterans. For eight weeks half of each group received Prozac and
the other half a placebo. The study was blinded: Neither we nor the patients knew
which substance they were taking, so that our preconceptions could not skew our
assessments.

Everyone in the study—even those who had
received the placebo—improved, at least to some degree. Most treatment studies of
PTSD find a significant placebo effect. People who screw up their courage to
participate in a study for which they aren’t paid, in which they’re
repeatedly poked with needles, and in which they have only a fifty-fifty chance of
getting an active drug are intrinsically motivated to solve their problem. Maybe
their reward is only the attention paid to them, the opportunity to respond to
questions about how they feel and think. But maybe the mother’s kisses that
soothe her child’s scrapes are “just” a placebo as well.

Prozac worked significantly better than
the placebo for the patients from the Trauma Clinic. They slept more soundly; they
had more control over their emotions and were less preoccupied with the past than
those who received a sugar pill.[20] Surprisingly, however, the Prozac had
no effect at all on the combat veterans at the VA—their PTSD symptoms were
unchanged. These results have held true for most subsequent pharmacological studies
on veterans: While a few have shown modest improvements, most have not benefited at
all. I have never been able to explain this, and I cannot accept the most common
explanation: that receiving a pension or disability benefits prevents people from
getting better. After all, the amygdala knows nothing of pensions—it just detects
threats.

Nonetheless, medications such as Prozac
and related drugs like Zoloft, Celexa, Cymbalta, and Paxil, have made a substantial
contribution to the treatment of trauma-related disorders. In our Prozac study we
used the Rorschach test to measure how traumatized people perceive their
surroundings. These data gave us an important clue to how this class of drugs
(formally known as selective serotonin reuptake inhibitors, or SSRIs) might work.
Before taking Prozac these patients’ emotions controlled their reactions. I
think of a Dutch patient, for example (not in the Prozac study) who came to see me
for treatment for a childhood rape and who was convinced that I would rape her as
soon as she heard my Dutch accent. Prozac made a radical difference: It gave PTSD patients a sense of
perspective[21] and helped them to gain considerable control over their impulses.
Jeffrey Gray must have been right: When their serotonin levels rose, many of my
patients became less reactive.

THE TRIUMPH OF PHARMACOLOGY

It did not take long for pharmacology to
revolutionize psychiatry. Drugs gave doctors a greater sense of efficacy and
provided a tool beyond talk therapy. Drugs also produced income and profits. Grants
from the pharmaceutical industry provided us with laboratories filled with energetic
graduate students and sophisticated instruments. Psychiatry departments, which had
always been located in the basements of hospitals, started to move up, both in terms
of location and prestige.

One symbol of this change occurred at
MMHC, where in the early 1990s the hospital’s swimming pool was paved over to
make space for a laboratory, and the indoor basketball court was carved up into
cubicles for the new medication clinic. For decades doctors and patients had
democratically shared the pleasures of splashing in the pool and passing balls down
the court. I’d spent hours in the gym with patients back when I was a ward
attendant. It was the one place where we all could restore a sense of physical
well-being, an island in the midst of the misery we faced every day. Now it had
become a place for patients to “get fixed.”

The drug revolution that started out
with so much promise may in the end have done as much harm as good. The theory that
mental illness is caused primarily by chemical imbalances in the brain that can be
corrected by specific drugs has become broadly accepted, by the media and the public
as well as by the medical profession.[22] In many places drugs have displaced
therapy and enabled patients to suppress their problems without addressing the
underlying issues. Antidepressants can make all the difference in the world in
helping with day-to-day functioning, and if it comes to a choice between taking a
sleeping pill and drinking yourself into a stupor every night to get a few hours of
sleep, there is no question which is preferable. For people who are exhausted from
trying to make it on their own through yoga classes, workout routines, or simply
toughing it out, medications often can bring life-saving relief. The SSRIs can be
very helpful in making traumatized people less enslaved by their emotions, but they
should only be considered adjuncts in their overall treatment.[23]

After conducting numerous studies of
medications for PTSD, I have come to realize that psychiatric medications have a
serious downside, as they may deflect
attention from dealing with the underlying issues. The brain-disease model takes
control over people’s fate out of their own hands and puts doctors and
insurance companies in charge of fixing their problems.

Over the past three decades psychiatric
medications have become a mainstay in our culture, with dubious consequences.
Consider the case of antidepressants. If they were indeed as effective as we have
been led to believe, depression should by now have become a minor issue in our
society. Instead, even as antidepressant use continues to increase, it has not made
a dent in hospital admissions for depression. The number of people treated for
depression has tripled over the past two decades, and one in ten Americans now take
antidepressants.[24]

The new generation of antipsychotics,
such as Abilify, Risperdal, Zyprexa, and Seroquel, are the top-selling drugs in the
United States. In 2012 the public spent $1,526,228,000 on Abilify, more than on any
other medication. Number three was Cymbalta, an antidepressant that sold well over a
billion dollars’ worth of pills,[25] even though it has never been shown to
be superior to older antidepressants like Prozac, for which much cheaper generics
are available. Medicaid, the government health program for the poor, spends more on
antipsychotics than on any other class of drugs.[26] In 2008, the most recent year for
which complete data are available, it funded $3.6 billion for antipsychotic
medications, up from $1.65 billion in 1999. The number of people under the age of
twenty receiving Medicaid-funded prescriptions for antipsychotic drugs tripled
between 1999 and 2008. On November 4, 2013, Johnson & Johnson agreed to pay more
than $2.2 billion in criminal and civil fines to settle accusations that it had
improperly promoted the antipsychotic drug Risperdal to older adults, children, and
people with developmental disabilities.[27] But nobody is holding the doctors who
prescribed them accountable.

Half a million children in the United
States currently take antipsychotic drugs. Children from low-income families are
four times as likely as privately insured children to receive antipsychotic
medicines. These medications often are used to make abused and neglected children
more tractable. In 2008 19,045 children age five and under were prescribed
antipsychotics through Medicaid.[28] One study, based on Medicaid data in
thirteen states, found that 12.4 percent of children in foster care received
antipsychotics, compared with 1.4 percent of Medicaid-eligible children in
general.[29]
These medications make children more manageable and less aggressive, but they also
interfere with motivation, play, and curiosity, which are indispensable for maturing
into a well-functioning and contributing member of society. Children who take them are also at risk of becoming
morbidly obese and developing diabetes. Meanwhile, drug overdoses involving a
combination of psychiatric and pain medications continue to rise.[30]

Because drugs have become so profitable,
major medical journals rarely publish studies on nondrug treatments of mental health
problems.[31]
Practitioners who explore treatments are typically marginalized as
“alternative.” Studies of nondrug treatments are rarely funded unless
they involve so-called manualized protocols, where patients and therapists go
through narrowly prescribed sequences that allow little fine-tuning to individual
patients’ needs. Mainstream medicine is firmly committed to a better life
through chemistry, and the fact that we can actually change our own physiology and
inner equilibrium by means other than drugs is rarely considered.

ADAPTATION OR DISEASE?

The brain-disease model overlooks four
fundamental truths: (1) our capacity to destroy one another is matched by our
capacity to heal one another. Restoring relationships and community is central to
restoring well-being; (2) language gives us the power to change ourselves and others
by communicating our experiences, helping us to define what we know, and finding a
common sense of meaning; (3) we have the ability to regulate our own physiology,
including some of the so-called involuntary functions of the body and brain, through
such basic activities as breathing, moving, and touching; and (4) we can change
social conditions to create environments in which children and adults can feel safe
and where they can thrive.

When we ignore these quintessential
dimensions of humanity, we deprive people of ways to heal from trauma and restore
their autonomy. Being a patient, rather than a participant in one’s healing
process, separates suffering people from their community and alienates them from an
inner sense of self. Given the limitations of drugs, I started to wonder if we could
find more natural ways to help people deal with their post-traumatic responses.

CHAPTER 3

Looking into the Brain: The
Neuroscience Revolution

If we could look through the skull into the
brain of a consciously thinking person, and if the place of optimal excitability
were luminous, then we should see playing over the cerebral surface, a bright spot,
with fantastic, waving borders constantly fluctuating in size and form, and
surrounded by darkness, more or less deep, covering the rest of the hemisphere.

—Ivan Pavlov

You observe a lot by watching.

—Yogi Berra

In the early 1990s novel brain-imaging
techniques opened up undreamed-of capacities to gain a sophisticated understanding
about the way the brain processes information. Gigantic multimillion-dollar machines
based on advanced physics and computer technology rapidly made neuroscience into one
of the most popular areas for research. Positron emission tomography (PET) and,
later, functional magnetic resonance imaging (fMRI) enabled scientists to visualize
how different parts of the brain are activated when people are engaged in certain
tasks or when they remember events from the past. For the first time we could watch
the brain as it processed memories, sensations, and emotions and begin to map the
circuits of mind and consciousness. The earlier technology of measuring brain
chemicals like serotonin or norepinephrine had enabled scientists to look at what
fueled neural activity, which
is a bit like trying to understand a car’s engine by studying gasoline.
Neuroimaging made it possible to see inside the engine. By doing so it has also
transformed our understanding of trauma.

Harvard Medical School was and is at the
forefront of the neuroscience revolution, and in 1994 a young psychiatrist, Scott
Rauch, was appointed as the first director of the Massachusetts General Hospital
Neuroimaging Laboratory. After considering the most relevant questions that this new
technology could answer and reading some articles I had written, Scott asked me
whether I thought we could study what happens in the brains of people who have
flashbacks.

I had just finished a study on how
trauma is remembered (to be discussed in chapter 12),
in which participants repeatedly told me how upsetting it was to be suddenly
hijacked by images, feelings, and sounds from the past. When several said they
wished they knew what trick their brains were playing on them during these
flashbacks, I asked eight of them if they would be willing to return to the clinic
and lie still inside a scanner (an entirely new experience that I described in
detail) while we re-created a scene from the painful events that haunted them. To my
surprise, all eight agreed, many of them expressing their hope that what we learned
from their suffering could help other people.

My research assistant, Rita Fisler, who
was working with us prior to entering Harvard Medical School, sat down with every
participant and carefully constructed a script that re-created their trauma moment
to moment. We deliberately tried to collect just isolated fragments of their
experience—particular images, sounds, and feelings—rather than the entire story,
because that is how trauma is experienced. Rita also asked the participants to
describe a scene where they felt safe and in control. One person described her
morning routine; another, sitting on the porch of a farmhouse in Vermont overlooking
the hills. We would use this script for a second scan, to provide a baseline
measurement.

After the participants checked the
scripts for accuracy (reading silently, which is less overwhelming than hearing or
speaking), Rita made a voice recording that would be played back to them while they
were in the scanner. A typical script:

You are six years old and getting
ready for bed. You hear your mother and father yelling at each other. You are
frightened and your stomach is in a knot. You and your younger brother and
sister are huddled at the top of the stairs. You look over the banister and see
your father holding your
mother’s arms while she struggles to free herself. Your mother is crying,
spitting and hissing like an animal. Your face is flushed and you feel hot all
over. When your mother frees herself, she runs to the dining room and breaks a
very expensive Chinese vase. You yell at your parents to stop, but they ignore
you. Your mom runs upstairs and you hear her breaking the TV. Your little
brother and sister try to get her to hide in the closet. Your heart pounds and
you are trembling.

At this first session we explained the
purpose of the radioactive oxygen the participants would be breathing: As any part
of the brain became more or less metabolically active, its rate of oxygen
consumption would immediately change, which would be picked up by the scanner. We
would monitor their blood pressure and heart rate throughout the procedure, so that
these physiological signs could be compared with brain activity.

Several days later the participants came
to the imaging lab. Marsha, a forty-year-old schoolteacher from a suburb outside of
Boston, was the first volunteer to be scanned. Her script took her back to the day,
thirteen years earlier, when she picked up her five-year-old daughter, Melissa, from
day camp. As they drove off, Marsha heard a persistent beeping, indicating that
Melissa’s seatbelt was not properly fastened. When Marsha reached over to
adjust the belt, she ran a red light. Another car smashed into hers from the right,
instantly killing her daughter. In the ambulance on the way to the emergency room,
the seven-month-old fetus Marsha was carrying also died.

Overnight Marsha had changed from a
cheerful woman who was the life of the party into a haunted and depressed person
filled with self-blame. She moved from classroom teaching into school
administration, because working directly with children had become intolerable—as for
many parents who have lost children, their happy laughter had become a powerful
trigger. Even hiding behind her paperwork she could barely make it through the day.
In a futile attempt to keep her feelings at bay, she coped by working day and
night.

I was standing outside the scanner as
Marsha underwent the procedure and could follow her physiological reactions on a
monitor. The moment we turned on the tape recorder, her heart started to race, and
her blood pressure jumped. Simply hearing the script similar activated the same
physiological responses that had occurred during the accident thirteen years
earlier. After the recorded script concluded and Marsha’s heart rate and blood
pressure returned to normal, we played her second script: getting out of bed and
brushing her teeth. This time her heart rate and blood pressure did not change.

Picturing the brain on trauma.
Bright spots in (A) the limbic brain, and (B) the visual cortex, show heightened
activation. In drawing (C) the brain’s speech center shows markedly decreased
activation.

As she emerged from the scanner, Marsha
looked defeated, drawn out, and frozen. Her breathing was shallow, her eyes were
opened wide, and her shoulders were hunched—the very image of vulnerability and
defenselessness. We tried to comfort her, but I wondered if whatever we discovered
would be worth the price of her distress.

After all eight participants completed
the procedure, Scott Rauch went to work with his mathematicians and statisticians to
create composite images that compared the arousal created by a flashback with the
brain in neutral. After a few weeks he sent me the results, which you see above. I
taped the scans up on the refrigerator in my kitchen, and for the next few months I
stared at them every evening. It occurred to me that this was how early astronomers
must have felt when they peered through a telescope at a new constellation.

There were some puzzling dots and colors
on the scan, but the biggest area of brain activation—a large red spot in the right
lower center of the brain, which is the limbic area, or emotional brain—came as no
surprise. It was already well known that intense emotions activate the limbic
system, in particular an area within it called the amygdala. We depend on the
amygdala to warn us of impending danger and to activate the body’s stress
response. Our study clearly showed that when traumatized people are presented with
images, sounds, or thoughts related to their particular experience, the amygdala
reacts with alarm—even, as in Marsha’s case, thirteen years after the event.
Activation of this fear center triggers the cascade of stress hormones and nerve
impulses that drive up blood pressure, heart rate, and oxygen intake—preparing the
body for fight or flight.[1] The monitors attached to Marsha’s arms recorded this
physiological state of frantic arousal, even though she never totally lost track of the fact that she
was resting quietly in the scanner.

SPEECHLESS HORROR

Our most surprising finding was a white
spot in the left frontal lobe of the cortex, in a region called Broca’s area.
In this case the change in color meant that there was a significant decrease in that
part of the brain. Broca’s area is one of the speech centers of the brain,
which is often affected in stroke patients when the blood supply to that region is
cut off. Without a functioning Broca’s area, you cannot put your thoughts and
feelings into words. Our scans showed that Broca’s area went offline whenever
a flashback was triggered. In other words, we had visual proof that the effects of
trauma are not necessarily different from—and can overlap with—the effects of
physical lesions like strokes.

All trauma is preverbal. Shakespeare
captures this state of speechless terror in Macbeth, after the murdered
king’s body is discovered: “Oh horror! horror! horror! Tongue
nor heart cannot conceive nor name thee! Confusion now hath made his
masterpiece!” Under extreme conditions people may scream obscenities, call for
their mothers, howl in terror, or simply shut down. Victims of assaults and
accidents sit mute and frozen in emergency rooms; traumatized children “lose
their tongues” and refuse to speak. Photographs of combat soldiers show
hollow-eyed men staring mutely into a void.

Even years later traumatized people
often have enormous difficulty telling other people what has happened to them. Their
bodies reexperience terror, rage, and helplessness, as well as the impulse to fight
or flee, but these feelings are almost impossible to articulate. Trauma by nature
drives us to the edge of comprehension, cutting us off from language based on common
experience or an imaginable past.

This doesn’t mean that people
can’t talk about a tragedy that has befallen them. Sooner or later most
survivors, like the veterans in chapter 1, come up
with what many of them call their “cover story” that offers some
explanation for their symptoms and behavior for public consumption. These stories,
however, rarely capture the inner truth of the experience. It is enormously
difficult to organize one’s traumatic experiences into a coherent account—a
narrative with a beginning, a middle, and an end. Even a seasoned reporter like the
famed CBS correspondent Ed Murrow struggled to convey the atrocities he saw when the
Nazi concentration camp Buchenwald was liberated in 1945: “I pray you believe
what I have said. I reported what I saw and heard, but only part of it. For most of
it I have no words.”

When words fail, haunting images capture
the experience and return as nightmares and flashbacks. In contrast to the
deactivation of Broca’s area, another region, Brodmann’s area 19, lit up
in our participants. This is a region in the visual cortex that registers images
when they first enter the brain. We were surprised to see brain activation in this
area so long after the original experience of the trauma. Under ordinary conditions
raw images registered in area 19 are rapidly diffused to other brain areas that
interpret the meaning of what has been seen. Once again, we were witnessing a brain
region rekindled as if the trauma were actually occurring.

As we will see in chapter 12, which discusses memory, other
unprocessed sense fragments of trauma, like sounds and smells and physical
sensations, are also registered separately from the story itself. Similar sensations
often trigger a flashback that brings them back into consciousness, apparently
unmodified by the passage of time.

SHIFTING TO ONE SIDE OF THE
BRAIN

The scans also revealed that during
flashbacks, our subjects’ brains lit up only on the right side. Today
there’s a huge body of scientific and popular literature about the difference
between the right and left brains. Back in the early nineties I had heard that some
people had begun to divide the world between left-brainers (rational, logical
people) and right-brainers (the intuitive, artistic ones), but I hadn’t paid
much attention to this idea. However, our scans clearly showed that images of past
trauma activate the right hemisphere of the brain and deactivate the left.

We now know that the two halves of the
brain do speak different languages. The right is intuitive, emotional, visual,
spatial, and tactual, and the left is linguistic, sequential, and analytical. While
the left half of the brain does all the talking, the right half of the brain carries
the music of experience. It communicates through facial expressions and body
language and by making the sounds of love and sorrow: by singing, swearing, crying,
dancing, or mimicking. The right brain is the first to develop in the womb, and it
carries the nonverbal communication between mothers and infants. We know the left
hemisphere has come online when children start to understand language and learn how
to speak. This enables them to name things, compare them, understand their
interrelations, and begin to communicate their own unique, subjective experiences to
others.

The left and right sides of the brain
also process the imprints of the past in dramatically different ways.[2] The left brain
remembers facts, statistics, and the
vocabulary of events. We call on it to explain our experiences and put them in
order. The right brain stores memories of sound, touch, smell, and the emotions they
evoke. It reacts automatically to voices, facial features, and gestures and places
experienced in the past. What it recalls feels like intuitive truth—the way things
are. Even as we enumerate a loved one’s virtues to a friend, our feelings may
be more deeply stirred by how her face recalls the aunt we loved at age four.[3]

Under ordinary circumstances the two
sides of the brain work together more or less smoothly, even in people who might be
said to favor one side over the other. However, having one side or the other shut
down, even temporarily, or having one side cut off entirely (as sometimes happened
in early brain surgery) is disabling.

Deactivation of the left hemisphere has
a direct impact on the capacity to organize experience into logical sequences and to
translate our shifting feelings and perceptions into words. (Broca’s area,
which blacks out during flashbacks, is on the left side.) Without sequencing we
can’t identify cause and effect, grasp the long-term effects of our actions,
or create coherent plans for the future. People who are very upset sometimes say
they are “losing their minds.” In technical terms they are experiencing
the loss of executive functioning.

When something reminds traumatized
people of the past, their right brain reacts as if the traumatic event were
happening in the present. But because their left brain is not working very well,
they may not be aware that they are reexperiencing and reenacting the past—they are
just furious, terrified, enraged, ashamed, or frozen. After the emotional storm
passes, they may look for something or somebody to blame for it. They behaved the
way they did because you were ten minutes late, or because you
burned the potatoes, or because you “never listen to me.” Of
course, most of us have done this from time to time, but when we cool down, we
hopefully can admit our mistake. Trauma interferes with this kind of awareness, and,
over time, our research demonstrated why.

STUCK IN FIGHT OR FLIGHT

What had happened to Marsha in the
scanner gradually started to make sense. Thirteen years after her tragedy we had
activated the sensations—the sounds and images from the accident—that were still
stored in her memory. When these sensations came to the surface, they activated her
alarm system, which caused her to react as if she were back in the hospital being
told that her daughter had died. The
passage of thirteen years was erased. Her sharply increased heart rate and blood
pressure readings reflected her physiological state of frantic alarm.

Adrenaline is one of the hormones that
are critical to help us fight back or flee in the face of danger. Increased
adrenaline was responsible for our participants’ dramatic rise in heart rate
and blood pressure while listening to their trauma narrative. Under normal
conditions people react to a threat with a temporary increase in their stress
hormones. As soon as the threat is over, the hormones dissipate and the body returns
to normal. The stress hormones of traumatized people, in contrast, take much longer
to return to baseline and spike quickly and disproportionately in response to mildly
stressful stimuli. The insidious effects of constantly elevated stress hormones
include memory and attention problems, irritability, and sleep disorders. They also
contribute to many long-term health issues, depending on which body system is most
vulnerable in a particular individual.

We now know that there is another
possible response to threat, which our scans aren’t yet capable of measuring.
Some people simply go into denial: Their bodies register the threat, but their
conscious minds go on as if nothing has happened. However, even though the mind may
learn to ignore the messages from the emotional brain, the alarm signals don’t
stop. The emotional brain keeps working, and stress hormones keep sending signals to
the muscles to tense for action or immobilize in collapse. The physical effects on
the organs go on unabated until they demand notice when they are expressed as
illness. Medications, drugs, and alcohol can also temporarily dull or obliterate
unbearable sensations and feelings. But the body continues to keep the score.

We can interpret what happened to Marsha
in the scanner from several different perspectives, each of which has implications
for treatment. We can focus on the neurochemical and physiological disruptions that
were so evident and make a case that she is suffering from a biochemical imbalance
that is reactivated whenever she is reminded of her daughter’s death. We might
then search for a drug or a combination of drugs that would damp down the reaction
or, in the best case, restore her chemical equilibrium. Based on the results of our
scans, some of my colleagues at MGH began investigating drugs that might make people
less responsive to the effects of elevated adrenaline.

We can also make a strong case that
Marsha is hypersensitized to her memories of the past and that the best treatment
would be some form of desensitization.[4] After repeatedly rehearsing the details
of the trauma with a therapist, her
biological responses might become muted, so that she could realize and remember that
“that was then and this is now,” rather than reliving the experience
over and over.

For a hundred years or more, every
textbook of psychology and psychotherapy has advised that some method of talking
about distressing feelings can resolve them. However, as we’ve seen, the
experience of trauma itself gets in the way of being able to do that. No matter how
much insight and understanding we develop, the rational brain is basically impotent
to talk the emotional brain out of its own reality. I am continually impressed by
how difficult it is for people who have gone through the unspeakable to convey the
essence of their experience. It is so much easier for them to talk about what has
been done to them—to tell a story of victimization and revenge—than to notice, feel,
and put into words the reality of their internal experience.

Our scans had revealed how their dread
persisted and could be triggered by multiple aspects of daily experience. They had
not integrated their experience into the ongoing stream of their life. They
continued to be “there” and did not know how to be
“here”—fully alive in the present.

Three years after being a participant in
our study Marsha came to see me as a patient. I successfully treated her with EMDR,
the subject of chapter 15.

Part Two

THIS IS YOUR BRAIN ON TRAUMA

CHAPTER 4

Running for Your Life: The Anatomy
of Survival

Prior to the advent of brain, there was no
color and no sound in the universe, nor was there any flavor or aroma and probably
little sense and no feeling or emotion. Before brains the universe was also free of
pain and anxiety.

—Roger Sperry[1]

On September 11, 2001, five-year-old Noam
Saul witnessed the first passenger plane slam into the World Trade Center from the
windows of his first-grade classroom at PS 234, less than 1,500 feet away. He and
his classmates ran with their teacher down the stairs to the lobby, where most of
them were reunited with parents who had dropped them off at school just moments
earlier. Noam, his older brother, and their dad were three of the tens of thousands
of people who ran for their lives through the rubble, ash, and smoke of lower
Manhattan that morning.

Ten days later I visited his family, who
are friends of mine, and that evening his parents and I went for a walk in the eerie
darkness through the still-smoking pit where Tower One once stood, making our way
among the rescue crews who were working around the clock under the blazing klieg
lights. When we returned home, Noam was still awake, and he showed me a picture that
he had drawn at 9:00 a.m. on September 12. The drawing depicted what he had seen the
day before: an airplane slamming into the tower, a ball of fire, firefighters, and
people jumping from the tower’s windows. But at the bottom of the picture he
had drawn something else: a black circle at the foot of the buildings. I had no idea
what it was, so I asked him. “A
trampoline,” he replied. What was a trampoline doing there? Noam explained,
“So that the next time when people have to jump they will be safe.” I
was stunned: This five-year-old boy, a witness to unspeakable mayhem and disaster
just twenty-four hours before he made that drawing, had used his imagination to
process what he had seen and begin to go on with his life.

Noam was fortunate. His entire family
was unharmed, he had grown up surrounded by love, and he was able to grasp that the
tragedy they had witnessed had come to an end. During disasters young children
usually take their cues from their parents. As long as their caregivers remain calm
and responsive to their needs, they often survive terrible incidents without serious
psychological scars.

But Noam’s experience allows us to
see in outline two critical aspects of the adaptive response to threat that is basic
to human survival. At the time the disaster occurred, he was able to take an active
role by running away from it, thus becoming an agent in his own rescue. And once he
had reached the safety of home, the alarm bells in his brain and body quieted. This
freed his mind to make some sense of what
had happened and even to imagine a creative alternative to what he had seen—a
lifesaving trampoline.

Five-year-old Noam’s drawing made
after he witnessed the World Trade Center attack on 9/11. He reproduced
the image that haunted so many survivors—people jumping to escape from the
inferno—but with a life-saving addition: a trampoline at the bottom of the
collapsing building.

In contrast to Noam, traumatized people
become stuck, stopped in their growth because they can’t integrate new
experiences into their lives. I was very moved when the veterans of Patton’s
army gave me a World War II army-issue watch for Christmas, but it was a sad memento
of the year their lives had effectively stopped: 1944. Being traumatized means
continuing to organize your life as if the trauma were still going on—unchanged and
immutable—as every new encounter or event is contaminated by the past.

After trauma the world is experienced
with a different nervous system. The survivor’s energy now becomes focused on
suppressing inner chaos, at the expense of spontaneous involvement in their lives.
These attempts to maintain control over unbearable physiological reactions can
result in a whole range of physical symptoms, including fibromyalgia, chronic
fatigue, and other autoimmune diseases. This explains why it is critical for trauma
treatment to engage the entire organism, body, mind, and brain.

Trauma affects the entire human organism—body,
mind, and brain. In PTSD the body continues to defend against a threat that belongs
to the past. Healing from PTSD means being able to terminate this continued stress
mobilization and restoring the entire organism to safety.

ORGANIZED TO SURVIVE

This illustration on page 53 shows the whole-body response to
threat.

When the brain’s alarm system is
turned on, it automatically triggers preprogrammed physical escape plans in the
oldest parts of the brain. As in other animals, the nerves and chemicals that make
up our basic brain structure have a direct connection with our body. When the old
brain takes over, it partially shuts down the higher brain, our conscious mind, and
propels the body to run, hide, fight, or, on occasion, freeze. By the time we are
fully aware of our situation, our body may already be on the move. If the
fight/flight/freeze response is successful and we escape the danger, we recover our
internal equilibrium and gradually “regain our senses.”

If for some reason the normal response
is blocked—for example, when people are held down, trapped, or
otherwise prevented from taking effective action, be it in a war zone, a car
accident, domestic violence, or a rape—the brain keeps secreting stress chemicals,
and the brain’s electrical circuits continue to fire in vain.[2] Long after the
actual event has passed, the brain may keep sending signals to the body to escape a
threat that no longer exists. Since at least 1889, when the French psychologist
Pierre Janet published the first scientific account of traumatic stress,[3] it has been
recognized that trauma survivors are prone
to “continue the action, or rather the (futile) attempt at action, which began
when the thing happened.” Being able to move and do something to
protect oneself is a critical factor in determining whether or not a horrible
experience will leave long-lasting scars.

Effective action versus
immobilization. Effective action (the result of fight/flight) ends the
threat. Immobilization keeps the body in a state of inescapable shock and learned
helplessness. Faced with danger people automatically secrete stress hormones to fuel
resistance and escape. Brain and body are programmed to run for home, where safety
can be restored and stress hormones can come to rest. In these strapped-down men who
are being evacuated far from home after Hurricane Katrina stress hormone levels
remain elevated and are turned against the survivors, stimulating ongoing fear,
depression, rage, and physical disease.

In this chapter I’m going to go
deeper into the brain’s response to trauma. The more neuroscience discovers
about the brain, the more we realize that it is a vast network of interconnected
parts organized to help us survive and flourish. Knowing how these parts work
together is essential to understanding how trauma affects every part of the human
organism and can serve as an indispensable guide to resolving traumatic stress.

THE BRAIN FROM BOTTOM TO TOP

The most important job of the brain is to
ensure our survival, even under the most miserable conditions. Everything else is
secondary. In order to do that, brains need to: (1) generate internal signals that
register what our bodies need, such as food, rest, protection, sex, and shelter; (2)
create a map of the world to point us where to go to satisfy those needs; (3)
generate the necessary energy and actions to get us there; (4) warn us of dangers
and opportunities along the way; and (5) adjust our actions based on the
requirements of the moment.[4] And since we human beings are mammals, creatures that can only
survive and thrive in groups, all of these imperatives require coordination and
collaboration. Psychological problems occur when our internal signals don’t
work, when our maps don’t lead us where we need to go, when we are too
paralyzed to move, when our actions do not correspond to our needs, or when our
relationships break down. Every brain structure that I discuss has a role to play in
these essential functions, and as we will see, trauma can interfere with every one
of them.

Our rational, cognitive brain is
actually the youngest part of the brain and occupies only about 30 percent of the
area inside our skull. The rational brain is primarily concerned with the world
outside us: understanding how things and people work and figuring out how to
accomplish our goals, manage our time, and sequence our actions. Beneath the
rational brain lie two evolutionarily older, and to some degree separate, brains,
which are in charge of everything else: the moment-by-moment registration and
management of our body’s physiology and the identification of comfort, safety,
threat, hunger, fatigue, desire, longing, excitement, pleasure, and pain.

The brain is built from the bottom up.
It develops level by level within every
child in the womb, just as it did in the course of evolution. The most primitive
part, the part that is already online when we are born, is the ancient animal brain,
often called the reptilian brain. It is located in the brain stem, just above the
place where our spinal cord enters the skull. The reptilian brain is responsible for
all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel
temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and
defecating. The brain stem and the hypothalamus (which sits directly above it)
together control the energy levels of the body. They coordinate the functioning of
the heart and lungs and also the endocrine and immune systems, ensuring that these
basic life-sustaining systems are maintained within the relatively stable internal
balance known as homeostasis.

Breathing, eating, sleeping, pooping,
and peeing are so fundamental that their significance is easily neglected when
we’re considering the complexities of mind and behavior. However, if your
sleep is disturbed or your bowels don’t work, or if you always feel hungry, or
if being touched makes you want to scream (as is often the case with traumatized
children and adults), the entire organism is thrown into disequilibrium. It is
amazing how many psychological problems involve difficulties with sleep, appetite,
touch, digestion, and arousal. Any effective treatment for trauma has to address
these basic housekeeping functions of the body.

Right above the reptilian brain is the
limbic system. It’s also known as the mammalian brain, because all animals
that live in groups and nurture their young possess one. Development of this part of
the brain truly takes off after a baby is born. It is the seat of the emotions, the
monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is
or is not important for survival purposes. It is also a central command post for
coping with the challenges of living within our complex social networks.

The limbic system is shaped in response
to experience, in partnership with the infant’s own genetic makeup and inborn
temperament. (As all parents of more than one child quickly notice, babies differ
from birth in the intensity and nature of their reactions to similar events.)
Whatever happens to a baby contributes to the emotional and perceptual map of the
world that its developing brain creates. As my colleague Bruce Perry explains it,
the brain is formed in a “use-dependent manner.”[5] This is another way of
describing neuroplasticity, the relatively recent discovery that neurons that
“fire together, wire together.” When a circuit fires repeatedly, it can
become a default setting—the response most likely to occur. If you feel safe and
loved, your brain becomes specialized in exploration, play, and cooperation; if you
are frightened and unwanted, it specializes in managing feelings of fear and
abandonment.

As infants and toddlers we learn about the
world by moving, grabbing, and crawling and by discovering what happens when we cry,
smile, or protest. We are constantly experimenting with our surroundings—how do our
interactions change the way our bodies feel? Attend any two-year-old’s
birthday party and notice how little Kimberly will engage you, play with you, flirt
with you, without any need for language. These early explorations shape the limbic
structures devoted to emotions and memory, but these structures can also be
significantly modified by later experiences: for the better by a close friendship or
a beautiful first love, for example, or for the worse by a violent assault,
relentless bullying, or neglect.

Taken together the reptilian brain and
limbic system make up what I’ll call the “emotional brain”
throughout this book.[6] The emotional brain is at the heart of the central nervous system,
and its key task is to look out for your welfare. If it detects danger or a special
opportunity—such as a promising partner—it alerts you by releasing a squirt of
hormones. The resulting visceral sensations (ranging from mild queasiness to the
grip of panic in your chest) will interfere with whatever your mind is currently
focused on and get you moving—physically and mentally—in a different direction. Even
at their most subtle, these sensations have a huge influence on the small and large
decisions we make throughout our lives: what we choose to eat, where we like to
sleep and with whom, what music we prefer, whether we like to garden or sing in a
choir, and whom we befriend and whom we detest.

The emotional brain’s cellular
organization and biochemistry are simpler than those of the neocortex, our rational
brain, and it assesses incoming information in a more global way. As a result, it
jumps to conclusions based on rough similarities, in contrast with the rational
brain, which is organized to sort through a complex set of options. (The textbook
example is leaping back in terror when you see a snake—only to realize that
it’s just a coiled rope.) The emotional brain initiates preprogrammed escape
plans, like the fight-or-flight responses. These muscular and physiological
reactions are automatic, set in motion without any thought or planning on our part,
leaving our conscious, rational capacities to catch up later, often well after the
threat is over.

Finally we reach the top layer of the
brain, the neocortex. We share this outer layer with other mammals, but it is much
thicker in us humans. In the second year of life the frontal lobes, which make up
the bulk of our neocortex, begin to develop at a rapid pace. The ancient
philosophers called seven years “the age of reason.” For us first grade
is the prelude of things to come, a life organized around frontal-lobe capacities:
sitting still; keeping sphincters in
check; being able to use words rather than acting out; understanding abstract and
symbolic ideas; planning for tomorrow; and being in tune with teachers and
classmates.

The frontal lobes are responsible for
the qualities that make us unique within the animal kingdom.[7] They enable us to use
language and abstract thought. They give us our ability to absorb and integrate vast
amounts of information and attach meaning to it. Despite our excitement about the
linguistic feats of chimpanzees and rhesus monkeys, only human beings command the
words and symbols necessary to create the communal, spiritual, and historical
contexts that shape our lives.

The frontal lobes allow us to plan and
reflect, to imagine and play out future scenarios. They help us to predict what will
happen if we take one action (like applying for a new job) or neglect another (not
paying the rent). They make choice possible and underlie our astonishing creativity.
Generations of frontal lobes, working in close collaboration, have created culture,
which got us from dug-out canoes, horse-drawn carriages, and letters to jet planes,
hybrid cars, and e-mail. They also gave us Noam’s lifesaving trampoline.

MIRRORING EACH OTHER: INTERPERSONAL
NEUROBIOLOGY

Crucial for understanding trauma, the
frontal lobes are also the seat of empathy—our ability to “feel into”
someone else. One of the truly sensational discoveries of modern neuroscience took
place in 1994, when in a lucky accident a group of Italian scientists identified
specialized cells in the cortex that came to be known as mirror neurons.[8] The researchers
had attached electrodes to individual neurons in a monkey’s premotor area,
then set up a computer to monitor precisely which neurons fired when the monkey
picked up a peanut or grasped a banana. At one point an experimenter was putting
food pellets into a box when he looked up at the computer. The monkey’s brain
cells were firing at the exact location where the motor command neurons were
located. But the monkey wasn’t eating or moving. He was watching the
researcher, and his brain was vicariously mirroring the researcher’s
actions.

Numerous other experiments followed
around the world, and it soon became clear that mirror neurons explained many
previously unexplainable aspects of the mind, such as empathy, imitation, synchrony,
and even the development of language. One writer compared mirror neurons to
“neural WiFi”[9]—we pick up not
only another person’s movement but her emotional state and intentions as well.
When people are in sync with each other, they tend to stand or sit similar ways, and
their voices take on the same rhythms. But our mirror neurons also make us
vulnerable to others’ negativity, so that we respond to their anger with fury
or are dragged down by their depression. I’ll have more to say about mirror
neurons later in this book, because trauma almost invariably involves not being
seen, not being mirrored, and not being taken into account. Treatment needs to
reactivate the capacity to safely mirror, and be mirrored, by others, but also to
resist being hijacked by others’ negative emotions.

As anybody who has worked with
brain-damaged people or taken care of demented parents has learned the hard way,
well-functioning frontal lobes are crucial for harmonious relationships with our
fellow humans. Realizing that other people can think and feel differently from us is
a huge developmental step for two- and three-year-olds. They learn to understand
others’ motives, so they can adapt and stay safe in groups that have different
perceptions, expectations, and values. Without flexible, active frontal lobes people
become creatures of habit, and their
relationships become superficial and routine. Invention and innovation, discovery
and wonder—all are lacking.

The Triune (Three-part) Brain.
The brain develops from the bottom up. The reptilian brain develops in the womb and
organizes basic life sustaining functions. It is highly responsive to threat
throughout our entire life span. The limbic system is organized mainly during the
first six years of life but continues to evolve in a use-dependent manner. Trauma
can have a major impact of its functioning throughout life. The prefrontal cortex
develops last, and also is affected by trauma exposure, including being unable to
filter out irrelevant information. Throughout life it is vulnerable to go off-line
in response to threat.

Our frontal lobes can also (sometimes,
but not always) stop us from doing things that will embarrass us or hurt others. We
don’t have to eat every time we’re hungry, kiss anybody who rouses our
desires, or blow up every time we’re angry. But it is exactly on that edge
between impulse and acceptable behavior where most of our troubles begin. The more
intense the visceral, sensory input from the emotional brain, the less capacity the
rational brain has to put a damper on it.

IDENTIFYING DANGER: THE COOK AND THE
SMOKE DETECTOR

Danger is a normal part of life, and the
brain is in charge of detecting it and organizing our response. Sensory information
about the outside world arrives through our eyes, nose, ears, and skin. These
sensations converge in the thalamus, an area inside the limbic system that acts as
the “cook” within the brain. The thalamus stirs all the input from our
perceptions into a fully blended autobiographical soup, an integrated, coherent
experience of “this is what is happening to me.”[10] The sensations are then
passed on in two directions—down to the amygdala, two small almond-shaped structures
that lie deeper in the limbic, unconscious brain, and up to the frontal lobes, where
they reach our conscious awareness. The neuroscientist Joseph LeDoux calls the
pathway to the amygdala “the low road,” which is extremely fast, and
that to the frontal cortex the “high road,” which takes several
milliseconds longer in the midst of an overwhelmingly threatening experience.
However, processing by the thalamus can break down. Sights, sounds, smells, and
touch are encoded as isolated, dissociated fragments, and normal memory processing
disintegrates. Time freezes, so that the present danger feels like it will last
forever.

The central function of the amygdala,
which I call the brain’s smoke detector, is to identify whether incoming input
is relevant for our survival.[11] It does so quickly and automatically,
with the help of feedback from the hippocampus, a nearby structure that relates the
new input to past experiences. If the amygdala senses a threat—a potential collision
with an oncoming vehicle, a person on the street who looks threatening—it sends an
instant message down to the hypothalamus and the brain stem, recruiting the
stress-hormone system and the autonomic nervous system (ANS) to orchestrate a
whole-body response. Because the amygdala processes the information it receives from the thalamus faster than
the frontal lobes do, it decides whether incoming information is a threat to our
survival even before we are consciously aware of the danger. By the time we realize
what is happening, our body may already be on the move.

The emotional brain has first dibs on
interpreting incoming information. Sensory Information about the
environment and body state received by the eyes, ears, touch, kinesthetic sense,
etc., converges on the thalamus, where it is processed, and then passed on to the
amygdala to interpret its emotional significance. This occurs with lightning speed.
If a threat is detected the amygdala sends messages to the hypothalamus to secrete
stress hormones to defend against that threat. The neuroscientist Joseph LeDoux
calls this the low road. The second neural pathway, the high road, runs from the
thalamus, via the hippocampus and anterior cingulate, to the prefrontal cortex, the
rational brain, for a conscious and much more refined interpretation. This takes
several microseconds longer. If the interpretation of threat by the amygdala is too
intense, and/or the filtering system from the higher areas of the brain are too
weak, as often happens in PTSD, people lose control over automatic emergency
responses, like prolonged startle or aggressive outbursts.

The amygdala’s danger signals
trigger the release of powerful stress hormones, including cortisol and adrenaline,
which increase heart rate, blood pressure, and rate of breathing, preparing us to
fight back or run away. Once the danger is past, the body returns to its normal
state fairly quickly. But when recovery is blocked, the body is triggered to defend
itself, which makes people feel agitated and aroused.

While the smoke detector is usually
pretty good at picking up danger clues, trauma increases the risk of misinterpreting
whether a particular situation is
dangerous or safe. You can get along with other people only if you can accurately
gauge whether their intentions are benign or dangerous. Even a slight misreading can
lead to painful misunderstandings in relationships at home and at work. Functioning
effectively in a complex work environment or a household filled with rambunctious
kids requires the ability to quickly assess how people are feeling and continuously
adjusting your behavior accordingly. Faulty alarm systems lead to blowups or
shutdowns in response to innocuous comments or facial expressions.

CONTROLLING THE STRESS RESPONSE: THE
WATCHTOWER

If the amygdala is the smoke detector in
the brain, think of the frontal lobes—and specifically the medial prefrontal cortex
(MPFC),[12]
located directly above our eyes—as the watchtower, offering a view of the scene from
on high. Is that smoke you smell the sign that your house is on fire and you need to
get out, fast—or is it coming from the steak you put over too high a flame? The
amygdala doesn’t make such judgments; it just gets you ready to fight back or
escape, even before the frontal lobes get a chance to weigh in with their
assessment. As long as you are not too upset, your frontal lobes can restore your
balance by helping you realize that you are responding to a false alarm and abort
the stress response.

Ordinarily the executive capacities of
the prefrontal cortex enable people to observe what is going on, predict what will
happen if they take a certain action, and make a conscious choice. Being able to
hover calmly and objectively over our thoughts, feelings, and emotions (an ability
I’ll call mindfulness throughout this book) and then take our time to respond
allows the executive brain to inhibit, organize, and modulate the hardwired
automatic reactions preprogrammed into the emotional brain. This capacity is crucial
for preserving our relationships with our fellow human beings. As long as our
frontal lobes are working properly, we’re unlikely to lose our temper every
time a waiter is late with our order or an insurance company agent puts us on hold.
(Our watchtower also tells us that other people’s anger and threats are a
function of their emotional state.) When that system breaks down, we become
like conditioned animals: The moment we detect danger we automatically go into
fight-or-flight mode.

In PTSD the critical balance between the
amygdala (smoke detector) and the MPFC (watchtower) shifts radically, which makes it
much harder to control emotions and
impulses. Neuroimaging studies of human beings in highly emotional states reveal
that intense fear, sadness, and anger all increase the activation of subcortical
brain regions involved in emotions and significantly reduce the activity in various
areas in the frontal lobe, particularly the MPFC. When that occurs, the inhibitory
capacities of the frontal lobe break down, and people “take leave of their
senses”: They may startle in response to any loud sound, become enraged by
small frustrations, or freeze when somebody touches them.[13]

Top down or bottom up.
Structures in the emotional brain decide what we perceive as dangerous or safe.
There are two ways of changing the threat detection system: from the top down, via
modulating messages from the medial prefrontal cortex (not just prefrontal cortex),
or from the bottom up, via the reptilian brain, through breathing, movement, and
touch.

Effectively dealing with stress depends
upon achieving a balance between the smoke detector and the watchtower. If you want
to manage your emotions better, your brain gives you two options: You can learn to
regulate them from the top down or from the bottom up.

Knowing the difference between top down
and bottom up regulation is central for understanding and treating traumatic stress.
Top-down regulation involves strengthening the capacity of the watchtower to monitor
your body’s sensations. Mindfulness meditation and yoga can help with this.
Bottom-up regulation involves recalibrating the autonomic nervous system, (which, as we have seen, originates in
the brain stem). We can access the ANS through breath, movement, or touch. Breathing
is one of the few body functions under both conscious and autonomic control. In part
5 of this book we’ll explore specific techniques for increasing both top-down
and bottom-up regulation.

THE RIDER AND THE HORSE

For now I want to emphasize that emotion
is not opposed to reason; our emotions assign value to experiences and thus are the
foundation of reason. Our self-experience is the product of the balance between our
rational and our emotional brains. When these two systems are in balance, we
“feel like ourselves.” However, when our survival is at stake, these
systems can function relatively independently.

If, say, you are driving along, chatting
with a friend, and a truck suddenly looms in the corner of your eye, you instantly
stop talking, slam on the brakes, and turn your steering wheel to get out of
harm’s way. If your instinctive actions have saved you from a collision, you
may resume where you left off. Whether you are able to do so depends largely on how
quickly your visceral reactions subside to the threat.

The neuroscientist Paul MacLean, who
developed the three-part description of the brain that I’ve used here,
compared the relationship between the rational brain and the emotional brain to that
between a more or less competent rider and his unruly horse.[14] As long as the weather is
calm and the path is smooth, the rider can feel in excellent control. But unexpected
sounds or threats from other animals can make the horse bolt, forcing the rider to
hold on for dear life. Likewise, when people feel that their survival is at stake or
they are seized by rages, longings, fear, or sexual desires, they stop listening to
the voice of reason, and it makes little sense to argue with them. Whenever the
limbic system decides that something is a question of life or death, the pathways
between the frontal lobes and the limbic system become extremely tenuous.

Psychologists usually try to help people
use insight and understanding to manage their behavior. However, neuroscience
research shows that very few psychological problems are the result of defects in
understanding; most originate in pressures from deeper regions in the brain that
drive our perception and attention. When the alarm bell of the emotional brain keeps
signaling that you are in danger, no amount of insight will silence it. I am
reminded of the comedy in which a seven-time recidivist in an anger-management program extols the virtue of the
techniques he’s learned: “They are great and work terrific—as long as
you are not really angry.”

When our emotional and rational brains
are in conflict (as when we’re enraged with someone we love, frightened by
someone we depend on, or lust after someone who is off limits), a tug-of-war ensues.
This war is largely played out in the theater of visceral experience—your gut, your
heart, your lungs—and will lead to both physical discomfort and psychological
misery. Chapter 6 will discuss how the brain and
viscera interact in safety and danger, which is key to understanding the many
physical manifestations of trauma.

I’d like to end this chapter by
examining two more brain scans that illustrate some of the core features of
traumatic stress: timeless reliving; reexperiencing images, sounds, and emotions;
and dissociation.

STAN AND UTE’S BRAINS ON
TRAUMA

On a fine September morning in 1999, Stan
and Ute Lawrence, a professional couple in their forties, set out from their home in
London, Ontario, to attend a business meeting in Detroit. Halfway through the
journey they ran into a wall of dense fog that reduced visibility to zero in a split
second. Stan immediately slammed on the brakes, coming to a standstill sideways on
the highway, just missing a huge truck. An eighteen-wheeler went flying over the
trunk of their car; vans and cars slammed into them and into each other. People who
got out of their cars were hit as they ran for their lives. The earsplitting crashes
went on and on—with each jolt from behind they felt this would be the one that
killed them. Stan and Ute were trapped in car number thirteen of an eighty-seven-car
pileup, the worst road disaster in Canadian history.[15]

Then came the eerie silence. Stan
struggled to open the doors and windows, but the eighteen-wheeler that had crushed
their trunk was wedged against the car. Suddenly, someone was pounding on their
roof. A girl was screaming, “Get me out of here—I’m on fire!”
Helplessly, they saw her die as the car she’d been in was consumed by flames.
The next thing they knew, a truck driver was standing on the hood of their car with
a fire extinguisher. He smashed the windshield to free them, and Stan climbed
through the opening. Turning around to help his wife, he saw Ute sitting frozen in
her seat. Stan and the truck driver lifted her out and an ambulance took them to an
emergency room. Aside from a few cuts, they were found to be physically
unscathed.

At home that night, neither Stan nor Ute
wanted to go to sleep. They felt that if they let go, they would die. They were
irritable, jumpy, and on edge. That night, and for many to come, they drank copious
quantities of wine to numb their fear. They could not stop the images that were
haunting them or the questions that went on and on: What if they’d left
earlier? What if they hadn’t stopped for gas? After three months of this, they
sought help from Dr. Ruth Lanius, a psychiatrist at the University of Western
Ontario.

Dr. Lanius, who had been my student at
the Trauma Center a few years earlier, told Stan and Ute she wanted to visualize
their brains with an fMRI scan before beginning treatment. The fMRI measures neural
activity by tracking changes in blood flow in the brain, and unlike the PET scan, it
does not require exposure to radiation. Dr. Lanius used the same kind of
script-driven imagery we had used at Harvard, capturing the images, sounds, smells,
and other sensations Stan and Ute had experienced while they were trapped in the
car.

Stan went first and immediately went
into a flashback, just as Marsha had in our Harvard study. He came out of the
scanner sweating, with his heart racing and his blood pressure sky high. “This
was just the way I felt during the accident,” he reported. “I was sure I
was going to die, and there was nothing I could do to save myself.” Instead of
remembering the accident as something that had happened three months earlier, Stan
was reliving it.

DISSOCIATION AND RELIVING

Dissociation is the essence of trauma.
The overwhelming experience is split off and fragmented, so that the emotions,
sounds, images, thoughts, and physical sensations related to the trauma take on a
life of their own. The sensory fragments of memory intrude into the present, where
they are literally relived. As long as the trauma is not resolved, the stress
hormones that the body secretes to protect itself keep circulating, and the
defensive movements and emotional responses keep getting replayed. Unlike Stan,
however, many people may not be aware of the connection between their
“crazy” feelings and reactions and the traumatic events that are being
replayed. They have no idea why they respond to some minor irritation as if they
were about to be annihilated.

Flashbacks and reliving are in some ways
worse than the trauma itself. A traumatic event has a beginning and an end—at some
point it is over. But for people with PTSD a flashback can occur at any time,
whether they are awake or asleep. There is
no way of knowing when it’s going to occur again or how long it will last.
People who suffer from flashbacks often organize their lives around trying to
protect against them. They may compulsively go to the gym to pump iron (but finding
that they are never strong enough), numb themselves with drugs, or try to cultivate
an illusory sense of control in highly dangerous situations (like motorcycle racing,
bungee jumping, or working as an ambulance driver). Constantly fighting unseen
dangers is exhausting and leaves them fatigued, depressed, and weary.

If elements of the trauma are replayed
again and again, the accompanying stress hormones engrave those memories ever more
deeply in the mind. Ordinary, day-to-day events become less and less compelling. Not
being able to deeply take in what is going on around them makes it impossible to
feel fully alive. It becomes harder to feel the joys and aggravations of ordinary
life, harder to concentrate on the tasks at hand. Not being fully alive in the
present keeps them more firmly imprisoned in the past.

Triggered responses manifest in various
ways. Veterans may react to the slightest cue—like hitting a bump in the road or a
seeing a kid playing in the street—as if they were in a war zone. They startle
easily and become enraged or numb. Victims of childhood sexual abuse may anesthetize
their sexuality and then feel intensely ashamed if they become excited by sensations
or images that recall their molestation, even when those sensations are the natural
pleasures associated with particular body parts. If trauma survivors are forced to
discuss their experiences, one person’s blood pressure may increase while
another responds with the beginnings of a migraine headache. Still others may shut
down emotionally and not feel any obvious changes. However, in the lab we have no
problem detecting their racing hearts and the stress hormones churning through their
bodies.

These reactions are irrational and
largely outside people’s control. Intense and barely controllable urges and
emotions make people feel crazy—and makes them feel they don’t belong to the
human race. Feeling numb during birthday parties for your kids or in response to the
death of loved ones makes people feel like monsters. As a result, shame becomes the
dominant emotion and hiding the truth the central preoccupation.

They are rarely in touch with the
origins of their alienation. That is where therapy comes in—is the beginning of
bringing the emotions that were generated by trauma being able to feel, the capacity
to observe oneself online. However, the bottom line is that the threat-perception
system of the brain has changed, and people’s physical reactions are dictated
by the imprint of the past.

The trauma that started “out
there” is now played out on the battlefield of their own bodies, usually
without a conscious connection between what happened back then and what is going on
right now inside. The challenge is not so much learning to accept the terrible
things that have happened but learning how to gain mastery over one’s internal
sensations and emotions. Sensing, naming, and identifying what is going on inside is
the first step to recovery.

THE SMOKE DETECTOR GOES ON
OVERDRIVE

Stan’s brain scan shows his
flashback in action. This is what reliving trauma looks like in the brain: the
brightly lit area in the lower right-hand corner, the blanked-out lower left side,
and the four symmetrical white holes around the center. (You may recognize the
lit-up amygdala and the off-line left brain from the Harvard study discussed in chapter 3.) Stan’s amygdala made no
distinction between past and present. It activated just as if the car crash were
happening in the scanner, triggering powerful stress hormones and nervous-system
responses. These were responsible for his sweating and trembling, his racing heart
and elevated blood pressure: entirely normal and potentially lifesaving responses if
a truck has just smashed into your car.

Imaging a flashback with fMRI.
Notice how much more activity appears on the right side than on the left.

It’s important to have an efficient
smoke detector: You don’t want to get caught unawares by a raging fire. But if
you go into a frenzy every time you smell smoke, it becomes intensely disruptive.
Yes, you need to detect whether somebody is getting upset with you, but if your
amygdala goes into overdrive, you may become chronically scared that people hate
you, or you may feel like they are out to get you.

THE TIMEKEEPER COLLAPSES

Both Stan and Ute had become
hypersensitive and irritable after the accident, suggesting that their prefrontal
cortex was struggling to maintain control in the face of stress. Stan’s
flashback precipitated a more extreme reaction.

The two white areas in the front of the
brain (on top in the picture) are the right and left dorsolateral prefrontal cortex.
When those areas are deactivated, people lose their sense of time and become trapped
in the moment, without a sense of past, present, or future.[16]

Two brain systems are relevant for the
mental processing of trauma: those dealing with emotional intensity and context.
Emotional intensity is defined by the smoke alarm, the amygdala, and its
counterweight, the watchtower, the medial prefrontal cortex. The context and meaning
of an experience are determined by the system that includes the dorsolateral
prefrontal cortex (DLPFC) and the hippocampus. The DLPFC is located to the side in
the front brain, while the MPFC is in the center. The structures along the midline
of the brain are devoted to your inner experience of yourself, those on the side are
more concerned with your relationship with your surroundings.

The DLPFC tells us how our present
experience relates to the past and how it may affect the future—you can think of it
as the timekeeper of the brain. Knowing that whatever is happening is finite and
will sooner or later come to an end makes most experiences tolerable. The opposite
is also true—situations become intolerable if they feel interminable. Most of us
know from sad personal experience that terrible grief is typically accompanied by
the sense that this wretched state will
last forever, and that we will never get over our loss. Trauma is the ultimate
experience of “this will last forever.”

Stan’s scan reveals why people can
recover from trauma only when the brain structures that were knocked out during the
original experience—which is why the event registered in the brain as trauma in the
first place—are fully online. Visiting the past in therapy should be done while
people are, biologically speaking, firmly rooted in the present and feeling as calm,
safe, and grounded as possible. (“Grounded” means that you can feel your
butt in your chair, see the light coming through the window, feel the tension in
your calves, and hear the wind stirring the tree outside.) Being anchored in the
present while revisiting the trauma opens the possibility of deeply knowing that the
terrible events belong to the past. For that to happen, the brain’s
watchtower, cook, and timekeeper need to be online. Therapy won’t work as long
as people keep being pulled back into the past.

THE THALAMUS SHUTS DOWN

Look again at the scan of Stan’s
flashback, and you can see two more white holes in the lower half of the brain.
These are his right and left thalamus—blanked out during the flashback as they were
during the original trauma. As I’ve said, the thalamus functions as a
“cook”—a relay station that collects sensations from the ears, eyes, and
skin and integrates them into the soup that is our autobiographical memory.
Breakdown of the thalamus explains why trauma is primarily remembered not as a
story, a narrative with a beginning middle and end, but as isolated sensory
imprints: images, sounds, and physical sensations that are accompanied by intense
emotions, usually terror and helplessness.[17]

In normal circumstances the thalamus
also acts as a filter or gatekeeper. This makes it a central component of attention,
concentration, and new learning—all of which are compromised by trauma. As you sit
here reading, you may hear music in the background or traffic rumbling by or feel a
faint gnawing in your stomach telling you it’s time for a snack. If you are
able to stay focused on this page, your thalamus is helping you distinguish between
sensory information that is relevant and information that you can safely ignore. In
chapter 19, on neurofeedback, I’ll discuss
some of the tests we use to measure how well this gating system works, as well as
ways to strengthen it.

People with PTSD have their floodgates
wide open. Lacking a filter, they are on constant sensory overload. In order to
cope, they try to shut themselves down and develop tunnel vision and hyperfocus. If
they can’t shut down naturally, they may enlist drugs or alcohol to block out
the world. The tragedy is that the price
of closing down includes filtering out sources of pleasure and joy, as well.

DEPERSONALIZATION: SPLIT OFF FROM
THE SELF

Let’s now look at Ute’s
experience in the scanner. Not all people react to trauma in exactly the same way,
but in this case the difference is particularly dramatic, since Ute was sitting
right next to Stan in the wrecked car. She responded to her trauma script by going
numb: Her mind went blank, and nearly every area of her brain showed markedly
decreased activity. Her heart rate and blood pressure didn’t elevate. When
asked how she’d felt during the scan, she replied: “I felt just like I
felt at the time of the accident: I felt nothing.”

Blanking out (dissociation) in response
to being reminded of past trauma. In this case almost every area of the
brain has decreased activation, interfering with thinking, focus, and
orientation.

The medical term for Ute’s response
is depersonalization.[18] Anyone who deals with traumatized men,
women, or children is sooner or later confronted with blank stares and absent minds,
the outward manifestation of the biological freeze reaction. Depersonalization is
one symptom of the massive dissociation created by trauma. Stan’s flashbacks
came from his thwarted efforts to escape the crash—cued by the script, all his
dissociated, fragmented sensations and emotions roared back into the present. But
instead of struggling to escape, Ute had dissociated her fear and felt nothing.

I see depersonalization regularly in my
office when patients tell me horrendous stories without any feeling. All the energy
drains out of the room, and I have to make a valiant effort to keep paying
attention. A lifeless patient forces you to work much harder to keep the therapy
alive, and I often used to pray for the hour to be over quickly.

After seeing Ute’s scan, I started
to take a very different approach toward blanked-out patients. With nearly every
part of their brains tuned out, they obviously cannot think, feel deeply, remember,
or make sense out of what is going on. Conventional talk therapy, in those
circumstances, is virtually useless.

In Ute’s case it was possible to
guess why she responded so differently from Stan. She was utilizing a survival
strategy her brain had learned in childhood to cope with her mother’s harsh
treatment. Ute’s father died when she was nine years old, and her mother
subsequently was often nasty and demeaning to her. At some point Ute discovered that
she could blank out her mind when her mother yelled at her. Thirty-five years later,
when she was trapped in her demolished car, Ute’s brain automatically went
into the same survival mode—she made herself disappear.

The challenge for people like Ute is to
become alert and engaged, a difficult but unavoidable task if they want to recapture
their lives. (Ute herself did recover—she wrote a book about her experiences and
started a successful journal called Mental Fitness.) This is where a
bottom-up approach to therapy becomes essential. The aim is actually to change the
patient’s physiology, his or her relationship to bodily sensations. At the
Trauma Center we work with such basic measures as heart rate and breathing patterns.
We help patients evoke and notice bodily sensations by tapping acupressure[19] points.
Rhythmic interactions with other people are also effective—tossing a beach ball back
and forth, bouncing on a Pilates ball, drumming, or dancing to music.

Numbing is the other side of the coin in
PTSD. Many untreated trauma survivors start out like Stan, with explosive
flashbacks, then numb out later in life.
While reliving trauma is dramatic, frightening, and potentially self-destructive,
over time a lack of presence can be even more damaging. This is a particular problem
with traumatized children. The acting-out kids tend to get attention; the
blanked-out ones don’t bother anybody and are left to lose their future bit by
bit.

LEARNING TO LIVE IN THE PRESENT

The challenge of trauma treatment is not
only dealing with the past but, even more, enhancing the quality of day-to-day
experience. One reason that traumatic memories become dominant in PTSD is that
it’s so difficult to feel truly alive right now. When you can’t be fully
here, you go to the places where you did feel alive—even if those places are filled
with horror and misery.

Many treatment approaches for traumatic
stress focus on desensitizing patients to their past, with the expectation that
reexposure to their traumas will reduce emotional outbursts and flashbacks. I
believe that this is based on a misunderstanding of what happens in traumatic
stress. We must most of all help our patients to live fully and securely in the
present. In order to do that, we need to help bring those brain structures that
deserted them when they were overwhelmed by trauma back. Desensitization may make
you less reactive, but if you cannot feel satisfaction in ordinary everyday things
like taking a walk, cooking a meal, or playing with your kids, life will pass you
by.

CHAPTER 5

Body-Brain Connections

Life is about rhythm. We vibrate, our hearts
are pumping blood. We are a rhythm machine, that’s what we are.

—Mickey Hart

Toward the end of his career, in 1872,
Charles Darwin published The Expression of the Emotions in Man and
Animals.[1] Until recently most scientific discussion of Darwin’s
theories has focused on On the Origin of Species (1859) and The Descent
of Man (1871). But The Expression of the Emotions turns
out to be an extraordinary exploration of the foundations of emotional life, filled
with observations and anecdotes drawn from decades of inquiry, as well as
close-to-home stories of Darwin’s children and household pets. It’s also
a landmark in book illustration—one of the first books ever to include photographs.
(Photography was still a relatively new technology and, like most scientists, Darwin
wanted to make use of the latest techniques to make his points.) It’s still in
print today, readily available in a recent edition with a terrific introduction and
commentaries by Paul Ekman, a modern pioneer in the study of emotions.

Darwin starts his discussion by noting
the physical organization common to all mammals, including human beings—the lungs,
kidneys, brains, digestive organs, and sexual organs that sustain and continue life.
Although many scientists today would accuse him of anthropomorphism, Darwin stands
with animal lovers when he proclaims: “Man and the higher
animals … [also] have instincts in common. All have the same senses,
intuition, sensation, passions, affections, and emotions, even the more complex ones
such as jealousy, suspicion, emulation,
gratitude, and magnanimity.”[2] He observes that we humans share some
of the physical signs of animal emotion. Feeling the hair on the back of your neck
stand up when you’re frightened or baring your teeth when you’re enraged
can only be understood as vestiges of a long evolutionary process.

“When a man sneers or snarls at another,
is the corner of the canine or eye tooth raised on the side facing the man whom he
addresses?” —Charles Darwin, 1872

For Darwin mammalian emotions are
fundamentally rooted in biology: They are the indispensable source of motivation to
initiate action. Emotions (from the Latin emovere—to move out) give shape
and direction to whatever we do, and their primary expression is through the muscles
of the face and body. These facial and physical movements communicate our mental
state and intention to others: Angry expressions and threatening postures caution
them to back off. Sadness attracts care and attention. Fear signals helplessness or
alerts us to danger.

We instinctively read the dynamic
between two people simply from their tension or relaxation, their postures and tone
of voice, their changing facial expressions. Watch a movie in a language you
don’t know, and you can still guess the quality of the relationship between
the characters. We often can read other mammals (monkeys, dogs, horses) in the same
way.

Darwin goes on to observe that the
fundamental purpose of emotions is to initiate movement that will restore the
organism to safety and physical equilibrium. Here is his comment on the origin of
what today we would call PTSD:

Behaviors to avoid or escape from
danger have clearly evolved to render each organism competitive in terms of
survival. But inappropriately prolonged escape or avoidance behavior would put the
animal at a disadvantage in that successful species preservation demands
reproduction which, in turn, depends upon feeding, shelter and mating activities
all of which are reciprocals of avoidance and escape.[3]

In other words: If an organism is stuck
in survival mode, its energies are focused on fighting off unseen enemies, which
leaves no room for nurture, care, and love. For us humans, it means that as long as
the mind is defending itself against invisible assaults, our closest bonds are
threatened, along with our ability to imagine, plan, play, learn, and pay attention
to other people’s needs.

Darwin also wrote about body-brain
connections that we are still exploring today. Intense emotions involve not only the
mind but also the gut and the heart: “Heart, guts, and brain communicate
intimately via the ‘pneumogastric’ nerve, the critical nerve involved in
the expression and management of emotions in both humans and animals. When the mind
is strongly excited, it instantly affects the state of the viscera; so that under
excitement there will be much mutual action and reaction between these, the two most
important organs of the body.”[4]

The first time I encountered this
passage, I reread it with growing excitement. Of course we experience our most
devastating emotions as gut-wrenching feelings and heartbreak. As long as we
register emotions primarily in our heads, we can remain pretty much in control, but
feeling as if our chest is caving in or we’ve been punched in the gut is
unbearable. We’ll do anything to make these awful visceral sensations go away,
whether it is clinging desperately to another human being, rendering ourselves
insensible with drugs or alcohol, or taking a knife to the skin to replace
overwhelming emotions with definable sensations. How many mental health problems,
from drug addiction to self-injurious behavior, start as attempts to cope with the
unbearable physical pain of our emotions? If Darwin was right, the solution requires
finding ways to help people alter the inner sensory landscape of their bodies.

Until recently, this bidirectional
communication between body and mind was largely ignored by Western science, even as
it had long been central to traditional healing practices in many other parts of the
world, notably in India and China. Today it is transforming our understanding of
trauma and recovery.

A WINDOW INTO THE NERVOUS
SYSTEM

All of the little signs we instinctively
register during a conversation—the muscle shifts and tensions in the other
person’s face, eye movements and pupil dilation, pitch and speed of the
voice—as well as the fluctuations in our own inner landscape—salivation, swallowing, breathing, and heart
rate—are linked by a single regulatory system.[5] All are a product of the synchrony
between the two branches of the autonomic nervous system (ANS): the sympathetic,
which acts as the body’s accelerator, and the parasympathetic, which serves as
its brake.[6]
These are the “reciprocals” Darwin spoke of, and working together they
play an important role in managing the body’s energy flow, one preparing for
its expenditure, the other for its conservation.

The sympathetic nervous system (SNS) is
responsible for arousal, including the fight-or-flight response (Darwin’s
“escape or avoidance behavior”). Almost two thousand years ago the Roman
physician Galen gave it the name “sympathetic” because he observed that
it functioned with the emotions (sym pathos). The SNS moves blood to the
muscles for quick action, partly by triggering the adrenal glands to squirt out
adrenaline, which speeds up the heart rate and increases blood pressure.

The second branch of the ANS is the
parasympathetic (“against emotions”) nervous system (PNS), which
promotes self-preservative functions like digestion and wound healing. It triggers
the release of acetylcholine to put a brake on arousal, slowing the heart down,
relaxing muscles, and returning breathing to normal. As Darwin pointed out,
“feeding, shelter, and mating activities” depend on the PNS.

There is a simple way to experience
these two systems for yourself. Whenever you take a deep breath, you activate the
SNS. The resulting burst of adrenaline speeds up your heart, which explains why many
athletes take a few short, deep breaths before starting competition. Exhaling, in
turn, activates the PNS, which slows down the heart. If you take a yoga or a
meditation class, your instructor will probably urge you to pay particular attention
to the exhalation, since deep, long breaths out help calm you down. As we breathe,
we continually speed up and slow down the heart, and because of that the interval
between two successive heartbeats is never precisely the same. A measurement called
heart rate variability (HRV) can be used to test the flexibility of this system, and
good HRV—the more fluctuation, the better—is a sign that the brake and accelerator
in your arousal system are both functioning properly and in balance. We had a
breakthrough when we acquired an instrument to measure HRV, and I will explain in chapter 16 how we can use HRV to help treat
PTSD.

THE NEURAL LOVE CODE[7]

In 1994 Stephen Porges, who was a
researcher at the University of Maryland at the time we started our investigation of
HRV, and who is now at the University of
North Carolina, introduced the Polyvagal Theory, which built on Darwin’s
observations and added another 140 years of scientific discoveries to those early
insights. (Polyvagal refers to the many branches of the vagus
nerve—Darwin’s “pneumogastric nerve”—which connects numerous
organs, including the brain, lungs, heart, stomach, and intestines.) The Polyvagal
Theory provided us with a more sophisticated understanding of the biology of safety
and danger, one based on the subtle interplay between the visceral experiences of
our own bodies and the voices and faces of the people around us. It explained why a
kind face or a soothing tone of voice can dramatically alter the way we feel. It
clarified why knowing that we are seen and heard by the important people in our
lives can make us feel calm and safe, and why being ignored or dismissed can
precipitate rage reactions or mental collapse. It helped us understand why focused
attunement with another person can shift us out of disorganized and fearful
states.[8]

In short, Porges’s theory made us
look beyond the effects of fight or flight and put social relationships front and
center in our understanding of trauma. It also suggested new approaches to healing
that focus on strengthening the body’s system for regulating arousal.

Human beings are astoundingly attuned to
subtle emotional shifts in the people (and animals) around them. Slight changes in
the tension of the brow, wrinkles around the eyes, curvature of the lips, and angle
of the neck quickly signal to us how comfortable, suspicious, relaxed, or frightened
someone is.[9] Our
mirror neurons register their inner experience, and our own bodies make internal
adjustments to whatever we notice. Just so, the muscles of our own faces give others
clues about how calm or excited we feel, whether our heart is racing or quiet, and
whether we’re ready to pounce on them or run away. When the message we receive
from another person is “You’re safe with me,” we relax. If
we’re lucky in our relationships, we also feel nourished, supported, and
restored as we look into the face and eyes of the other.

Our culture teaches us to focus on
personal uniqueness, but at a deeper level we barely exist as individual organisms.
Our brains are built to help us function as members of a tribe. We are part of that
tribe even when we are by ourselves, whether listening to music (that other people
created), watching a basketball game on television (our own muscles tensing as the
players run and jump), or preparing a spreadsheet for a sales meeting (anticipating
the boss’s reactions). Most of our energy is devoted to connecting with
others.

If we look beyond the list of specific
symptoms that entail formal psychiatric diagnoses, we find that almost all mental
suffering involves either trouble in creating workable and satisfying relationships
or difficulties in regulating arousal (as
in the case of habitually becoming enraged, shut down, overexcited, or
disorganized). Usually it’s a combination of both. The standard medical focus
on trying to discover the right drug to treat a particular “disorder”
tends to distract us from grappling with how our problems interfere with our
functioning as members of our tribe.

SAFETY AND RECIPROCITY

A few years ago I heard Jerome Kagan, a
distinguished emeritus professor of child psychology at Harvard, say to the Dalai
Lama that for every act of cruelty in this world there are hundreds of small acts of
kindness and connection. His conclusion: “To be benevolent rather than
malevolent is probably a true feature of our species.” Being able to feel safe
with other people is probably the single most important aspect of mental health;
safe connections are fundamental to meaningful and satisfying lives. Numerous
studies of disaster response around the globe have shown that social support is the
most powerful protection against becoming overwhelmed by stress and trauma.

Social support is not the same as merely
being in the presence of others. The critical issue is reciprocity: being
truly heard and seen by the people around us, feeling that we are held in someone
else’s mind and heart. For our physiology to calm down, heal, and grow we need
a visceral feeling of safety. No doctor can write a prescription for friendship and
love: These are complex and hard-earned capacities. You don’t need a history
of trauma to feel self-conscious and even panicked at a party with strangers—but
trauma can turn the whole world into a gathering of aliens.

Many traumatized people find themselves
chronically out of sync with the people around them. Some find comfort in groups
where they can replay their combat experiences, rape, or torture with others who
have similar backgrounds or experiences. Focusing on a shared history of trauma and
victimization alleviates their searing sense of isolation, but usually at the price
of having to deny their individual differences: Members can belong only if they
conform to the common code.

Isolating oneself into a narrowly
defined victim group promotes a view of others as irrelevant at best and dangerous
at worst, which eventually only leads to further alienation. Gangs, extremist
political parties, and religious cults may provide solace, but they rarely foster
the mental flexibility needed to be fully open to what life has to offer and as such
cannot liberate their members from their traumas. Well-functioning people are able
to accept individual differences and acknowledge the humanity of others.

In the past two decades it has become
widely recognized that when adults or children are too skittish or shut down to
derive comfort from human beings, relationships with other mammals can help. Dogs
and horses and even dolphins offer less complicated companionship while providing
the necessary sense of safety. Dogs and horses, in particular, are now extensively
used to treat some groups of trauma patients.[10]

THREE LEVELS OF SAFETY

After trauma the world is experienced
with a different nervous system that has an altered perception of risk and safety.
Porges coined the word “neuroception” to describe the capacity to
evaluate relative danger and safety in one’s environment. When we try to help
people with faulty neuroception, the great challenge is finding ways to reset their
physiology, so that their survival mechanisms stop working against them. This means
helping them to respond appropriately to danger but, even more, to recover the
capacity to experience safety, relaxation, and true reciprocity.

I have extensively interviewed and
treated six people who survived plane crashes. Two reported having lost
consciousness during the incident; even though they were not physically injured,
they collapsed mentally. Two went into a panic and stayed frantic until well after
we had started treatment. Two remained calm and resourceful and helped evacuate
fellow passengers from the burning wreckage. I’ve found a similar range of
responses in survivors of rape, car crashes, and torture. In the previous chapter we
saw the radically different reactions of Stan and Ute as they relived the highway
disaster they’d experienced side by side. What accounts for this spectrum of
responses: focused, collapsed, or frantic?

Porges’s theory provides an
explanation: The autonomic nervous system regulates three fundamental physiological
states. The level of safety determines which one of these is activated at any
particular time. Whenever we feel threatened, we instinctively turn to the first
level, social engagement. We call out for help, support, and comfort from
the people around us. But if no one comes to our aid, or we’re in immediate
danger, the organism reverts to a more primitive way to survive: fight or
flight. We fight off our attacker, or we run to a safe place. However, if
this fails—we can’t get away, we’re held down or trapped—the organism
tries to preserve itself by shutting down and expending as little energy as
possible. We are then in a state of freeze or collapse.

This is where the many-branched vagus
nerve comes in, and I’ll describe its anatomy briefly because it’s central to
understanding how people deal with trauma. The social-engagement system depends on
nerves that have their origin in the brain stem regulatory centers, primarily the
vagus—also known as the tenth cranial nerve—together with adjoining nerves that
activate the muscles of the face, throat, middle ear, and voice box or larynx. When
the “ventral vagal complex” (VVC) runs the show, we smile when others
smile at us, we nod our heads when we agree, and we frown when friends tell us of
their misfortunes. When the VVC is engaged, it also sends signals down to our heart
and lungs, slowing down our heart rate and increasing the depth of breathing. As a
result, we feel calm and relaxed, centered, or pleasurably aroused.

The many-branched vagus. The
vagus nerve (which Darwin called the pneumogastric nerve) registers heartbreak and
gut-wrenching feelings. When a person becomes upset, the throat gets dry, the voice
becomes tense, the heart speeds up, and respiration becomes rapid and shallow.

Three responses to threat.

1. The social engagement system: an alarmed monkey signals danger
and calls for help. VVC.
2. Fight or flight: Teeth bared, the
face of rage and terror. SNS.
3. Collapse: The body signals
defeat and withdraws. DVC.

Any threat to our safety or social
connections triggers changes in the areas innervated by the VVC. When something
distressing happens, we automatically signal our upset in our facial expressions and
tone of voice, changes meant to beckon others to come to our assistance.[11] However, if no
one responds to our call for help, the threat increases, and the older limbic brain
jumps in. The sympathetic nervous system takes over, mobilizing muscles, heart, and
lungs for fight or flight.[12] Our voice becomes faster and more strident and our heart
starts pumping faster. If a dog is in the room, she will stir and growl, because she
can smell the activation of our sweat glands.

Finally, if there’s no way out,
and there’s nothing we can do to stave off the inevitable, we will activate
the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches
down below the diaphragm to the stomach, kidneys, and intestines and drastically
reduces metabolism throughout the body. Heart rate plunges (we feel our heart
“drop”), we can’t breathe, and our gut stops working or empties
(literally “scaring the shit out of” us). This is the point at which we
disengage, collapse, and freeze.

FIGHT OR FLIGHT VERSUS COLLAPSE

As we saw in Stan’s and Ute’s
brain scans, trauma is expressed not only as fight or flight but also as shutting
down and failing to engage in the present. A different level of brain activity is
involved for each response: the mammalian fight-or-flight system, which is
protective and keeps us from shutting down, and the reptilian brain, which produces
the collapse response. You can see the difference between these two systems at any big pet
store. Kittens, puppies, mice and gerbils constantly play around, and when
they’re tired they huddle together, skin to skin, in a pile. In contrast, the
snakes and lizards lie motionless in the corners of their cages, unresponsive to the
environment.[13] This sort of immobilization, generated by the reptilian brain,
characterizes many chronically traumatized people, as opposed to the mammalian panic
and rage that make more recent trauma survivors so frightened and frightening.

Almost everyone knows what that
quintessential fight/flight response, road rage, feels like: A sudden threat
precipitates an intense impulse to move and attack. Danger turns off our
social-engagement system, decreases our responsiveness to the human voice, and
increases our sensitivity to threatening sounds. Yet for many people panic and rage
are preferable to the opposite: shutting down and becoming dead to the world.
Activating flight/flight at least makes them feel energized. That is why so many
abused and traumatized people feel fully alive in the face of actual danger, while
they go numb in situations that are more complex but objectively safe, like birthday
parties or family dinners.

When fighting or running does not take
care of the threat, we activate the last resort—the reptilian brain, the ultimate
emergency system. This system is most likely to engage when we are physically
immobilized, as when we are pinned down by an attacker or when a child has no escape
from a terrifying caregiver. Collapse and disengagement are controlled by the DVC,
an evolutionarily ancient part of the parasympathetic nervous system that is
associated with digestive symptoms like diarrhea and nausea. It also slows down the
heart and induces shallow breathing. Once this system takes over, other people, and
we ourselves, cease to matter. Awareness is shut down, and we may no longer even
register physical pain.

HOW WE BECOME HUMAN

In Porges’s grand theory the VVC
evolved in mammals to support an increasingly complex social life. All mammals,
including human beings, band together to mate, nurture their young, defend against
common enemies, and coordinate hunting and food acquisition. The more efficiently
the VVC synchronizes the activity of the sympathetic and parasympathetic nervous
systems, the better the physiology of each individual will be attuned to that of
other members of the tribe.

Thinking about the VVC in this way
illuminates how parents naturally help their kids to regulate themselves. Newborn
babies are not very social; they sleep
most of the time and wake up when they’re hungry or wet. After having been fed
they may spend a little time looking around, fussing, or staring, but they will soon
be asleep again, following their own internal rhythms. Early in life they are pretty
much at the mercy of the alternating tides of their sympathetic and parasympathetic
nervous systems, and their reptilian brain runs most of the show.

But day by day, as we coo and smile and
cluck at them, we stimulate the growth of synchronicity in the developing VVC. These
interactions help to bring our babies’ emotional arousal systems into sync
with their surroundings. The VVC controls sucking, swallowing, facial expression,
and the sounds produced by the larynx. When these functions are stimulated in an
infant, they are accompanied by a sense of pleasure and safety, which helps create
the foundation for all future social behavior.[14] As my friend Ed Tronick taught me a
long time ago, the brain is a cultural organ—experience shapes the brain.

Being in tune with other members of our
species via the VVC is enormously rewarding. What begins as the attuned play of
mother and child continues with the rhythmicity of a good basketball game, the
synchrony of tango dancing, and the harmony of choral singing or playing a piece of
jazz or chamber music—all of which foster a deep sense of pleasure and
connection.

We can speak of trauma when that system
fails: when you beg for your life, but the assailant ignores your pleas; when you
are a terrified child lying in bed, hearing your mother scream as her boyfriend
beats her up; when you see your buddy trapped under a piece of metal that
you’re not strong enough to lift; when you want to push away the priest who is
abusing you, but you’re afraid you’ll be punished. Immobilization is at
the root of most traumas. When that occurs the DVC is likely to take over: Your
heart slows down, your breathing becomes shallow, and, zombielike, you lose touch
with yourself and your surroundings. You dissociate, faint and collapse.

DEFEND OR RELAX?

Steve Porges helped me realize that the
natural state of mammals is to be somewhat on guard. However, in order to feel
emotionally close to another human being, our defensive system must temporarily shut
down. In order to play, mate, and nurture our young, the brain needs to turn off its
natural vigilance.

Many traumatized individuals are too
hypervigilant to enjoy the ordinary pleasures that life has to offer, while others
are too numb to absorb new experiences—or to be alert to signs of real danger. When
the smoke detectors of the brain malfunction, people no longer run when they should
be trying to escape or fight back when
they should be defending themselves. The landmark ACE (Adverse Childhood
Experiences) study, which I’ll discuss in more detail in chapter 9, showed that women who had an early
history of abuse and neglect were seven times more likely to be raped in adulthood.
Women who, as children, had witnessed their mothers being assaulted by their
partners had a vastly increased chance to fall victim to domestic violence.[15]

Many people feel safe as long as they
can limit their social contact to superficial conversations, but actual physical
contact can trigger intense reactions. However, as Porges points out, achieving any
sort of deep intimacy—a close embrace, sleeping with a mate, and sex—requires
allowing oneself to experience immobilization without fear.[16] It is especially
challenging for traumatized people to discern when they are actually safe and to be
able to activate their defenses when they are in danger. This requires having
experiences that can restore the sense of physical safety, a topic to which
we’ll return many times in the chapters that follow.

NEW APPROACHES TO TREATMENT

If we understand that traumatized
children and adults get stuck in fight/flight or in chronic shut-down, how do we
help them to deactivate these defensive maneuvers that once ensured their
survival?

Some gifted people who work with trauma
survivors know how to do this intuitively. Steve Gross used to run the play program
at the Trauma Center. Steve often walked around the clinic with a brightly colored
beach ball, and when he saw angry or frozen kids in the waiting room, he would flash
them a big smile. The kids rarely responded. Then, a little later, he would return
and “accidentally” drop his ball close to where a kid was sitting. As
Steve leaned over to pick it up, he’d nudge it gently toward the kid,
who’d usually give a half hearted push in return. Gradually Steve got a
back-and-forth going, and before long you’d see smiles on both faces.

From simple, rhythmically attuned
movements, Steve had created a small, safe place where the social-engagement system
could begin to reemerge. In the same way, severely traumatized people may get more
out of simply helping to arrange chairs before a meeting or joining others in
tapping out a musical rhythm on the chair seats than they would from sitting in
those same chairs and discussing the failures in their life.

One thing is certain: Yelling at someone
who is already out of control can only lead to further dysregulation. Just as your
dog cowers if you shout and wags his tail when you speak in a high singsong, we
humans respond to harsh voices with fear,
anger, or shutdown and to playful tones by opening up and relaxing. We simply cannot
help but respond to these indicators of safety or danger.

Sadly, our educational system, as well
as many of the methods that profess to treat trauma, tend to bypass this
emotional-engagement system and focus instead on recruiting the cognitive capacities
of the mind. Despite the well-documented effects of anger, fear, and anxiety on the
ability to reason, many programs continue to ignore the need to engage the safety
system of the brain before trying to promote new ways of thinking. The last things
that should be cut from school schedules are chorus, physical education, recess, and
anything else involving movement, play, and joyful engagement. When children are
oppositional, defensive, numbed out, or enraged, it’s also important to
recognize that such “bad behavior” may repeat action patterns that were
established to survive serious threats, even if they are intensely upsetting or
off-putting.

Porges’s work has had a profound
effect on how my Trauma Center colleagues and I organize the treatment of abused
children and traumatized adults. It’s true that we would probably have
developed a therapeutic yoga program for women at some point, given that yoga had
proved so successful in helping them calm down and get in touch with their
dissociated bodies. We would also have been likely to experiment with a theater
program in the Boston inner-city schools, with a karate program for rape survivors
called impact model mugging, and with play techniques and body modalities like
sensory stimulation that have now been used with survivors around the world. (All of
these and more will be explored in part 5.)

But the polyvagal theory helped us
understand and explain why all these disparate, unconventional techniques
worked so well. It enabled us to become more conscious of combining top-down
approaches (to activate social engagement) with bottom-up methods (to calm the
physical tensions in the body). We were more open to the value of other age-old,
nonpharmacological approaches to health that have long been practiced outside
Western medicine, ranging from breath exercises (pranayama) and chanting to martial
arts like qigong to drumming and group singing and dancing. All rely on
interpersonal rhythms, visceral awareness, and vocal and facial communication, which
help shift people out of fight/flight states, reorganize their perception of danger,
and increase their capacity to manage relationships.

The body keeps the score:[17] If the memory
of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in
autoimmune disorders and skeletal/muscular problems, and if mind/brain/visceral
communication is the royal road to emotion regulation, this demands a radical shift
in our therapeutic assumptions.

CHAPTER 6

Losing Your Body, Losing Your
Self

Be patient toward all that is unsolved in your
heart and try to love the questions themselves. … Live the questions now.
Perhaps you will gradually, without noticing it, live along some distant day into
the answer.

—Rainer Maria Rilke, Letters to a Young Poet

Sherry walked into my office with her
shoulders slumped, her chin nearly touching her chest. Even before we spoke
a word, her body was telling me that she was afraid to face the world. I also
noticed that her long sleeves only partially covered the scabs on her forearms.
After sitting down, she told me in a high-pitched monotone that she couldn’t
stop herself from picking at the skin on her arms and chest until she bled.

As far back as Sherry could remember,
her mother had run a foster home, and their house was often packed with as many as
fifteen strange, disruptive, frightened, and frightening kids who disappeared as
suddenly as they arrived. Sherry had grown up taking care of these transient
children, feeling that there was no room for her and her needs. “I know I
wasn’t wanted,” she told me. “I’m not sure when I first
realized that, but I’ve thought about things that my mother said to me, and
the signs were always there. She’d tell me, ‘You know, I don’t
think you belong in this family. I think they gave us the wrong baby.’ And
she’d say it with a smile on her face. But, of course, people often pretend to
joke when they say something serious.”

Over the years our research team has
repeatedly found that chronic emotional
abuse and neglect can be just as devastating as physical abuse and sexual
molestation.[1] Sherry turned out to be a living example of these findings: Not
being seen, not being known, and having nowhere to turn to feel safe is devastating
at any age, but it is particularly destructive for young children, who are still
trying to find their place in the world.

Sherry had graduated from college, but
she now worked in a joyless clerical job, lived alone with her cats, and had no
close friends. When I asked her about men, she told me that her only
“relationship” had been with a man who’d kidnapped her while she
was on a college vacation in Florida. He’d held her captive and raped her
repeatedly for five consecutive days. She remembered having been curled up,
terrified and frozen for most of that time, until she realized she could try to get
away. She escaped by simply walking out while he was in the bathroom. When she
called her mother collect for help, her mother refused to take the call. Sherry
finally managed to get home with assistance from a domestic violence shelter.

Sherry told me that she’d started
to pick at her skin because it gave her some relief from feeling numb. The physical
sensations made her feel more alive but also deeply ashamed—she knew she was
addicted to these actions but could not stop them. She’d consulted many mental
health professionals before me and had been questioned repeatedly about her
“suicidal behavior.” She’d also been subjected to involuntary
hospitalization by a psychiatrist who refused to treat her unless she could promise
that she would never pick at herself again. However, in my experience, patients who
cut themselves or pick at their skin like Sherry, are seldom suicidal but are trying
to make themselves feel better in the only way they know.

This is a difficult concept for many
people to understand. As I discussed in the previous chapter, the most common
response to distress is to seek out people we like and trust to help us and give us
the courage to go on. We may also calm down by engaging in a physical activity like
biking or going to the gym. We start learning these ways of regulating our feelings
from the first moment someone feeds us when we’re hungry, covers us when
we’re cold, or rocks us when we’re hurt or scared.

But if no one has ever looked at you
with loving eyes or broken out in a smile when she sees you; if no one has rushed to
help you (but instead said, “Stop crying, or I’ll give you something to
cry about”), then you need to discover other ways of taking care of yourself.
You are likely to experiment with anything—drugs, alcohol, binge eating, or
cutting—that offers some kind of relief.

While Sherry dutifully came to every
appointment and answered my questions with great sincerity, I did not feel we were
making the sort of vital connection that
is necessary for therapy to work. Struck by how frozen and uptight she was, I
suggested that she see Liz, a massage therapist I had worked with previously. During
their first meeting Liz positioned Sherry on the massage table, then moved to the
end of the table and gently held Sherry’s feet. Lying there with her eyes
closed, Sherry suddenly yelled in a panic: “Where are you?” Somehow
Sherry had lost track of Liz, even though Liz was right there, with her hands on
Sherry’s feet.

Sherry was one of the first patients who
taught me about the extreme disconnection from the body that so many people with
histories of trauma and neglect experience. I discovered that my professional
training, with its focus on understanding and insight, had largely ignored the
relevance of the living, breathing body, the foundation of our selves. Sherry knew
that picking her skin was a destructive thing to do and that it was related to her
mother’s neglect, but understanding the source of the impulse made no
difference in helping her control it.

LOSING YOUR BODY

Once I was alerted to this, I was amazed
to discover how many of my patients told me they could not feel whole areas of their
bodies. Sometimes I’d ask them to close their eyes and tell me what I had put
into their outstretched hands. Whether it was a car key, a quarter, or a can opener,
they often could not even guess what they were holding—their sensory perceptions
simply weren’t working.

I talked this over with my friend
Alexander McFarlane in Australia, who had observed the same phenomenon. In his
laboratory in Adelaide he had studied the question: How do we know without looking
at it that we’re holding a car key? Recognizing an object in the palm of your
hand requires sensing its shape, weight, temperature, texture, and position. Each of
those distinct sensory experiences is transmitted to a different part of the brain,
which then needs to integrate them into a single perception. McFarlane found that
people with PTSD often have trouble putting the picture together.[2]

When our senses become muffled, we no
longer feel fully alive. In an article called “What Is an Emotion?”
(1884),[3]
William James, the father of American psychology, reported a striking case of
“sensory insensibility” in a woman he interviewed: “I
have … no human sensations,” she told him. “[I am] surrounded
by all that can render life happy and agreeable, still to me the faculty of
enjoyment and of feeling is wanting. … Each of my senses, each part of my
proper self, is as it were separated from me and can no longer afford me any feeling; this impossibility seems to depend
upon a void which I feel in the front of my head, and to be due to the diminution of
the sensibility over the whole surface of my body, for it seems to me that I never
actually reach the objects which I touch. All this would be a small matter enough,
but for its frightful result, which is that of the impossibility of any other kind
of feeling and of any sort of enjoyment, although I experience a need and desire of
them that render my life an incomprehensible torture.”

This response to trauma raises an
important question: How can traumatized people learn to integrate ordinary sensory
experiences so that they can live with the natural flow of feeling and feel secure
and complete in their bodies?

HOW DO WE KNOW WE’RE
ALIVE?

Most early neuroimaging studies of
traumatized people were like those we’ve seen in chapter 3; they focused on how subjects reacted to specific reminders of
the trauma. Then, in 2004, my colleague Ruth Lanius, who scanned Stan and Ute
Lawrence’s brains, posed a new question: What happens in the brains of trauma
survivors when they are not thinking about the past? Her studies on the
idling brain, the “default state network” (DSN), opened up a whole new
chapter in understanding how trauma affects self-awareness, specifically sensory
self-awareness.[4]

Dr. Lanius recruited a group of sixteen
“normal” Canadians to lie in a brain scanner while thinking about
nothing in particular. This is not easy for anyone to do—as long as we are awake,
our brains are churning—but she asked them to focus their attention on their
breathing and try to empty their minds as much as possible. She then repeated the
same experiment with eighteen people who had histories of severe, chronic childhood
abuse.

What is your brain doing when you have
nothing in particular on your mind? It turns out that you pay attention to yourself:
The default state activates the brain areas that work together to create your sense
of “self.”

When Ruth looked at the scans of her
normal subjects, she found activation of DSN regions that previous researchers had
described. I like to call this the Mohawk of self-awareness, the midline structures
of the brain, starting out right above our eyes, running through the center of the
brain all the way to the back. All these midline structures are involved in our
sense of self. The largest bright region at the back of the brain is the posterior
cingulate, which gives us a physical sense of where we are—our internal GPS. It is
strongly connected to the medial prefrontal cortex (MPFC), the watchtower I
discussed in chapter 4. (This connection
doesn’t show up on the scan because the fMRI can’t measure it.) It is
also connected with brain areas that register sensations coming from the rest of the
body: the insula, which relays messages from the viscera to the emotional centers;
the parietal lobes, which integrate sensory information; and the anterior cingulate,
which coordinates emotions and thinking. All of these areas contribute to
consciousness.

Locating the self. The Mohawk
of self-awareness. Starting from the front of the brain (at right), this consists
of: the orbital prefrontal cortex, the medial prefrontal cortex, the anterior
cingulate, the posterior cingulate, and the insula. In individuals with histories of
chronic trauma the same regions show sharply decreased activity, making it difficult
to register internal states and assessing the personal relevance of incoming
information.

The contrast with the scans of the eighteen
chronic PTSD patients with severe early-life trauma was startling. There was almost
no activation of any of the self-sensing areas of the brain: The MPFC, the anterior
cingulate, the parietal cortex, and the insula did not light up at all; the only
area that showed a slight activation was the posterior cingulate, which is
responsible for basic orientation in space.

There could be only one explanation for
such results: In response to the trauma itself, and in coping with the dread that
persisted long afterward, these patients had learned to shut down the brain areas
that transmit the visceral feelings and emotions that accompany and define terror.
Yet in everyday life, those same brain areas are responsible for registering the
entire range of emotions and sensations that form the foundation of our
self-awareness, our sense of who we are. What we witnessed here was a tragic
adaptation: In an effort to shut off terrifying sensations, they also deadened their
capacity to feel fully alive.

The disappearance of medial prefrontal
activation could explain why so many traumatized people lose their sense of purpose
and direction. I used to be surprised by how often my patients asked me for advice
about the most ordinary things, and then by how rarely they followed it. Now I
understood that their relationship with their own inner reality was impaired. How
could they make decisions, or put any plan into action, if they couldn’t
define what they wanted or, to be more precise, what the sensations in their bodies,
the basis of all emotions, were trying to tell them?

The lack of self-awareness in victims of
chronic childhood trauma is sometimes so profound that they cannot recognize
themselves in a mirror. Brain scans show that this is not the result of mere
inattention: The structures in charge of self-recognition may be knocked out along
with the structures related to self-experience.

When Ruth Lanius showed me her study, a
phrase from my classical high school education came back to me. The mathematician
Archimedes, teaching about the lever, is supposed to have said: “Give me a
place to stand and I will move the world.” Or, as the great twentieth-century
body therapist Moshe Feldenkrais put it: “You can’t do what you want
till you know what you’re doing.” The implications are clear: to feel
present you have to know where you are and be aware of what is going on with you. If
the self-sensing system breaks down we need to find ways to reactivate it.

THE SELF-SENSING SYSTEM

It was fascinating to see how much Sherry
benefited from her massage therapy. She felt more relaxed and adventurous in her
day-to-day life and she was also more relaxed and open with me. She became truly
involved in her therapy and was genuinely curious about her behavior, thoughts, and
feelings. She stopped picking at her skin, and when summer came she started to spend
evenings sitting outside on her stoop, chatting with her neighbors. She even joined a church choir, a wonderful
experience of group synchrony.

It was at about this time that I met
Antonio Damasio at a small think tank that Dan Schacter, the chair of the psychology
department at Harvard, had organized. In a series of brilliant scientific articles
and books Damasio clarified the relationship among body states, emotions, and
survival. A neurologist who has treated hundreds of people with various forms of
brain damage, he became fascinated with consciousness and with identifying the areas
of the brain necessary for knowing what you feel. He has devoted his career to
mapping out what is responsible for our experience of “self.” The
Feeling of What Happens is, for me, his most important book, and reading it
was a revelation.[5] Damasio starts by pointing out the deep divide between our sense of
self and the sensory life of our bodies. As he poetically explains, “Sometimes
we use our minds not to discover facts, but to hide them. … One of the
things the screen hides most effectively is the body, our own body, by which I mean
the ins of it, its interiors. Like a veil thrown over the skin to secure its
modesty, the screen partially removes from the mind the inner states of the body,
those that constitute the flow of life as it wanders in the journey of each
day.”[6]

He goes on to describe how this
“screen” can work in our favor by enabling us to attend to pressing
problems in the outside world. Yet it has a cost: “It tends to prevent us from
sensing the possible origin and nature of what we call self.”[7] Building on the
century-old work of William James, Damasio argues that the core of our
self-awareness rests on the physical sensations that convey the inner states of the
body:

[P]rimordial feelings provide a
direct experience of one’s own living body, wordless, unadorned, and
connected to nothing but sheer existence. These primordial feelings reflect the
current state of the body along varied dimensions, … along the scale
that ranges from pleasure to pain, and they originate at the level of the brain
stem rather than the cerebral cortex. All feelings of emotion are complex
musical variations on primordial feelings.[8]

Our sensory world takes shape even
before we are born. In the womb we feel amniotic fluid against our skin, we hear the
faint sounds of rushing blood and a digestive tract at work, we pitch and roll with
our mother’s movements. After birth, physical sensation defines our
relationship to ourselves and to our surroundings. We start off being our
wetness, hunger, satiation, and sleepiness. A cacophony of incomprehensible sounds and
images presses in on our pristine nervous system. Even after we acquire
consciousness and language, our bodily sensing system provides crucial feedback on
our moment-to-moment condition. Its constant hum communicates changes in our viscera
and in the muscles of our face, torso, and extremities that signal pain and comfort,
as well as urges such as hunger and sexual arousal. What is taking place around us
also affects our physical sensations. Seeing someone we recognize, hearing
particular sounds—a piece of music, a siren—or sensing a shift in temperature all
change our focus of attention and, without our being aware of it, prime our
subsequent thoughts and actions.

As we have seen, the job of the brain is
to constantly monitor and evaluate what is going on within and around us. These
evaluations are transmitted by chemical messages in the bloodstream and electrical
messages in our nerves, causing subtle or dramatic changes throughout the body and
brain. These shifts usually occur entirely without conscious input or awareness: The
subcortical regions of the brain are astoundingly efficient in regulating our
breathing, heartbeat, digestion, hormone secretion, and immune system. However,
these systems can become overwhelmed if we are challenged by an ongoing threat, or
even the perception of threat. This accounts for the wide array of physical problems
researchers have documented in traumatized people.

Yet our conscious self also plays a
vital role in maintaining our inner equilibrium: We need to register and act on our
physical sensations to keep our bodies safe. Realizing we’re cold compels us
to put on a sweater; feeling hungry or spacey tells us our blood sugar is low and
spurs us to get a snack; the pressure of a full bladder sends us to the bathroom.
Damasio points out that all of the brain structures that register background
feelings are located near areas that control basic housekeeping functions, such as
breathing, appetite, elimination, and sleep/wake cycles: “This is because the
consequences of having emotion and attention are entirely related to the fundamental
business of managing life within the organism. It is not possible to manage life and
maintain homeostatic balance without data on the current state of the
organism’s body.”[9] Damasio calls these housekeeping areas
of the brain the “proto-self,” because they create the “wordless
knowledge” that underlies our conscious sense of self.

THE SELF UNDER THREAT

In 2000 Damasio and his colleagues
published an article in the world’s foremost scientific publication,
Science, which reported that reliving a strong negative emotion causes significant changes in the brain
areas that receive nerve signals from the muscles, gut, and skin—areas that are
crucial for regulating basic bodily functions. The team’s brain scans showed
that recalling an emotional event from the past causes us to actually reexperience
the visceral sensations felt during the original event. Each type of emotion
produced a characteristic pattern, distinct from the others. For example, a
particular part of the brain stem was “active in sadness and anger, but not in
happiness or fear.”[10] All of these brain regions are below the limbic system, to
which emotions are traditionally assigned, yet we acknowledge their involvement
every time we use one of the common expressions that link strong emotions with the
body: “You make me sick”; “It made my skin crawl”; “I
was all choked up”; “My heart sank”; “He makes me
bristle.”

The elementary self system in the brain
stem and limbic system is massively activated when people are faced with the threat
of annihilation, which results in an overwhelming sense of fear and terror
accompanied by intense physiological arousal. To people who are reliving a trauma,
nothing makes sense; they are trapped in a life-or-death situation, a state of
paralyzing fear or blind rage. Mind and body are constantly aroused, as if they are
in imminent danger. They startle in response to the slightest noises and are
frustrated by small irritations. Their sleep is chronically disturbed, and food
often loses its sensual pleasures. This in turn can trigger desperate attempts to
shut those feelings down by freezing and dissociation.[11]

How do people regain control when their
animal brains are stuck in a fight for survival? If what goes on deep inside our
animal brains dictates how we feel, and if our body sensations are orchestrated by
subcortical (subconscious) brain structures, how much control over them can we
actually have?

AGENCY: OWNING YOUR LIFE

“Agency” is the technical
term for the feeling of being in charge of your life: knowing where you stand,
knowing that you have a say in what happens to you, knowing that you have some
ability to shape your circumstances. The veterans who put their fists through
drywall at the VA were trying to assert their agency—to make something happen. But
they ended up feeling even more out of control, and many of these once-confident men
were trapped in a cycle between frantic activity and immobility.

Agency starts with what scientists call
interoception, our awareness of our subtle sensory, body-based feelings: the greater
that awareness, the greater our potential to control our lives. Knowing
what we feel is the first step to knowing why we feel that way. If we are
aware of the constant changes in our inner and outer environment, we can
mobilize to manage them. But we can’t do this unless our watchtower, the MPFC,
learns to observe what is going on inside us. This is why mindfulness practice,
which strengthens the MPFC, is a cornerstone of recovery from trauma.[12]

After I saw the wonderful movie
March of the Penguins, I found myself thinking about some of my
patients. The penguins are stoic and endearing, and it’s tragic to learn how,
from time immemorial, they have trudged seventy miles inland from the sea, endured
indescribable hardships to reach their breeding grounds, lost numerous viable eggs
to exposure, and then, almost starving, dragged themselves back to the ocean. If
penguins had our frontal lobes, they would have used their little flippers to build
igloos, devised a better division of labor, and reorganized their food supplies.
Many of my patients have survived trauma through tremendous courage and persistence,
only to get into the same kinds of trouble over and over again. Trauma has shut down
their inner compass and robbed them of the imagination they need to create something
better.

The neuroscience of self hood and agency
validates the kinds of somatic therapies that my friends Peter Levine[13] and Pat
Ogden[14] have
developed. I’ll discuss these and other sensorimotor approaches in more detail
in part V, but in essence their aim is threefold:

- to draw out the sensory information that
is blocked and frozen by trauma;

- to help patients befriend (rather than
suppress) the energies released by that inner experience;

- to complete the self-preserving physical
actions that were thwarted when they were trapped, restrained, or immobilized by
terror.

Our gut feelings signal what is safe,
life sustaining, or threatening, even if we cannot quite explain why we feel a
particular way. Our sensory interiority continuously sends us subtle messages about
the needs of our organism. Gut feelings also help us to evaluate what is going on
around us. They warn us that the guy who is approaching feels creepy, but they also
convey that a room with western exposure surrounded by daylilies makes us feel
serene. If you have a comfortable connection with your inner sensations—if you can
trust them to give you accurate information—you will feel in charge of your body,
your feelings, and your self.

However, traumatized people chronically
feel unsafe inside their bodies: The past is alive in the form of gnawing interior
discomfort. Their bodies are constantly
bombarded by visceral warning signs, and, in an attempt to control these processes,
they often become expert at ignoring their gut feelings and in numbing awareness of
what is played out inside. They learn to hide from their selves.

The more people try to push away and
ignore internal warning signs, the more likely they are to take over and leave them
bewildered, confused, and ashamed. People who cannot comfortably notice what is
going on inside become vulnerable to respond to any sensory shift either by shutting
down or by going into a panic—they develop a fear of fear itself.

We now know that panic symptoms are
maintained largely because the individual develops a fear of the bodily sensations
associated with panic attacks. The attack may be triggered by something he or she
knows is irrational, but fear of the sensations keeps them escalating into a
full-body emergency. “Scared stiff” and “frozen in fear”
(collapsing and going numb) describe precisely what terror and trauma feel like.
They are its visceral foundation. The experience of fear derives from primitive
responses to threat where escape is thwarted in some way. People’s lives will
be held hostage to fear until that visceral experience changes.

The price for ignoring or distorting the
body’s messages is being unable to detect what is truly dangerous or harmful
for you and, just as bad, what is safe or nourishing. Self-regulation depends on
having a friendly relationship with your body. Without it you have to rely on
external regulation—from medication, drugs like alcohol, constant reassurance, or
compulsive compliance with the wishes of others.

Many of my patients respond to stress
not by noticing and naming it but by developing migraine headaches or asthma
attacks.[15]
Sandy, a middle-aged visiting nurse, told me she’d felt terrified and lonely
as a child, unseen by her alcoholic parents. She dealt with this by becoming
deferential to everybody she depended on (including me, her therapist). Whenever her
husband made an insensitive remark, she would come down with an asthma attack. By
the time she noticed that she couldn’t breathe, it was too late for an inhaler
to be effective, and she had to be taken to the emergency room.

Suppressing our inner cries for help
does not stop our stress hormones from mobilizing the body. Even though Sandy had
learned to ignore her relationship problems and block out her physical distress
signals, they showed up in symptoms that demanded her attention. Her therapy focused
on identifying the link between her physical sensations and her emotions, and I also
encouraged her to enroll in a kickboxing program. She had no emergency room visits
during the three years she was my patient.

Somatic symptoms for which no clear
physical basis can be found are ubiquitous in traumatized children and adults. They
can include chronic back and neck pain, fibromyalgia, migraines, digestive problems,
spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of
asthma.[16]
Traumatized children have fifty times the rate of asthma as their nontraumatized
peers.[17]
Studies have shown that many children and adults with fatal asthma attacks were not
aware of having breathing problems before the attacks.

ALEXITHYMIA: NO WORDS FOR
FEELINGS

I had a widowed aunt with a painful
trauma history who became an honorary grandmother to our children. She came on
frequent visits that were marked by much doing—making curtains, rearranging kitchen
shelves, sewing children’s clothes—and very little talking. She was always
eager to please, but it was difficult to figure out what she enjoyed. After
several days of exchanging pleasantries, conversation would come to a halt, and
I’d have to work hard to fill the long silences. On the last day of her visits
I’d drive her to the airport, where she’d give me a stiff good-bye hug
while tears streamed down her face. Without a trace of irony she’d then
complain that the cold wind at Logan International Airport made her eyes water. Her
body felt the sadness that her mind couldn’t register—she was leaving our
young family, her closest living relatives.

Psychiatrists call this phenomenon
alexithymia—Greek for not having words for feelings. Many traumatized children and
adults simply cannot describe what they are feeling because they cannot identify
what their physical sensations mean. They may look furious but deny that they are
angry; they may appear terrified but say that they are fine. Not being able to
discern what is going on inside their bodies causes them to be out of touch with
their needs, and they have trouble taking care of themselves, whether it involves
eating the right amount at the right time or getting the sleep they need.

Like my aunt, alexithymics substitute
the language of action for that of emotion. When asked, “How would you feel if
you saw a truck coming at you at eighty miles per hour?” most people would
say, “I’d be terrified” or “I’d be frozen with
fear.” An alexithymic might reply, “How would I feel? I don’t
know. … I’d get out of the way.”[18] They tend to register
emotions as physical problems rather than as signals that something deserves their
attention. Instead of feeling angry or sad, they experience muscle pain, bowel
irregularities, or other symptoms for which no cause can be found. About three
quarters of patients with anorexia nervosa, and more than half of all patients with
bulimia, are bewildered by their emotional feelings and have great difficulty describing them.[19] When researchers showed
pictures of angry or distressed faces to people with alexithymia, they could not
figure out what those people were feeling.[20]

One of the first people who taught me
about alexithymia was the psychiatrist Henry Krystal, who worked with more than a
thousand Holocaust survivors in his effort to understand massive psychic trauma.[21] Krystal,
himself a concentration camp survivor, found that many of his patients were
professionally successful, but their intimate relationships were bleak and distant.
Suppressing their feelings had made it possible to attend to the business of the
world, but at a price. They learned to shut down their once overwhelming emotions,
and, as a result, they no longer recognized what they were feeling. Few of them had
any interest in therapy.

Paul Frewen at the University of Western
Ontario did a series of brain scans of people with PTSD who suffered from
alexithymia. One of the participants told him: “I don’t know what I
feel, it’s like my head and body aren’t connected. I’m living in a
tunnel, a fog, no matter what happens it’s the same reaction—numbness,
nothing. Having a bubble bath and being burned or raped is the same feeling. My
brain doesn’t feel.” Frewen and his colleague Ruth Lanius found that the
more people were out of touch with their feelings, the less activity they had in the
self-sensing areas of the brain.[22]

Because traumatized people often have
trouble sensing what is going on in their bodies, they lack a nuanced response to
frustration. They either react to stress by becoming “spaced out” or
with excessive anger. Whatever their response, they often can’t tell what is
upsetting them. This failure to be in touch with their bodies contributes to their
well-documented lack of self-protection and high rates of revictimization[23] and also to
their remarkable difficulties feeling pleasure, sensuality, and having a sense of
meaning.

People with alexithymia can get better
only by learning to recognize the relationship between their physical sensations and
their emotions, much as colorblind people can only enter the world of color by
learning to distinguish and appreciate shades of gray. Like my aunt and Henry
Krystal’s patients, they usually are reluctant to do that: Most seem to have
made an unconscious decision that it is better to keep visiting doctors and treating
ailments that don’t heal than to do the painful work of facing the demons of
the past.

DEPERSONALIZATION

One step further down on the ladder to
self-oblivion is depersonalization—losing your sense of yourself. Ute’s brain
scan in chapter 4 is, in its very blankness, a vivid illustration of depersonalization.
Depersonalization is common during traumatic experiences. I was once mugged late at
night in a park close to my home and, floating above the scene, saw myself lying in
the snow with a small head wound, surrounded by three knife-wielding teenagers. I
dissociated the pain of their stab wounds on my hands and did not feel the slightest
fear as I calmly negotiated for the return of my emptied wallet.

I did not develop PTSD, partly, I think,
because I was intensely curious about having an experience I had studied so closely
in others, and partly because I had the delusion that I would be able make a drawing
of my muggers to show to the police. Of course, they were never caught, but my
fantasy of revenge must have given me a satisfying sense of agency.

Traumatized people are not so fortunate
and feel separated from their bodies. One particularly good description of
depersonalization comes from the German psychoanalyst Paul Schilder, writing in
Berlin in 1928:[24] “To the depersonalized individual the world appears strange,
peculiar, foreign, dream-like. Objects appear at times strangely diminished in size,
at times flat. Sounds appear to come from a distance. … The emotions
likewise undergo marked alteration. Patients complain that they are capable of
experiencing neither pain nor pleasure. … They have become strangers to
themselves.”

I was fascinated to learn that a group
of neuroscientists at the University of Geneva[25] had induced similar out-of-body
experiences by delivering mild electric current to a specific spot in the brain, the
temporal parietal junction. In one patient this produced a sensation that she was
hanging from the ceiling, looking down at her body; in another it induced an eerie
feeling that someone was standing behind her. This research confirms what our
patients tell us: that the self can be detached from the body and live a phantom
existence on its own. Similarly, Lanius and Frewen, as well as a group of
researchers at the University of Groningen in the Netherlands,[26] did brain scans on people
who dissociated their terror and found that the fear centers of the brain simply
shut down as they recalled the event.

BEFRIENDING THE BODY

Trauma victims cannot recover until they
become familiar with and befriend the sensations in their bodies. Being frightened
means that you live in a body that is always on guard. Angry people live in angry
bodies. The bodies of child-abuse victims are tense and defensive until they find a
way to relax and feel safe. In order to
change, people need to become aware of their sensations and the way that their
bodies interact with the world around them. Physical self-awareness is the first
step in releasing the tyranny of the past.

How can people open up to and explore
their internal world of sensations and emotions? In my practice I begin the process
by helping my patients to first notice and then describe the feelings in their
bodies—not emotions such as anger or anxiety or fear but the physical sensations
beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling
hollow, and so on. I also work on identifying the sensations associated with
relaxation or pleasure. I help them become aware of their breath, their gestures and
movements. I ask them to pay attention to subtle shifts in their bodies, such as
tightness in their chests or gnawing in their bellies, when they talk about negative
events that they claim did not bother them.

Noticing sensations for the first time
can be quite distressing, and it may precipitate flashbacks in which people curl up
or assume defensive postures. These are somatic reenactments of the undigested
trauma and most likely represent the postures they assumed when the trauma occurred.
Images and physical sensations may deluge patients at this point, and the therapist
must be familiar with ways to stem torrents of sensation and emotion to prevent them
from becoming retraumatized by accessing the past. (Schoolteachers, nurses, and
police officers are often very skilled at soothing terror reactions because many of
them are confronted almost daily with out-of-control or painfully disorganized
people.)

All too often, however, drugs such as
Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills
to deal with such distressing physical reactions. Of course, medications only blunt
sensations and do nothing to resolve them or transform them from toxic agents into
allies.

The most natural way for human beings to
calm themselves when they are upset is by clinging to another person. This means
that patients who have been physically or sexually violated face a dilemma: They
desperately crave touch while simultaneously being terrified of body contact. The
mind needs to be reeducated to feel physical sensations, and the body needs to be
helped to tolerate and enjoy the comforts of touch. Individuals who lack emotional
awareness are able, with practice, to connect their physical sensations to
psychological events. Then they can slowly reconnect with themselves.[27]

CONNECTING WITH YOURSELF, CONNECTING
WITH OTHERS

I’ll end this chapter with one
final study that demonstrates the cost of losing your body. After Ruth Lanius and
her group scanned the idling brain, they focused on another question from everyday
life: What happens in chronically traumatized people when they make face-to-face
contact?

Many patients who come to my office are
unable to make eye contact. I immediately know how distressed they are by their
difficulty meeting my gaze. It always turns out that they feel disgusting and that
they can’t stand having me see how despicable they are. It never occurred to
me that these intense feelings of shame would be reflected in abnormal brain
activation. Ruth Lanius once again showed that mind and brain are
indistinguishable—what happens in one is registered in the other.

Ruth bought an expensive device that
presents a video character to a person lying in a scanner. (In this case, the
cartoon resembled a kindly Richard Gere.) The figure can approach either head on
(looking directly at the person) or at a forty-five-degree angle with an averted
gaze. This made it possible to compare the effects of direct eye contact on brain
activation with those of an averted gaze.[28]

The most striking difference between
normal controls and survivors of chronic trauma was in activation of the prefrontal
cortex in response to a direct eye gaze. The prefrontal cortex (PFC) normally helps
us to assess the person coming toward us, and our mirror neurons help to pick up his
intentions. However, the subjects with PTSD did not activate any part of their
frontal lobe, which means they could not muster any curiosity about the stranger.
They just reacted with intense activation deep inside their emotional brains, in the
primitive areas known as the Periaqueductal Gray, which generates startle,
hypervigilance, cowering, and other self-protective behaviors. There was no
activation of any part of the brain involved in social engagement. In response to
being looked at they simply went into survival mode.

What does this mean for their ability to
make friends and get along with others? What does it mean for their therapy? Can
people with PTSD trust a therapist with their deepest fears? To have genuine
relationships you have to be able to experience others as separate individuals, each
with his or her particular motivations and intentions. While you need to be able to
stand up for yourself, you also need to recognize that other people have their own
agendas. Trauma can make all that hazy and gray.

Part Three

THE MINDS OF CHILDREN

CHAPTER 7

Getting on the Same Wavelength:
Attachment and Attunement

The roots of resilience … are to be
found in the sense of being understood by and existing in the mind and heart of a
loving, attuned, and self-possessed other.

—Diana Fosha

The Children’s Clinic at the
Massachusetts Mental Health Center was filled with disturbed and disturbing kids.
They were wild creatures who could not sit still and who hit and bit other children,
and sometimes even the staff. They would run up to you and cling to you one moment
and run away, terrified, the next. Some masturbated compulsively; others lashed out
at objects, pets, and themselves. They were at once starving for affection and angry
and defiant. The girls in particular could be painfully compliant. Whether
oppositional or clingy, none of them seemed able to explore or play in ways typical
for children their age. Some of them had hardly developed a sense of self—they
couldn’t even recognize themselves in a mirror.

At the time, I knew very little about
children, apart from what my two preschoolers were teaching me. But I was fortunate
in my colleague Nina Fish-Murray, who had studied with Jean Piaget in Geneva, in
addition to raising five children of her own. Piaget based his theories of child
development on meticulous, direct observation of children themselves, starting with
his own infants, and Nina brought this spirit to the incipient Trauma Center at
MMHC.

Nina was married to the former chairman
of the Harvard psychology department,
Henry Murray, one of the pioneers of personality theory, and she actively encouraged
any junior faculty members who shared her interests. She was fascinated by my
stories about combat veterans because they reminded her of the troubled kids she
worked with in the Boston public schools. Nina’s privileged position and
personal charm gave us access to the Children’s Clinic, which was run by child
psychiatrists who had little interest in trauma.

Henry Murray had, among other things,
become famous for designing the widely used Thematic Apperception Test. The TAT is a
so-called projective test, which uses a set of cards to discover how people’s
inner reality shapes their view of the world. Unlike the Rorschach cards we used
with the veterans, the TAT cards depict realistic but ambiguous and somewhat
troubling scenes: a man and a woman gloomily staring away from each other, a boy
looking at a broken violin. Subjects are asked to tell stories about what is going
on in the photo, what has happened previously, and what happens next. In most cases
their interpretations quickly reveal the themes that preoccupy them.

Nina and I decided to create a set of
test cards specifically for children, based on pictures we cut out of magazines in
the clinic waiting room. Our first study compared twelve six- to eleven-year-olds at
the children’s clinic with a group of children from a nearby school who
matched them as closely as possible in age, race, intelligence, and family
constellation.[1] What differentiated our patients was the abuse they had suffered
within their families. They included a boy who was severely bruised from repeated
beatings by his mother; a girl whose father had molested her at the age of four; two
boys who had been repeatedly tied to a chair and whipped; and a girl who, at the age
of five, had seen her mother (a prostitute) raped, dismembered, burned, and put into
the trunk of a car. The mother’s pimp was suspected of sexually abusing the
girl.

The children in our control group also
lived in poverty in a depressed area of Boston where they regularly witnessed
shocking violence. While the study was being conducted, one boy at their
school threw gasoline at a classmate and set him on fire. Another boy was caught in
crossfire while walking to school with his father and a friend. He was wounded in
the groin, and his friend was killed. Given their exposure to such a high baseline
level of violence, would their responses to the cards differ from those of the
hospitalized children?

One of our cards depicted a family
scene: two smiling kids watching dad repair a car. Every child who looked at it
commented on the danger to the man lying
underneath the vehicle. While the control children told stories with benign
endings—the car would get fixed, and maybe dad and the kids would drive to
McDonald’s—the traumatized kids came up with gruesome tales. One girl said
that the little girl in the picture was about to smash in her father’s skull
with a hammer. A nine-year-old boy who had been severely physically abused told an
elaborate story about how the boy in the picture kicked away the jack, so that the
car mangled his father’s body and his blood spurted all over the garage.

As they told us these stories, our
patients got very excited and disorganized. We had to take considerable time out at
the water cooler and going for walks before we could show them the next card. It was
little wonder that almost all of them had been diagnosed with ADHD, and most were on
Ritalin—though the drug certainly didn’t seem to dampen their arousal in this
situation.

The abused kids gave similar responses
to a seemingly innocuous picture of a pregnant woman silhouetted against a window.
When we showed it to the seven-year-old girl who’d been sexually abused at age
four, she talked about penises and vaginas and repeatedly asked Nina questions like
“How many people have you humped?” Like several of the other sexually
abused girls in the study, she became so agitated that we had to stop. A
seven-year-old girl from the control group picked up the wistful mood of the
picture: Her story was about a widowed lady sadly looking out the window, missing
her husband. But in the end, the lady
found a loving man to be a good father to her baby.

In card after card we saw that, despite
their alertness to trouble, the children who had not been abused still trusted in an
essentially benign universe; they could imagine ways out of bad situations. They
seemed to feel protected and safe within their own families. They also felt loved by
at least one of their parents, which seemed to make a substantial difference in
their eagerness to engage in schoolwork and to learn.

The responses of the clinic children
were alarming. The most innocent images stirred up intense feelings of danger,
aggression, sexual arousal, and terror. We had not selected these photos because
they had some hidden meaning that sensitive people could uncover; they were ordinary
images of everyday life. We could only conclude that for abused children, the whole
world is filled with triggers. As long as they can imagine only disastrous outcomes
to relatively benign situations, anybody walking into a room, any stranger, any
image, on a screen or on a billboard might be perceived as a harbinger of
catastrophe. In this light the bizarre behavior of the kids at the children’s
clinic made perfect sense.[2]

To my amazement, staff discussions on
the unit rarely mentioned the horrific
real-life experiences of the children and the impact of those traumas on their
feelings, thinking, and self-regulation. Instead, their medical records were filled
with diagnostic labels: “conduct disorder” or “oppositional
defiant disorder” for the angry and rebellious kids; or “bipolar
disorder.” ADHD was a “comorbid” diagnosis for almost all. Was the
underlying trauma being obscured by this blizzard of diagnoses?

Now we faced two big challenges. One was
to learn whether the different worldview of normal children could account for their
resilience and, on a deeper level, how each child actually creates her map of the
world. The other, equally crucial, question was: Is it possible to help the minds
and brains of brutalized children to redraw their inner maps and incorporate a sense
of trust and confidence in the future?

MEN WITHOUT MOTHERS

The scientific study of the vital
relationship between infants and their mothers was started by upper-class Englishmen
who were torn from their families as young boys to be sent off to boarding schools,
where they were raised in regimented same-sex settings. The first time I visited the
famed Tavistock Clinic in London I noticed a collection of black-and-white
photographs of these great twentieth-century psychiatrists hanging on the wall going
up the main staircase: John Bowlby, Wilfred Bion, Harry Guntrip, Ronald Fairbairn,
and Donald Winnicott. Each of them, in his own way, had explored how our early
experiences become prototypes for all our later connections with others, and how our
most intimate sense of self is created in our minute-to-minute exchanges with our
caregivers.

Scientists study what puzzles them most,
so that they often become experts in subjects that others take for granted. (Or, as
the attachment researcher Beatrice Beebe once told me, “most research is
me-search.”) These men who studied the role of mothers in children’s
lives had themselves been sent off to school at a vulnerable age, sometime between
six and ten, long before they should have faced the world alone. Bowlby himself told
me that just such boarding-school experiences probably inspired George
Orwell’s novel 1984, which brilliantly expresses how human beings may
be induced to sacrifice everything they hold dear and true—including their sense of
self—for the sake of being loved and approved of by someone in a position of
authority.

Since Bowlby was close friends with the
Murrays, I had a chance to talk with him about his work whenever he visited Harvard.
He was born into an aristocratic family
(his father was surgeon to the King’s household), and he trained in
psychology, medicine, and psychoanalysis at the temples of the British
establishment. After attending Cambridge University, he worked with delinquent boys
in London’s East End, a notoriously rough and crime-ridden neighborhood that
was largely destroyed during the Blitz. During and after his service in World War
II, he observed the effects of wartime evacuations and group nurseries that
separated young children from their families. He also studied the effect of
hospitalization, showing that even brief separations (parents back then were not
allowed to visit overnight) compounded the children’s suffering. By the late
1940s Bowlby had become persona non grata in the British psychoanalytic
community, as a result of his radical claim that children’s disturbed behavior
was a response to actual life experiences—to neglect, brutality, and
separation—rather than the product of infantile sexual fantasies. Undaunted, he
devoted the rest of his life to developing what came to be called attachment
theory.[3]

A SECURE BASE

As we enter this world we scream to
announce our presence. Someone immediately engages with us, bathes us, swaddles us,
and fills our stomachs, and, best of all, our mother may put us on her belly or
breast for delicious skin-to-skin contact. We are profoundly social creatures; our
lives consist of finding our place within the community of human beings. I love the
expression of the great French psychiatrist Pierre Janet: “Every life is a
piece of art, put together with all means available.”

As we grow up, we gradually learn to
take care of ourselves, both physically and emotionally, but we get our first
lessons in self-care from the way that we are cared for. Mastering the
skill of self-regulation depends to a large degree on how harmonious our early
interactions with our caregivers are. Children whose parents are reliable sources of
comfort and strength have a lifetime advantage—a kind of buffer against the worst
that fate can hand them.

John Bowlby realized that children are
captivated by faces and voices and are exquisitely sensitive to facial expression,
posture, tone of voice, physiological changes, tempo of movement and incipient
action. He saw this inborn capacity as a product of evolution, essential to the
survival of these helpless creatures. Children are also programmed to choose one
particular adult (or at most a few) with whom their natural communication system
develops. This creates a primary attachment bond. The more responsive the adult is
to the child, the deeper the attachment
and the more likely the child will develop healthy ways of responding to the people
around him.

Bowlby would often visit Regent’s
Park in London, where he would make systematic observations of the interactions
between children and their mothers. While the mothers sat quietly on park benches,
knitting or reading the paper, the kids would wander off to explore, occasionally
looking over their shoulders to ascertain that Mum was still watching. But when a
neighbor stopped by and absorbed his mother’s interest with the latest gossip,
the kids would run back and stay close, making sure he still had her attention. When
infants and young children notice that their mothers are not fully engaged with
them, they become nervous. When their mothers disappear from sight, they may cry and
become inconsolable, but as soon as their mothers return, they quiet down and resume
their play.

Bowlby saw attachment as the secure base
from which a child moves out into the world. Over the subsequent five decades
research has firmly established that having a safe haven promotes self-reliance and
instills a sense of sympathy and helpfulness to others in distress. From the
intimate give-and-take of the attachment bond children learn that other people have
feelings and thoughts that are both similar to and different from theirs. In other
words, they get “in sync” with their environment and with the people
around them and develop the self-awareness, empathy, impulse control, and
self-motivation that make it possible to become contributing members of the larger
social culture. These qualities were painfully missing in the kids at our
Children’s Clinic.

THE DANCE OF ATTUNEMENT

Children become attached to whoever
functions as their primary caregiver. But the nature of that attachment—whether it
is secure or insecure—makes a huge difference over the course of a child’s
life. Secure attachment develops when caregiving includes emotional attunement.
Attunement starts at the most subtle physical levels of interaction between babies
and their caretakers, and it gives babies the feeling of being met and understood.
As Edinburghbased attachment researcher Colwyn Trevarthen says: “The brain
coordinates rhythmic body movements and guides them to act in sympathy with other
people’s brains. Infants hear and learn musicality from their mother’s
talk, even before birth.”[4]

In chapter
4 I described the discovery of mirror neurons, the brain-to-brain links that
give us our capacity for empathy. Mirror neurons start functioning as soon as babies are born. When researcher
Andrew Meltzoff at the University of Oregon pursed his lips or stuck out his tongue
at six-hour-old babies, they promptly mirrored his actions.[5] (Newborns can focus their
eyes only on objects within eight to twelve inches—just enough see the person who is
holding them). Imitation is our most fundamental social skill. It assures that we
automatically pick up and reflect the behavior of our parents, teachers, and
peers.

Most parents relate to their babies so
spontaneously that they are barely aware of how attunement unfolds. But an
invitation from a friend, the attachment researcher Ed Tronick, gave me the chance
to observe that process more closely. Through a one-way mirror at Harvard’s
Laboratory of Human Development, I watched a mother playing with her two-month-old
son, who was propped in an infant seat facing her.

They were cooing to each other and
having a wonderful time—until the mother leaned in to nuzzle him and the baby, in
his excitement, yanked on her hair. The mother was caught unawares and yelped with
pain, pushing away his hand while her face contorted with anger. The baby let go
immediately, and they pulled back physically from each other. For both of them the
source of delight had become a source of distress. Obviously frightened, the baby
brought his hands up to his face to block out the sight of his angry mother. The
mother, in turn, realizing that her baby was upset, refocused on him, making
soothing sounds in an attempt to smooth things over. The infant still had his eyes
covered, but his craving for connection soon reemerged. He started peeking out to
see if the coast was clear, while his mother reached toward him with a concerned
expression. As she started to tickle his belly, he dropped his arms and broke into a
happy giggle, and harmony was reestablished. Infant and mother were attuned again.
This entire sequence of delight, rupture, repair, and new delight took slightly less
than twelve seconds.

Tronick and other researchers have now
shown that when infants and caregivers are in sync on an emotional level,
they’re also in sync physically.[6] Babies can’t regulate their own
emotional states, much less the changes in heart rate, hormone levels, and
nervous-system activity that accompany emotions. When a child is in sync with his
caregiver, his sense of joy and connection is reflected in his steady heartbeat and
breathing and a low level of stress hormones. His body is calm; so are his
emotions. The moment this music is disrupted—as it often is in the course of a
normal day—all these physiological factors change as well. You can tell equilibrium
has been restored when the physiology calms down.

We soothe newborns, but parents soon start
teaching their children to tolerate higher levels of arousal, a job that is often
assigned to fathers. (I once heard the psychologist John Gottman say, “Mothers
stroke, and fathers poke.”) Learning how to manage arousal is a key life
skill, and parents must do it for babies before babies can do it for themselves. If
that gnawing sensation in his belly makes a baby cry, the breast or bottle arrives.
If he’s scared, someone holds and rocks him until he calms down. If his bowels
erupt, someone comes to make him clean and dry. Associating intense sensations with
safety, comfort, and mastery is the foundation of self-regulation, self-soothing,
and self-nurture, a theme to which I return throughout this book.

A secure attachment combined with the
cultivation of competency builds an internal locus of control, the key
factor in healthy coping throughout life.[7] Securely attached children learn what
makes them feel good; they discover what makes them (and others) feel bad, and they
acquire a sense of agency: that their actions can change how they feel and how
others respond. Securely attached kids learn the difference between situations they
can control and situations where they need help. They learn that they can play an
active role when faced with difficult situations. In contrast, children with
histories of abuse and neglect learn that their terror, pleading, and crying do not
register with their caregiver. Nothing they can do or say stops the beating or
brings attention and help. In effect they’re being conditioned to give up when
they face challenges later in life.

BECOMING REAL

Bowlby’s contemporary, the
pediatrician and psychoanalyst Donald Winnicott, is the father of modern studies of
attunement. His minute observations of mothers and children started with the way
mothers hold their babies. He proposed that these physical interactions lay the
groundwork for a baby’s sense of self—and, with that, a lifelong sense of
identity. The way a mother holds her child underlies “the ability to feel the
body as the place where the psyche lives.”[8] This visceral and kinesthetic
sensation of how our bodies are met lays the foundation for what we experience as
“real.”[9]

Winnicott thought that the vast majority
of mothers did just fine in their attunement to their infants—it does not require
extraordinary talent to be what he called a “good enough mother.”[10] But things
can go seriously wrong when mothers are unable to tune in to their baby’s
physical reality. If a mother cannot meet her baby’s impulses and needs,
“the baby learns to become the mother’s idea of what the baby is.”
Having to discount its inner sensations, and trying to adjust to its caregiver’s needs,
means the child perceives that “something is wrong” with the way it is.
Children who lack physical attunement are vulnerable to shutting down the direct
feedback from their bodies, the seat of pleasure, purpose, and direction.

In the years since Bowlby’s and
Winnicott’s ideas were introduced, attachment research around the world has
shown that the vast majority of children are securely attached. When they grow up,
their history of reliable, responsive caregiving will help to keep fear and anxiety
at bay. Barring exposure to some overwhelming life event—trauma—that breaks down the
self-regulatory system, they will maintain a fundamental state of emotional security
throughout their lives. Secure attachment also forms a template for children’s
relationships. They pick up what others are feeling and early on learn to tell a
game from reality, and they develop a good nose for phony situations or dangerous
people. Securely attached children usually become pleasant playmates and have lots
of self-affirming experiences with their peers. Having learned to be in tune with
other people, they tend to notice subtle changes in voices and faces and to adjust
their behavior accordingly. They learn to live within a shared understanding of the
world and are likely to become valued members of the community.

This upward spiral can, however, be
reversed by abuse or neglect. Abused kids are often very sensitive to changes in
voices and faces, but they tend to respond to them as threats rather than as cues
for staying in sync. Dr. Seth Pollak of the University of Wisconsin showed a series
of faces to a group of normal eight-year-olds and compared their responses with
those of a group of abused children the same age. Looking at this spectrum of angry
to sad expressions, the abused kids were hyperalert to the slightest features of
anger.[11]

COPYRIGHT © 2000, AMERICAN PSYCHOLOGICAL
ASSOCIATION

This is one reason abused children so
easily become defensive or scared. Imagine what it’s like to make your way
through a sea of faces in the school corridor, trying to figure out who might
assault you. Children who overreact to their peers’ aggression, who
don’t pick up on other kids’ needs, who easily shut down or lose control
of their impulses, are likely to be shunned and left out of sleepovers or play
dates. Eventually they may learn to cover up their fear by putting up a tough front. Or they may spend more
and more time alone, watching TV or playing computer games, falling even further
behind on interpersonal skills and emotional self-regulation.

The need for attachment never lessens.
Most human beings simply cannot tolerate being disengaged from others for any length
of time. People who cannot connect through work, friendships, or family usually find
other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is
preferable to that godforsaken sense of irrelevance and alienation.

A few years ago, on Christmas Eve, I was
called to examine a fourteen-year-old boy at the Suffolk County Jail. Jack had been
arrested for breaking into the house of neighbors who were away on vacation. The
burglar alarm was howling when the police found him in the living room.

The first question I asked Jack was who
he expected would visit him in jail on Christmas. “Nobody,” he told me.
“Nobody ever pays attention to me.” It turned out that he had been
caught during break-ins numerous times before. He knew the police, and they knew
him. With delight in his voice, he told me that when the cops saw him standing in
the middle of the living room, they yelled, “Oh my God, it’s Jack again,
that little motherfucker.” Somebody recognized him; somebody knew his name. A
little while later Jack confessed, “You know, that is what makes it
worthwhile.” Kids will go to almost any length to feel seen and connected.

LIVING WITH THE PARENTS YOU
HAVE

Children have a biological instinct to
attach—they have no choice. Whether their parents or caregivers are loving and
caring or distant, insensitive, rejecting, or abusive, children will develop a
coping style based on their attempt to get at least some of their needs met.

We now have reliable ways to assess and
identify these coping styles, thanks largely to the work of two American scientists,
Mary Ainsworth and Mary Main, and their colleagues, who conducted thousands of hours
of observation of mother-infant pairs over many years. Based on these studies,
Ainsworth created a research tool called the Strange Situation, which looks at how
an infant reacts to temporary separation from the mother. Just as Bowlby had
observed, securely attached infants are distressed when their mother leaves them,
but they show delight when she returns, and after a brief check-in for reassurance,
they settle down and resume their play.

But with infants who are insecurely
attached, the picture is more complex. Children whose primary caregiver is
unresponsive or rejecting learn to deal
with their anxiety in two distinct ways. The researchers noticed that some seemed
chronically upset and demanding with their mothers, while others were more passive
and withdrawn. In both groups contact with the mothers failed to settle them
down—they did not return to play contentedly, as happens in secure attachment.

In one pattern, called “avoidant
attachment,” the infants look like nothing really bothers them—they
don’t cry when their mother goes away and they ignore her when she comes back.
However, this does not mean that they are unaffected. In fact, their chronically
increased heart rates show that they are in a constant state of hyperarousal. My
colleagues and I call this pattern “dealing but not feeling.”[12] Most mothers
of avoidant infants seem to dislike touching their children. They have trouble
snuggling and holding them, and they don’t use their facial expressions and
voices to create pleasurable back-and-forth rhythms with their babies.

In another pattern, called
“anxious” or “ambivalent” attachment, the infants constantly
draw attention to themselves by crying, yelling, clinging, or screaming: They are
“feeling but not dealing.”[13] They seem to have concluded that
unless they make a spectacle, nobody is going to pay attention to them. They become
enormously upset when they do not know where their mother is but derive little
comfort from her return. And even though they don’t seem to enjoy her company,
they stay passively or angrily focused on her, even in situations when other
children would rather play.[14]

Attachment researchers think that the
three “organized” attachment strategies (secure, avoidant, and anxious)
work because they elicit the best care a particular caregiver is capable of
providing. Infants who encounter a consistent pattern of care—even if it’s
marked by emotional distance or insensitivity—can adapt to maintain the
relationship. That does not mean that there are no problems: Attachment patterns
often persist into adulthood. Anxious toddlers tend to grow into anxious adults,
while avoidant toddlers are likely to become adults who are out of touch with their
own feelings and those of others. (As in, “There’s nothing wrong with a
good spanking. I got hit and it made me the success I am today.”) In school
avoidant children are likely to bully other kids, while the anxious children are
often their victims.[15] However, development is not linear, and many life experiences
can intervene to change these outcomes.

But there is another group that is less
stably adapted, a group that makes up the bulk of the children we treat and a
substantial proportion of the adults who are seen in psychiatric clinics. Some
twenty years ago, Mary Main and her
colleagues at Berkeley began to identify a group of children (about 15 percent of
those they studied) who seemed to be unable to figure out how to engage with their
caregivers. The critical issue turned out to be that the caregivers themselves were
a source of distress or terror to the children.[16]

Children in this situation have no one
to turn to, and they are faced with an unsolvable dilemma; their mothers are
simultaneously necessary for survival and a source of fear.[17] They “can neither
approach (the secure and ambivalent ‘strategies’), shift [their]
attention (the avoidant ‘strategy’), nor flee.”[18] If you observe such
children in a nursery school or attachment laboratory, you see them look toward
their parents when they enter the room and then quickly turn away. Unable to choose
between seeking closeness and avoiding the parent, they may rock on their hands and
knees, appear to go into a trance, freeze with their arms raised, or get up to greet
their parent and then fall to the ground. Not knowing who is safe or whom they
belong to, they may be intensely affectionate with strangers or may trust nobody.
Main called this pattern “disorganized attachment.” Disorganized
attachment is “fright without solution.”[19]

BECOMING DISORGANIZED WITHIN

Conscientious parents often become
alarmed when they discover attachment research, worrying that their occasional
impatience or their ordinary lapses in attunement may permanently damage their kids.
In real life there are bound to be misunderstandings, inept responses, and failures
of communication. Because mothers and fathers miss cues or are simply preoccupied
with other matters, infants are frequently left to their own devices to discover how
they can calm themselves down. Within limits this is not a problem. Kids need to
learn to handle frustrations and disappointments. With “good enough”
caregivers, children learn that broken connections can be repaired. The critical
issue is whether they can incorporate a feeling of being viscerally safe with their
parents or other caregivers.[20]

In a study of attachment patterns in
over two thousand infants in “normal” middle-class environments, 62
percent were found to be secure, 15 percent avoidant, 9 percent anxious (also known
as ambivalent), and 15 percent disorganized.[21] Interestingly, this large study
showed that the child’s gender and basic temperament have little effect on
attachment style; for example, children with “difficult” temperaments
are not more likely to develop a disorganized style. Kids from lower socioeconomic
groups are more likely to be disorganized,[22] with parents often severely stressed
by economic and family instability.

Children who don’t feel safe in
infancy have trouble regulating their moods and emotional responses as they grow
older. By kindergarten, many disorganized infants are either aggressive or spaced
out and disengaged, and they go on to develop a range of psychiatric problems.[23] They also
show more physiological stress, as expressed in heart rate, heart rate
variability,[24] stress hormone responses, and lowered immune factors.[25] Does this
kind of biological dysregulation automatically reset to normal as a child matures or
is moved to a safe environment? So far as we know, it does not.

Parental abuse is not the only cause of
disorganized attachment: Parents who are preoccupied with their own trauma, such as
domestic abuse or rape or the recent death of a parent or sibling, may also be too
emotionally unstable and inconsistent to offer much comfort and protection.[26],[27] While all
parents need all the help they can get to help raise secure children, traumatized
parents, in particular, need help to be attuned to their children’s needs.

Caregivers often don’t realize
that they are out of tune. I vividly remember a videotape Beatrice Beebe showed
me.[28] It
featured a young mother playing with her three-month-old infant. Everything was
going well until the baby pulled back and turned his head away, signaling that he
needed a break. But the mother did not pick up on his cue, and she intensified her
efforts to engage him by bringing her face closer to his and increasing the volume
of her voice. When he recoiled even more, she kept bouncing and poking him. Finally
he started to scream, at which point the mother put him down and walked away,
looking crestfallen. She obviously felt terrible, but she had simply missed the
relevant cues. It’s easy to imagine how this kind of misattunement, repeated
over and over again, can gradually lead to a chronic disconnection. (Anyone
who’s raised a colicky or hyperactive baby knows how quickly stress rises when
nothing seems to make a difference.) Chronically failing to calm her baby down and
establish an enjoyable face-to-face interaction, the mother is likely to come to
perceive him as a difficult child who makes her feel like a failure, and give up on
trying to comfort her child.

In practice it often is difficult to
distinguish the problems that result from disorganized attachment from those that
result from trauma: They are often intertwined. My colleague Rachel Yehuda studied
rates of PTSD in adult New Yorkers who had been assaulted or raped.[29] Those whose
mothers were Holocaust survivors with PTSD had a significantly higher rate of
developing serious psychological problems after these traumatic experiences. The
most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it
difficult for them to regain their equilibrium after being violated. Yehuda found a
similar vulnerability in the children of pregnant women who were in the World Trade
Center that fatal day in 2001.[30]

Similarly, the reactions of children to
painful events are largely determined by how calm or stressed their parents are. My
former student Glenn Saxe, now chairman of the Department of Child and Adolescent
Psychiatry at NYU, showed that when children were hospitalized for treatment of
severe burns, the development of PTSD could be predicted by how safe they felt with
their mothers.[31] The security of their attachment to their mothers predicted the
amount of morphine that was required to control their pain—the more secure the
attachment, the less painkiller was needed.

Another colleague, Claude Chemtob, who
directs the Family Trauma Research Program at NYU Langone Medical Center, studied
112 New York City children who had directly witnessed the terrorist attacks on
9/11.[32]
Children whose mothers were diagnosed with PTSD or depression during follow-up were
six times more likely to have significant emotional problems and eleven times more
likely to be hyperaggressive in response to their experience. Children whose fathers
had PTSD showed behavioral problems as well, but Chemtob discovered that this effect
was indirect and was transmitted via the mother. (Living with an irascible,
withdrawn, or terrified spouse is likely to impose a major psychological burden on
the partner, including depression.)

If you have no internal sense of
security, it is difficult to distinguish between safety and danger. If you feel
chronically numbed out, potentially dangerous situations may make you feel alive. If
you conclude that you must be a terrible person (because why else would your parents
have you treated that way?), you start expecting other people to treat you horribly.
You probably deserve it, and anyway, there is nothing you can do about it. When
disorganized people carry self-perceptions like these, they are set up to be
traumatized by subsequent experiences.[33]

THE LONG-TERM EFFECTS OF
DISORGANIZED ATTACHMENT

In the early 1980s my colleague Karlen
Lyons-Ruth, a Harvard attachment researcher, began to videotape face-to-face
interactions between mothers and their infants at six months, twelve months and
eighteen months. She taped them again when the children were five years old and once
more when they were seven or eight.[34] All were from high-risk families: 100
percent met federal poverty guidelines, and almost half the mothers were single
parents.

Disorganized attachment showed up in two
different ways: One group of mothers seemed to be too preoccupied with their own
issues to attend to their infants. They were often intrusive and hostile; they
alternated between rejecting their infants and acting as if they expected them to
respond to their needs. Another group of mothers seemed helpless and
fearful. They often came across as sweet or fragile, but they didn’t know how
to be the adult in the relationship and seemed to want their children to comfort
them. They failed to greet their children after having been away and
did not pick them up when the children were distressed. The mothers didn’t
seem to be doing these things deliberately—they simply didn’t know how to be
attuned to their kids and respond to their cues and thus failed to comfort and
reassure them. The hostile/intrusive mothers were more likely to have childhood
histories of physical abuse and/or of witnessing domestic violence, while the
withdrawn/dependent mothers were more likely to have histories of sexual abuse or
parental loss (but not physical abuse).[35]

I have always wondered how parents come
to abuse their kids. After all, raising healthy offspring is at the very core of our
human sense of purpose and meaning. What could drive parents to deliberately hurt or
neglect their children? Karlen’s research provided me with one answer:
Watching her videos, I could see the children becoming more and more inconsolable,
sullen, or resistant to their misattuned mothers. At the same time, the mothers
became increasingly frustrated, defeated, and helpless in their interactions. Once
the mother comes to see the child not as her partner in an attuned relationship but
as a frustrating, enraging, disconnected stranger, the stage is set for subsequent
abuse.

About eighteen years later, when these
kids were around twenty years old, Lyons-Ruth did a follow-up study to see how they
were coping. Infants with seriously disrupted emotional communication patterns with
their mothers at eighteen months grew up to become young adults with an unstable
sense of self, self-damaging impulsivity (including excessive spending, promiscuous
sex, substance abuse, reckless driving, and binge eating), inappropriate and intense
anger, and recurrent suicidal behavior.

Karlen and her colleagues had expected
that hostile/intrusive behavior on the part of the mothers would be the most
powerful predictor of mental instability in their adult children, but they
discovered otherwise. Emotional withdrawal had the most profound and long-lasting
impact. Emotional distance and role reversal (in which mothers expected the kids to
look after them) were specifically linked to aggressive behavior against self and
others in the young adults.

DISSOCIATION: KNOWING AND NOT
KNOWING

Lyons-Ruth was particularly interested in
the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed,
abandoned, and disconnected from the world and in seeing oneself as unloved, empty,
helpless, trapped, and weighed down. She found a “striking and
unexpected” relationship between maternal disengagement and misattunement
during the first two years of life and dissociative symptoms in early adulthood.
Lyons-Ruth concludes that infants who are not truly seen and known by their mothers
are at high risk to grow into adolescents who are unable to know and to
see.”[36]

Infants who live in secure relationships
learn to communicate not only their frustrations and distress but also their
emerging selves—their interests, preferences, and goals. Receiving a sympathetic
response cushions infants (and adults) against extreme levels of frightened arousal.
But if your caregivers ignore your needs, or resent your very existence, you learn
to anticipate rejection and withdrawal. You cope as well as you can by blocking out
your mother’s hostility or neglect and act as if it doesn’t matter, but
your body is likely to remain in a state of high alert, prepared to ward off blows,
deprivation, or abandonment. Dissociation means simultaneously knowing and not
knowing.[37]

Bowlby wrote: “What cannot be
communicated to the [m]other cannot be communicated to the self.”[38] If you
cannot tolerate what you know or feel what you feel, the only option is denial and
dissociation.[39] Maybe the most devastating long-term effect of this shutdown is
not feeling real inside, a condition we saw in the kids in the Children’s
Clinic and that we see in the children and adults who come to the Trauma Center.
When you don’t feel real nothing matters, which makes it impossible to protect
yourself from danger. Or you may resort to extremes in an effort to feel
something—even cutting yourself with a razor blade or getting into
fistfights with strangers.

Karlen’s research showed that
dissociation is learned early: Later abuse or other traumas did not account for
dissociative symptoms in young adults.[40] Abuse and trauma accounted for many
other problems, but not for chronic dissociation or aggression against self. The
critical underlying issue was that these patients didn’t know how to feel
safe. Lack of safety within the early caregiving relationship led to an impaired
sense of inner reality, excessive clinging, and self-damaging behavior: Poverty,
single parenthood, or maternal psychiatric symptoms did not predict these
symptoms.

This does not imply that child abuse is
irrelevant[41], but that the quality of early caregiving is critically important
in preventing mental health problems, independent of other traumas.[42] For that reason treatment
needs to address not only the imprints of specific traumatic events but also the
consequences of not having been mirrored, attuned to, and given consistent care and
affection: dissociation and loss of self-regulation.

RESTORING SYNCHRONY

Early attachment patterns create the
inner maps that chart our relationships throughout life, not only in terms of what
we expect from others, but also in terms of how much comfort and pleasure we can
experience in their presence. I doubt that the poet e. e. cummings could have
written his joyous lines “i like my body when it is with your
body. … muscles better and nerves more” if his earliest experiences
had been frozen faces and hostile glances.[43] Our relationship maps are implicit,
etched into the emotional brain and not reversible simply by understanding how they
were created. You may realize that your fear of intimacy has something to do with
your mother’s postpartum depression or with the fact that she herself was
molested as a child, but that alone is unlikely to open you to happy, trusting
engagement with others.

However, that realization may help you
to start exploring other ways to connect in relationships—both for your own sake and
in order to not pass on an insecure attachment to your own children. In part 5
I’ll discuss a number of approaches to healing damaged attunement systems
through training in rhythmicity and reciprocity.[44] Being in synch with oneself and with
others requires the integration of our body-based senses—vision, hearing, touch, and
balance. If this did not happen in infancy and early childhood, there is an
increased chance of later sensory integration problems (to which trauma and neglect
are by no means the only pathways).

Being in synch means resonating through
sounds and movements that connect, which are embedded in the daily sensory rhythms
of cooking and cleaning, going to bed and waking up. Being in synch may mean sharing
funny faces and hugs, expressing delight or disapproval at the right moments,
tossing balls back and forth, or singing together. At the Trauma Center, we have
developed programs to coach parents in connection and attunement, and my patients
have told me about many other ways to get themselves in synch, ranging from choral
singing and ballroom dancing to joining basketball teams, jazz bands and chamber
music groups. All of these foster a sense of attunement and communal pleasure.

CHAPTER 8

Trapped in Relationships: The Cost
of Abuse and Neglect

The “night sea journey” is the
journey into the parts of ourselves that are split off, disavowed, unknown,
unwanted, cast out, and exiled to the various subterranean worlds of
consciousness. … The goal of this journey is to reunite us with ourselves.
Such a homecoming can be surprisingly painful, even brutal. In order to undertake
it, we must first agree to exile nothing.

—Stephen Cope

Marilyn was a tall, athletic-looking
woman in her midthirties who worked as an operating-room nurse in a nearby town. She
told me that a few months earlier she’d started to play tennis at her sports
club with a Boston fireman named Michael. She usually steered clear of men, she
said, but she had gradually become comfortable enough with Michael to accept his
invitations to go out for pizza after their matches. They’d talk about tennis,
movies, their nephews and nieces—nothing too personal. Michael clearly enjoyed her
company, but she told herself he didn’t really know her.

One Saturday evening in August, after
tennis and pizza, she invited him to stay over at her apartment. She described
feeling “uptight and unreal” as soon as they were alone together. She
remembered asking him to go slow but had very little sense of what had happened
after that. After a few glasses of wine and a rerun of Law & Order,
they apparently fell asleep together on top of her bed. At around two in the
morning, Michael turned over in his sleep. When Marilyn felt his body touch hers,
she exploded—pounding him with her
fists, scratching and biting, screaming, “You bastard, you bastard!”
Michael, startled awake, grabbed his belongings and fled. After he left, Marilyn sat
on her bed for hours, stunned by what had happened. She felt deeply humiliated and
hated herself for what she had done, and now she’d come to me for help in
dealing with her terror of men and her inexplicable rage attacks.

My work with veterans had prepared me to
listen to painful stories like Marilyn’s without trying to jump in immediately
to fix the problem. Therapy often starts with some inexplicable behavior: attacking
a boyfriend in the middle of the night, feeling terrified when somebody looks you in
the eye, finding yourself covered with blood after cutting yourself with a piece of
glass, or deliberately vomiting up every meal. It takes time and patience to allow
the reality behind such symptoms to reveal itself.

TERROR AND NUMBNESS

As we talked, Marilyn told me that
Michael was the first man she’d taken home in more than five years, but this
was not the first time she’d lost control when a man spent the night with her.
She repeated that she always felt uptight and spaced out when she was alone with a
man, and there had been other times when she’d “come to” in her
apartment, cowering in a corner, unable to remember clearly what had happened.

Marilyn also said she felt as if she was
just “going through the motions” of having a life. Except for when she
was at the club playing tennis or at work in the operating room, she usually felt
numb. A few years earlier she’d found that she could relieve her numbness by
scratching herself with a razor blade, but she had become frightened when she found
that she was cutting herself more and more deeply, and more and more often, to get
relief. She had tried alcohol, too, but that reminded her of her dad and his
out-of-control drinking, which made her feel disgusted with herself. So, instead,
she played tennis fanatically, whenever she could. That made her feel alive.

When I asked her about her past, Marilyn
said she guessed that she “must have had” a happy childhood, but she
could remember very little from before age twelve. She told me she’d been a
timid adolescent, until she had a violent confrontation with her alcoholic father
when she was sixteen and ran away from home. She worked her way through community
college and went on to get a degree in nursing without any help from her parents.
She felt ashamed that during this time she’d slept around, which she described
as “looking for love in all the wrong places.”

As I often did with new patients, I
asked her to draw a family portrait, and when I saw her drawing (reproduced above),
I decided to go slowly. Clearly Marilyn was harboring some terrible memories, but
she could not allow herself to recognize what her own picture revealed. She had
drawn a wild and terrified child, trapped in some kind of cage and threatened not
only by three nightmarish figures—one with no eyes—but also by a huge erect penis
protruding into her space. And yet this woman said she “must have had” a
happy childhood.

As the poet W. H. Auden wrote:

Truth, like love and sleep, resents

Approaches that are too intense.[1]

I call this Auden’s rule, and in
keeping with it I deliberately did not push Marilyn to tell me what she remembered.
In fact, I’ve learned that it’s not important for me to know every
detail of a patient’s trauma. What is critical is that the patients themselves
learn to tolerate feeling what they feel and knowing what they know. This may take
weeks or even years. I decided to start Marilyn’s treatment by inviting her to
join an established therapy group where she could find support and acceptance before
facing the engine of her distrust, shame, and rage.

As I expected, Marilyn arrived at the
first group meeting looking terrified, much like the girl in her family portrait;
she was withdrawn and did not reach out to anybody. I’d chosen this group for
her because its members had always been helpful and accepting of new members who
were too scared to talk. They knew from their own experience that unlocking secrets
is a gradual process. But this time they surprised me, asking so many intrusive
questions about Marilyn’s love life that I recalled her drawing of the little
girl under assault. It was almost as though Marilyn had unwittingly enlisted the
group to repeat her traumatic past. I intervened to help her set some boundaries
about what she’d talk about, and she began to settle in.

Three months later Marilyn told the
group that she had stumbled and fallen a few times on the sidewalk between the
subway and my office. She worried that her eyesight was beginning to fail:
She’d also been missing a lot of tennis balls recently. I thought again about
her drawing and the wild child with the huge, terrified eyes. Was this some sort of
“conversion reaction,” in which patients express their conflicts by
losing function in some part of their body? Many soldiers in both world wars had
suffered paralysis that couldn’t be traced to physical injuries, and I had
seen cases of “hysterical blindness” in Mexico and India

Still, as a physician, I wasn’t
about to conclude without further assessment that this was “all in her
head.” I referred her to colleagues at the Massachusetts Eye and Ear Infirmary
and asked them to do a very thorough workup. Several weeks later the tests came
back. Marilyn had lupus erythematosus of her retina, an autoimmune disease that was
eroding her vision, and she would need immediate treatment. I was appalled: Marilyn
was the third person that year whom I’d suspected of having an incest history
and who was then diagnosed with an autoimmune disease—a disease in which the body
starts attacking itself.

After making sure that Marilyn was
getting the proper medical care, I consulted with two of my colleagues at
Massachusetts General, psychiatrist Scott Wilson and Richard Kradin, who ran the
immunology laboratory there. I told them Marilyn’s story, showed them the
picture she’d drawn, and asked them to collaborate on a study. They generously
volunteered their time and the considerable expense of a full immunology workup. We
recruited twelve women with incest histories who were not taking any medications,
plus twelve women who had never been traumatized and who also did not take meds—a
surprisingly difficult control group to find. (Marilyn was not in the study; we
generally do not ask our clinical patients to be part of our research efforts.)

When the study was completed and the data
analyzed, Rich reported that the group of incest survivors had abnormalities in
their CD45 RA-to-RO ratio, compared with their nontraumatized peers. CD45 cells are
the “memory cells” of the immune system. Some of them, called RA cells,
have been activated by past exposure to toxins; they quickly respond to
environmental threats they have encountered before. The RO cells, in contrast, are
kept in reserve for new challenges; they are turned on to deal with threats the body
has not met previously. The RA-to-RO ratio is the balance between cells that
recognize known toxins and cells that wait for new information to activate. In
patients with histories of incest, the proportion of RA cells that are ready to
pounce is larger than normal. This makes the immune system oversensitive to threat,
so that it is prone to mount a defense when none is needed, even when this means
attacking the body’s own cells.

Our study showed that, on a deep level,
the bodies of incest victims have trouble distinguishing between danger and safety.
This means that the imprint of past trauma does not consist only of distorted
perceptions of information coming from the outside; the organism itself also has a
problem knowing how to feel safe. The past is impressed not only on their minds, and
in misinterpretations of innocuous events (as when Marilyn attacked Michael because
he accidentally touched her in her sleep), but also on the very core of their
beings: in the safety of their bodies.[2]

A TORN MAP OF THE WORLD

How do people learn what is safe and what
is not safe, what is inside and what is outside, what should be resisted and what
can safely be taken in? The best way we can understand the impact of child abuse and
neglect is to listen to what people like Marilyn can teach us. One of the things
that became clear as I came to know her better was that she had her own unique view
of how the world functions.

As children, we start off at the center
of our own universe, where we interpret everything that happens from an egocentric
vantage point. If our parents or grandparents keep telling us we’re the
cutest, most delicious thing in the world, we don’t question their judgment—we
must be exactly that. And deep down, no matter what else we learn about ourselves,
we will carry that sense with us: that we are basically adorable. As a result, if we
later hook up with somebody who treats us badly, we will be outraged. It won’t
feel right: It’s not familiar; it’s not like home. But if we are abused
or ignored in childhood, or grow up in a family where sexuality is treated with
disgust, our inner map contains a
different message. Our sense of our self is marked by contempt and humiliation, and
we are more likely to think “he (or she) has my number” and fail to
protest if we are mistreated.

Marilyn’s past shaped her view of
every relationship. She was convinced that men didn’t give a damn about other
people’s feelings and that they got away with whatever they wanted. Women
couldn’t be trusted either. They were too weak to stand up for themselves, and
they’d sell their bodies to get men to take care of them. If you were in
trouble, they wouldn’t lift a finger to help you. This worldview manifested
itself in the way Marilyn approached her colleagues at work: She was suspicious of
the motives of anyone who was kind to her and called them on the slightest deviation
from the nursing regulations. As for herself: She was a bad seed, a fundamentally
toxic person who made bad things happen to those around her.

When I first encountered patients like
Marilyn, I used to challenge their thinking and try to help them see the world in a
more positive, flexible way. One day a woman named Kathy set me straight. A group
member had arrived late to a session because her car had broken down, and Kathy
immediately blamed herself: “I saw how rickety your car was last week; I knew
I should have offered you a ride.” Her self-criticism escalated to the point
that, only a few minutes later, she was taking responsibility for her sexual abuse:
“I brought it on myself: I was seven years old and I loved my daddy. I wanted
him to love me, and I did what he wanted me to do. It was my own fault.” When
I intervened to reassure her, saying, “Come on, you were just a little girl—it
was your father’s responsibility to maintain the boundaries,” Kathy
turned toward me. “You know, Bessel,” she said, “I know how
important it is for you to be a good therapist, so when you make stupid comments
like that, I usually thank you profusely. After all, I am an incest survivor—I was
trained to take care of the needs of grown-up, insecure men. But after two years I
trust you enough to tell you that those comments make me feel terrible. Yes,
it’s true; I instinctively blame myself for everything bad that happens to the
people around me. I know that isn’t rational, and I feel really dumb for
feeling this way, but I do. When you try to talk me into being more reasonable I
only feel even more lonely and isolated—and it confirms the feeling that nobody in
the whole world will ever understand what it feels like to be me.”

I genuinely thanked her for her
feedback, and I’ve tried ever since not to tell my patients that they should
not feel the way they do. Kathy taught me that my responsibility goes much deeper: I
have to help them reconstruct their inner map of the world.

As I discussed in the previous chapter,
attachment researchers have shown that
our earliest caregivers don’t only feed us, dress us, and comfort us when we
are upset; they shape the way our rapidly growing brain perceives reality. Our
interactions with our caregivers convey what is safe and what is dangerous: whom we
can count on and who will let us down; what we need to do to get our needs met. This
information is embodied in the warp and woof of our brain circuitry and forms the
template of how we think of ourselves and the world around us. These inner maps are
remarkably stable across time.

This doesn’t mean, however, that
our maps can’t be modified by experience. A deep love relationship,
particularly during adolescence, when the brain once again goes through a period of
exponential change, truly can transform us. So can the birth of a child, as our
babies often teach us how to love. Adults who were abused or neglected as children
can still learn the beauty of intimacy and mutual trust or have a deep spiritual
experience that opens them to a larger universe. In contrast, previously
uncontaminated childhood maps can become so distorted by an adult rape or assault
that all roads are rerouted into terror or despair. These responses are not
reasonable and therefore cannot be changed simply by reframing irrational beliefs.
Our maps of the world are encoded in the emotional brain, and changing them means
having to reorganize that part of the central nervous system, the subject of the
treatment section of this book.

Nonetheless, learning to recognize
irrational thoughts and behavior can be a useful first step. People like Marilyn
often discover that their assumptions are not the same as those of their friends. If
they are lucky, their friends and colleagues will tell them in words, rather than in
actions, that their distrust and self-hatred makes collaboration difficult. But that
rarely happens, and Marilyn’s experience was typical: After she assaulted
Michael, he had absolutely no interest in working things out, and she lost both his
friendship and her favorite tennis partner. It is at this point that smart and
courageous people like Marilyn, who maintain their curiosity and determination in
the face of repeated defeats, start looking for help.

Generally the rational brain can
override the emotional brain, as long as our fears don’t hijack us. (For
example, your fear at being flagged down by the police can turn instantly to
gratitude when the cop warns you that there’s an accident ahead.) But the
moment we feel trapped, enraged, or rejected, we are vulnerable to activating old
maps and to follow their directions. Change begins when we learn to
“own” our emotional brains. That means learning to observe and tolerate
the heartbreaking and gut-wrenching sensations that register misery and humiliation.
Only after learning to bear what is going on inside can we start to befriend, rather than obliterate,
the emotions that keep our maps fixed and immutable.

LEARNING TO REMEMBER

About a year into Marilyn’s group,
another member, Mary, asked permission to talk about what had happened to her when
she was thirteen years old. Mary worked as a prison guard, and she was involved in a
sadomasochistic relationship with another woman. She wanted the group to know her
background in the hope that they would become more tolerant of her extreme
reactions, such as her tendency to shut down or blow up in response to the slightest
provocation.

Struggling to get the words out, Mary
told us that one evening, when she was thirteen years old, she was raped by her
older brother and a gang of his friends. The rape resulted in pregnancy, and her
mother gave her an abortion at home, on the kitchen table. The group sensitively
tuned in to what Mary was sharing and comforted her through her sobbing. I was
profoundly moved by their empathy—they were consoling Mary in a way that they must
have wished somebody had comforted them when they first confronted their
traumas.

When time ran out, Marilyn asked if she
could take a few more minutes to talk about what she had experienced during the
session. The group agreed, and she told us: “Hearing that story, I wonder if I
may have been sexually abused myself.” My mouth must have dropped open. Based
on her family drawing, I had always assumed that she was aware, at least on some
level, that this was the case. She had reacted like an incest victim in her response
to Michael, and she chronically behaved as if the world were a terrifying place.

Yet even though she’d drawn a girl
who was being sexually molested, she—or at least her cognitive, verbal self—had no
idea what had actually happened to her. Her immune system, her muscles, and her fear
system all had kept the score, but her conscious mind lacked a story that could
communicate the experience. She reenacted her trauma in her life, but she had no
narrative to refer to. As we will see in chapter 12,
traumatic memory differs in complex ways from normal recall, and it involves many
layers of mind and brain.

Triggered by Mary’s story, and
spurred on by the nightmares that followed, Marilyn began individual therapy with me
in which she started to deal with her past. At first she experienced waves of
intense, free-floating terror. She tried stopping for several weeks, but when she
found she could no longer sleep and had
to take time off from work, she continued our sessions. As she told me later:
“My only criterion for whether a situation is harmful is feeling, ‘This
is going to kill me if I don’t get out.’”

I began to teach Marilyn calming
techniques, such as focusing on breathing deeply—in and out, in and out, at six
breaths a minute—while following the sensations of the breath in her body. This was
combined with tapping acupressure points, which helped her not to become
overwhelmed. We also worked on mindfulness: Learning to keep her mind alive while
allowing her body to feel the feelings that she had come to dread slowly enabled
Marilyn to stand back and observe her experience, rather than being immediately
hijacked by her feelings. She had tried to dampen or abolish those feelings with
alcohol and exercise, but now she began to feel safe enough to begin to remember
what had happened to her as a girl. As she gained ownership over her physical
sensations, she also began to be able to tell the difference between past and
present: Now if she felt someone’s leg brush against her in the night, she
might be able to recognize it as Michael’s leg, the leg of the handsome tennis
partner she’d invited to her apartment. That leg did not belong to anyone
else, and its touch didn’t mean someone was trying to molest her. Being still
enabled her to know—fully, physically know—that she was a thirty-four-year-old woman
and not a little girl.

When Marilyn finally began to access her
memories, they emerged as flashbacks of the wallpaper in her childhood bedroom. She
realized that this was what she had focused on when her father raped her when she
was eight years old. His molestation had scared her beyond her capacity to endure,
so she had needed to push it out of her memory bank. After all, she had to keep
living with this man, her father, who had assaulted her. Marilyn remembered having
turned to her mother for protection, but when she ran to her and tried to hide
herself by burying her face in her mother’s skirt, she was met with only a
limp embrace. At times her mother remained silent; at others she cried or angrily
scolded Marilyn for “making Daddy so angry.” The terrified child found
no one to protect her, to offer strength or shelter.

As Roland Summit wrote in his classic
study The Child Sexual Abuse Accommodation Syndrome: “Initiation,
intimidation, stigmatization, isolation, helplessness and self-blame depend on a
terrifying reality of child sexual abuse. Any attempts by the child to divulge the
secret will be countered by an adult conspiracy of silence and disbelief.
‘Don’t worry about things like that; that could never happen in our
family.’ ‘How could you ever think of such a terrible thing?’
‘Don’t let me ever hear you say anything like that again!’ The
average child never asks and never tells.”[3]

After forty years of doing this work I
still regularly hear myself saying, “That’s unbelievable,” when
patients tell me about their childhoods. They often are as incredulous as I am—how
could parents inflict such torture and terror on their own child? Part of them
continues to insist that they must have made the experience up or that they are
exaggerating. All of them are ashamed about what happened to them, and they blame
themselves—on some level they firmly believe that these terrible things were done to
them because they are terrible people.

Marilyn now began to explore how the
powerless child had learned to shut down and comply with whatever was asked of her.
She had done so by making herself disappear: The moment she heard her father’s
footsteps in the corridor outside her bedroom, she would “put her head in the
clouds.” Another patient of mine who had a similar experience made a drawing
that depicts how that process works. When her father started to touch her, she made
herself disappear; she floated up to the ceiling, looking down on some other little
girl in the bed.[4] She was glad that it was not really her—it was some other girl who
was being molested.

Looking at these heads separated from
their bodies by an impenetrable fog really opened my eyes to the experience of
dissociation, which is so common among incest victims. Marilyn herself later
realized that, as an adult, she had continued to float up to the ceiling when she
found herself in a sexual situation. In
the period when she’d been more sexually active, a partner would occasionally
tell her how amazing she’d been in bed—that he’d barely recognized her,
that she’d even talked differently. Usually she did not remember what had
happened, but at other times she’d become angry and aggressive. She had no
sense of who she really was sexually, so she gradually withdrew from dating
altogether—until Michael.

HATING YOUR HOME

Children have no choice who their parents
are, nor can they understand that parents may simply be too depressed, enraged, or
spaced out to be there for them or that their parents’ behavior may have
little to do with them. Children have no choice but to organize themselves to
survive within the families they have. Unlike adults, they have no other authorities
to turn to for help—their parents are the authorities. They cannot rent an
apartment or move in with someone else: Their very survival hinges on their
caregivers.

Children sense—even if it they are not
explicitly threatened—that if they talked about their beatings or molestation to
teachers they would be punished. Instead, they focus their energy on not
thinking about what has happened and not feeling the residues of terror and panic in
their bodies. Because they cannot tolerate knowing what they have experienced, they
also cannot understand that their anger, terror, or collapse has anything to do with
that experience. They don’t talk; they act and deal with their feelings by
being enraged, shut down, compliant, or defiant.

Children are also programmed to be
fundamentally loyal to their caretakers, even if they are abused by them. Terror
increases the need for attachment, even if the source of comfort is also the source
of terror. I have never met a child below the age of ten who was tortured at home
(and who had broken bones and burned skin to show for it) who, if given the option,
would not have chosen to stay with his or her family rather than being placed in a
foster home. Of course, clinging to one’s abuser is not exclusive to
childhood. Hostages have put up bail for their captors, expressed a wish to marry
them, or had sexual relations with them; victims of domestic violence often cover up
for their abusers. Judges often tell me how humiliated they feel when they try to
protect victims of domestic violence by issuing restraining orders, only to find out
that many of them secretly allow their partners to return.

It took Marilyn a long time before she
was ready to talk about her abuse: She was not ready to violate her loyalty to her
family—deep inside she felt that she still needed them to protect her against her
fears. The price of this loyalty is
unbearable feelings of loneliness, despair, and the inevitable rage of helplessness.
Rage that has nowhere to go is redirected against the self, in the form of
depression, self-hatred, and self-destructive actions. One of my patients told me,
“It is like hating your home, your kitchen and pots and pans, your bed, your
chairs, your table, your rugs.” Nothing feels safe—least of all your own
body.

Learning to trust is a major challenge.
One of my other patients, a schoolteacher whose grandfather raped her repeatedly
before she was six, sent me the following e-mail: “I started mulling the
danger of opening up with you in traffic on the way home after our therapy
appointment, and then, as I merged into Route 124, I realized that I had broken the
rule of not getting attached, to you and to my students.”

During our next meeting she told me she
had also been raped by her lab instructor in college. I asked her whether she had
sought help and made a complaint against him. “I couldn’t make myself
cross the road to the clinic,” she replied. “I was desperate for help,
but as I stood there, I felt very deeply that I would only be hurt even more. And
that might well have been true. Of course, I had to hide what had happened from my
parents—and from everyone else.”

After I told her that I was concerned
about what was going on with her, she wrote me another e-mail: “I’m
trying to remind myself that I didn’t do anything to deserve such treatment. I
don’t think I have ever had anyone look at me like that and say they were
worried about me, and I am holding on to it like a treasure: the idea that I am
worth being worried about by someone I respect and who does understand how deeply I
am struggling now.”

In order to know who we are—to have an
identity—we must know (or at least feel that we know) what is and what was
“real.” We must observe what we see around us and label it correctly; we
must also be able trust our memories and be able to tell them apart from our
imagination. Losing the ability to make these distinctions is one sign of what
psychoanalyst William Niederland called “soul murder.” Erasing awareness
and cultivating denial are often essential to survival, but the price is that you
lose track of who you are, of what you are feeling, and of what and whom you can
trust.[5]

REPLAYING THE TRAUMA

One memory of Marilyn’s childhood
trauma came to her in a dream in which she felt as if she were being choked and was
unable to breathe. A white tea towel was wrapped around her hands, and then she was
lifted up with the towel around her
neck, so that she could not touch the ground with her feet. She woke in a panic,
thinking that she was surely going to die. Her dream reminded me of the nightmares
war veterans had reported to me: seeing the precise, unadulterated images of faces
and body parts they had encountered in battle. These dreams were so terrifying that
they tried to not fall asleep at night; only daytime napping, which was not
associated with nocturnal ambushes, felt halfway safe.

During this stage of therapy Marilyn was
repeatedly flooded with images and sensations related to the choking dream. She
remembered sitting in the kitchen as a four-year-old with swollen eyes, a sore neck,
and a bloody nose, while her father and brother laughed at her and called her a
stupid, stupid girl. One day Marilyn reported, “As I was brushing my teeth
last evening, I was overcome with feelings of thrashing around. I was like a fish
out of water, violently turning my body as I fought against the lack of air. I
sobbed and choked as I brushed my teeth. Panic was rising up out of my chest with
the feeling of thrashing. I had to use every bit of strength I had not to scream,
‘NONONONONONO,’ as I stood over the sink.” She went to bed and
fell asleep but woke up like clockwork every two hours during the rest of the
night.

Trauma is not stored as a narrative with
an orderly beginning, middle, and end. As I’ll discuss in detail in chapters
11 and 12, memories initially return as they did for Marilyn: as flashbacks that
contain fragments of the experience, isolated images, sounds, and body sensations
that initially have no context other than fear and panic. When Marilyn was a child,
she had no way of giving voice to the unspeakable, and it would have made no
difference anyway—nobody was listening.

Like so many survivors of childhood
abuse, Marilyn exemplified the power of the life force, the will to live and to own
one’s life, the energy that counteracts the annihilation of trauma. I
gradually came to realize that the only thing that makes it possible to do the work
of healing trauma is awe at the dedication to survival that enabled my patients to
endure their abuse and then to endure the dark nights of the soul that inevitably
occur on the road to recovery.

CHAPTER 9

What’s Love Got to Do with
it?

Initiation, intimidation, stigmatization,
isolation, helplessness and self-blame depend on a terrifying reality of child
sexual abuse. … “Don’t worry about things like that; that
could never happen in our family.” “How could you ever think of such a
terrible thing?” “Don’t let me ever hear you say anything like
that again!” The average child never asks and never tells.

—Roland Summit The Child Sexual Abuse
Accommodation Syndrome

How do we organize our thinking with
regard to individuals like Marilyn, Mary, and Kathy, and what can we do to help
them? The way we define their problems, our diagnosis, will determine how we
approach their care. Such patients typically receive five or six different unrelated
diagnoses in the course of their psychiatric treatment. If their doctors focus on
their mood swings, they will be identified as bipolar and prescribed lithium or
valproate. If the professionals are most impressed with their despair, they will be
told they are suffering from major depression and given antidepressants. If the
doctors focus on their restlessness and lack of attention, they may be categorized
as ADHD and treated with Ritalin or other stimulants. And if the clinic staff
happens to take a trauma history, and the patient actually volunteers the relevant
information, he or she might receive the diagnosis of PTSD. None of these diagnoses will be completely off the mark, and
none of them will begin to meaningfully describe who these patients are and what
they suffer from.

Psychiatry, as a subspecialty of
medicine, aspires to define mental illness as precisely as, let’s say, cancer
of the pancreas, or streptococcal infection of the lungs. However, given the
complexity of mind, brain, and human attachment systems, we have not come even close
to achieving that sort of precision. Understanding what is “wrong” with
people currently is more a question of the mind-set of the practitioner (and of what
insurance companies will pay for) than of verifiable, objective facts.

The first serious attempt to create a
systematic manual of psychiatric diagnoses occurred in 1980, with the release of the
third edition of the Diagnostic and Statistical Manual of Mental Disorders,
the official list of all mental diseases recognized by the American Psychiatric
Association (APA). The preamble to the DSM-III warned explicitly that its categories
were insufficiently precise to be used in forensic settings or for insurance
purposes. Nonetheless it gradually became an instrument of enormous power: Insurance
companies require a DSM diagnosis for reimbursement, until recently all research
funding was based on DSM diagnoses, and academic programs are organized around DSM
categories. DSM labels quickly found their way into the larger culture as well.
Millions of people know that Tony Soprano suffered from panic attacks and depression
and that Carrie Mathison of Homeland struggles with bipolar disorder. The
manual has become a virtual industry that has earned the American Psychiatric
Association well over $100 million.[1] The question is: Has it provided
comparable benefits for the patients it is meant to serve?

A psychiatric diagnosis has serious
consequences: Diagnosis informs treatment, and getting the wrong treatment can have
disastrous effects. Also, a diagnostic label is likely to attach to people for the
rest of their lives and have a profound influence on how they define themselves. I
have met countless patients who told me that they “are” bipolar or
borderline or that they “have” PTSD, as if they had been sentenced to
remain in an underground dungeon for the rest of their lives, like the Count of
Monte Cristo.

None of these diagnoses takes into
account the unusual talents that many of our patients develop or the creative
energies they have mustered to survive. All too often diagnoses are mere tallies of
symptoms, leaving patients such as Marilyn, Kathy, and Mary likely to be viewed as
out-of-control women who need to be straightened out.

The dictionary defines diagnosis as
“a. The act or process of identifying or determining the nature and cause of a disease or
injury through evaluation of patient history, examination, and review of laboratory
data. b. The opinion derived from such an evaluation.”[2] In this chapter, and the
next, I will discuss the chasm between official diagnoses and what our patients
actually suffer from and discuss how my colleagues and I have tried to change the
way patients with chronic trauma histories are diagnosed.

HOW DO YOU TAKE A TRAUMA
HISTORY?

In 1985 I started to collaborate with
psychiatrist Judith Herman, whose first book, Father-Daughter Incest, had
recently been published. We were both working at Cambridge Hospital (one of
Harvard’s teaching hospitals) and, sharing an interest in how trauma had
affected the lives of our patients, we began to meet regularly and compare notes. We
were struck by how many of our patients who were diagnosed with borderline
personality disorder (BPD) told us horror stories about their childhoods. BPD is
marked by clinging but highly unstable relationships, extreme mood swings, and
self-destructive behavior, including self-mutilation and repeated suicide attempts.
In order to uncover whether there was, in fact, a relationship between childhood
trauma and BPD, we designed a formal scientific study and sent off a grant proposal
to the National Institutes of Health. It was rejected.

Undeterred, Judy and I decided to
finance the study ourselves, and we found an ally in Chris Perry, the director of
research at Cambridge Hospital, who was funded by the National Institutes of Mental
Health to study BPD and other near neighbor diagnoses, so called personality
disorders, in patients recruited from the Cambridge Hospital. He had collected
volumes of valuable data on these subjects but had never inquired about childhood
abuse and neglect. Even though he did not hide his skepticism about our proposal, he
was very generous to us and arranged for us to interview fifty-five patients from
the hospital’s outpatient department, and he agreed to compare our findings
with records in the large database he had already collected.

The first question Judy and I faced was:
How do you take a trauma history? You can’t ask a patient point blank:
“Were you molested as a kid?” or “Did your father beat you
up?” How many would trust a complete stranger with such delicate information?
Keeping in mind that people universally feel ashamed about the traumas they have
experienced, we designed an interview instrument, the Traumatic Antecedents
Questionnaire (TAQ).[3] The interview started with a series of simple questions:
“Where do you live, and who do you live with?”; “Who pays the
bills and who does the cooking and cleaning?” It progressed gradually to more
revealing questions: “Who do you rely on in your daily life?” As in:
When you’re sick, who does the shopping or takes you to the doctor? “Who
do you talk to when you are upset?” In other words, who provides you with
emotional and practical support? Some patients gave us surprising answers: “my
dog” or “my therapist”—or “nobody.”

We then asked similar questions about
their childhood: Who lived in the household? How often did you move? Who was your
primary caretaker? Many of the patients reported frequent relocations that required
them to change schools in the middle of the year. Several had primary caregivers who
had gone to jail, been placed in a mental hospital, or joined the military. Others
had moved from foster home to foster home or had lived with a string of different
relatives.

The next section of the questionnaire
addressed childhood relationships: “Who in your family was affectionate to
you?” “Who treated you as a special person?” This was followed by
a critical question—one that, to my knowledge, had never before been asked in a
scientific study: “Was there anybody who you felt safe with growing up?”
One out of four patients we interviewed could not recall anyone they had felt safe
with as a child. We checked “nobody” on our work sheets and did not
comment, but we were stunned. Imagine being a child and not having a source of
safety, making your way into the world unprotected and unseen.

The questions continued: “Who made
the rules at home and enforced the discipline?” “How were kids kept in
line—by talking, scolding, spanking, hitting, locking you up?” “How did
your parents solve their disagreements?” By then the floodgates had usually
opened, and many patients were volunteering detailed information about their
childhoods. One woman had witnessed her little sister being raped; another told us
she’d had her first sexual experience at age eight—with her grandfather. Men
and women reported lying awake at night listening to furniture crashing and parents
screaming; a young man had come down to the kitchen and found his mother lying in a
pool of blood. Others talked about not being picked up at elementary school or
coming home to find an empty house and spending the night alone. One woman who made
her living as a cook had learned to prepare meals for her family after her mother
was jailed on a drug conviction. Another had been nine when she grabbed and steadied
the car’s steering wheel because her drunken mother was swerving down a
four-lane highway during rush hour.

Our patients did not have the option to
run away or escape; they had nobody to turn to and no place to hide. Yet they
somehow had to manage their terror and despair. They probably went to school the
next morning and tried to pretend that
everything was fine. Judy and I realized that the BPD group’s
problems—dissociation, desperate clinging to whomever might be enlisted to help—had
probably started off as ways of dealing with overwhelming emotions and inescapable
brutality.

After our interviews Judy and I met to
code our patients’ answers—that is, to translate them into numbers for
computer analysis, and Chris Perry then collated them with the extensive information
on these patients he had stored on Harvard’s mainframe computer. One Saturday
morning in April he left us a message asking us to come to his office. There we
found a huge stack of printouts, on top of which Chris had placed a Gary Larson
cartoon of a group of scientists studying dolphins and being puzzled by “those
strange ‘aw blah es span yol’ sounds.” The data had convinced him
that unless you understand the language of trauma and abuse, you cannot really
understand BPD.

As we later reported in the American
Journal of Psychiatry, 81 percent of the patients diagnosed with BPD at
Cambridge Hospital reported severe histories of child abuse and/or neglect; in the
vast majority the abuse began before age seven.[4] This finding was particularly
important because it suggested that the impact of abuse depends, at least in part,
on the age at which it begins. Later research by Martin Teicher at McLean Hospital
showed that different forms of abuse have different impacts on various brain areas
at different stages of development.[5] Although numerous studies have since
replicated our findings,[6] I still regularly get scientific papers to review that say
things like “It has been hypothesized that borderline patients may have
histories of childhood trauma.” When does a hypothesis become a scientifically
established fact?

Our study clearly supported the
conclusions of John Bowlby.

When children feel pervasively
angry or guilty or are chronically frightened about being abandoned, they have
come by such feelings honestly; that is because of experience. When, for
example, children fear abandonment, it is not in counterreaction to their
intrinsic homicidal urges; rather, it is more likely because they have been
abandoned physically or psychologically, or have been repeatedly threatened with
abandonment. When children are pervasively filled with rage, it is due to
rejection or harsh treatment. When children experience intense inner conflict
regarding their angry feelings, this is likely because expressing them may be
forbidden or even dangerous.

Bowlby noticed that when children must
disown powerful experiences they have had, this creates serious problems, including
“chronic distrust of other people, inhibition of curiosity, distrust of their
own senses, and the tendency to find everything unreal.”[7] As we will see, this has
important implications for treatment.

Our study expanded our thinking beyond
the impact of particular horrendous events, the focus of the PTSD diagnosis, to look
at the long-term effects of brutalization and neglect in caregiving relationships.
It also raised another critical question: What therapies are effective for people
with a history of abuse, particularly those who feel chronically suicidal and
deliberately hurt themselves?

SELF-HARM

During my training I was called from my
bed at around 3:00 a.m. three nights in a row to stitch up a woman who had slashed
her neck with whatever sharp object she could lay her hands on. She told me,
somewhat triumphantly, that cutting herself made her feel much better. Ever since
then I’d asked myself why. Why do some people deal with being upset by playing
three sets of tennis or drinking a stiff martini, while others carve their arms with
razor blades? Our study showed that having a history of childhood sexual and
physical abuse was a strong predictor of repeated suicide attempts and
self-cutting.[8] I wondered if their suicidal ruminations had started when they were
very young and whether they had found comfort in plotting their escape by hoping to
die or doing damage to themselves. Does inflicting harm on oneself begin as a
desperate attempt to gain some sense of control?

Chris Perry’s database had
follow-up information on all the patients who were treated in the hospital’s
outpatient clinics, including reports on suicidality and self-destructive behavior.
After three years of therapy approximately two-thirds of the patients had markedly
improved. Now the question was, which members of the group had benefited from
therapy and which had continued to feel suicidal and self-destructive? Comparing the
patients’ ongoing behavior with our TAQ interviews provided some answers. The
patients who remained self-destructive had told us that they did not remember
feeling safe with anybody as a child; they had reported being abandoned, shuttled
from place to place, and generally left to their own devices.

I concluded that, if you carry a memory
of having felt safe with somebody long ago, the traces of that earlier affection can
be reactivated in attuned relationships
when you are an adult, whether these occur in daily life or in good therapy.
However, if you lack a deep memory of feeling loved and safe, the receptors in the
brain that respond to human kindness may simply fail to develop.[9] If that is the case,
how can people learn to calm themselves down and feel grounded in their bodies?
Again, this has important implications for therapy, and I’ll return to this
question throughout part 5, on treatment.

THE POWER OF DIAGNOSIS

Our study also confirmed that there was a
traumatized population quite distinct from the combat soldiers and accident victims
for whom the PTSD diagnosis had been created. People like Marilyn and Kathy, as well
as the patients Judy and I had studied, and the kids in the outpatient clinic at
MMHC that I described in chapter 7, do not
necessarily remember their traumas (one of the criteria for the PTSD diagnosis) or
at least are not preoccupied with specific memories of their abuse, but they
continue to behave as if they were still in danger. They go from one extreme to the
other; they have trouble staying on task, and they continually lash out against
themselves and others. To some degree their problems do overlap with those of combat
soldiers, but they are also very different in that their childhood trauma has
prevented them from developing some of the mental capacities that adult soldiers
possessed before their traumas occurred.

After we realized this, a group of
us[10] went
to see Robert Spitzer, who, after having guided the development of the
DSM-III, was in the process of revising the manual. He listened
carefully to what we told him. He told us it was likely that clinicians who spend
their days treating a particular patient population are likely to develop
considerable expertise in understanding what ails them. He suggested that we do a
study, a so-called field trial, to compare the problems of different groups of
traumatized individuals.[11] Spitzer put me in charge of the project. First we developed a
rating scale that incorporated all the different trauma symptoms that had been
reported in the scientific literature, then we interviewed 525 adult patients at
five sites around the country to see if particular populations suffered from
different constellations of problems. Our populations fell into three groups: those
with histories of childhood physical or sexual abuse by caregivers; recent victims
of domestic violence; and people who had recently been through a natural
disaster.

There were clear differences among these
groups, particularly those on the extreme ends of the spectrum: victims of child
abuse and adults who had survived
natural disasters. The adults who had been abused as children often had trouble
concentrating, complained of always being on edge, and were filled with
self-loathing. They had enormous trouble negotiating intimate relationships, often
veering from indiscriminate, high-risk, and unsatisfying sexual involvements to
total sexual shutdown. They also had large gaps in their memories, often engaged in
self-destructive behaviors, and had a host of medical problems. These symptoms were
relatively rare in the survivors of natural disasters.

Each major diagnosis in the DSM had a
workgroup responsible for suggesting revisions for the new edition. I presented the
results of the field trial to our DSM-IV PTSD work group, and we voted
nineteen to two to create a new trauma diagnosis for victims of interpersonal
trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS),
or “Complex PTSD” for short.[12],[13] We then eagerly anticipated the
publication of the DSM-IV in May 1994. But much to our surprise the
diagnosis that our work group had overwhelmingly approved did not appear in the
final product. None of us had been consulted.

This was a tragic exclusion. It meant
that large numbers of patients could not be accurately diagnosed and that clinicians
and researchers would be unable to scientifically develop appropriate treatments for
them. You cannot develop a treatment for a condition that does not exist. Not having
a diagnosis now confronts therapists with a serious dilemma: How do we treat people
who are coping with the fall-out of abuse, betrayal and abandonment when we are
forced to diagnose them with depression, panic disorder, bipolar illness, or
borderline personality, which do not really address what they are coping with?

The consequences of caretaker abuse and
neglect are vastly more common and complex than the impact of hurricanes or motor
vehicle accidents. Yet the decision makers who determined the shape of our
diagnostic system decided not to recognize this evidence. To this day, after twenty
years and four subsequent revisions, the DSM and the entire system based on it fail
victims of child abuse and neglect—just as they ignored the plight of veterans
before PTSD was introduced back in 1980.

THE HIDDEN EPIDEMIC

How do you turn a newborn baby with all
its promise and infinite capacities into a thirty-year-old homeless drunk? As with
so many great discoveries, internist Vincent Felitti came across the answer to this
question accidentally.

In 1985 Felitti was chief of Kaiser
Permanente’s Department of Preventive Medicine in San Diego, which at the time
was the largest medical screening program in the world. He was also running an
obesity clinic that used a technique called “supplemented absolute
fasting” to bring about dramatic weight loss without surgery. One day a
twenty-eight-year-old nurse’s aide showed up in his office. Felitti accepted
her claim that obesity was her principal problem and enrolled her in the program.
Over the next fifty-one weeks her weight dropped from 408 pounds to 132 pounds.

However, when Felitti next saw her a few
months later, she had regained more weight than he thought was biologically possible
in such a short time. What had happened? It turned out that her newly svelte body
had attracted a male coworker, who started to flirt with her and then suggested sex.
She went home and began to eat. She stuffed herself during the day and ate while
sleepwalking at night. When Felitti probed this extreme reaction, she revealed a
lengthy incest history with her grandfather.

This was only the second case of incest
Felitti had encountered in his twenty-three-year medical practice, and yet about ten
days later he heard a similar story. As he and his team started to inquire more
closely, they were shocked to discover that most of their morbidly obese patients
had been sexually abused as children. They also uncovered a host of other family
problems.

In 1990 Felitti went to Atlanta to
present data from the team’s first 286 patient interviews at a meeting of the
North American Association for the Study of Obesity. He was stunned by the harsh
response of some experts: Why did he believe such patients? Didn’t he realize
they would fabricate any explanation for their failed lives? However, an
epidemiologist from the Centers for Disease Control and Prevention (CDC) encouraged
Felitti to start a much larger study, drawing on a general population, and invited
him to meet with a small group of researchers at the CDC. The result was the
monumental investigation of Adverse Childhood Experiences (now known as the ACE
study), a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD,
and Vincent Felitti, MD, as co–principal investigators.

More than fifty thousand Kaiser patients
came through the Department of Preventive Medicine annually for a comprehensive
evaluation, filling out an extensive medical questionnaire in the process. Felitti
and Anda spent more than a year developing ten new questions[14] covering carefully
defined categories of adverse childhood experiences, including physical and sexual
abuse, physical and emotional neglect, and family dysfunction, such as having had
parents who were divorced, mentally ill, addicted, or in prison. They then asked
25,000 consecutive patients if they would be willing to provide information about childhood events; 17,421 said yes.
Their responses were then compared with the detailed medical records that Kaiser
kept on all patients.

The ACE study revealed that traumatic
life experiences during childhood and adolescence are far more common than expected.
The study respondents were mostly white, middle class, middle aged, well educated,
and financially secure enough to have good medical insurance, and yet only one-third
of the respondents reported no adverse childhood experiences.

- One out of ten individuals responded yes
to the question “Did a parent or other adult in the household often or
very often swear at you, insult you, or put you down?”

- More than a quarter responded yes to the
questions “Did one of your parents often or very often push, grab, slap,
or throw something at you?” and “Did one of your parents often or
very often hit you so hard that you had marks or were injured?” In other
words, more than a quarter of the U.S. population is likely to have been
repeatedly physically abused as a child.

- To the questions “Did an adult or person
at least 5 years older ever have you touch their body in a sexual way?”
and “Did an adult or person at least 5 years older ever attempt oral,
anal, or vaginal intercourse with you?” 28 percent of women and 16 percent
of men responded affirmatively.

- One in eight people responded positively to
the questions: “As a child, did you witness your mother sometimes, often,
or very often pushed, grabbed, slapped, or had something thrown at her?”
“As a child, did you witness your mother sometimes, often, or very often
kicked, bitten, hit with a fist, or hit with something hard?”[15]

Each yes answer was scored as one point,
leading to a possible ACE score ranging from zero to ten. For example, a person who
experienced frequent verbal abuse, who had an alcoholic mother, and whose parents
divorced would have an ACE score of three. Of the two-thirds of respondents who
reported an adverse experience, 87 percent scored two or more. One in six of all
respondents had an ACE score of four or higher.

In short, Felitti and his team had found
that adverse experiences are interrelated, even though they’re usually studied
separately. People typically don’t grow up in a household where one brother is
in prison but everything else is fine. They don’t live in families where their
mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are
never stand-alone events. And for each additional adverse experience reported, the
toll in later damage increases.

Felitti and his team found that the
effects of childhood trauma first become evident in school. More than half of those
with ACE scores of four or higher reported having learning or behavioral problems,
compared with 3 percent of those with a score of zero. As the children matured, they
didn’t “outgrow” the effects of their early experiences. As
Felitti notes, “Traumatic experiences are often lost in time and concealed by
shame, secrecy, and social taboo,” but the study revealed that the impact of
trauma pervaded these patients’ adult lives. For example, high ACE scores
turned out to correlate with higher workplace absenteeism, financial problems, and
lower lifetime income.

When it came to personal suffering, the
results were devastating. As the ACE score rises, chronic depression in adulthood
also rises dramatically. For those with an ACE score of four or more, its prevalence
is 66 percent in women and 35 percent in men, compared with an overall rate of 12
percent in those with an ACE score of zero. The likelihood of being on
antidepressant medication or prescription painkillers also rose proportionally. As
Felitti has pointed out, we may be treating today experiences that happened fifty
years ago—at ever-increasing cost. Antidepressant drugs and painkillers constitute a
significant portion of our rapidly rising national health-care expenditures.[16] (Ironically,
research has shown that depressed patients without prior histories of abuse or
neglect tend to respond much better to antidepressants than patients with those
backgrounds.[17])

Self-acknowledged suicide attempts rise
exponentially with ACE scores. From a score of zero to a score of six there is about
a 5,000 percent increased likelihood of suicide attempts. The more isolated and
unprotected a person feels, the more death will feel like the only escape. When the
media report an environmental link to a 30 percent increase in the risk of some
cancer, it is headline news, yet these far more dramatic figures are overlooked.

As part of their initial medical
evaluation, study participants were asked, “Have you ever considered yourself
to be an alcoholic?” People with an ACE score of four were seven times more
likely to be alcoholic than adults with a score of zero. Injection drug use
increased exponentially: For those with an ACE score of six or more, the likelihood
of IV drug use was 4,600 percent greater than in those with a score of zero.

Women in the study were asked about rape
during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at
a score of four or more it was 33 percent. Why are abused or neglected girls so much
more likely to be raped later in life? The answers to this question have
implications far beyond rape. For example, numerous studies have shown that girls
who witness domestic violence while
growing up are at much higher risk of ending up in violent relationships themselves,
while for boys who witness domestic violence, the risk that they will abuse their
own partners rises sevenfold.[18] More than 12 percent of study
participants had seen their mothers being battered.

The list of high-risk behaviors
predicted by the ACE score included smoking, obesity, unintended pregnancies,
multiple sexual partners, and sexually transmitted diseases. Finally, the toll of
major health problems was striking: Those with an ACE score of six or above had a 15
percent or greater chance than those with an ACE score of zero of currently
suffering from any of the ten leading causes of death in the United States,
including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and
liver disease. They were twice as likely to suffer from cancer and four times as
likely to have emphysema. The ongoing stress on the body keeps taking its toll.

WHEN PROBLEMS ARE REALLY
SOLUTIONS

Twelve years after he originally treated
her, Felitti again saw the woman whose dramatic weight loss and gain had started him
on his quest. She told him that she’d subsequently had bariatric surgery but
that after she’d lost ninety-six pounds she’d become suicidal. It had
taken five psychiatric hospitalizations and three courses of electroshock to control
her suicidality. Felitti points out that obesity, which is considered a major public
health problem, may in fact be a personal solution for many. Consider the
implications: If you mistake someone’s solution for a problem to be
eliminated, not only are they likely to fail treatment, as often happens in
addiction programs, but other problems may emerge.

One female rape victim told Felitti,
“Overweight is overlooked, and that’s the way I need to be.”[19] Weight can
protect men, as well. Felitti recalls two guards at a state prison in his obesity
program. They promptly regained the weight they had lost, because they felt a lot
safer being the biggest guy on the cellblock. Another male patient became obese
after his parents divorced and he moved in with his violent alcoholic grandfather.
He explained: “It wasn’t that I ate because I was hungry and all of
that. It was just a place for me to feel safe. All the way from kindergarten I used
to get beat up all the time. When I got the weight on it didn’t happen
anymore.”

The ACE study group concluded:
“Although widely understood to be harmful to health, each adaptation [such as
smoking, drinking, drugs, obesity] is notably difficult to give up. Little
consideration is given to the possibility that many long-term health risks might also be
personally beneficial in the short term. We repeatedly hear from patients of the
benefits of these ‘health risks.’ The idea of the problem being a
solution, while understandably disturbing to many, is certainly in keeping with the
fact that opposing forces routinely coexist in biological systems. … What
one sees, the presenting problem, is often only the marker for the real problem,
which lies buried in time, concealed by patient shame, secrecy and sometimes
amnesia—and frequently clinician discomfort.”

CHILD ABUSE: OUR NATION’S
LARGEST PUBLIC HEALTH PROBLEM

The first time I heard Robert Anda
present the results of the ACE study, he could not hold back his tears. In his
career at the CDC he had previously worked in several major risk areas, including
tobacco research and cardiovascular health. But when the ACE study data started to
appear on his computer screen, he realized that they had stumbled upon the gravest
and most costly public health issue in the United States: child abuse. He had
calculated that its overall costs exceeded those of cancer or heart disease and that
eradicating child abuse in America would reduce the overall rate of depression by
more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic
violence by three-quarters.[20] It would also have a dramatic effect
on workplace performance and vastly decrease the need for incarceration.

When the surgeon general’s report
on smoking and health was published in 1964, it unleashed a decades-long legal and
medical campaign that has changed daily life and long-term health prospects for
millions. The number of American smokers fell from 42 percent of adults in 1965 to
19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer
were prevented between 1975 and 2000.[21]

The ACE study, however, has had no such
effect. Follow-up studies and papers are still appearing around the world, but the
day-to-day reality of children like Marilyn and the children in outpatient clinics
and residential treatment centers around the country remains virtually the same.
Only now they receive high doses of psychotropic agents, which makes them more
tractable but which also impairs their ability to feel pleasure and curiosity, to
grow and develop emotionally and intellectually, and to become contributing members
of society.

CHAPTER 10

Developmental Trauma: The Hidden
Epidemic

The notion that early childhood adverse
experiences lead to substantial developmental disruptions is more clinical intuition
than a research-based fact. There is no known evidence of developmental disruptions
that were preceded in time in a causal fashion by any type of trauma syndrome.

—From the American Psychiatric Association’s rejection of a
Developmental Trauma Disorder diagnosis, May 2011

Research on the effects of early maltreatment
tells a different story: that early maltreatment has enduring negative effects on
brain development. Our brains are sculpted by our early experiences. Maltreatment is
a chisel that shapes a brain to contend with strife, but at the cost of deep,
enduring wounds. Childhood abuse isn’t something you “get over.”
It is an evil that we must acknowledge and confront if we aim to do anything about
the unchecked cycle of violence in this country.

—Martin Teicher, MD, PhD, Scientific American

There are hundreds of thousands of
children like the ones I am about to describe, and they absorb enormous resources,
often without appreciable benefit. They end up filling our jails, our welfare rolls,
and our medical clinics. Most of the public knows them only as statistics. Tens of
thousands of schoolteachers, probation
officers, welfare workers, judges, and mental health professionals spend their days
trying to help them, and the taxpayer pays the bills.

Anthony was only two and a half when he
was referred to our Trauma Center by a child-care center because its employees could
not manage his constant biting and pushing, his refusal to take naps, and his
intractable crying, head banging, and rocking. He did not feel safe with any staff
member and fluctuated between despondent collapse and angry defiance.

When we met with him and his mother, he
anxiously clung to her, hiding his face, while she kept saying, “Don’t
be such a baby.” He startled when a door banged somewhere down the corridor
and then burrowed deeper into his mom’s lap. When she pushed him away, he sat
in a corner and started to bang his head. “He just does that to bug me,”
his mother remarked. When we asked about her own background, she told us that
she’d been abandoned by her parents and raised by a series of relatives who
hit her, ignored her, and started to sexually abuse her at age thirteen. She’d
become pregnant by a drunken boyfriend who left her when she told him she was
carrying his child. Anthony was just like his father, she said—a good-for-nothing.
She had had numerous violent rows with subsequent boyfriends, but she was sure that
this had happened too late at night for Anthony to notice.

If Anthony were admitted to a hospital,
he would likely be diagnosed with a host of different psychiatric disorders:
depression, oppositional defiant disorder, anxiety, reactive attachment disorder,
ADHD, and PTSD. None of these diagnoses, however, would clarify what was wrong with
Anthony: that he was scared to death and fighting for his life, and he did not trust
that his mother could help him.

Then there’s Maria, a
fifteen-year-old Latina, one of the more than half a million kids in the United
States who grow up in foster care and residential treatment programs. Maria is obese
and aggressive. She has a history of sexual, physical, and emotional abuse and has
lived in more than twenty out-of-home placements since age eight. The pile of
medical charts that arrived with her described her as mute, vengeful, impulsive,
reckless, and self-harming, with extreme mood swings and an explosive temper. She
describes herself as “garbage, worthless, rejected.”

After multiple suicide attempts Maria
was placed in one of our residential treatment centers. Initially she was mute and
withdrawn and became violent when people got too close to her. After other
approaches failed to work, she was placed in an equine therapy program where she
groomed her horse daily and learned simple dressage. Two years later I spoke with
Maria at her high school graduation. She
had been accepted by a four-year college. When I asked her what had helped her most,
she answered, “The horse I took care of.” She told me that she first
started to feel safe with her horse; he was there every day, patiently waiting for
her, seemingly glad upon her approach. She started to feel a visceral connection
with another creature and began to talk to him like a friend. Gradually she started
talking with the other kids in the program and, eventually, with her counselor.

Virginia is a thirteen-year-old adopted
white girl. She was taken away from her biological mother because of the
mother’s drug abuse; after her first adoptive mother fell ill and died, she
moved from foster home to foster home before being adopted again. Virginia was
seductive with any male who crossed her path, and she reported sexual and physical
abuse by various babysitters and temporary caregivers. She came to our residential
treatment program after thirteen crisis hospitalizations for suicide attempts. The
staff described her as isolated, controlling, explosive, sexualized, intrusive,
vindictive, and narcissistic. She described herself as disgusting and said she
wished she were dead. The diagnoses in her chart were bipolar disorder, intermittent
explosive disorder, reactive attachment disorder, attention deficit disorder (ADD)
hyperactive subtype, oppositional defiant disorder (ODD), and substance use
disorder. But who, really, is Virginia? How can we help her have a life?[1]

We can hope to solve the problems of
these children only if we correctly define what is going on with them and do more
than developing new drugs to control them or trying to find “the” gene
that is responsible for their “disease.” The challenge is to find ways
to help them lead productive lives and, in so doing, save hundreds of millions of
dollars of taxpayers’ money. That process starts with facing the facts.

BAD GENES?

With such pervasive problems and such
dysfunctional parents we would be tempted to ascribe their problems simply to bad
genes. Technology always produces new directions for research, and when it became
possible to do genetic testing, psychiatry became committed to finding the genetic
causes of mental illness. Finding a genetic link seemed particularly relevant for
schizophrenia, a fairly common (affecting about 1 percent of the population),
severe, and perplexing form of mental illness and one that clearly runs in families.
And yet after thirty years and millions upon millions of dollars’ worth of
research, we have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness, for
that matter.[2]
Some of my colleagues have also worked hard to discover genetic factors that
predispose people to develop traumatic stress.[3] That quest continues, but so far it
has failed to yield any solid answers.[4]

Recent research has swept away the
simple idea that “having” a particular gene produces a particular
result. It turns out that many genes work together to influence a single outcome.
Even more important, genes are not fixed; life events can trigger biochemical
messages that turn them on or off by attaching methyl groups, a cluster of carbon
and hydrogen atoms, to the outside of the gene (a process called methylation),
making it more or less sensitive to messages from the body. While life events can
change the behavior of the gene, they do not alter its fundamental structure.
Methylation patterns, however, can be passed on to offspring—a phenomenon known as
epigenetics. Once again, the body keeps the score, at the deepest levels of the
organism.

One of the most cited experiments in
epigenetics was conducted by McGill University researcher Michael Meaney, who
studies newborn rat pups and their mothers.[5] He discovered that how much a mother
rat licks and grooms her pups during the first twelve hours after their birth
permanently affects the brain chemicals that respond to stress—and modifies the
configuration of over a thousand genes. The rat pups that are intensively licked by
their mothers are braver and produce lower levels of stress hormones under stress
than rats whose mothers are less attentive. They also recover more quickly—an
equanimity that lasts throughout their lives. They develop thicker connections in
the hippocampus, a key center for learning and memory, and they perform better in an
important rodent skill—finding their way through mazes.

We are just beginning to learn that
stressful experiences affect gene expression in humans, as well. Children whose
pregnant mothers had been trapped in unheated houses in a prolonged ice storm in
Quebec had major epigenetic changes compared with the children of mothers whose heat
had been restored within a day.[6] McGill researcher Moshe Szyf compared
the epigenetic profiles of hundreds of children born into the extreme ends of social
privilege in the United Kingdom and measured the effects of child abuse on both
groups. Differences in social class were associated with distinctly different
epigenetic profiles, but abused children in both groups had in common specific
modifications in seventy-three genes. In Szyf’s words, “Major changes to
our bodies can be made not just by chemicals and toxins, but also in the way the
social world talks to the hard-wired world.”[7],[8]

MONKEYS CLARIFY OLD QUESTIONS ABOUT
NATURE VERSUS NURTURE

One of the clearest ways of understanding
how the quality of parenting and environment affects the expression of genes comes
from the work of Stephen Suomi, chief of the National Institutes of Health’s
Laboratory of Comparative Ethology.[9] For more than forty years Suomi has
been studying the transmission of personality through generations of rhesus monkeys,
which share 95 percent of human genes, a number exceeded only by chimpanzees and
bonobos. Like humans, rhesus monkeys live in large social groups with complex
alliances and status relationships, and only members who can synchronize their
behavior with the demands of the troop survive and flourish.

Rhesus monkeys are also like humans in
their attachment patterns. Their infants depend on intimate physical contact with
their mothers, and just as Bowlby observed in humans, they develop by exploring
their reactions to their environment, running back to their mothers whenever they
feel scared or lost. Once they become more independent, play with their peers is the
primary way they learn to get along in life.

Suomi identified two personality types
that consistently ran into trouble: uptight, anxious monkeys, who become fearful,
withdrawn, and depressed even in situations where other monkeys will play and
explore; and highly aggressive monkeys, who make so much trouble that they are often
shunned, beaten up, or killed. Both types are biologically different from their
peers. Abnormalities in arousal levels, stress hormones, and metabolism of brain
chemicals like serotonin can be detected within the first few weeks of life, and
neither their biology nor their behavior tends to change as they mature. Suomi
discovered a wide range of genetically driven behaviors. For example, the uptight
monkeys (classified as such on the basis of both their behavior and their high
cortisol levels at six months) will consume more alcohol in experimental situations
than the others when they reach the age of four. The genetically aggressive monkeys
also overindulge—but they binge drink to the point of passing out, while the uptight
monkeys seem to drink to calm down.

And yet the social environment also
contributes significantly to behavior and biology. The uptight, anxious females
don’t play well with others and thus often lack social support when they give
birth and are at high risk for neglecting or abusing their firstborns. But when
these females belong to a stable social group they often become diligent mothers who
carefully watch out for their young. Under some conditions being an anxious mom can
provide much needed protection. The
aggressive mothers, on the other hand, did not provide any social advantages: very
punitive with their offspring, there is lots of hitting, kicking, and biting. If the
infants survive, their mothers usually keep them from making friends with their
peers.

In real life it is impossible to tell
whether people’s aggressive or uptight behavior is the result of
parents’ genes or of having been raised by an abusive mother—or both. But in a
monkey lab you can take newborns with vulnerable genes away from their biological
mothers and have them raised by supportive mothers or in playgroups with peers.

Young monkeys who are taken away from
their mothers at birth and brought up solely with their peers become intensely
attached to them. They desperately cling to one another and don’t peel away
enough to engage in healthy exploration and play. What little play there is lacks
the complexity and imagination typical of normal monkeys. These monkeys grow up to
be uptight: scared in new situations and lacking in curiosity. Regardless of their
genetic predisposition, peer-raised monkeys overreact to minor stresses: Their
cortisol increases much more in response to loud noises than does that of monkeys
who were raised by their mothers. Their serotonin metabolism is even more abnormal
than that of the monkeys who are genetically predisposed to aggression but who were
raised by their own mothers. This leads to the conclusion that, at least in monkeys,
early experience has at least as much impact on biology as heredity does.

Monkeys and humans share the same two
variants of the serotonin gene (known as the short and long serotonin transporter
alleles). In humans the short allele has been associated with impulsivity,
aggression, sensation seeking, suicide attempts, and severe depression. Suomi showed
that, at least in monkeys, the environment shapes how these genes affect behavior.
Monkeys with the short allele that were raised by an adequate mother behaved
normally and had no deficit in their serotonin metabolism. Those who were raised
with their peers became aggressive risk takers.[10] Similarly, New Zealand researcher
Alec Roy found that humans with the short allele had higher rates of depression than
those with the long version but that this was true only if they also had a childhood
history of abuse or neglect. The conclusion is clear: Children who are fortunate
enough to have an attuned and attentive parent are not going to develop this
genetically related problem.[11]

Suomi’s work supports everything
we’ve learned from our colleagues who study human attachment and from our own
clinical research: Safe and protective early relationships are critical to protect
children from long-term problems. In addition, even parents with their own genetic
vulnerabilities can pass on that
protection to the next generation provided that they are given the right
support.

THE NATIONAL CHILD TRAUMATIC STRESS
NETWORK

Nearly every medical disease, from cancer
to retinitis pigmentosa, has advocacy groups that promote the study and treatment of
that particular condition. But until 2001, when the National Child Traumatic Stress
Network was established by an act of Congress, there was no comprehensive
organization dedicated to the research and treatment of traumatized children.

In 1998 I received a call from Adam
Cummings from the Nathan Cummings Foundation telling me that they were interested in
studying the effects of trauma on learning. I told them that while some very good
work had been done on that subject,[12] there was no forum to implement the
discoveries that had already been made. The mental, biological, or moral development
of traumatized children was not being systematically taught to child-care workers,
to pediatricians, or in graduate schools of psychology or social work.

Adam and I agreed that we had to address
this problem. Some eight months later we convened a think tank that included
representatives from the U.S. Department of Health and Human Services and the U.S.
Department of Justice, Senator Ted Kennedy’s health-care adviser, and a group
of my colleagues who specialized in childhood trauma. We all were familiar with the
basics of how trauma affects the developing mind and brain, and we all were aware
that childhood trauma is radically different from traumatic stress in fully formed
adults. The group concluded that, if we hoped to ever put the issue of childhood
trauma firmly on the map, there needed to be a national organization that would
promote both the study of childhood trauma and the education of teachers, judges,
ministers, foster parents, physicians, probation officers, nurses, and mental health
professionals—anyone who deals with abused and traumatized kids.

One member of our work group, Bill
Harris, had extensive experience with child-related legislation, and he went to work
with Senator Kennedy’s staff to craft our ideas into law. The bill
establishing the National Child Traumatic Stress Network was ushered through the
Senate with overwhelming bipartisan support, and since 2001 it has grown from a
collaborative network of 17 sites to more than 150 centers nationwide. Led by
coordinating centers at Duke University and UCLA, the NCTSN includes universities,
hospitals, tribal agencies, drug rehab programs, mental health clinics, and graduate schools. Each of the sites, in
turn, collaborates with local school systems, hospitals, welfare agencies, homeless
shelters, juvenile justice programs, and domestic violence shelters, with a total of
well over 8,300 affiliated partners.

Once the NCTSN was up and running, we
had the means to assemble a clearer profile of traumatized kids in every part of the
country. My Trauma Center colleague Joseph Spinazzola led a survey that examined the
records of nearly two thousand children and adolescents from agencies across the
network.[13]
We soon confirmed what we had suspected: The vast majority came from extremely
dysfunctional families. More than half had been emotionally abused and/or had a
caregiver who was too impaired to care for their needs. Almost 50 percent had
temporarily lost caregivers to jail, treatment programs, or military service and had
been looked after by strangers, foster parents, or distant relatives. About half
reported having witnessed domestic violence, and a quarter were also victims of
sexual and/or physical abuse. In other words, the children and adolescents in the
survey were mirrors of the middle-aged, middle-class Kaiser Permanente patients with
high ACE scores that Vincent Felitti had studied in the Adverse Childhood
Experiences (ACE) Study.

THE POWER OF DIAGNOSIS

In the 1970s there was no way to classify
the wide-ranging symptoms of hundreds of thousands of returning Vietnam veterans. As
we saw in the opening chapters of this book, this forced clinicians to improvise the
treatment of their patients and prevented them from being able to systematically
study what approaches actually worked. The adoption of the PTSD diagnosis by the DSM
III in 1980 led to extensive scientific studies and to the development of effective
treatments, which turned out to be relevant not only to combat veterans but also to
victims of a range of traumatic events, including rape, assault, and motor vehicle
accidents.[14] An example of the far-ranging power of having a specific diagnosis
is the fact that between 2007 and 2010 the Department of Defense spent more than
$2.7 billion for the treatment of and research on PTSD in combat veterans, while in
fiscal year 2009 alone the Department of Veterans Affairs spent $24.5 million on
in-house PTSD research.

The DSM definition of PTSD is quite
straightforward: A person is exposed to a horrendous event “that involved
actual or threatened death or serious
injury, or a threat to the physical integrity of self or others,” causing
“intense fear, helplessness, or horror,” which results in a variety of
manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams,
feeling as if the event were occurring), persistent and crippling avoidance (of
people, places, thoughts, or feelings associated with the trauma, sometimes with
amnesia for important parts of it), and increased arousal (insomnia, hypervigilance,
or irritability). This description suggests a clear story line: A person is suddenly
and unexpectedly devastated by an atrocious event and is never the same again. The
trauma may be over, but it keeps being replayed in continually recycling memories
and in a reorganized nervous system.

How relevant was this definition to the
children we were seeing? After a single traumatic incident—a dog bite, an accident,
or witnessing a school shooting—children can indeed develop basic PTSD symptoms
similar to those of adults, even if they live in safe and supportive homes. As a
result of having the PTSD diagnosis, we now can treat those problems quite
effectively.

In the case of the troubled children
with histories of abuse and neglect who show up in clinics, schools, hospitals, and
police stations, the traumatic roots of their behaviors are less obvious,
particularly because they rarely talk about having been hit, abandoned, or molested,
even when asked. Eighty two percent of the traumatized children seen in the National
Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.[15] Because they
often are shut down, suspicious, or aggressive they now receive pseudoscientific
diagnoses such as “oppositional defiant disorder,” meaning “This
kid hates my guts and won’t do anything I tell him to do,” or
“disruptive mood dysregulation disorder,” meaning he has temper
tantrums. Having as many problems as they do, these kids accumulate numerous
diagnoses over time. Before they reach their twenties, many patients have been given
four, five, six, or more of these impressive but meaningless labels. If they receive
treatment at all, they get whatever is being promulgated as the method of management
du jour: medications, behavioral modification, or exposure therapy. These rarely
work and often cause more damage.

As the NCTSN treated more and more kids,
it became increasingly obvious that we needed a diagnosis that captured the reality
of their experience. We began with a database of nearly twenty thousand kids who
were being treated in various sites within the network and collected all the
research articles we could find on abused and neglected kids. These were winnowed
down to 130 particularly relevant studies that reported on more than one hundred
thousand children and adolescents worldwide. A core work group of twelve clinician/researchers specializing in
childhood trauma[16] then convened twice a year for four years to draft a proposal for
an appropriate diagnosis, which we decided to call Developmental Trauma
Disorder.[17]

As we organized our findings, we
discovered a consistent profile: (1) a pervasive pattern of dysregulation, (2)
problems with attention and concentration, and (3) difficulties getting along with
themselves and others. These children’s moods and feelings rapidly shifted
from one extreme to another—from temper tantrums and panic to detachment, flatness,
and dissociation. When they got upset (which was much of the time), they could
neither calm themselves down nor describe what they were feeling.

Having a biological system that keeps
pumping out stress hormones to deal with real or imagined threats leads to physical
problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch
or sound. Being so agitated or shut down keeps them from being able to focus their
attention and concentration. To relieve their tension, they engage in chronic
masturbation, rocking, or self-harming activities (biting, cutting, burning, and
hitting themselves, pulling their hair out, picking at their skin until it bled). It
also leads to difficulties with language processing and fine-motor coordination.
Spending all their energy on staying in control, they usually have trouble paying
attention to things, like schoolwork, that are not directly relevant to survival,
and their hyperarousal makes them easily distracted.

Having been frequently ignored or
abandoned leaves them clinging and needy, even with the people who have abused them.
Having been chronically beaten, molested, and otherwise mistreated, they can not
help but define themselves as defective and worthless. They come by their
self-loathing, sense of defectiveness, and worthlessness honestly. Was it any
surprise that they didn’t trust anyone? Finally, the combination of feeling
fundamentally despicable and overreacting to slight frustrations makes it difficult
for them to make friends.

We published the first articles about
our findings, developed a validated rating scale,[18] and collected data on about 350 kids
and their parents or foster parents to establish that this one diagnosis,
Developmental Trauma Disorder, captured the full range of what was wrong with these
children. It would enable us to give them a single diagnosis, as opposed to multiple
labels, and would firmly locate the origin of their problems in a combination of
trauma and compromised attachment.

In February 2009 we submitted our
proposed new diagnosis of Developmental Trauma Disorder to the American Psychiatric
Association, stating the following in a cover letter:

Children who develop in the context
of ongoing danger, maltreatment and disrupted caregiving systems are being ill
served by the current diagnostic systems that lead to an emphasis on behavioral
control with no recognition of interpersonal trauma. Studies on the sequelae of
childhood trauma in the context of caregiver abuse or neglect consistently
demonstrate chronic and severe problems with emotion regulation, impulse
control, attention and cognition, dissociation, interpersonal relationships, and
self and relational schemas. In absence of a sensitive trauma-specific
diagnosis, such children are currently diagnosed with an average of 3–8
co-morbid disorders. The continued practice of applying multiple distinct
co-morbid diagnoses to traumatized children has grave consequences: it defies
parsimony, obscures etiological clarity, and runs the danger of relegating
treatment and intervention to a small aspect of the child’s
psychopathology rather than promoting a comprehensive treatment approach.

Shortly after submitting our proposal, I
gave a talk on Developmental Trauma Disorder in Washington DC to a meeting of the
mental health commissioners from across the country. They offered to support our
initiative by writing a letter to the APA. The letter began by pointing out that the
National Association of State Mental Health Program Directors served 6.1 million
people annually, with a budget of $29.5 billion, and concluded: “We urge the
APA to add developmental trauma to its list of priority areas to clarify and better
characterize its course and clinical sequelae and to emphasize the strong need to
address developmental trauma in the assessment of patients.”

I felt confident that this letter would
ensure that the APA would take our proposal seriously, but several months after our
submission, Matthew Friedman, executive director of the National Center for PTSD and
chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be
included in the DSM-5. The consensus, he wrote, was that no new diagnosis was
required to fill a “missing diagnostic niche.” One million children who
are abused and neglected every year in the United States a “diagnostic
niche”?

The letter went on: “The notion
that early childhood adverse experiences lead to substantial developmental
disruptions is more clinical intuition than a research-based fact. This statement is
commonly made but cannot be backed up by prospective studies.” In fact, we had
included several prospective studies in our proposal. Let’s look at just two
of them here.

HOW RELATIONSHIPS SHAPE
DEVELOPMENT

Beginning in 1975 and continuing for
almost thirty years, Alan Sroufe and his colleagues tracked 180 children and their
families through the Minnesota Longitudinal Study of Risk and Adaptation.[19] At the time
the study began there was an intense debate about the role of nature versus nurture,
and temperament versus environment in human development, and this study set out to
answer those questions. Trauma was not yet a popular topic, and child abuse and
neglect were not a central focus of this study—at least initially, until they
emerged as the most important predictors of adult functioning.

Working with local medical and social
agencies, the researchers recruited first-time (Caucasian) mothers who were poor
enough to qualify for public assistance but who had different backgrounds and
different kinds and levels of support available for parenting. The study began three
months before the children were born and followed the children for thirty years into
adulthood, assessing and, where relevant, measuring all the major aspects of their
functioning and all the significant circumstances of their lives. It considered
several fundamental questions: How do children learn to pay attention while
regulating their arousal (i.e., avoiding extreme highs or lows) and keeping their
impulses under control? What kinds of supports do they need, and when are these
needed?

After extensive interviews and testing
of the prospective parents, the study really got off the ground in the newborn
nursery, where researchers observed the newborns and interviewed the nurses caring
for them. They then made home visits seven and ten days after birth. Before the
children entered first grade, they and their parents were carefully assessed a total
of fifteen times. After that, the children were interviewed and tested at regular
intervals until age twenty-eight, with continuing input from mothers and
teachers.

Sroufe and his colleagues found that
quality of care and biological factors were closely interwoven. It is fascinating to
see how the Minnesota results echo—though with far greater complexity—what Stephen
Suomi found in his primate laboratory. Nothing was written in stone.
Neither the mother’s personality, nor the infant’s neurological
anomalies at birth, nor its IQ, nor its temperament—including its activity level and
reactivity to stress—predicted whether a child would develop serious behavioral
problems in adolescence.[20] The key issue, rather, was the nature of the parent-child
relationship: how parents felt about and interacted with their kids. As with
Suomi’s monkeys, the combination of vulnerable infants and inflexible
caregivers made for clingy, uptight kids. Insensitive, pushy, and intrusive behavior
on the part of the parents at six
months predicted hyperactivity and attention problems in kindergarten and
beyond.[21]

Focusing on many facets of development,
particularly relationships with caregivers, teachers, and peers, Sroufe and his
colleagues found that caregivers not only help keep arousal within manageable bounds
but also help infants develop their own ability to regulate their arousal. Children
who were regularly pushed over the edge into overarousal and disorganization did not
develop proper attunement of their inhibitory and excitatory brain systems and grew
up expecting that they would lose control if something upsetting happened. This was
a vulnerable population, and by late adolescence half of them had diagnosable mental
health problems. There were clear patterns: The children who received consistent
caregiving became well-regulated kids, while erratic caregiving produced kids who
were chronically physiologically aroused. The children of unpredictable parents
often clamored for attention and became intensely frustrated in the face of small
challenges. Their persistent arousal made them chronically anxious. Constantly
looking for reassurance got in the way of playing and exploration, and, as a result,
they grew up chronically nervous and nonadventurous.

Early parental neglect or harsh
treatment led to behavior problems in school and predicted troubles with peers and a
lack of empathy for the distress of others.[22] This set up a vicious cycle: Their
chronic arousal, coupled with lack of parental comfort, made them disruptive,
oppositional, and aggressive. Disruptive and aggressive kids are unpopular and
provoke further rejection and punishment, not only from their caregivers but also
from their teachers and peers.[23]

Sroufe also learned a great deal about
resilience: the capacity to bounce back from adversity. By far the most important
predictor of how well his subjects coped with life’s inevitable
disappointments was the level of security established with their primary caregiver
during the first two years of life. Sroufe informally told me that he thought that
resilience in adulthood could be predicted by how lovable mothers rated their kids
at age two.[24]

THE LONG-TERM EFFECTS OF INCEST

In 1986 Frank Putnam and Penelope
Trickett, his colleague at the National Institute of Mental Health, initiated the
first longitudinal study of the impact of sexual abuse on female development.[25] Until the
results of this study came out, our knowledge about the effects of incest was based
entirely on reports from children who had recently disclosed their abuse and on
accounts from adults reconstructing
years or even decades later how incest had affected them. No study had ever followed
girls as they matured to examine how sexual abuse might influence their school
performance, peer relationships, and self-concept, as well as their later dating
life. Putnam and Trickett also looked at changes over time in their subjects’
stress hormones, reproductive hormones, immune function, and other physiological
measures. In addition they explored potential protective factors, such as
intelligence and support from family and peers.

The researchers painstakingly recruited
eighty-four girls referred by the District of Columbia Department of Social Services
who had a confirmed history of sexual abuse by a family member. These were matched
with a comparison group of eighty-two girls of the same age, race, socioeconomic
status, and family constellation who had not been abused. The average starting age
was eleven. Over the next twenty years these two groups were thoroughly assessed six
times, once a year for the first three years and again at ages eighteen, nineteen,
and twenty-five. Their mothers participated in the early assessments, and their own
children took part in the last. A remarkable 96 percent of the girls, now grown
women, have stayed in the study from its inception.

The results were unambiguous: Compared
with girls of the same age, race, and social circumstances, sexually abused girls
suffer from a large range of profoundly negative effects, including cognitive
deficits, depression, dissociative symptoms, troubled sexual development, high rates
of obesity, and self-mutilation. They dropped out of high school at a higher rate
than the control group and had more major illnesses and health-care utilization.
They also showed abnormalities in their stress hormone responses, had an earlier
onset of puberty, and accumulated a host of different, seemingly unrelated,
psychiatric diagnoses.

The follow-up research revealed many
details of how abuse affects development. For example, each time they were assessed,
the girls in both groups were asked to talk about the worst thing that had happened
to them during the previous year. As they told their stories, the researchers
observed how upset they became, while measuring their physiology. During the first
assessment all the girls reacted by becoming distressed. Three years later, in
response to the same question, the nonabused girls once again displayed signs of
distress, but the abused girls shut down and became numb. Their biology matched
their observable reactions: During the first assessment all of the girls showed an
increase in the stress hormone cortisol; three years later cortisol went down in the
abused girls as they reported on the most stressful event of the past year. Over
time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends,
and others are not likely to notice that a girl is upset; she may not even register
it herself. By numbing out she no longer reacts to distress the way she should, for
example, by taking protective action.

Putnam’s study also captured the
pervasive long-term effects of incest on friendships and partnering. Before the
onset of puberty nonabused girls usually have several girlfriends, as well as one
boy who functions as a sort of spy who informs them about what these strange
creatures, boys, are all about. After they enter adolescence, their contacts with
boys gradually increase. In contrast, before puberty the abused girls rarely have
close friends, girls or boys, but adolescence brings many chaotic and often
traumatizing contacts with boys.

Lacking friends in elementary school
makes a crucial difference. Today we’re aware how cruel third-, fourth-, and
fifth-grade girls can be. It’s a complex and rocky time when friends can
suddenly turn on one another and alliances dissolve in exclusions and betrayals. But
there is an upside: By the time girls get to middle school, most have begun to
master a whole set of social skills, including being able to identify what they
feel, negotiating relationships with others, pretending to like people they
don’t, and so on. And most of them have built a fairly steady support network
of girls who become their stress-debriefing team. As they slowly enter the world of
sex and dating, these relationships give them room for reflection, gossip, and
discussion of what it all means.

The sexually abused girls have an
entirely different developmental pathway. They don’t have friends of either
gender because they can’t trust; they hate themselves, and their biology is
against them, leading them either to overreact or numb out. They can’t keep up
in the normal envy-driven inclusion/exclusion games, in which players have to stay
cool under stress. Other kids usually don’t want anything to do with them—they
simply are too weird.

But that’s only the beginning of
the trouble. The abused, isolated girls with incest histories mature sexually a year
and a half earlier than the nonabused girls. Sexual abuse speeds up their biological
clocks and the secretion of sex hormones. Early in puberty the abused girls had
three to five times the levels of testosterone and androstenedione, the hormones
that fuel sexual desire, as the girls in the control group.

Results of Putnam and Trickett’s
study continue to be published, but it has already created an invaluable road map
for clinicians dealing with sexually abused girls. At the Trauma Center, for
example, one of our clinicians reported on a Monday morning that a patient named
Ayesha had been raped—again—over the
weekend. She had run away from her group home at five o’clock on Saturday,
gone to a place in Boston where druggies hang out, smoked some dope and done some
other drugs, and then left with a bunch of boys in a car. At five o’clock
Sunday morning they had gang-raped her. Like so many of the adolescents we see,
Ayesha can’t articulate what she wants or needs and can’t think through
how she might protect herself. Instead, she lives in a world of actions. Trying to
explain her behavior in terms of victim/perpetrator isn’t helpful, nor are
labels like “depression,” “oppositional defiant disorder,”
“intermittent explosive disorder,” “bipolar disorder,” or
any of the other options our diagnostic manuals offer us. Putnam’s work has
helped us understand how Ayesha experiences the world—why she cannot tell us what is
going on with her, why she is so impulsive and lacking in self-protection, and why
she views us as frightening and intrusive rather than as people who can help
her.

THE DSM-5: A VERITABLE SMORGASBORD
OF “DIAGNOSES”

When DSM-5 was published in May 2013 it
included some three hundred disorders in its 945 pages. It offers a veritable
smorgasbord of possible labels for the problems associated with severe early-life
trauma, including some new ones such as Disruptive Mood Regulation Disorder,[26] Non-suicidal
Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement
Disorder, and Disruptive Impulse Control Disorder.[27]

Before the late nineteenth century
doctors classified illnesses according to their surface manifestations, like fevers
and pustules, which was not unreasonable, given that they had little else to go
on.[28] This
changed when scientists like Louis Pasteur and Robert Koch discovered that many
diseases were caused by bacteria that were invisible to the naked eye. Medicine then
was transformed by its attempts to discover ways to get rid of those organisms
rather than just treating the boils and the fevers that they caused. With DSM-5
psychiatry firmly regressed to early-nineteenth-century medical practice. Despite
the fact that we know the origin of many of the problems it identifies, its
“diagnoses” describe surface phenomena that completely ignore the
underlying causes.

Even before DSM-5 was released, the
American Journal of Psychiatry published the results of validity tests
of various new diagnoses, which indicated that the DSM largely lacks what in the
world of science is known as “reliability”—the ability to produce
consistent, replicable results. In other words, it lacks scientific validity. Oddly, the lack of
reliability and validity did not keep the DSM-5 from meeting its deadline for
publication, despite the near-universal consensus that it represented no improvement
over the previous diagnostic system.[29] Could the fact that the APA had
earned $100 million on the DSM-IV and is slated to take in a similar amount with the
DSM-5 (because all mental health practitioners, many lawyers, and other
professionals will be obliged to purchase the latest edition) be the reason we have
this new diagnostic system?

Diagnostic reliability isn’t an
abstract issue: If doctors can’t agree on what ails their patients, there is
no way they can provide proper treatment. When there’s no relationship between
diagnosis and cure, a mislabeled patient is bound to be a mistreated patient. You
would not want to have your appendix removed when you are suffering from a kidney
stone, and you would not want to have somebody labeled as “oppositional”
when, in fact, his behavior is rooted in an attempt to protect himself against real
danger.

In a statement released in June 2011,
the British Psychological Society complained to the APA that the sources of
psychological suffering in the DSM-5 were identified “as located within
individuals” and overlooked the “undeniable social causation of many
such problems.”[30] This was in addition to a flood of protest from American
professionals, including leaders of the American Psychological Association and the
American Counseling Association. Why are relationships or social conditions left
out?[31] If
you pay attention only to faulty biology and defective genes as the cause of mental
problems and ignore abandonment, abuse, and deprivation, you are likely to run into
as many dead ends as previous generations did blaming it all on terrible
mothers.

The most stunning rejection of the DSM-5
came from the National Institute of Mental Health, which funds most psychiatric
research in America. In April 2013, a few weeks before DSM-5 was formally released,
NIMH director Thomas Insel announced that his agency could no longer support
DSM’s “symptom-based diagnosis.”[32] Instead the institute would focus its
funding on what are called Research Domain Criteria (RDoC)[33] to create a framework for
studies that would cut across current diagnostic categories. For example, one of the
NIMH domains is “Arousal/Modulatory Systems (Arousal, Circadian Rhythm, Sleep
and Wakefulness),” which are disturbed to varying degrees in many
patients.

Like the DSM-5, the RDoC framework
conceptualizes mental illnesses solely as brain disorders. This means that future
research funding will explore the brain circuits “and other neurobiological
measures” that underlie mental problems. Insel sees this as a first step toward the
sort of “precision medicine that has transformed cancer diagnosis and
treatment.” Mental illness, however, is not at all like cancer: Humans are
social animals, and mental problems involve not being able to get along with other
people, not fitting in, not belonging, and in general not being able to get on the
same wavelength.

Everything about us—our brains, our
minds, and our bodies—is geared toward collaboration in social systems. This is our
most powerful survival strategy, the key to our success as a species, and it is
precisely this that breaks down in most forms of mental suffering. As we saw in part
2, the neural connections in brain and body are vitally important for understanding
human suffering, but it is important not to ignore the foundations of our humanity:
relationships and interactions that shape our minds and brains when we are young and
that give substance and meaning to our entire lives.

People with histories of abuse, neglect,
or severe deprivation will remain mysterious and largely untreated unless we heed
the admonition of Alan Sroufe: “To fully understand how we become the persons
we are—the complex, step-by-step evolution of our orientations, capacities, and
behavior over time—requires more than a list of ingredients, however important any
one of them might be. It requires an understanding of the process of development,
how all of these factors work together in an ongoing way over time.”[34]

Frontline mental health
workers—overwhelmed and underpaid social workers and therapists alike—seem to agree
with our approach. Shortly after the APA rejected Developmental Trauma Disorder for
inclusion in the DSM, thousands of clinicians from around the country sent small
contributions to the Trauma Center to help us conduct a large scientific study,
known as a field trial, to further study DTD. That support has enabled us to
interview hundreds of kids, parents, foster parents, and mental health workers at
five different network sites over the last few years with scientifically constructed
interview tools. The first results from these studies have now been published, and
more will appear as this book is going to print.[35]

WHAT DIFFERENCE WOULD DTD MAKE?

One answer is that it would focus
research and treatment (not to mention funding) on the central principles that
underlie the protean symptoms of chronically traumatized children and adults:
pervasive biological and emotional dysregulation, failed or disrupted attachment,
problems staying focused and on track, and a hugely deficient sense of coherent
personal identity and competence. These issues transcend and include almost all
diagnostic categories, but treatment
that doesn’t put them front and center is more than likely to miss the mark.
Our great challenge is to apply the lessons of neuroplasticity, the flexibility of
brain circuits, to rewire the brains and reorganize the minds of people who have
been programmed by life itself to experience others as threats and themselves as
helpless.

Social support is a biological
necessity, not an option, and this reality should be the backbone of all prevention
and treatment. Recognizing the profound effects of trauma and deprivation on child
development need not lead to blaming parents. We can assume that parents do the best
they can, but all parents need help to nurture their kids. Nearly every
industrialized nation, with the exception of the United States, recognizes this and
provides some form of guaranteed support to families. James Heckman, winner of the
2000 Nobel Prize in Economics, has shown that quality early-childhood programs that
involve parents and promote basic skills in disadvantaged children more than pay for
themselves in improved outcomes.[36]

In the early 1970s psychologist David
Olds was working in a Baltimore day-care center where many of the preschoolers came
from homes wracked by poverty, domestic violence, and drug abuse. Aware that only
addressing the children’s problems at school was not sufficient to improve
their home conditions, he started a home-visitation program in which skilled nurses
helped mothers to provide a safe and stimulating environment for their children and,
in the process, to imagine a better future for themselves. Twenty years later, the
children of the home-visitation mothers were not only healthier but also less likely
to report having been abused or neglected than a similar group whose mothers had not
been visited. They also were more likely to have finished school, to have stayed out
of jail, and to be working in wellpaying jobs. Economists have calculated that every
dollar invested in high-quality home visitation, day care, and preschool programs
results in seven dollars of savings on welfare payments, health-care costs,
substance-abuse treatment, and incarceration, plus higher tax revenues due to
better-paying jobs.[37]

When I go to Europe to teach, I often am
contacted by officials at the ministries of health in the Scandinavian countries,
the United Kingdom, Germany, or the Netherlands and asked to spend an afternoon with
them sharing the latest research on the treatment of traumatized children,
adolescents, and their families. The same is true for many of my colleagues. These
countries have already made a commitment to universal health care, ensuring a
guaranteed minimum wage, paid parental leave for both parents after a child is born,
and high-quality childcare for all working mothers.

Could this approach to public health have
something to do with the fact that the incarceration rate in Norway is 71/100,000,
in the Netherlands 81/100,000, and the US 781/100,000, while the crime rate in those
countries is much lower than in ours, and the cost of medical care about half?
Seventy percent of prisoners in California spent time in foster care while growing
up. The United States spends $84 billion per year to incarcerate people at
approximately $44,000 per prisoner; the northern European countries a fraction of
that amount. Instead, they invest in helping parents to raise their children in safe
and predictable surroundings. Their academic test scores and crime rates seem to
reflect the success of those investments.

Part Four

THE IMPRINT OF TRAUMA

CHAPTER 11

Uncovering Secrets: The Problem of
Traumatic Memory

It is a strange thing that all the memories
have these two qualities. They are always full of quietness, that is the most
striking thing about them; and even when things weren’t like that in reality,
they still seem to have that quality. They are soundless apparitions, which speak to
me by looks and gestures, wordless and silent—and their silence is precisely what
disturbs me.

—Erich Maria Remarque, All Quiet on the Western Front

In the spring of 2002 I was asked to
examine a young man who claimed to have been sexually abused while he was growing up
by Paul Shanley, a Catholic priest who had served in his parish in Newton,
Massachusetts. Now twenty-five years old, he had apparently forgotten the abuse
until he heard that the priest was currently under investigation for molesting young
boys. The question posed to me was: Even though he had seemingly
“repressed” the abuse for well over a decade after it ended, were his
memories credible, and was I prepared to testify to that fact before a judge?

I will share what this man, whom
I’ll call Julian, told me, drawing on my original case notes. (Even though his
real name is in the public record, I’m using a pseudonym because I hope that
he has regained some privacy and peace with the passage of time.[1])

His experiences illustrate the
complexities of traumatic memory. The controversies over the case against Father
Shanley are also typical of the passions
that have swirled around this issue since psychiatrists first described the unusual
nature of traumatic memories in the final decades of the nineteenth century.

FLOODED BY SENSATIONS AND
IMAGES

On February 11, 2001, Julian was serving
as a military policeman at an air force base. During his daily phone conversation
with his girlfriend, Rachel, she mentioned a lead article she’d read that
morning in the Boston Globe. A priest named Shanley was under suspicion for
molesting children. Hadn’t Julian once told her about a Father Shanley who had
been his parish priest back in Newton? “Did he ever do anything to you?”
she asked. Julian initially recalled Father Shanley as a kind man who’d been
very supportive after his parents got divorced. But as the conversation went on, he
started to go into a panic. He suddenly saw Shanley silhouetted in a doorframe, his
hands stretched out at forty-five degrees, staring at Julian as he urinated.
Overwhelmed by emotion, he told Rachel, “I’ve got to go.” He
called his flight chief, who came over accompanied by the first sergeant. After he
met with the two of them, they took him to the base chaplain. Julian recalls telling
him: “Do you know what is going on in Boston? It happened to me, too.”
The moment he heard himself say those words, he knew for certain that Shanley had
molested him—even though he did not remember the details. Julian felt extremely
embarrassed about being so emotional; he had always been a strong kid who kept
things to himself.

That night he sat on the corner of his
bed, hunched over, thinking he was losing his mind and terrified that he would be
locked up. Over the subsequent week images kept flooding into his mind, and he was
afraid of breaking down completely. He thought about taking a knife and plunging it
into his leg just to stop the mental pictures. Then the panic attacks started to be
accompanied by seizures, which he called “epileptic fits.” He scratched
his body until he bled. He constantly felt hot, sweaty, and agitated.
Between panic attacks he “felt like a zombie”; he was observing himself
from a distance, as if what he was experiencing were actually happening to somebody
else.

In April he received an administrative
discharge, just ten days short of being eligible to receive full benefits.

When Julian entered my office almost a
year later, I saw a handsome, muscular guy who looked depressed and defeated. He
told me immediately that he felt terrible about having left the air force. He had
wanted to make it his career, and he’d always received excellent evaluations.
He loved the challenges and the
teamwork, and he missed the structure of the military lifestyle.

Julian was born in a Boston suburb, the
second-oldest of five children. His father left the family when Julian was about six
because he could not tolerate living with Julian’s emotionally labile mother.
Julian and his father get along quite well, but he sometimes reproaches his father
for having worked too hard to support his family and for abandoning him to the care
of his unbalanced mother. Neither his parents nor any of his siblings has ever
received psychiatric care or been involved with drugs.

Julian was a popular athlete in high
school. Although he had many friends, he felt pretty bad about himself and covered
up for being a poor student by drinking and partying. He feels ashamed that he took
advantage of his popularity and good looks by having sex with many girls. He
mentioned wanting to call several of them to apologize for how badly he’d
treated them.

He remembered always hating his body. In
high school he took steroids to pump himself up and smoked marijuana almost every
day. He did not go to college, and after graduating from high school he was
virtually homeless for almost a year because he could no longer stand living with
his mother. He enlisted to try to get his life back on track.

Julian met Father Shanley at age six
when he was taking a CCD (catechism) class at the parish church. He remembered
Father Shanley taking him out of the class for confession. Father Shanley rarely
wore a cassock, and Julian remembered the priest’s dark blue corduroy pants.
They would go to a big room with one chair facing another and a bench to kneel on.
The chairs were covered with red and there was a red velvet cushion on the bench.
They played cards, a game of war that turned into strip poker. Then he remembered
standing in front of a mirror in that room. Father Shanley made him bend over. He
remembered Father Shanley putting a finger into his anus. He does not think Shanley
ever penetrated him with his penis, but he believes that the priest fingered him on
numerous occasions.

Other than that, his memories were quite
incoherent and fragmentary. He had flashes of images of Shanley’s face and of
isolated incidents: Shanley standing in the door of the bathroom; the priest going
down on his knees and moving “it” around with his tongue. He could not
say how old he was when that happened. He remembered the priest telling him how to
perform oral sex, but he did not remember actually doing it. He remembered passing
out pamphlets in church and then Father Shanley sitting next to him in a pew,
fondling him with one hand and holding Julian’s hand on himself with the
other. He remembered that, as he grew older, Father Shanley would pass close to him and caress his penis. Paul
did not like it but did not know what to do to stop it. After all, he told me,
“Father Shanley was the closest thing to God in my neighborhood.”

In addition to these memory fragments,
traces of his sexual abuse were clearly being activated and replayed. Sometimes when
he was having sex with his girlfriend, the priest’s image popped into his
head, and, as he said, he would “lose it.” A week before I interviewed
him, his girlfriend had pushed a finger into his mouth and playfully said:
“You give good head.” Julian jumped up and screamed, “If you ever
say that again I’ll fucking kill you.” Then, terrified, they both
started to cry. This was followed by one of Julian’s “epileptic
fits,” in which he curled up in a fetal position, shaking and whimpering like
a baby. While telling me this Julian looked very small and very frightened.

Julian alternated between feeling sorry
for the old man that Father Shanley had become and simply wanting to “take him
into a room somewhere and kill him.” He also spoke repeatedly of how ashamed
he felt, how hard it was to admit that he could not protect himself: “Nobody
fucks with me, and now I have to tell you this.” His self-image was of a big,
tough Julian.

How do we make sense of a story like
Julian’s: years of apparent forgetting, followed by fragmented, disturbing
images, dramatic physical symptoms, and sudden reenactments? As a therapist treating
people with a legacy of trauma, my primary concern is not to determine exactly what
happened to them but to help them tolerate the sensations, emotions, and reactions
they experience without being constantly hijacked by them. When the subject of blame
arises, the central issue that needs to be addressed is usually self-blame—accepting
that the trauma was not their fault, that it was not caused by some defect in
themselves, and that no one could ever have deserved what happened to them.

Once a legal case is involved, however,
determination of culpability becomes primary, and with it the admissibility of
evidence. I had previously examined twelve people who had been sadistically abused
as children in a Catholic orphanage in Burlington, Vermont. They had come forward
(with many other claimants) more than four decades later, and although none had had
any contact with the others until the first claim was filed, their abuse memories
were astonishingly similar: They all named the same names and the particular abuses
that each nun or priest had committed—in the same rooms, with the same furniture,
and as part of the same daily routines. Most of them subsequently accepted an
out-of-court settlement from the Vermont diocese.

Before a case goes to trial, the judge
holds a so-called Daubert hearing to set the standards for expert testimony to be
presented to the jury. In a 1996 case I
had convinced a federal circuit court judge in Boston that it was common for
traumatized people to lose all memories of the event in question, only to regain
access to them in bits and pieces at a much later date. The same standards would
apply in Julian’s case. While my report to his lawyer remains confidential, it
was based on decades of clinical experience and research on traumatic memory,
including the work of some of the great pioneers of modern psychiatry.

NORMAL VERSUS TRAUMATIC MEMORY

We all know how fickle memory is; our
stories change and are constantly revised and updated. When my brothers, sisters,
and I talk about events in our childhood, we always end up feeling that we grew up
in different families—so many of our memories simply do not match. Such
autobiographical memories are not precise reflections of reality; they are stories
we tell to convey our personal take on our experience.

The extraordinary capacity of the human
mind to rewrite memory is illustrated in the Grant Study of Adult Development, which
has systematically followed the psychological and physical health of more than two
hundred Harvard men from their sophomore years of 1939–44 to the present.[2] Of course,
the designers of the study could not have anticipated that most of the participants
would go off to fight in World War II, but we can now track the evolution of their
wartime memories. The men were interviewed in detail about their war experiences in
1945/1946 and again in 1989/1990. Four and a half decades later, the majority gave
very different accounts from the narratives recorded in their immediate postwar
interviews: With the passage of time, events had been bleached of their intense
horror. In contrast, those who had been traumatized and subsequently developed PTSD
did not modify their accounts; their memories were preserved essentially intact
forty-five years after the war ended.

Whether we remember a particular event
at all, and how accurate our memories of it are, largely depends on how personally
meaningful it was and how emotional we felt about it at the time. The key factor is
our level of arousal. We all have memories associated with particular people, songs,
smells, and places that stay with us for a long time. Most of us still have precise
memories of where we were and what we saw on Tuesday, September 11, 2001, but only a
fraction of us recall anything in particular about September 10.

Most day-to-day experience passes
immediately into oblivion. On ordinary days we don’t have much to report when
we come home in the evening. The mind
works according to schemes or maps, and incidents that fall outside the established
pattern are most likely to capture our attention. If we get a raise or a friend
tells us some exciting news, we will retain the details of the moment, at least for
a while. We remember insults and injuries best: The adrenaline that we secrete to
defend against potential threats helps to engrave those incidents into our minds.
Even if the content of the remark fades, our dislike for the person who made it
usually persists.

When something terrifying happens, like
seeing a child or a friend get hurt in an accident, we will retain an intense and
largely accurate memory of the event for a long time. As James McGaugh and
colleagues have shown, the more adrenaline you secrete, the more precise your memory
will be.[3] But
that is true only up to a certain point. Confronted with horror—especially the
horror of “inescapable shock”—this system becomes overwhelmed and breaks
down.

Of course, we cannot monitor what
happens during a traumatic experience, but we can reactivate the trauma in the
laboratory, as was done for the brain scans in chapters 3 and 4. When memory traces
of the original sounds, images, and sensations are reactivated, the frontal lobe
shuts down, including, as we’ve seen, the region necessary to put feelings
into words,[4]
the region that creates our sense of location in time, and the thalamus, which
integrates the raw data of incoming sensations. At this point the emotional brain,
which is not under conscious control and cannot communicate in words, takes over.
The emotional brain (the limbic area and the brain stem) expresses its altered
activation through changes in emotional arousal, body physiology, and muscular
action. Under ordinary conditions these two memory systems—rational and
emotional—collaborate to produce an integrated response. But high arousal not only
changes the balance between them but also disconnects other brain areas necessary
for the proper storage and integration of incoming information, such as the
hippocampus and the thalamus.[5] As a result, the imprints of traumatic
experiences are organized not as coherent logical narratives but in fragmented
sensory and emotional traces: images, sounds, and physical sensations.[6] Julian saw a
man with outstretched arms, a pew, a staircase, a strip poker game; he felt a
sensation in his penis, a panicked sense of dread. But there was little or no
story.

UNCOVERING THE SECRETS OF
TRAUMA

In the late nineteenth century, when
medicine first began the systematic study of mental problems, the nature of
traumatic memory was one of the central
topics under discussion. In France and England a prodigious number of articles were
published on a syndrome known as “railway spine,” a psychological
aftermath of railroad accidents that included loss of memory.

The greatest advances, however, came in
the study of hysteria, a mental disorder characterized by emotional outbursts,
susceptibility to suggestion, and contractions and paralyses of the muscles that
could not be explained by simple anatomy.[7] Once considered an affliction of
unstable or malingering women (the name comes from the Greek word for
“womb”), hysteria now became a window into the mysteries of mind and
body. The names of some of the greatest pioneers in neurology and psychiatry, such
as Jean-Martin Charcot, Pierre Janet, and Sigmund Freud, are associated with the
discovery that trauma is at the root of hysteria, particularly the trauma of
childhood sexual abuse.[8] These early researchers referred to traumatic memories as
“pathogenic secrets”[9] or “mental parasites,”[10] because as
much as the sufferers wanted to forget whatever had happened, their memories kept
forcing themselves into consciousness, trapping them in an ever-renewing present of
existential horror.[11]

The interest in hysteria was
particularly strong in France, and, as so often happens, its roots lay in the
politics of the day. Jean-Martin Charcot, who is widely regarded as the father of
neurology and whose pupils, such as Gilles de la Tourette, lent their names to
numerous neurological diseases, was also active in politics. After Emperor Napoleon
III abdicated in 1870, there was a struggle between the monarchists (the old order
backed by the clergy), and the advocates of the fledgling French Republic, who
believed in science and in secular democracy. Charcot believed that women would be a
critical factor in this struggle, and his investigation of hysteria “offered a
scientific explanation for phenomena such as demonic possession states, witchcraft,
exorcism, and religious ecstasy.”[12]

Charcot conducted meticulous studies of
the physiological and neurological correlates of hysteria in both men and women, all
of which emphasized embodied memory and a lack of language. For example, in 1889 he
published the case of a patient named LeLog, who developed paralysis of the legs
after being involved in a traffic accident with a horse-drawn cart. Although Lelog
fell to the ground and lost consciousness, his legs appeared unhurt, and there were
no neurological signs that would indicate a physical cause for his paralysis.
Charcot discovered that just before Lelog passed out, he saw the wheels of the cart
approaching him and strongly believed he would be run over. He noted that “the
patient … does not preserve any recollection. … Questions
addressed to him upon this point are attended with no result. He knows nothing or
almost nothing.”[13] Like many other patients at the Salpêtrière, Lelog expressed his experience physically:
Instead of remembering the accident, he developed paralysis of his legs.[14]

Jean-Martin Charcot presents the case
of a patient with hysteria. Charcot transformed La Salpêtrière, an
ancient asylum for the poor of Paris, which he transformed into a modern hospital.
Notice the patient’s dramatic posture.

PAINTING BY ANDRE BROUILLET

But for me the real hero of this story
is Pierre Janet, who helped Charcot establish a research laboratory devoted to the
study of hysteria at the Salpêtrière. In 1889, the same year that the Eiffel Tower
was built, Janet published the first book-length scientific account of traumatic
stress: L’automatisme psychologique.[15] Janet proposed that at the root of
what we now call PTSD was the experience of “vehement emotions,” or
intense emotional arousal. This treatise explained that, after having been
traumatized, people automatically keep repeating certain actions, emotions, and
sensations related to the trauma. And unlike Charcot, who was primarily interested
in measuring and documenting patients’ physical symptoms, Janet spent untold
hours talking with them, trying to discover what was going on in their minds. Also
in contrast to Charcot, whose research focused on understanding the phenomenon of
hysteria, Janet was first and foremost a
clinician whose goal was to treat his patients. That is why I studied his case
reports in detail and why he became one of my most important teachers.[16]

AMNESIA, DISSOCIATION, AND
REENACTMENT

Janet was the first to point out the
difference between “narrative memory”—the stories people tell about
trauma—and traumatic memory itself. One of his case histories was the story of
Irène, a young woman who was hospitalized following her mother’s death from
tuberculosis.[17] Irène had nursed her mother for many months while continuing to
work outside the home to support her alcoholic father and pay for her mother’s
medical care. When her mother finally died, Irène—exhausted from stress and lack of
sleep—tried for several hours to revive the corpse, calling out to her mother and
trying to force medicine down her throat. At one point the lifeless body dropped off
the bed while Irène’s drunken father lay passed out nearby. Even after an aunt
arrived and started preparing for the burial, Irène’s denial persisted. She
had to be persuaded to attend the funeral, and she laughed throughout the service. A
few weeks later she was brought to the Salpêtrière, where Janet took over her
case.

In addition to amnesia for her
mother’s death, Irène suffered from another symptom: Several times a week she
would stare, trancelike, at an empty bed, ignore whatever was going on around her,
and begin to care for an imaginary person. She meticulously reproduced, rather than
remembered, the details of her mother’s death.

Traumatized people simultaneously
remember too little and too much. On the one hand, Irène had no conscious memory of
her mother’s death—she could not tell the story of what had happened. On the
other she was compelled to physically act out the events of her mother’s
death. Janet’s term “automatism” conveys the involuntary,
unconscious nature of her actions.

Janet treated Irène for several months,
mainly with hypnosis. At the end he asked her again about her mother’s death.
Irène started to cry and said, “Don’t remind me of those terrible
things. … My mother was dead and my father was a complete drunk, as
always. I had to take care of her dead body all night long. I did a lot of silly
things in order to revive her. … In the morning I lost my mind.” Not
only was Irène able to tell the story, but she had also recovered her emotions:
“I feel very sad and abandoned.” Janet now called her memory
“complete” because it now was accompanied by the appropriate
feelings.

Janet noted significant differences
between ordinary and traumatic memory. Traumatic memories are precipitated by
specific triggers. In Julian’s case the trigger was his girlfriend’s
seductive comments; in Irène’s it was a bed. When one element of a traumatic
experience is triggered, other elements are likely to automatically follow.

Traumatic memory is not condensed: It
took Irène three to four hours to reenact her story, but when she was finally able
to tell what had happened it took less than a minute. The traumatic enactment serves
no function. In contrast, ordinary memory is adaptive; our stories are flexible and
can be modified to fit the circumstances. Ordinary memory is essentially social;
it’s a story that we tell for a purpose: in Irène’s case, to enlist her
doctor’s help and comfort; in Julian’s case, to recruit me to join his
search for justice and revenge. But there is nothing social about traumatic memory.
Julian’s rage at his girlfriend’s remark served no useful purpose.
Reenactments are frozen in time, unchanging, and they are always lonely,
humiliating, and alienating experiences.

Janet coined the term
“dissociation” to describe the splitting off and isolation of memory
imprints that he saw in his patients. He was also prescient about the heavy cost of
keeping these traumatic memories at bay. He later wrote that when patients
dissociate their traumatic experience, they become “attached to an
insurmountable obstacle”:[18] “[U]nable to integrate their
traumatic memories, they seem to lose their capacity to assimilate new experiences
as well. It is … as if their personality has definitely stopped at a
certain point, and cannot enlarge any more by the addition or assimilation of new
elements.”[19] He predicted that unless they became aware of the split-off
elements and integrated them into a story that had happened in the past but was now
over, they would experience a slow decline in their personal and professional
functioning. This phenomenon has now been well documented in contemporary
research.[20]

Janet discovered that, while it is
normal to change and distort one’s memories, people with PTSD are unable to
put the actual event, the source of those memories, behind them.
Dissociation prevents the trauma from becoming integrated within the conglomerated,
ever-shifting stores of autobiographical memory, in essence creating a dual memory
system. Normal memory integrates the elements of each experience into the continuous
flow of self-experience by a complex process of association; think of a dense but
flexible network where each element exerts a subtle influence on many others. But in
Julian’s case, the sensations, thoughts, and emotions of the trauma were
stored separately as frozen, barely comprehensible fragments. If the problem with PTSD is dissociation, the goal
of treatment would be association: integrating the cut-off elements of the
trauma into the ongoing narrative of life, so that the brain can recognize that
“that was then, and this is now.”

THE ORIGINS OF THE “TALKING
CURE”

Psychoanalysis was born on the wards of
the Salpêtrière. In 1885 Freud went to Paris to work with Charcot, and he later
named his firstborn son Jean-Martin in Charcot’s honor. In 1893 Freud and his
Viennese mentor, Josef Breuer, cited both Charcot and Janet in a brilliant paper on
the cause of hysteria. “Hysterics suffer mainly from
reminiscences,” they proclaim, and go on to note that these memories are
not subject to the “wearing away process” of normal memories but
“persist for a long time with astonishing freshness.” Nor can
traumatized people control when they will emerge: “We must … mention
another remarkable fact … namely, that these memories, unlike other
memories of their past lives, are not at the patients’ disposal. On the
contrary, these experiences are completely absent from the patients’
memory when they are in a normal psychical state, or are only present in a
highly summary form.”[21] (All italics in the quoted passages
are Breuer and Freud’s.)

Breuer and Freud believed that traumatic
memories were lost to ordinary consciousness either because “circumstances
made a reaction impossible,” or because they started during “severely
paralyzing affects, such as fright.” In 1896 Freud boldly claimed that
“the ultimate cause of hysteria is always the seduction of the child by an
adult.”[22] Then, faced with his own evidence of an epidemic of abuse in the
best families of Vienna—one, he noted, that would implicate his own father—he
quickly began to retreat. Psychoanalysis shifted to an emphasis on unconscious
wishes and fantasies, though Freud occasionally kept acknowledging the reality of
sexual abuse.[23] After the horrors of World War I confronted him with the reality
of combat neuroses, Freud reaffirmed that lack of verbal memory is central in trauma
and that, if a person does not remember, he is likely to act out: “[H]e
reproduces it not as a memory but as an action; he repeats it, without knowing, of
course, that he is repeating, and in the end, we understand that this is his way of
remembering.”[24]

The lasting legacy of Breuer and
Freud’s 1893 paper is what we now call the “talking cure”:
“[W]e found, to our great surprise, at first, that each individual
hysterical symptom immediately and permanently disappeared when we had succeeded
in bringing clearly to light the memory of the event by which it was provoked
and in arousing its accompanying affect, and when the patient
had described that event in the
greatest possible detail and had put the affect into words (all italics in
original). Recollection without affect almost invariably produces no
result.”

They explain that unless there is an
“energetic reaction” to the traumatic event, the affect “remains
attached to the memory” and cannot be discharged. The reaction can be
discharged by an action—“from tears to acts of revenge.” “But
language serves as a substitute for action; by its help, an affect can be
‘abreacted’ almost as effectively.” “It will now be
understood,” they conclude, “how it is that the psychotherapeutic
procedure which we have described in these pages has a curative effect. It
brings to an end the operative force … which was not abreacted in the
first instance [i.e., at the time of the trauma], by allowing its
strangulated affect to find a way out through speech; and it subjects it to
associative correction by introducing it into normal
consciousness.”

Even though psychoanalysis is today in
eclipse, the “talking cure” has lived on, and psychologists have
generally assumed that telling the trauma story in great detail will help people to
leave it behind. That is also a basic premise of cognitive behavioral therapy (CBT),
which today is taught in graduate psychology courses around the world.

Although the diagnostic labels have
changed, we continue to see patients similar to those described by Charcot, Janet,
and Freud. In 1986 my colleagues and I wrote up the case of a woman who had been a
cigarette girl at Boston’s Cocoanut Grove nightclub when it burned down in
1942.[25]
During the 1970s and 1980s she annually reenacted her escape on Newbury Street, a
few blocks from the original location, which resulted in her being hospitalized with
diagnoses like schizophrenia and bipolar disorder. In 1989 I reported on a Vietnam
veteran who yearly staged an “armed robbery” on the exact anniversary of
a buddy’s death.[26] He would put a finger in his pants pocket, claim that it was a
pistol, and tell a shopkeeper to empty his cash register—giving him plenty of time
to alert the police. This unconscious attempt to commit “suicide by cop”
came to an end after a judge referred the veteran to me for treatment. Once we had
dealt with his guilt about his friend’s death, there were no further
reenactments.

Such incidents raise a critical
question: How can doctors, police officers, or social workers recognize that someone
is suffering from traumatic stress as long as he reenacts rather than remember? How
can patients themselves identify the source of their behavior? If their history is
not known, they are likely to be labeled as crazy or punished as criminals rather
than helped to integrate the past.

TRAUMATIC MEMORY ON TRIAL

At least two dozen men had claimed they
were molested by Paul Shanley, and many of them reached civil settlements with the
Boston archdiocese. Julian was the only victim who was called to testify in
Shanley’s trial. In February 2005 the former priest was found guilty on two
counts of raping a child and two counts of assault and battery on a child. He was
sentenced to twelve to fifteen years in prison.

In 2007 Shanley’s attorney, Robert
F. Shaw Jr., filed a motion for a new trial, challenging Shanley’s convictions
as a miscarriage of justice. Shaw tried to make the case that “repressed
memories” were not generally accepted in the scientific community, that the
convictions were based on “junk science,” and that there had been
insufficient testimony about the scientific status of repressed memories before the
trial. The appeal was rejected by the original trial judge but two years later was
taken up by the Supreme Judicial Court of Massachusetts. Almost one hundred leading
psychiatrists and psychologists from around the United States and eight foreign
countries signed an amicus curiae brief stating that “repressed memory”
has never been shown to exist and that it should not have been admitted as evidence.
However, on January 10, 2010, the court unanimously upheld Shanley’s
conviction with this statement: “In sum, the judge’s finding that the
lack of scientific testing did not make unreliable the theory that an individual may
experience dissociative amnesia was supported in the record. … There was
no abuse of discretion in the admission of expert testimony on the subject of
dissociative amnesia.”

In the following chapter I’ll talk
more about memory and forgetting and about how the debate over repressed memory,
which started with Freud, continues to be played out today.

CHAPTER 12

The Unbearable Heaviness of
Remembering

Our bodies are the texts that carry the
memories and therefore remembering is no less than reincarnation.

—Katie Cannon

Scientific interest in trauma has
fluctuated wildly during the past 150 years. Charcot’s death in 1893 and
Freud’s shift in emphasis to inner conflicts, defenses, and instincts at the
root of mental suffering were just part of mainstream medicine’s overall loss
of interest in the subject. Psychoanalysis rapidly gained in popularity. In 1911 the
Boston psychiatrist Morton Prince, who had studied with William James and Pierre
Janet, complained that those interested in the effects of trauma were like
“clams swamped by the rising tide in Boston Harbor.”

This neglect lasted for only a few
years, though, because the outbreak of World War in 1914 once again confronted
medicine and psychology with hundreds of thousands of men with bizarre psychological
symptoms, unexplained medical conditions, and memory loss. The new technology of
motion pictures made it possible to film these soldiers, and today on YouTube we can
observe their bizarre physical postures, strange verbal utterances, terrified facial
expressions, and tics—the physical, embodied expression of trauma: “a memory
that is inscribed simultaneously in the mind, as interior images and words, and on
the body.”[1]

Early in the war the British created the
diagnosis of “shell shock,” which entitled combat veterans to treatment
and a disability pension. The alternative, similar, diagnosis was “neurasthenia,” for
which they received neither treatment nor a pension. It was up to the orientation of
the treating physician which diagnosis a soldier received.[2]

More than a million British soldiers
served on the Western Front at any one time. In the first few hours of July 1, 1916
alone, in the Battle of the Somme, the British army suffered 57,470 casualties,
including 19,240 dead, the bloodiest day in its history. The historian John Keegan
says of their commander, Field Marshal Douglas Haig, whose statue today dominates
Whitehall in London, once the center of the British Empire: “In his public
manner and private diaries no concern for human suffering was or is
discernible.” At the Somme “he had sent the flower of British youth to
death or mutilation.”[3]

As the war wore on, shell shock
increasingly compromised the efficiency of the fighting forces. Caught between
taking the suffering of their soldiers seriously and pursuing victory over the
Germans, the British General Staff issued General Routine Order Number 2384 in June
of 1917, which stated, “In no circumstances whatever will the expression
‘shell shock’ be used verbally or be recorded in any regimental or other
casualty report, or any hospital or other medical document.” All soldiers with
psychiatric problems were to be given a single diagnosis of “NYDN” (Not
Yet Diagnosed, Nervous).[4] In November 1917 the General Staff denied Charles Samuel Myers,
who ran four field hospitals for wounded soldiers, permission to submit a paper on
shell shock to the British Medical Journal. The Germans were even more
punitive and treated shell shock as a character defect, which they managed with a
variety of painful treatments, including electroshock.

In 1922 the British government issued
the Southborough Report, whose goal was to prevent the diagnosis of shell shock in
any future wars and to undermine any more claims for compensation. It suggested the
elimination of shell shock from all official nomenclature and insisted that these
cases should no more be classified “as a battle casualty than sickness or
disease is so regarded.”[5] The official view was that
well-trained troops, properly led, would not suffer from shell shock and that the
servicemen who had succumbed to the disorder were undisciplined and unwilling
soldiers. While the political storm about the legitimacy of shell shock continued to
rage for several more years, reports on how to best treat these cases disappeared
from the scientific literature.[6]

In the United States the fate of
veterans was also fraught with problems. In 1918, when they returned home from the
battlefields of France and Flanders, they had been welcomed as national heroes, just
as the soldiers returning from Iraq and
Afghanistan are today. In 1924 Congress voted to award them a bonus of $1.25 for
each day they had served overseas, but disbursement was postponed until 1945.

By 1932 the nation was in the middle of
the Great Depression, and in May of that year about fifteen thousand unemployed and
penniless veterans camped on the Mall in Washington DC to petition for immediate
payment of their bonuses. The Senate defeated the bill to move up disbursement by a
vote of sixty-two to eighteen. A month later President Hoover ordered the army to
clear out the veterans’ encampment. Army chief of staff General Douglas
MacArthur commanded the troops, supported by six tanks. Major Dwight D. Eisenhower
was the liaison with the Washington police, and Major George Patton was in charge of
the cavalry. Soldiers with fixed bayonets charged, hurling tear gas into the crowd
of veterans. The next morning the Mall was deserted and the camp was in flames.[7] The veterans
never received their pensions.

While politics and medicine turned their
backs on the returning soldiers, the horrors of the war were memorialized in
literature and art. In All Quiet on the Western Front,[8] a novel about the war
experiences of frontline soldiers by the German writer Erich Maria Remarque, the
book’s protagonist, Paul Bäumer, spoke for an entire generation: “I am
aware that I, without realizing it, have lost my feelings—I don’t belong here
anymore, I live in an alien world. I prefer to be left alone, not disturbed by
anybody. They talk too much—I can’t relate to them—they are only busy with
superficial things.”[9] Published in 1929, the novel instantly
became an international best seller, with translations in twenty-five languages. The
1930 Hollywood film version won the Academy Award for Best Picture.

But when Hitler came to power a few
years later, All Quiet on the Western Front was one of the first
“degenerate” books the Nazis burned in the public square in front of
Humboldt University in Berlin.[10] Apparently awareness of the
devastating effects of war on soldiers’ minds would have constituted a threat
to the Nazis’ plunge into another round of insanity.

Denial of the consequences of trauma can
wreak havoc with the social fabric of society. The refusal to face the damage caused
by the war and the intolerance of “weakness” played an important role in
the rise of fascism and militarism around the world in the 1930s. The extortionate
war reparations of the Treaty of Versailles further humiliated an already disgraced
Germany. German society, in turn, dealt ruthlessly with its own traumatized war
veterans, who were treated as inferior creatures. This cascade of humiliations of
the powerless set the stage for the ultimate debasement of human rights under the Nazi regime: the moral
justification for the strong to vanquish the inferior—the rationale for the ensuing
war.

THE NEW FACE OF TRAUMA

The outbreak of World War II prompted
Charles Samuel Myers and the American psychiatrist Abram Kardiner to publish the
accounts of their work with World War I soldiers and veterans. Shell Shock in
France 1914–1918 (1940)[11] and The Traumatic Neuroses of
War (1941)[12] served as the principal guides for psychiatrists who were
treating soldiers in the new conflict who had “war neuroses.” The U.S.
war effort was prodigious, and the advances in frontline psychiatry reflected that
commitment. Again, YouTube offers a direct window on the past: Hollywood director
John Huston’s documentary Let There Be Light (1946) shows the
predominant treatment for war neuroses at that time: hypnosis.[13]

In Huston’s film, made while he
was serving in the Army Signal Corps, the doctors are still patriarchal and the
patients are still terrified young men. But they manifest their trauma differently:
While the World War I soldiers flail, have facial tics, and collapse with paralyzed
bodies, the following generation talks and cringes. Their bodies still keep the
score: Their stomachs are upset, their hearts race, and they are overwhelmed by
panic. But the trauma did not just affect their bodies. The trance state induced by
hypnosis allowed them to find words for the things they had been too afraid to
remember: their terror, their survivor’s guilt, and their conflicting
loyalties. It also struck me that these soldiers seemed to keep a much tighter lid
on their anger and hostility than the younger veterans I’d worked with.
Culture shapes the expression of traumatic stress.

The feminist theorist Germaine Greer
wrote about the treatment of her father’s PTSD after World War II: “When
[the medical officers] examined men exhibiting severe disturbances they almost
invariably found the root cause in pre-war experience: the sick men were not
first-grade fighting material. … The military proposition is [that it is]
not war which makes men sick, but that sick men can not fight wars.”[14] It seems
unlikely the doctors did her father any good, but Greer’s efforts to come to
grips with his suffering undoubtedly helped fuel her exploration of sexual
domination in all its ugly manifestations of rape, incest, and domestic
violence.

When I worked at the VA, I was puzzled
that the vast majority of the patients we saw on the psychiatry service were young,
recently discharged Vietnam veterans, while the corridors and elevators that led to
the medical departments were filled by
old men. Curious about this disparity, I conducted a survey of the World War II
veterans in the medical clinics in 1983. The vast majority of them scored positive
for PTSD on the rating scales that I administered, but their treatment focused on
medical rather than psychiatric complaints. These vets communicated their distress
via stomach cramps and chest pains rather than with nightmares and rage, from which,
my research showed, they also suffered. Doctors shape how their patients communicate
their distress: When a patient complains about terrifying nightmares and his doctor
orders a chest X-ray, the patient realizes that he’ll get better care if he
focuses on his physical problems. Like my relatives who fought in or were captured
during World War II, most of these men were extremely reluctant to share their
experiences. My sense was that neither the doctors nor their patients wanted to
revisit the war.

However, military and civilian leaders
came away from World War II with important lessons that the previous generation had
failed to grasp. After the defeat of Nazi Germany and imperial Japan, the United
States helped rebuild Europe by means of the Marshall Plan, which formed the
economic foundation of the next fifty years of relative peace. At home, the GI Bill
provided millions of veterans with educations and home mortgages, which promoted
general economic well-being and created a broad-based, well-educated middle class.
The armed forces led the nation in racial integration and opportunity. The Veterans
Administration built facilities nationwide to help combat veterans with their health
care. Still, with all this thoughtful attention to the returning veterans, the
psychological scars of war went unrecognized, and traumatic neuroses disappeared
entirely from official psychiatric nomenclature. The last scientific writing on
combat trauma after World War II appeared in 1947.[15]

TRAUMA REDISCOVERED

As I noted earlier, when I started to
work with Vietnam veterans, there was not a single book on war trauma in the library
of the VA, but the Vietnam War inspired numerous studies, the formation of scholarly
organizations, and the inclusion of a trauma diagnosis, PTSD, in the professional
literature. At the same time, interest in trauma was exploding in the general
public.

In 1974 Freedman and Kaplan’s
Comprehensive Textbook of Psychiatry stated that “incest is
extremely rare, and does not occur in more than 1 out of 1.1 million
people.”[16] As we have seen in chapter 2 this
authoritative textbook then went on to extol the possible benefits of incest:
“Such incestuous activity
diminishes the subject’s chance of psychosis and allows for a better
adjustment to the external world. … The vast majority of them were none
the worse for the experience.”

How misguided those statements were
became obvious when the ascendant feminist movement, combined with awareness of
trauma in returning combat veterans, emboldened tens of thousands of survivors of
childhood sexual abuse, domestic abuse, and rape to come forward.
Consciousnessraising groups and survivor groups were formed, and numerous popular
books, including The Courage to Heal (1988), a best-selling self-help book
for survivors of incest, and Judith Herman’s book Trauma and Recovery
(1992), discussed the stages of treatment and recovery in great detail.

Cautioned by history, I began to wonder
if we were headed toward another backlash like those of 1895, 1917, and 1947 against
acknowledging the reality of trauma. That proved to be the case, for by the early
1990s articles had started to appear in many leading newspapers and magazines in
United States and in Europe about a so-called False Memory Syndrome in which
psychiatric patients supposedly manufactured elaborate false memories of sexual
abuse, which they then claimed had lain dormant for many years before being
recovered.

What was striking about these articles
was the certainty with which they stated that there was no evidence that people
remember trauma any differently than they do ordinary events. I vividly recall a
phone call from a well-known newsweekly in London, telling me that they planned to
publish an article about traumatic memory in their next issue and asking me whether
I had any comments on the subject. I was quite enthusiastic about their question and
told them that memory loss for traumatic events had first been studied in England
well over a century earlier. I mentioned John Eric Erichsen and Frederic
Myers’s work on railway accidents in the 1860s and 1870s and Charles Samuel
Myers’s and W. H. R. Rivers’s extensive studies of memory problems in
combat soldiers of World War I. I also suggested they look at an article published
in The Lancet in 1944, which described the aftermath of the rescue of the
entire British army from the beaches of Dunkirk in 1940. More than 10 percent of the
soldiers who were studied had suffered from major memory loss after the
evacuation.[17] The following week, the magazine told its readers that there was
no evidence whatsoever that people sometimes lose some or all memory for traumatic
events.

The issue of delayed recall of trauma
was not particularly controversial when Myers and Kardiner first described this
phenomenon in their books on combat neuroses in World War I; when major memory loss
was observed after the evacuation from
Dunkirk; or when I wrote about Vietnam veterans and the survivor of the Cocoanut
Grove nightclub fire. However, during the 1980s and early 1990s, as similar memory
problems began to be documented in women and children in the context of domestic
abuse, the efforts of abuse victims to seek justice against their alleged
perpetrators moved the issue from science into politics and law. This, in turn,
became the context for the pedophile scandals in the Catholic Church, in which
memory experts were pitted against one another in courtrooms across the United
States and later in Europe and Australia.

Experts testifying on behalf of the
Church claimed that memories of childhood sexual abuse were unreliable at best and
that the claims being made by alleged victims more likely resulted from false
memories implanted in their minds by therapists who were oversympathetic, credulous,
or driven by their own agendas. During this period I examined more than fifty adults
who, like Julian, remembered having been abused by priests. Their claims were denied
in about half the cases.

THE SCIENCE OF REPRESSED MEMORY

There have in fact been hundreds of
scientific publications spanning well over a century documenting how the memory of
trauma can be repressed, only to resurface years or decades later.[18] Memory loss has been
reported in people who have experienced natural disasters, accidents, war trauma,
kidnapping, torture, concentration camps, and physical and sexual abuse. Total
memory loss is most common in childhood sexual abuse, with incidence ranging from 19
percent to 38 percent.[19] This issue is not particularly controversial: As early as 1980
the DSM-III recognized the existence of memory loss for traumatic events in the
diagnostic criteria for dissociative amnesia: “an inability to recall
important personal information, usually of a traumatic or stressful nature, that is
too extensive to be explained by normal forgetfulness.” Memory loss has been
part of the criteria for PTSD since that diagnosis was first introduced.

One of the most interesting studies of
repressed memory was conducted by Dr. Linda Meyer Williams, which began when she was
a graduate student in sociology at the University of Pennsylvania in the early
1970s. Williams interviewed 206 girls between the ages of ten and twelve who had
been admitted to a hospital emergency room following sexual abuse. Their laboratory
tests, as well as the interviews with the children and their parents, were kept in
the hospital’s medical records. Seventeen years later Williams was able to track down 136 of the children,
now adults, with whom she conducted extensive follow-up interviews.[20] More than a
third of the women (38 percent) did not recall the abuse that was documented in
their medical records, while only fifteen women (12 percent) said that they had
never been abused as children. More than two-thirds (68 percent) reported other
incidents of childhood sexual abuse. Women who were younger at the time of the
incident and those who were molested by someone they knew were more likely to have
forgotten their abuse.

This study also examined the reliability
of recovered memories. One in ten women (16 percent of those who recalled the abuse)
reported that they had forgotten it at some time in the past but later remembered
that it had happened. In comparison with the women who had always remembered their
molestation, those with a prior period of forgetting were younger at the time of
their abuse and were less likely to have received support from their mothers.
Williams also determined that the recovered memories were approximately as accurate
as those that had never been lost: All the women’s memories were accurate for
the central facts of the incident, but none of their stories precisely matched every
detail documented in their charts.[21]

Williams’s findings are supported
by recent neuroscience research that shows that memories that are retrieved tend to
return to the memory bank with modifications.[22] As long as a memory is inaccessible,
the mind is unable to change it. But as soon as a story starts being told,
particularly if it is told repeatedly, it changes—the act of telling itself changes
the tale. The mind cannot help but make meaning out of what it knows, and the
meaning we make of our lives changes how and what we remember.

Given the wealth of evidence that trauma
can be forgotten and resurface years later, why did nearly one hundred reputable
memory scientists from several different countries throw the weight of their
reputations behind the appeal to overturn Father Shanley’s conviction,
claiming that “repressed memories” were based on “junk
science”? Because memory loss and delayed recall of traumatic experiences had
never been documented in the laboratory, some cognitive scientists adamantly denied
that these phenomena existed[23] or that retrieved traumatic memories
could be accurate.[24] However, what doctors encounter in emergency rooms, on psychiatric
wards, and on the battlefield is necessarily quite different from what scientists
observe in their safe and well-organized laboratories.

Consider what is known as the
“lost in the mall” experiment, for example. Academic researchers have
shown that it is relatively easy to implant memories of events that never took
place, such as having been lost in a shopping mall as a child.[25] About 25 percent of subjects in these
studies later “recall” that they were frightened and even fill in
missing details. But such recollections involve none of the visceral terror that a
lost child would actually experience.

Another line of research documented the
unreliability of eyewitness testimony. Subjects might be shown a video of a car
driving down a street and asked afterward if they saw a stop sign or a traffic
light; children might be asked to recall what a male visitor to their classroom had
been wearing. Other eyewitness experiments demonstrated that the questions witnesses
were asked could alter what they claimed to remember. These studies were valuable in
bringing many police and courtroom practices into question, but they have little
relevance to traumatic memory.

The fundamental problem is this: Events
that take place in the laboratory cannot be considered equivalent to the conditions
under which traumatic memories are created. The terror and helplessness associated
with PTSD simply can’t be induced de novo in such a setting. We can
study the effects of existing traumas in the lab, as in our script-driven imaging
studies of flashbacks, but the original imprint of trauma cannot be laid down there.
Dr. Roger Pitman conducted a study at Harvard in which he showed college students a
film called Faces of Death, which contained newsreel footage of violent
deaths and executions. This movie, now widely banned, is as extreme as any
institutional review board would allow, but it did not cause Pitman’s normal
volunteers to develop symptoms of PTSD. If you want to study traumatic memory, you
have to study the memories of people who have actually been traumatized.

Interestingly, once the excitement and
profitability of courtroom testimony diminished, the “scientific”
controversy disappeared as well, and clinicians were left to deal with the wreckage
of traumatic memory.

NORMAL VERSUS TRAUMATIC MEMORY

In 1994 I and my colleagues at
Massachusetts General Hospital decided to undertake a systematic study comparing how
people recall benign experiences and horrific ones. We placed advertisements in
local newspapers, in laundromats, and on student union bulletin boards that said:
“Has something terrible happened to you that you cannot get out of your mind?
Call 727-5500; we will pay you $10.00 for participating in this study.” In
response to our first ad seventy-six volunteers showed up.[26]

After we introduced ourselves, we
started off by asking each participant: “Can you tell us about an event in your life that
you think you will always remember but that is not traumatic?” One participant
lit up and said, “The day that my daughter was born”; others mentioned
their wedding day, playing on a winning sports team, or being valedictorian at their
high school graduation. Then we asked them to focus on specific sensory details of
those events, such as: “Are you ever somewhere and suddenly have a vivid image
of what your husband looked like on your wedding day?” The answers were always
negative. “How about what your husband’s body felt like on your wedding
night?” (We got some odd looks on that one.) We continued: “Do you ever
have a vivid, precise recollection of the speech you gave as a valedictorian?”
“Do you ever have intense sensations recalling the birth of your first
child?” The replies were all in the negative.

Then we asked them about the traumas
that had brought them into the study—many of them rapes. “Do you ever suddenly
remember how your rapist smelled?” we asked, and, “Do you ever
experience the same physical sensations you had when you were raped?” Such
questions precipitated powerful emotional responses: “That is why I cannot go
to parties anymore, because the smell of alcohol on somebody’s breath makes me
feel like I am being raped all over again” or “I can no longer make love
to my husband, because when he touches me in a particular way I feel like I am being
raped again.”

There were two major differences between
how people talked about memories of positive versus traumatic experiences: (1) how
the memories were organized, and (2) their physical reactions to them. Weddings,
births, and graduations were recalled as events from the past, stories with a
beginning, a middle, and an end. Nobody said that there were periods when
they’d completely forgotten any of these events.

In contrast, the traumatic memories were
disorganized. Our subjects remembered some details all too clearly (the smell of the
rapist, the gash in the forehead of a dead child) but could not recall the sequence
of events or other vital details (the first person who arrived to help, whether an
ambulance or a police car took them to the hospital).

We also asked the participants how they
recalled their trauma at three points in time: right after it happened; when they
were most troubled by their symptoms; and during the week before the study. All of
our traumatized participants said that they had not been able to tell anybody
precisely what had happened immediately following the event. (This will not surprise
anyone who has worked in an emergency room or ambulance service: People brought in
after a car accident in which a child or a friend has been killed sit in stunned
silence, dumbfounded by terror.) Almost all had repeated flashbacks: They felt overwhelmed by images, sounds,
sensations, and emotions. As time went on, even more sensory details and feelings
were activated, but most participants also started to be able to make some sense out
of them. They began to “know” what had happened and to be able to tell
the story to other people, a story that we call “the memory of the
trauma.”

Gradually the images and flashbacks
decreased in frequency, but the greatest improvement was in the participants’
ability to piece together the details and sequence of the event. By the time of our
study, 85 percent of them were able to tell a coherent story, with a beginning, a
middle, and an end. Only a few were missing significant details. We noted that the
five who said they had been abused as children had the most fragmented
narratives—their memories still arrived as images, physical sensations, and intense
emotions.

In essence, our study confirmed the dual
memory system that Janet and his colleagues at the Salpêtrière had described more
than a hundred years earlier: Traumatic memories are fundamentally different from
the stories we tell about the past. They are dissociated: The different sensations
that entered the brain at the time of the trauma are not properly assembled into a
story, a piece of autobiography.

Perhaps the most important finding in
our study was that remembering the trauma with all its associated affects, does not,
as Breuer and Freud claimed back in 1893, necessarily resolve it. Our research did
not support the idea that language can substitute for action. Most of our study
participants could tell a coherent story and also experience the pain associated
with those stories, but they kept being haunted by unbearable images and physical
sensations. Research in contemporary exposure treatment, a staple of cognitive
behavioral therapy, has similarly disappointing results: The majority of patients
treated with that method continue to have serious PTSD symptoms three months after
the end of treatment.[27] As we will see, finding words to describe what has happened to
you can be transformative, but it does not always abolish flashbacks or improve
concentration, stimulate vital involvement in your life or reduce hypersensitivity
to disappointments and perceived injuries.

LISTENING TO SURVIVORS

Nobody wants to remember trauma. In that
regard society is no different from the victims themselves. We all want to live in a
world that is safe, manageable, and predictable, and victims remind us that this is
not always the case. In order to understand trauma, we have to overcome our natural
reluctance to confront that reality
and cultivate the courage to listen to the testimonies of survivors.

In his book Holocaust Testimonies:
The Ruins of Memory (1991), Lawrence Langer writes about his work in the
Fortunoff Video Archive at Yale University: “Listening to accounts of
Holocaust experience, we unearth a mosaic of evidence that constantly vanishes into
bottomless layers of incompletion.[28] We wrestle with the beginnings of a
permanently unfinished tale, full of incomplete intervals, faced by the spectacle of
a faltering witness often reduced to a distressed silence by the overwhelming
solicitations of deep memory.” As one of his witnesses says: “If you
were not there, it’s difficult to describe and say how it was. How men
function under such stress is one thing, and then how you communicate and express
that to somebody who never knew that such a degree of brutality exists seems like a
fantasy.”

Another survivor, Charlotte Delbo,
describes her dual existence after Auschwitz: “[T]he ‘self’ who
was in the camp isn’t me, isn’t the person who is here, opposite you.
No, it’s too unbelievable. And everything that happened to this other
‘self,’ the one from Auschwitz, doesn’t touch me now, me,
doesn’t concern me, so distinct are deep memory and common
memory. … Without this split, I wouldn’t have been able to come back
to life.”[29] She comments that even words have a dual meaning:
“Otherwise, someone [in the camps] who has been tormented by thirst for weeks
would never again be able to say: ‘I’m thirsty. Let’s make a cup
of tea.’ Thirst [after the war] has once more become a currently used term. On
the other hand, if I dream of the thirst I felt in Birkenau [the extermination
facilities in Auschwitz], I see myself as I was then, haggard, bereft of reason,
tottering.”[30]

Langer hauntingly concludes, “Who
can find a proper grave for such damaged mosaics of the mind, where they may rest in
pieces? Life goes on, but in two temporal directions at once, the future unable to
escape the grip of a memory laden with grief.”[31]

The essence of trauma is that it is
overwhelming, unbelievable, and unbearable. Each patient demands that we suspend our
sense of what is normal and accept that we are dealing with a dual reality: the
reality of a relatively secure and predictable present that lives side by side with
a ruinous, ever-present past.

NANCY’S STORY

Few patients have put that duality into
words as vividly as Nancy, the director of nursing in a Midwestern hospital who came
to Boston several times to consult with
me. Shortly after the birth of her third child, Nancy underwent what is usually
routine outpatient surgery, a laparoscopic tubal ligation in which the fallopian
tubes are cauterized to prevent future pregnancies. However, because she was given
insufficient anesthesia, she awakened after the operation began and remained aware
nearly to the end, at times falling into what she called “a light sleep”
or “dream,” at times experiencing the full horror of her situation. She
was unable to alert the OR team by moving or crying out because she had been given a
standard muscle relaxant to prevent muscle contractions during surgery.

Some degree of “anesthesia
awareness” is now estimated to occur in approximately thirty thousand surgical
patients in the United States every year,[32] and I had previously testified on
behalf of several people who were traumatized by the experience. Nancy, however, did
not want to sue her surgeon or anesthetist. Her entire focus was on bringing the
reality of her trauma to consciousness so that she could free herself from its
intrusions into her everyday life. I’d like to end this chapter by sharing
several passages from a remarkable series of e-mails in which she described her
grueling journey to recovery.

Initially Nancy did not know what had
happened to her. “When we went home I was still in a daze, doing the typical
things of running a household, yet not really feeling that I was alive or that I was
real. I had trouble sleeping that night. For days, I remained in my own little
disconnected world. I could not use a hair dryer, toaster, stove or anything that
warmed up. I could not concentrate on what people were doing or telling me. I just
didn’t care. I was increasingly anxious. I slept less and less. I knew I was
behaving strangely and kept trying to understand what was frightening me so.

“On the fourth night after the
surgery, around 3 AM, I started to realize that the dream I had been living all this
time related to conversations I had heard in the operating room. I was suddenly
transported back into the OR and could feel my paralyzed body being burned. I was
engulfed in a world of terror and horror.” From then on, Nancy says, memories
and flashbacks erupted into her life.

“It was as if the door was pushed
open slightly, allowing the intrusion. There was a mixture of curiosity and
avoidance. I continued to have irrational fears. I was deathly afraid of sleep; I
experienced a sense of terror when seeing the color blue. My husband, unfortunately,
was bearing the brunt of my illness. I would lash out at him when I truly did not
intend to. I was sleeping at most 2 to 3 hours, and my daytime was filled with hours
of flashbacks. I remained chronically
hyperalert, feeling threatened by my own thoughts and wanting to escape them. I lost
23 pounds in 3 weeks. People kept commenting on how great I looked.

“I began to think about dying. I
developed a very distorted view of my life in which all my successes diminished and
old failures were amplified. I was hurting my husband and found that I could not
protect my children from my rage.

“Three weeks after the surgery I
went back to work at the hospital. The first time I saw somebody in a surgical
scrubsuit was in the elevator. I wanted to get out immediately, but of course I
could not. I then had this irrational urge to clobber him, which I contained with
considerable effort. This episode triggered increasing flashbacks, terror and
dissociation. I cried all the way home from work. After that, I became adept at
avoidance. I never set foot in an elevator, I never went to the cafeteria, I avoided
the surgical floors.”

Gradually Nancy was able to piece
together her flashbacks and create an understandable, if horrifying, memory of her
surgery. She recalled the reassurances of the OR nurses and a brief period of sleep
after the anesthesia was started. Then she remembered how she began to awaken.

“The entire team was laughing
about an affair one of the nurses was having. This coincided with the first surgical
incision. I felt the stab of the scalpel, then the cutting, then the warm blood
flowing over my skin. I tried desperately to move, to speak, but my body
didn’t work. I couldn’t understand this. I felt a deeper pain as the
layers of muscle pulled apart under their own tension. I knew I wasn’t
supposed to feel this.”

Nancy next recalls someone
“rummaging around” in her belly and identified this as the laparoscopic
instruments being placed. She felt her left tube being clamped. “Then suddenly
there was an intense searing, burning pain. I tried to escape, but the cautery tip
pursued me, relentlessly burning through. There simply are no words to describe the
terror of this experience. This pain was not in the same realm as other pain I had
known and conquered, like a broken bone or natural childbirth. It begins as extreme
pain, then continues relentlessly as it slowly burns through the tube. The pain of
being cut with the scalpel pales beside this giant.”

“Then, abruptly, the right tube
felt the initial impact of the burning tip. When I heard them laugh, I briefly lost
track of where I was. I believed I was in a torture chamber, and I could not
understand why they were torturing me without even asking for
information. … My world narrowed to a small sphere around the operating
table. There was no sense of time, no past, and no future. There was only pain, terror, and horror. I
felt isolated from all humanity, profoundly alone in spite of the people surrounding
me. The sphere was closing in on me.

“In my agony, I must have made
some movement. I heard the nurse anesthetist tell the anesthesiologist that I was
‘light.’ He ordered more meds and then quietly said, ‘There is no
need to put any of this in the chart.’ That is the last memory I
recalled.”

In her later e-mails to me, Nancy
struggled to capture the existential reality of trauma.

“I want to tell you what a
flashback is like. It is as if time is folded or warped, so that the past and
present merge, as if I were physically transported into the past. Symbols related to
the original trauma, however benign in reality, are thoroughly contaminated and so
become objects to be hated, feared, destroyed if possible, avoided if not. For
example, an iron in any form—a toy, a clothes iron, a curling iron, came to be seen
as an instrument of torture. Each encounter with a scrub suit left me disassociated,
confused, physically ill and at times consciously angry.

“My marriage is slowly falling
apart—my husband came to represent the heartless laughing people [the surgical team]
who hurt me. I exist in a dual state. A pervasive numbness covers me with a blanket;
and yet the touch of a small child pulls me back to the world. For a moment, I am
present and a part of life, not just an observer.

“Interestingly, I function very
well at work, and I am constantly given positive feedback. Life proceeds with its
own sense of falsity.

“There is a strangeness,
bizarreness to this dual existence. I tire of it. Yet I cannot give up on life, and
I cannot delude myself into believing that if I ignore the beast it will go away.
I’ve thought many times that I had recalled all the events around the surgery,
only to find a new one.

“There are so many pieces of that
45 minutes of my life that remain unknown. My memories are still incomplete and
fragmented, but I no longer think that I need to know everything in order to
understand what happened.

“When the fear subsides I realize
I can handle it, but a part of me doubts that I can. The pull to the past is strong;
it is the dark side of my life; and I must dwell there from time to time. The
struggle may also be a way to know that I survive—a re-playing of the fight to
survive—which apparently I won, but cannot own.”

An early sign of recovery came when
Nancy needed another, more extensive operation. She chose a Boston hospital for the
surgery, asked for a preoperative meeting with the surgeons and the anesthesiologist
specifically to discuss her prior
experience, and requested that I be allowed to join them in the operating room. For
the first time in many years I put on a surgical scrub suit and accompanied her into
the OR while the anesthesia was induced. This time she woke up to a feeling of
safety.

Two years later I wrote Nancy asking her
permission to use her account of anesthesia awareness in this chapter. In her reply
she updated me on the progress of her recovery: “I wish I could say that the
surgery to which you were so kind to accompany me ended my suffering. That sadly was
not the case. After about six more months I made two choices that proved provident.
I left my CBT therapist to work with a psychodynamic psychiatrist and I joined a
Pilates class.

“In our last month of therapy, I
asked my psychiatrist why he did not try to fix me as all other therapists had
attempted, yet had failed. He told me that he assumed, given what I had be able to
accomplish with my children and career, that I had sufficient resiliency to heal
myself, if he created a holding environment for me to do so. This was an hour each
week that became a refuge where I could unravel the mystery of how I had become so
damaged and then re-construct a sense of myself that was whole, not fragmented,
peaceful, not tormented. Through Pilates, I found a stronger physical core, as well
as a community of women who willingly gave acceptance and social support that had
been distant in my life since the trauma. This combination of core
strengthening—psychological, social, and physical—created a sense of personal safety
and mastery, relegating my memories to the distant past, allowing the present and
future to emerge.”

Part Five

PATHS TO RECOVERY

CHAPTER 13

Healing from Trauma: Owning Your
Self

I don’t go to therapy to find out if
I’m a freak
I go and I find the one and only answer every week
And
when I talk about therapy, I know what people think
That it only makes you
selfish and in love with your shrink
But, oh how I loved everybody else

When I finally got to talk so much about myself

—Dar Williams, What Do You Hear in These Sounds

Nobody can “treat” a war, or
abuse, rape, molestation, or any other horrendous event, for that matter; what has
happened cannot be undone. But what can be dealt with are the imprints of
the trauma on body, mind, and soul: the crushing sensations in your chest that you
may label as anxiety or depression; the fear of losing control; always being on
alert for danger or rejection; the self-loathing; the nightmares and flashbacks; the
fog that keeps you from staying on task and from engaging fully in what you are
doing; being unable to fully open your heart to another human being.

Trauma robs you of the feeling that you
are in charge of yourself, of what I will call self-leadership in the chapters to
come.[1] The
challenge of recovery is to reestablish ownership of your body and your mind—of your
self. This means feeling free to know what you know and to feel what you feel
without becoming overwhelmed, enraged, ashamed, or collapsed. For most people this
involves (1) finding a way to become calm and focused, (2) learning to maintain that
calm in response to images,
thoughts, sounds, or physical sensations that remind you of the past, (3) finding a
way to be fully alive in the present and engaged with the people around you, (4) not
having to keep secrets from yourself, including secrets about the ways that you have
managed to survive.

These goals are not steps to be
achieved, one by one, in some fixed sequence. They overlap, and some may be more
difficult than others, depending on individual circumstances. In each of the
chapters that follow, I’ll talk about specific methods or approaches to
accomplish them. I have tried to make these chapters useful both to trauma survivors
and to the therapists who are treating them. People under temporary stress may also
find them useful. I’ve used every one of these methods extensively to treat my
patients, and I have also experienced them myself. Some people get better using just
one of these methods, but most are helped by different approaches at different
stages of their recovery.

I have done scientific studies of many
of the treatments I describe here and have published the research findings in
peer-reviewed scientific journals.[2] My aim in this chapter is to provide
an overview of underlying principles, a preview of what’s to come, and some
brief comments on methods I don’t cover in depth later on.

A NEW FOCUS FOR RECOVERY

When we talk about trauma, we often start
with a story or a question: “What happened during the war?” “Were
you ever molested?” “Let me tell you about that accident or that
rape,” or “Was anybody in your family a problem drinker?” However,
trauma is much more than a story about something that happened long ago. The
emotions and physical sensations that were imprinted during the trauma are
experienced not as memories but as disruptive physical reactions in the present.

In order to regain control over your
self, you need to revisit the trauma: Sooner or later you need to confront what has
happened to you, but only after you feel safe and will not be retraumatized by it.
The first order of business is to find ways to cope with feeling overwhelmed by the
sensations and emotions associated with the past.

As the previous parts of this book have
shown, the engines of posttraumatic reactions are located in the emotional brain. In
contrast with the rational brain, which expresses itself in thoughts, the emotional
brain manifests itself in physical reactions: gut-wrenching sensations, heart
pounding, breathing becoming fast and shallow, feelings of heartbreak, speaking with
an uptight and reedy voice, and the
characteristic body movements that signify collapse, rigidity, rage, or
defensiveness.

Why can’t we just be reasonable?
And can understanding help? The rational, executive brain is good at helping us
understand where feelings come from (as in: “I get scared when I get close to
a guy because my father molested me” or “I have trouble expressing my
love toward my son because I feel guilty about having killed a child in
Iraq”). However, the rational brain cannot abolish emotions,
sensations, or thoughts (such as living with a low-level sense of threat or feeling
that you are fundamentally a terrible person, even though you rationally know that
you are not to blame for having been raped). Understanding why you feel a
certain way does not change how you feel. But it can keep you from
surrendering to intense reactions (for example, assaulting a boss who reminds you of
a perpetrator, breaking up with a lover at your first disagreement, or jumping into
the arms of a stranger). However, the more frazzled we are, the more our rational
brains take a backseat to our emotions.[3]

LIMBIC SYSTEM THERAPY

The fundamental issue in resolving
traumatic stress is to restore the proper balance between the rational and emotional
brains, so that you can feel in charge of how you respond and how you conduct your
life. When we’re triggered into states of hyper- or hypoarousal, we are pushed
outside our “window of tolerance”—the range of optimal functioning.[4] We become
reactive and disorganized; our filters stop working—sounds and lights bother us,
unwanted images from the past intrude on our minds, and we panic or fly into rages.
If we’re shut down, we feel numb in body and mind; our thinking becomes
sluggish and we have trouble getting out of our chairs.

As long as people are either
hyperaroused or shut down, they cannot learn from experience. Even if they manage to
stay in control, they become so uptight (Alcoholics Anonymous calls this
“white-knuckle sobriety”) that they are inflexible, stubborn, and
depressed. Recovery from trauma involves the restoration of executive functioning
and, with it, self-confidence and the capacity for playfulness and creativity.

If we want to change posttraumatic
reactions, we have to access the emotional brain and do “limbic system
therapy”: repairing faulty alarm systems and restoring the emotional brain to
its ordinary job of being a quiet background presence that takes care of the
housekeeping of the body, ensuring that you eat, sleep, connect with intimate
partners, protect your children, and defend against danger.

Accessing the emotional brain.
The rational, analyzing part of the brain, centered on the dorsolateral prefrontal
cortex, has no direct connections with the emotional brain, where most imprints of
trauma reside, but the medial prefrontal cortex, the center of self-awareness, does.

DRAWING BY LICIA SKY

The neuroscientist Joseph LeDoux and his
colleagues have shown that the only way we can consciously access the emotional
brain is through self-awareness, i.e. by activating the medial prefrontal cortex,
the part of the brain that notices what is going on inside us and thus allows us to
feel what we’re feeling.[5] (The technical term for this is
“interoception”—Latin for “looking inside.”)
Most of our conscious brain is dedicated to focusing on the outside world: getting
along with others and making plans for the future. However, that does not help us
manage ourselves. Neuroscience research shows that the only way we can change the
way we feel is by becoming aware of our inner experience and learning to
befriend what is going inside ourselves.

BEFRIENDING THE EMOTIONAL BRAIN

1. DEALING WITH HYPERAROUSAL

Over the past few decades mainstream
psychiatry has focused on using drugs to change the way we feel, and this has become
the accepted way to deal with hyper-and hypoarousal. I will discuss drugs later in
this chapter, but first I need to stress
the fact that we have a host of inbuilt skills to keep us on an even keel. In chapter 5 we saw how emotions are registered in the
body. Some 80 percent of the fibers of the vagus nerve (which connects the brain
with many internal organs) are afferent; that is, they run from the body into the
brain.[6]
This means that we can directly train our arousal system by the way we breathe,
chant, and move, a principle that has been utilized since time immemorial in places
like China and India, and in every religious practice that I know of, but that is
suspiciously eyed as “alternative” in mainstream culture.

In research supported by the National
Institutes of Health, my colleagues and I have shown that ten weeks of yoga practice
markedly reduced the PTSD symptoms of patients who had failed to respond to any
medication or to any other treatment.[7] (I will discuss yoga in chapter 16.) Neurofeedback, the topic of chapter 19, also can be particularly effective for
children and adults who are so hyperaroused or shut down that they have trouble
focusing and prioritizing.[8]

Learning how to breathe calmly and
remaining in a state of relative physical relaxation, even while accessing painful
and horrifying memories, is an essential tool for recovery.[9] When you deliberately take
a few slow, deep breaths, you will notice the effects of the parasympathetic brake
on your arousal (as explained in chapter 5). The more
you stay focused on your breathing, the more you will benefit, particularly if you
pay attention until the very end of the out breath and then wait a moment before you
inhale again. As you continue to breathe and notice the air moving in and out of
your lungs you may think about the role that oxygen plays in nourishing your body
and bathing your tissues with the energy you need to feel alive and engaged. Chapter 16 documents the full-body effects of this
simple practice.

Since emotional regulation is the
critical issue in managing the effects of trauma and neglect, it would make an
enormous difference if teachers, army sergeants, foster parents, and mental health
professionals were thoroughly schooled in emotional-regulation techniques. Right now
this still is mainly the domain of preschool and kindergarten teachers, who deal
with immature brains and impulsive behavior on a daily basis and who are often very
adept at managing them.[10]

Mainstream Western psychiatric and
psychological healing traditions have paid scant attention to self-management. In
contrast to the Western reliance on drugs and verbal therapies, other traditions
from around the world rely on mindfulness, movement, rhythms, and action. Yoga in
India, tai chi and qigong in China, and
rhythmical drumming throughout Africa are just a few examples. The cultures of Japan
and the Korean peninsula have spawned martial arts, which focus on the cultivation
of purposeful movement and being centered in the present, abilities that are damaged
in traumatized individuals. Aikido, judo, tae kwon do, kendo, and jujitsu, as well
as capoeira from Brazil, are examples. These techniques all involve physical
movement, breathing, and meditation. Aside from yoga, few of these popular
non-Western healing traditions have been systematically studied for the treatment of
PTSD.

2. NO MIND WITHOUT MINDFULNESS

At the core of recovery is
self-awareness. The most important phrases in trauma therapy are “Notice
that” and “What happens next?” Traumatized people live with
seemingly unbearable sensations: They feel heartbroken and suffer from intolerable
sensations in the pit of their stomach or tightness in their chest. Yet avoiding
feeling these sensations in our bodies increases our vulnerability to being
overwhelmed by them.

Body awareness puts us in touch with our
inner world, the landscape of our organism. Simply noticing our annoyance,
nervousness, or anxiety immediately helps us shift our perspective and opens up new
options other than our automatic, habitual reactions. Mindfulness puts us in touch
with the transitory nature of our feelings and perceptions. When we pay focused
attention to our bodily sensations, we can recognize the ebb and flow of our
emotions and, with that, increase our control over them.

Traumatized people are often afraid of
feeling. It is not so much the perpetrators (who, hopefully, are no longer around to
hurt them) but their own physical sensations that now are the enemy. Apprehension
about being hijacked by uncomfortable sensations keeps the body frozen and the mind
shut. Even though the trauma is a thing of the past, the emotional brain keeps
generating sensations that make the sufferer feel scared and helpless. It’s
not surprising that so many trauma survivors are compulsive eaters and drinkers,
fear making love, and avoid many social activities: Their sensory world is largely
off limits.

In order to change you need to open
yourself to your inner experience. The first step is to allow your mind to focus on
your sensations and notice how, in contrast to the timeless, ever-present experience
of trauma, physical sensations are transient and respond to slight shifts in body
position, changes in breathing, and shifts in thinking. Once you pay attention to
your physical sensations, the next step
is to label them, as in “When I feel anxious, I feel a crushing sensation in
my chest.” I may then say to a patient: “Focus on that sensation and see
how it changes when you take a deep breath out, or when you tap your chest just
below your collarbone, or when you allow yourself to cry.” Practicing
mindfulness calms down the sympathetic nervous system, so that you are less likely
to be thrown into fight-or-flight.[11] Learning to observe and tolerate your
physical reactions is a prerequisite for safely revisiting the past. If you cannot
tolerate what you are feeling right now, opening up the past will only compound the
misery and retraumatize you further.[12]

We can tolerate a great deal discomfort
as long as we stay conscious of the fact that the body’s commotions constantly
shift. One moment your chest tightens, but after you take a deep breath and exhale,
that feeling softens and you may observe something else, perhaps a tension in your
shoulder. Now you can start exploring what happens when you take a deeper breath and
notice how your rib cage expands.[13] Once you feel calmer and more
curious, you can go back to that sensation in your shoulder. You should not be
surprised if a memory spontaneously arises in which that shoulder was somehow
involved.

A further step is to observe the
interplay between your thoughts and your physical sensations. How are particular
thoughts registered in your body? (Do thoughts like “My father loves me”
or “my girlfriend dumped me” produce different sensations?) Becoming
aware of how your body organizes particular emotions or memories opens up the
possibility of releasing sensations and impulses you once blocked in order to
survive.[14]
In chapter 20, on the benefits of theater, I’ll
describe in more detail how this works.

Jon Kabat-Zinn, one of the pioneers in
mind-body medicine, founded the Mindfulness-Based Stress Reduction (MBSR) program at
the University of Massachusetts Medical Center in 1979, and his method has been
thoroughly studied for more than three decades. As he describes mindfulness,
“One way to think of this process of transformation is to think of mindfulness
as a lens, taking the scattered and reactive energies of your mind and focusing them
into a coherent source of energy for living, for problem solving, for
healing.”[15]

Mindfulness has been shown to have a
positive effect on numerous psychiatric, psychosomatic, and stress-related symptoms,
including depression and chronic pain.[16] It has broad effects on physical
health, including improvements in immune response, blood pressure, and cortisol
levels.[17]
It has also been shown to activate the brain regions involved in emotional
regulation[18] and to lead to changes in the regions related to body awareness
and fear.[19]
Research by my Harvard colleagues Britta Hölzel and Sara Lazar has shown that practicing mindfulness even
decreases the activity of the brain’s smoke detector, the amygdala, and thus
decreases reactivity to potential triggers.[20]

3. RELATIONSHIPS

Study after study shows that having a
good support network constitutes the single most powerful protection against
becoming traumatized. Safety and terror are incompatible. When we are terrified,
nothing calms us down like the reassuring voice or the firm embrace of someone we
trust. Frightened adults respond to the same comforts as terrified children: gentle
holding and rocking and the assurance that somebody bigger and stronger is taking
care of things, so you can safely go to sleep. In order to recover, mind, body, and
brain need to be convinced that it is safe to let go. That happens only when you
feel safe at a visceral level and allow yourself to connect that sense of safety
with memories of past helplessness.

After an acute trauma, like an assault,
accident, or natural disaster, survivors require the presence of familiar people,
faces, and voices; physical contact; food; shelter and a safe place; and time to
sleep. It is critical to communicate with loved ones close and far and to reunite as
soon as possible with family and friends in a place that feels safe. Our attachment
bonds are our greatest protection against threat. For example, children who are
separated from their parents after a traumatic event are likely to suffer serious
negative long-term effects. Studies conducted during World War II in England showed
that children who lived in London during the Blitz and were sent away to the
countryside for protection against German bombing raids fared much worse than
children who remained with their parents and endured nights in bomb shelters and
frightening images of destroyed buildings and dead people.[21]

Traumatized human beings recover in the
context of relationships: with families, loved ones, AA meetings, veterans’
organizations, religious communities, or professional therapists. The role of those
relationships is to provide physical and emotional safety, including safety from
feeling shamed, admonished, or judged, and to bolster the courage to tolerate, face,
and process the reality of what has happened.

As we have seen, much the wiring of our
brain circuits is devoted to being in tune with others. Recovery from trauma
involves (re)connecting with our fellow human beings. This is why trauma that has
occurred within relationships is generally more difficult to treat than trauma
resulting from traffic accidents or natural disasters. In our society the most
common traumas in women and children
occur at the hands of their parents or intimate partners. Child abuse, molestation,
and domestic violence all are inflicted by people who are supposed to love you. That
knocks out the most important protection against being traumatized: being sheltered
by the people you love.

If the people whom you naturally turn to
for care and protection terrify or reject you, you learn to shut down and to ignore
what you feel.[22] As we saw in part 3, when your caregivers turn on you, you have to
find alternative ways to deal with feeling scared, angry, or frustrated. Managing
your terror all by yourself gives rise to another set of problems: dissociation,
despair, addictions, a chronic sense of panic, and relationships that are marked by
alienation, disconnection, and explosions. Patients with these histories rarely make
the connection between what happened to them long ago and how they currently feel
and behave. Everything just seems unmanageable.

Relief does not come until they are able
to acknowledge what has happened and recognize the invisible demons they’re
struggling with. Recall, for example, the men I described in chapter 11 who had been abused by pedophile priests.
They visited the gym regularly, took anabolic steroids, and were strong as oxen.
However, in our interviews they often acted like scared kids; the hurt boys deep
inside still felt helpless.

While human contact and attunement are
the wellspring of physiological self-regulation, the promise of closeness often
evokes fear of getting hurt, betrayed, and abandoned. Shame plays an important role
in this: “You will find out how rotten and disgusting I am and dump me as soon
as you really get to know me.” Unresolved trauma can take a terrible toll on
relationships. If your heart is still broken because you were assaulted by someone
you loved, you are likely to be preoccupied with not getting hurt again and fear
opening up to someone new. In fact, you may unwittingly try to hurt them before they
have a chance to hurt you.

This poses a real challenge for
recovery. Once you recognize that posttraumatic reactions started off as efforts to
save your life, you may gather the courage to face your inner music (or cacophony),
but you will need help to do so. You have to find someone you can trust enough to
accompany you, someone who can safely hold your feelings and help you listen to the
painful messages from your emotional brain. You need a guide who is not afraid of
your terror and who can contain your darkest rage, someone who can safeguard the
wholeness of you while you explore the fragmented experiences that you had to keep
secret from yourself for so long. Most traumatized individuals need an anchor and a
great deal of coaching to do this work.

Choosing a Professional Therapist

The training of competent trauma
therapists involves learning about the impact of trauma, abuse, and neglect and
mastering a variety of techniques that can help to (1) stabilize and calm patients
down, (2) help to lay traumatic memories and reenactments to rest, and (3) reconnect
patients with their fellow men and women. Ideally the therapist will also have been
on the receiving end of whatever therapy he or she practices.

While it’s inappropriate and
unethical for therapists to tell you the details of their personal struggles, it is
perfectly reasonable to ask what particular forms of therapy they have been trained
in, where they learned their skills, and whether they’ve personally benefited
from the therapy they propose for you.

There is no one “treatment of
choice” for trauma, and any therapist who believes that his or her particular
method is the only answer to your problems is suspect of being an ideologue rather
than somebody who is interested in making sure that you get well. No therapist can
possibly be familiar with every effective treatment, and he or she must be open to
your exploring options other than the ones he or she offers. He or she also must be
open to learning from you. Gender, race, and personal background are relevant only
if they interfere with helping the patient feel safe and understood.

Do you feel basically comfortable with
this therapist? Does he or she seem to feel comfortable in his or her own skin and
with you as a fellow human being? Feeling safe is a necessary condition for you to
confront your fears and anxieties. Someone who is stern, judgmental, agitated, or
harsh is likely to leave you feeling scared, abandoned, and humiliated, and that
won’t help you resolve your traumatic stress. There may be times as
old feelings from the past are stirred up, when you become suspicious that the
therapist resembles someone who once hurt or abused you. Hopefully, this is
something you can work through together, because in my experience patients get
better only if they develop deep positive feelings for their therapists. I also
don’t think that you can grow and change unless you feel that you have some
impact on the person who is treating you.

The critical question is this: Do you
feel that your therapist is curious to find out who you are and what
you, not some generic “PTSD patient,” need? Are you just a
list of symptoms on some diagnostic questionnaire, or does your therapist take the
time to find out why you do what you do and think what you think? Therapy is a
collaborative process—a mutual exploration of your self.

Patients who have been brutalized by their
caregivers as children often do not feel safe with anyone. I often ask my patients
if they can think of any person they felt safe with while they were growing up. Many
of them hold tight to the memory of that one teacher, neighbor, shopkeeper, coach,
or minister who showed that he or she cared, and that memory is often the seed of
learning to reengage. We are a hopeful species. Working with trauma is as much about
remembering how we survived as it is about what is broken.

I also ask my patients to imagine what
they were like as newborns—whether they were lovable and filled with spunk. All of
them believe they were and have some image of what they must have been like before
they were hurt.

Some people don’t remember anybody
they felt safe with. For them, engaging with horses or dogs may be much safer than
dealing with human beings. This principle is currently being applied in many
therapeutic settings to great effect, including in jails, residential treatment
programs, and veterans’ rehabilitation. Jennifer, a member of the first
graduating class of the Van der Kolk Center,[23] who had come to the program as an
out-of-control, mute fourteen-year-old, said during her graduation ceremony that
having been entrusted with the responsibility of caring for a horse was the critical
first step for her. Her growing bond with her horse helped her feel safe enough to
begin to relate to the staff of the center and then to focus on her classes, take
her SATs, and be accepted to college.[24]

4. COMMUNAL RHYTHMS AND SYNCHRONY

From the moment of our birth, our
relationships are embodied in responsive faces, gestures, and touch. As we saw in chapter 7, these are the foundations of attachment.
Trauma results in a breakdown of attuned physical synchrony: When you enter the
waiting room of a PTSD clinic, you can immediately tell the patients from the staff
by their frozen faces and collapsed (but simultaneously agitated) bodies.
Unfortunately, many therapists ignore those physical communications and focus only
on the words with which their patients communicate.

The healing power of community as
expressed in music and rhythms was brought home for me in the spring of 1997, when I
was following the work of the Truth and Reconciliation Commission in South Africa.
In some places we visited, terrible violence continued. One day I attended a group
for rape survivors in the courtyard of a clinic in a township outside Johannesburg.
We could hear the sound of bullets being fired at a distance while smoke billowed over the walls of the compound and the
smell of teargas hung in the air. Later we heard that forty people had been
killed.

Yet, while the surroundings were foreign
and terrifying, I recognized this group all too well: The women sat slumped over—sad
and frozen—like so many rape therapy groups I had seen in Boston. I felt a familiar
sense of helplessness, and, surrounded by collapsed people, I felt myself mentally
collapse as well. Then one of the women started to hum, while gently swaying back
and forth. Slowly a rhythm emerged; bit by bit other women joined in. Soon the whole
group was singing, moving, and getting up to dance. It was an astounding
transformation: people coming back to life, faces becoming attuned, vitality
returning to bodies. I made a vow to apply what I was seeing there and to study how
rhythm, chanting, and movement can help to heal trauma.

We will see more of this in chapter 20, on theater, where I show how groups of
young people—among them juvenile offenders and at-risk foster kids—gradually learn
to work together and to depend on one another, whether as partners in Shakespearean
swordplay or as the writers and performers of full-length musicals. Different
patients have told me how much choral singing, aikido, tango dancing, and kickboxing
have helped them, and I am delighted to pass their recommendations on to other
people I treat.

I learned another powerful lesson about
rhythm and healing when clinicians at the Trauma Center were asked to treat a
five-year-old mute girl, Ying Mee, who had been adopted from an orphanage in China.
After months of failed attempts to make contact with her, my colleagues Deborah
Rozelle and Liz Warner realized that her rhythmical engagement system didn’t
work—she could not resonate with the voices and faces of the people around her. That
led them to sensorimotor therapy.[25]

The sensory integration clinic in
Watertown, Massachusetts, is a wondrous indoor playground filled with swings, tubs
full of multicolored rubber balls so deep that you can make yourself disappear,
balance beams, crawl spaces fashioned from plastic tubing, and ladders that lead to
platforms from which you can dive onto foam-filled mats. The staff bathed Ying Mee
in the tub with plastic balls; that helped her feel sensations on her skin. They
helped her sway on swings and crawl under weighted blankets. After six weeks
something shifted—and she started to talk.[26]

Ying Mee’s dramatic improvement
inspired us to start a sensory integration clinic at the Trauma Center, which we now
also use in our residential treatment programs. We have not yet explored how well
sensory integration works for traumatized adults, but I regularly incorporate
sensory integration experiences and dance in my seminars.

Learning to become attuned provides
parents (and their kids) with the visceral experience of reciprocity. Parent-child
interaction therapy (PCIT) is an interactive therapy that fosters this, as is SMART
(sensory motor arousal regulation treatment), developed by my colleagues at the
Trauma Center.[27]

When we play together, we feel
physically attuned and experience a sense of connection and joy. Improvisation
exercises (such as those found at http://learnimprov.com/) also are a marvelous way to help people connect in
joy and exploration. The moment you see a group of grim-faced people break out in a
giggle, you know that the spell of misery has broken.

5. GETTING IN TOUCH

Mainstream trauma treatment has paid
scant attention to helping terrified people to safely experience their sensations
and emotions. Medications such as serotonin reuptake blockers, Respiridol and
Seroquel increasingly have taken the place of helping people to deal with their
sensory world.[28] However, the most natural way that we humans calm down our
distress is by being touched, hugged, and rocked. This helps with excessive arousal
and makes us feel intact, safe, protected, and in charge.

Rembrandt van Rijn: Christ Healing
the Sick. Gestures of comfort are universally recognizable and
reflect the healing power of attuned touch.

Touch, the most elementary tool that we
have to calm down, is proscribed from most therapeutic practices. Yet you
can’t fully recover if you don’t feel safe in your skin. Therefore, I
encourage all my patients to engage in some sort of bodywork, be it therapeutic
massage, Feldenkrais, or craniosacral therapy.

I asked my favorite bodywork
practitioner, Licia Sky, about her practice with traumatized individuals. Here is
some of what she told me: “I never begin a bodywork session without
establishing a personal connection. I’m not taking a history; I’m not
finding out how traumatized a person is or what happened to them. I check in where
they are in their body right now. I ask them if there is anything they want me to
pay attention to. All the while, I’m assessing their posture; whether they
look me in the eye; how tense or relaxed they seem; are they connecting with me or
not.

“The first decision I make is if
they will feel safer face up or face down. If I don’t know them, I usually
start face up. I am very careful about draping; very careful to let them feel safe
with whatever clothing they want to leave on. These are important boundaries to set
up right at the beginning.

“Then, with my first touch, I make
firm, safe contact. Nothing forced or sharp. Nothing too fast. The touch is slow,
easy for the client to follow, gently rhythmic. It can be as strong as a handshake.
The first place I might touch is their hand and forearm, because that’s the
safest place to touch anybody, the place where they can touch you back.

“You have to meet their point of
resistance—the place that has the most tension—and meet it with an equal amount of
energy. That releases the frozen tension. You can’t hesitate; hesitation
communicates a lack of trust in yourself. Slow movement, careful attuning to the
client is different from hesitation. You have to meet them with tremendous
confidence and empathy, let the pressure of your touch meet the tension they are
holding in their bodies.”

What does bodywork do for people?
Licia’s reply: “Just like you can thirst for water, you can thirst for
touch. It is a comfort to be met confidently, deeply, firmly, gently, responsively.
Mindful touch and movement grounds people and allows them to discover tensions that
they may have held for so long that they are no longer even aware of them. When you
are touched, you wake up to the part of your body that is being touched.

“The body is physically restricted
when emotions are bound up inside. People’s shoulders tighten; their facial
muscles tense. They spend enormous energy on holding back their tears—or any sound
or movement that might betray their inner state. When the physical tension is
released, the feelings can be released.
Movement helps breathing to become deeper, and as the tensions are released,
expressive sounds can be discharged. The body becomes freer—breathing freer, being
in flow. Touch makes it possible to live in a body that can move in response to
being moved.

“People who are terrified need to
get a sense of where their bodies are in space and of their boundaries. Firm and
reassuring touch lets them know where those boundaries are: what’s outside
them, where their bodies end. They discover that they don’t constantly have to
wonder who and where they are. They discover that their body is solid and that they
don’t have to be constantly on guard. Touch lets them know that they are
safe.”

6. TAKING ACTION

The body responds to extreme
experiences by secreting stress hormones. These are often blamed for subsequent
illness and disease. However, stress hormones are meant to give us the strength and
endurance to respond to extraordinary conditions. People who actively do
something to deal with a disaster—rescuing loved ones or strangers, transporting
people to a hospital, being part of a medical team, pitching tents or cooking
meals—utilize their stress hormones for their proper purpose and therefore are at
much lower risk of becoming traumatized. (Nonetheless, everyone has his or her
breaking point, and even the best-prepared person may become overwhelmed by the
magnitude of the challenge.)

Helplessness and immobilization keep
people from utilizing their stress hormones to defend themselves. When that happens,
their hormones still are being pumped out, but the actions they’re supposed to
fuel are thwarted. Eventually, the activation patterns that were meant to promote
coping are turned back against the organism and now keep fueling inappropriate
fight/flight and freeze responses. In order to return to proper functioning, this
persistent emergency response must come to an end. The body needs to be restored to
a baseline state of safety and relaxation from which it can mobilize to take action
in response to real danger.

My friends and teachers Pat Ogden and
Peter Levine have each developed powerful body-based therapies, sensorimotor
psychotherapy[29] and somatic experiencing[30] to deal with this issue. In these
treatment approaches the story of what has happened takes a backseat to exploring
physical sensations and discovering the location and shape of the imprints of past
trauma on the body. Before plunging into a full-fledged exploration of the trauma
itself, patients are helped to build up internal resources that foster safe access
sensations and emotions that
overwhelmed them at the time of the trauma. Peter Levine calls this process
pendulation—gently moving in and out of accessing internal sensations
and traumatic memories. In this way patients are helped to gradually expand their
window of tolerance.

Once patients can tolerate being aware
of their trauma-based physical experiences, they are likely to discover powerful
physical impulses—like hitting, pushing, or running—that arose during the trauma but
were suppressed in order to survive. These impulses manifest themselves in subtle
body movements such as twisting, turning, or backing away. Amplifying these
movements and experimenting with ways to modify them begins the process of bringing
the incomplete, trauma-related “action tendencies” to completion and can
eventually lead to resolution of the trauma. Somatic therapies can help patients to
relocate themselves in the present by experiencing that it is safe to move. Feeling
the pleasure of taking effective action restores a sense of agency and a sense of
being able to actively defend and protect themselves.

Back in 1893 Pierre Janet, the first
great explorer of trauma, wrote about “the pleasure of completed
action,” and I regularly observe that pleasure when I practice sensorimotor
psychotherapy and somatic experiencing: When patients can physically experience what
it would have felt like to fight back or run away, they relax, smile, and express a
sense of completion.

When people are forced to submit to
overwhelming power, as is true for most abused children, women trapped in domestic
violence, and incarcerated men and women, they often survive with resigned
compliance. The best way to overcome ingrained patterns of submission is to restore
a physical capacity to engage and defend. One of my favorite body-oriented ways to
build effective fight/flight responses is our local impact center’s model
mugging program, in which women (and increasingly men) are taught to actively fight
off a simulated attack.[31] The program started in Oakland, California, in 1971 after a
woman with a fifth-degree black belt in karate was raped. Wondering how this could
have happened to someone who supposedly could kill with her bare hands, her friends
concluded that she had become de-skilled by fear. In the terms of this book, her
executive functions—her frontal lobes—went off-line, and she froze. The model
mugging program teaches women to recondition the freeze response through many
repetitions of being placed in the “zero hour” (a military term for the
precise moment of an attack) and learning to transform fear into positive fighting
energy.

One of my patients, a college student
with a history of unrelenting child abuse, took the course. When I first met her,
she was collapsed, depressed, and overly compliant. Three months later, during her
graduation ceremony, she successfully
fought off a gigantic male attacker who ended up lying cringing on the floor
(shielded from her blows by a thick protective suit) while she faced him, arms
raised in a karate stance, calmly and clearly yelling no.

Not long afterward, she was walking home
from the library after midnight when three men jumped out of some bushes, yelling:
“Bitch, give us your money.” She later told me that she took that same
karate stance and yelled back: “Okay, guys, I’ve been looking forward to
this moment. Who wants to take me on first?” They ran away. If you’re
hunched over and too afraid to look around, you are easy prey to other
people’s sadism, but when you walk around projecting the message
“Don’t mess with me,” you’re not likely to be bothered.

INTEGRATING TRAUMATIC MEMORIES

People cannot put traumatic events behind
until they are able to acknowledge what has happened and start to recognize the
invisible demons they’re struggling with. Traditional psychotherapy has
focused mainly on constructing a narrative that explains why a person feels a
particular way or, as Sigmund Freud put it back in 1914 in Remembering,
Repeating and Working Through:[32] “While the patient lives [the
trauma] through as something real and actual, we have to accomplish the therapeutic
task, which consists chiefly of translating it back again in terms of the
past.” Telling the story is important; without stories, memory becomes frozen;
and without memory you cannot imagine how things can be different. But as we saw in
part 4, telling a story about the event does not guarantee that the traumatic
memories will be laid to rest.

There is a reason for that. When people
remember an ordinary event, they do not also relive the physical sensations,
emotions, images, smells, or sounds associated with that event. In contrast, when
people fully recall their traumas, they “have” the experience: They are
engulfed by the sensory or emotional elements of the past. The brain scans of Stan
and Ute Lawrence, the accident victims in chapter 4,
show how this happens. When Stan was remembering his horrendous accident, two key
areas in his brain went blank: the area that provides a sense of time and
perspective, which makes it possible to know that “that was then, but I am
safe now,” and another area that integrates the images, sounds, and sensations
of trauma into a coherent story. When those parts of the brain are knocked out, you
experience something not as an event with a beginning, a middle, and an end but in
fragments of sensations, images, and emotions.

A trauma can be successfully processed
only if all those brain structures are kept online. In Stan’s case, eye
movement desensitization and reprocessing (EMDR) allowed him to access his memories
of the accident without being overwhelmed by them. When the brain areas whose
absence is responsible for flashbacks can be kept online while remembering what has
happened, people can integrate their traumatic memories as belonging to the
past.

Ute’s dissociation (as you recall,
she shut down completely) complicated recovery in a different way. None of the brain
structures necessary to engage in the present were online, so that dealing with the
trauma was simply impossible. Without a brain that is alert and present there can be
no integration and resolution. She needed to be helped to increase her window of
tolerance before she could deal with her PTSD symptoms.

Hypnosis was the most widely practiced
treatment for trauma from the late 1800s, the time of Pierre Janet and Sigmund
Freud, until after World War II. On YouTube you can still watch the documentary
Let There Be Light, by the great Hollywood director John Huston, which
shows men undergoing hypnosis to treat “war neurosis.” Hypnosis fell out
of favor in the early 1990s and there have been no recent studies of its
effectiveness for treating PTSD. However, hypnosis can induce a state of relative
calm from which patients can observe their traumatic experiences without being
overwhelmed by them. Since that capacity to quietly observe oneself is a critical
factor in the integration of traumatic memories, it is likely that hypnosis, in some
form, will make a comeback.

COGNITIVE BEHAVIORAL THERAPY
(CBT)

During their training most psychologists
are taught cognitive behavioral therapy. CBT was first developed to treat phobias
such as fear of spiders, airplanes, or heights, to help patients compare their
irrational fears with harmless realities. Patients are gradually desensitized from
their irrational fears by bringing to mind what they are most afraid of, using their
narratives and images (“imaginal exposure”), or they are placed in
actual (but actually safe) anxiety-provoking situations (“in vivo
exposure”), or they are exposed to virtual-reality, computer-simulated scenes,
for example, in the case of combat-related PTSD, fighting in the streets of
Fallujah.

The idea behind cognitive behavioral
treatment is that when patients are repeatedly exposed to the stimulus without bad
things actually happening, they gradually will become less upset; the bad memories
will have become associated with
“corrective” information of being safe.[33] CBT also tries to help patients deal
with their tendency to avoid, as in “I don’t want to talk about
it.”[34] It sounds simple, but, as we have seen, reliving trauma
reactivates the brain’s alarm system and knocks out critical brain areas
necessary for integrating the past, making it likely that patients will relive
rather than resolve the trauma.

Prolonged exposure or
“flooding” has been studied more thoroughly than any other PTSD
treatment. Patients are asked to “focus their attention on the traumatic
material and … not distract themselves with other thoughts or
activities.”[35] Research has shown that up to one hundred minutes of flooding
(in which anxiety-provoking triggers are presented in an intense, sustained form)
are required before decreases in anxiety are reported.[36] Exposure sometimes helps
to deal with fear and anxiety, but it has not been proven to help with guilt or
other complex emotions.[37]

In contrast to its effectiveness for
irrational fears such as spiders, CBT has not done so well for traumatized
individuals, particularly those with histories of childhood abuse. Only about one in
three participants with PTSD who finish research studies show some improvement.[38] Those who
complete CBT treatment usually have fewer PTSD symptoms, but they rarely recover
completely: Most continue to have substantial problems with their health, work, or
mental well-being.[39]

In the largest published study of CBT
for PTSD more than one-third of the patients dropped out; the rest had a significant
number of adverse reactions. Most of the women in the study still suffered from
full-blown PTSD after three months in the study, and only 15 percent no longer had
major PTSD symptoms.[40] A thorough analysis of all the scientific studies of CBT show
that it works about as well as being in a supportive therapy relationship.[41] The poorest
outcome in exposure treatments occurs in patients who suffer from “mental
defeat”—those who have given up.[42]

Being traumatized is not just an issue
of being stuck in the past; it is just as much a problem of not being fully alive in
the present. One form of exposure treatment is virtual-reality therapy in which
veterans wear high-tech goggles that make it possible to refight the battle of
Fallujah in lifelike detail. As far as I know, the US Marines performed very well in
combat. The problem is that they cannot tolerate being home. Recent studies of
Australian combat veterans show that their brains are rewired to be alert for
emergencies, at the expense of being focused on the small details of everyday
life.[43]
(We’ll learn more about this in chapter 19, on
neurofeedback.) More than virtual-reality therapy, traumatized patients need
“real world” therapy, which helps them to feel as alive when walking through the
local supermarket or playing with their kids as they did in the streets of
Baghdad.

Patients can benefit from reliving their
trauma only if they are not overwhelmed by it. A good example is a study of Vietnam
veterans conducted in the early 1990s by my colleague Roger Pitman.[44] I visited
Roger’s lab every week during that time, since we were conducting the study of
brain opioids in PTSD that I discussed in chapter 2.
Roger would show me the videotapes of his treatment sessions and we would discuss
what we observed. He and his colleagues pushed the veterans to talk repeatedly about
every detail of their experiences in Vietnam, but the investigators had to stop the
study because many patients became panicked by their flashbacks, and the dread often
persisted after the sessions. Some never returned, while many of those who stayed
with the study became more depressed, violent, and fearful; some coped with their
increased symptoms by increasing their alcohol consumption, which led to further
violence and humiliation, as some of their families called the police to take them
to a hospital.

DESENSITIZATION

Over the past two decades the prevailing
treatment taught to psychology students has been some form of systematic
desensitization: helping patients become less reactive to certain emotions and
sensations. But is this the correct goal? Maybe the issue is not desensitization but
integration: putting the traumatic event into its proper place in the overall arc of
one’s life.

Desensitization makes me think of the
small boy—he must have been about five—I saw in front of my house recently. His
hulking father was yelling at him at the top of his voice as the boy rode his
tricycle down my street. The kid was unfazed, while my heart was racing and I felt
an impulse to deck the guy. How much brutality had it taken to numb a child this
young to his father’s brutality? His indifference to his father’s
yelling must have been the result of prolonged exposure, but, I wondered, at what
price? Yes, we can take drugs that blunt our emotions or we can learn to desensitize
ourselves. As medical students we learned to stay analytical when we had to treat
children with third-degree burns. But, as the neuroscientist Jean Decety at the
University of Chicago has shown, desensitization to our own or to other
people’s pain tends to lead to an overall blunting of emotional
sensitivity.[45]

A 2010 report on 49,425 veterans with
newly diagnosed PTSD from the Iraq and Afghanistan wars who sought care from the VA
showed that fewer than one out of ten actually completed the recommended
treatment.[46] As in Pitman’s
Vietnam veterans, exposure treatment, as currently practiced, rarely works for them.
We can only “process” horrendous experiences if they do not overwhelm
us. And that means that other approaches are necessary.

DRUGS TO SAFELY ACCESS TRAUMA?

When I was a medical student, I spent the
summer of 1966 working for Jan Bastiaans, a professor at Leiden University in the
Netherlands who was known for his work treating Holocaust survivors with LSD. He
claimed to have achieved spectacular results, but when colleagues inspected his
archives, they found few data to support his claims. The potential of mindaltering
substances for trauma treatment was subsequently neglected until 2000, when Michael
Mithoefer and his colleagues in South Carolina received FDA permission to conduct an
experiment with MDMA (ecstasy). MDMA was classified as a controlled substance in
1985 after having been used for years as a recreational drug. As with Prozac and
other psychotropic agents, we don’t know exactly how MDMA works, but it is
known to increase concentrations of a number of important hormones including
oxytocin, vasopressin, cortisol, and prolactin.[47] Most relevant for trauma treatment,
it increases people’s awareness of themselves; they frequently report a
heightened sense of compassionate energy, accompanied by curiosity, clarity,
confidence, creativity, and connectedness. Mithoefer and his colleagues were looking
for a medication that would enhance the effectiveness of psychotherapy, and they
became interested in MDMA because it decreases fear, defensiveness, and numbing, as
well as helping to access inner experience.[48] They thought MDMA might enable
patients to stay within the window of tolerance so they could revisit their
traumatic memories without suffering overwhelming physiological and emotional
arousal.

The initial pilot studies have supported
that expectation.[49] The first study, involving combat veterans, firefighters, and
police officers with PTSD, had positive results. In the next study, of a group of
twenty victims of assault who had been unresponsive to previous forms of therapy,
twelve subjects received MDMA and eight received an inactive placebo. Sitting or
lying in a comfortable room, they then all received two eight-hour psychotherapy
sessions, mainly using internal family systems (IFS) therapy, the subject of chapter 17 of this book. Two months later 83 percent
of the patients who received MDMA plus psychotherapy were considered completely
cured, compared with 25 percent of the placebo group. None of the patients had
adverse side effects. Perhaps most interesting, when the participants were
interviewed more than a year after the
study was completed, they had maintained their gains.

By being able to observe the trauma from
the calm, mindful state that IFS calls Self (a term I’ll discuss further in chapter 17), mind and brain are in a position to
integrate the trauma into the overall fabric of life. This is very different from
traditional desensitization techniques, which are about blunting a person’s
response to past horrors. This is about association and integration—making a
horrendous event that overwhelmed you in the past into a memory of something that
happened a long time ago.

Nonetheless, psychedelic substances are
powerful agents with a troubled history. They can easily be misused through careless
administration and poor maintenance of therapeutic boundaries. It is to be hoped
that MDMA will not be another magic cure released from Pandora’s box.

WHAT ABOUT MEDICATIONS?

People have always used drugs to deal
with traumatic stress. Each culture and each generation has its preferences—gin,
vodka, beer, or whiskey; hashish, marijuana, cannabis, or ganja; cocaine; opioids
like oxycontin; tranquilizers such as Valium, Xanax, and Klonopin. When people are
desperate, they will do just about anything to feel calmer and more in control.[50]

Mainstream psychiatry follows this
tradition. Over the past decade the Departments of Defense and Veterans Affairs
combined have spent over $4.5 billion on antidepressants, antipsychotics, and
antianxiety drugs. A June 2010 internal report from the Defense Department’s
Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or
20 percent of the 1.1 million active-duty troops surveyed, were taking some form of
psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other
controlled substances.[51]

However, drugs cannot “cure”
trauma; they can only dampen the expressions of a disturbed physiology. And they do
not teach the lasting lessons of self-regulation. They can help to control feelings
and behavior, but always at a price—because they work by blocking the chemical
systems that regulate engagement, motivation, pain, and pleasure. Some of my
colleagues remain optimistic: I keep attending meetings where serious scientists
discuss their quest for the elusive magic bullet that will miraculously reset the
fear circuits of the brain (as if traumatic stress involved only one simple brain
circuit). I also regularly prescribe medications.

Just about every group of psychotropic
agents has been used to treat some
aspect of PTSD.[52] The serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft,
Effexor, and Paxil have been most thoroughly studied, and they can make feelings
less intense and life more manageable. Patients on SSRIs often feel calmer and more
in control; feeling less overwhelmed often makes it easier to engage in therapy.
Other patients feel blunted by SSRIs—they feel they’re “losing their
edge.” I approach it as an empirical question: Let’s see what works, and
only the patient can be the judge of that. On the other hand, if one SSRI does not
work, it’s worth trying another, because they all have slightly different
effects. It’s interesting that the SSRIs are widely used to treat depression,
but in a study in which we compared Prozac with eye movement desensitization and
reprocessing (EMDR) for patients with PTSD, many of whom were also depressed, EMDR
proved to be a more effective antidepressant than Prozac.[53] I’ll return to that
subject in chapter 15.[54]

Medicines that target the autonomic
nervous system, like propranolol or clonidine, can help to decrease hyperarousal and
reactivity to stress.[55] This family of drugs works by blocking the physical effects of
adrenaline, the fuel of arousal, and thus reduces nightmares, insomnia, and
reactivity to trauma triggers.[56] Blocking adrenaline can help to keep
the rational brain online and make choices possible: “Is this really what I
want to do?” Since I have started to integrate mindfulness and yoga into my
practice, I use these medications less often, except occasionally to help patients
sleep more restfully.

Traumatized patients tend to like
tranquilizing drugs, benzodiazepines like Klonopin, Valium, Xanax, and Ativan. In
many ways, they work like alcohol, in that they make people feel calm and keep them
from worrying. (Casino owners love customers on benzodiazepines; they don’t
get upset when they lose and keep gambling.) But also, like alcohol, benzos weaken
inhibitions against saying hurtful things to people we love. Most civilian doctors
are reluctant to prescribe these drugs, because they have a high addiction potential
and they may also interfere with trauma processing. Patients who stop taking them
after prolonged use usually have withdrawal reactions that make them agitated and
increase posttraumatic symptoms.

I sometimes give my patients low doses
of benzodiazepines to use as needed, but not enough to take on a daily basis. They
have to choose when to use up their precious supply, and I ask them to keep a diary
of what was going on when they decided to take the pill. That gives us a chance to
discuss the specific incidents that triggered them.

A few studies have shown that
anticonvulsants and mood stabilizers, such as lithium or valproate, can have mildly
positive effects, taking the edge off hyperarousal and panic.[57] The most controversial
medications are the so-called
second-generation antipsychotic agents, such as Risperdal and Seroquel, the
largest-selling psychiatric drugs in the United States ($14.6 billion in 2008). Low
doses of these agents can be helpful in calming down combat veterans and women with
PTSD related to childhood abuse.[58] Using these drugs is sometimes
justified, for example when patients feel completely out of control and unable to
sleep or where other methods have failed.[59] But it’s important to keep in
mind that these medications work by blocking the dopamine system, the brain’s
reward system, which also functions as the engine of pleasure and motivation.

Antipsychotic medications such as
Risperdal, Abilify, or Seroquel can significantly dampen the emotional brain and
thus make patients less skittish or enraged, but they also may interfere with being
able to appreciate subtle signals of pleasure, danger, or satisfaction. They also
cause weight gain, increase the chance of developing diabetes, and make patients
physically inert, which is likely to further increase their sense of alienation.
These drugs are widely used to treat abused children who are inappropriately
diagnosed with bipolar disorder or mood dysregulation disorder. More than half a
million children and adolescents in America are now taking antipsychotic drugs,
which may calm them down but also interfere with learning age-appropriate skills and
developing friendships with other children.[60] A Columbia University study recently
found that prescriptions of antipsychotic drugs for privately insured two- to
five-year-olds had doubled between 2000 and 2007.[61] Only 40 percent of them had received
a proper mental health assessment.

Until it lost its patent, the
pharmaceutical company Johnson & Johnson doled out LEGO blocks stamped with the
word “Risperdal” for the waiting rooms of child psychiatrists. Children
from low-income families are four times as likely as the privately insured to
receive antipsychotic medicines. In one year alone Texas Medicaid spent $96 million
on antipsychotic drugs for teenagers and children—including three unidentified
infants who were given the drugs before their first birthdays.[62] There have been no
studies on the effects of psychotropic medications on the developing brain.
Dissociation, self-mutilation, fragmented memories, and amnesia generally do not
respond to any of these medications.

The Prozac study that I discussed in chapter 2 was the first to discover that traumatized
civilians tend to respond much better to medications than do combat veterans.[63] Since then
other studies have found similar discrepancies. In this light it is worrisome that
the Department of Defense and the VA prescribe enormous quantities of medications to
combat soldiers and returning veterans, often without providing other forms of
therapy. Between 2001 and 2011 the VA
spent about $1.5 billion on Seroquel and Risperdal, while Defense spent about $90
million during the same period, even though a research paper published in 2001
showed that Risperdal was no more effective than a placebo in treating PTSD.[64] Similarly,
between 2001 and 2012 the VA spent $72.1 million and Defense spent $44.1 million on
benzodiazepines[65]—medications that clinicians generally avoid prescribing to
civilians with PTSD because of their addiction potential and lack of significant
effectiveness for PTSD symptoms.

THE ROAD OF RECOVERY IS THE ROAD OF
LIFE

In the first chapter of this book I
introduced you to a patient named Bill whom I met over thirty years ago at the VA.
Bill became one of my longtime patient-teachers, and our relationship is also the
story of my evolution of trauma treatment.

Bill had served as a medic in Vietnam in
1967–71, and after he returned, he tried to use the skills he had learned in the
army by working on a burn unit in a local hospital. Nursing kept him frazzled,
explosive, and on edge, but he had no idea that these problems had anything to do
with what he had experienced in Vietnam. After all, the PTSD diagnosis did not yet
exist, and Irish working-class guys in Boston didn’t consult shrinks. His
nightmares and insomnia subsided a bit after he left nursing and enrolled in a
seminary to become a minister. He did not seek help until after his first son was
born in 1978.

The baby’s crying triggered
unrelenting flashbacks, in which he saw, heard, and smelled burned and mutilated
children in Vietnam. He was so out of control that some of my colleagues at the VA
wanted to put him in the hospital to treat what they thought was a psychosis.
However, as he and I started to work together and he began to feel safe with me, he
gradually opened up about what he had witnessed in Vietnam, and he slowly started to
tolerate his feelings without becoming overwhelmed. This helped him to refocus on
taking care of his family and on finishing his training as a minister. After two
years he was a pastor with his own parish, and we felt that our work was done.

I had no further contact with Bill until
he called me up eighteen years to the day after I first met him. He was experiencing
exactly the same symptoms—flashbacks, terrible nightmares, feelings that he was
going crazy—that he’d had right after his baby was born. That son had just
turned eighteen, and Bill had accompanied him to register for the draft—at the same
armory from which Bill himself had
been shipped off to Vietnam. By then I knew much more about treating traumatic
stress, and Bill and I dealt with the specific memories of what he had seen, heard,
and smelled back in Vietnam, details that he had been too scared to recall when we
first met. We could now integrate these memories with EMDR, so that they became
stories of what happened long ago instead of instant transports into the hell of
Vietnam. Once he felt more settled, he wanted to deal with his childhood: his brutal
upbringing and his guilt about having left behind his younger schizophrenic brother
when he enlisted for Vietnam, unprotected against their father’s violent
outbursts.

Another important theme of our time
together was the day-to-day pain Bill confronted as a minister—having to bury
adolescents killed in car crashes only a few years after he’d baptized them or
having couples he’d married come back in crisis over domestic violence. Bill
went on to organize a support group for fellow clergy faced with similar traumas,
and he became an important force in his community.

Bill’s third treatment started
five years later, when he developed a serious neurological illness at age
fifty-three. He had suddenly started to experience episodic paralysis in several
parts of his body, and he was beginning to accept that he would probably spend the
rest of his life in a wheelchair. I thought his problems might be due to multiple
sclerosis, but his neurologists could not find specific lesions, and they said there
was no cure for his condition. He told me how grateful he was for his wife’s
support. She already had arranged to have a wheelchair ramp built to the kitchen
entrance to their house.

Given his grim prognosis, I urged Bill
to find a way to fully feel and befriend the distressing feelings in his body, just
as he had learned to tolerate and live with his most painful memories of the war. I
suggested that he consult a body worker who had introduced me to Feldenkrais, a
gentle, hands-on approach to rearranging physical sensations and muscle movements.
When Bill came back to report on how he was doing, he expressed delight with his
increased sense of control. I mentioned that I’d recently started to do yoga
myself and that we had just opened up a yoga program at the Trauma Center. I invited
him to explore that as his next step.

Bill found a local Bikram yoga class, a
hot and intense practice usually reserved for young and energetic people. Bill loved
it, even though parts of his body occasionally gave way in class. Despite his
physical disability, he gained a sense of bodily pleasure and mastery that he had
never felt before.

Bill’s psychological treatment had
helped him put the horrendous experience of Vietnam in the past. Now befriending his
body was keeping him from organizing his
life around the loss of physical control. He decided to become certified as a yoga
instructor, and he began teaching yoga at his local armory to the veterans who were
returning from Iraq and Afghanistan.

Today, ten years later, Bill continues
to be fully engaged in life—with his children and grandchildren, through his work
with veterans, and in his church. He copes with his physical limitations as an
inconvenience. To date he has taught yoga classes to more than 1,300 returning
combat veterans. He still regularly suffers from the sudden weakness in his limbs
that requires him to sit or lie down. But, like his memories of childhood and
Vietnam, these episodes do not dominate his existence. They are simply part of the
ongoing, evolving story of his life.

CHAPTER 14

Language: Miracle and Tyranny

Give sorrow words; the grief that does not
speak knits up the o’er wrought heart and bids it break.

—William Shakespeare, Macbeth

We can hardly bear to look. The shadow may
carry the best of the life we have not lived. Go into the basement, the attic, the
refuse bin. Find gold there. Find an animal who has not been fed or watered. It is
you!! This neglected, exiled animal, hungry for attention, is a part of your
self.

—Marion Woodman (as quoted by Stephen Cope in The Great Work of Your
Life)

In September 2001 several organizations,
including the National Institutes of Health, Pfizer pharmaceuticals, and the New
York Times Company Foundation, organized expert panels to recommend the best
treatments for people traumatized by the attacks on the World Trade Center. Because
many widely used trauma interventions had never been carefully evaluated in random
communities (as opposed to patients who seek psychiatric help), I thought that this
presented an extraordinary opportunity to compare how well a variety of different
approaches would work. My colleagues were more conservative, and after lengthy
deliberations the committees recommended only two forms of treatment:
psychoanalytically oriented therapy and cognitive behavioral therapy. Why analytic talk therapy?
Since Manhattan is one of the last bastions of Freudian psychoanalysis, it would
have been bad politics to exclude a substantial proportion of local mental health
practitioners. Why CBT? Because behavioral treatment can be broken down into
concrete steps and “manualized” into uniform protocols, it is the
favorite treatment of academic researchers, another group that could not be ignored.
After the recommendations were approved, we sat back and waited for New Yorkers to
find their way to therapists’ offices. Almost nobody showed up.

Dr. Spencer Eth, who ran the psychiatry
department at the now-defunct St. Vincent’s Hospital in Greenwich Village, was
curious where survivors had turned for help, and early in 2002, together with some
medical students, he conducted a survey of 225 people who had escaped from the Twin
Towers. Asked what had been most helpful in overcoming the effects of their
experience, the survivors credited acupuncture, massage, yoga, and EMDR, in that
order.[1]
Among rescue workers, massages were particularly popular. Eth’s survey
suggests that the most helpful interventions focused on relieving the physical
burdens generated by trauma. The disparity between the survivors’ experience
and the experts’ recommendations is intriguing. Of course, we don’t know
how many survivors eventually did seek out more traditional therapies. But the
apparent lack of interest in talk therapy raises a basic question: What good is it
to talk about your trauma?

THE UNSPEAKABLE TRUTH

Therapists have an undying faith in the
capacity of talk to resolve trauma. That confidence dates back to 1893, when Freud
(and his mentor, Breuer) wrote that trauma “immediately and permanently
disappeared when we had succeeded in bringing clearly to light the memory of the
event by which it was provoked and in arousing its accompanying affect, and when the
patient had described that event in the greatest possible detail and had put the
affect into words.”[2]

Unfortunately, it’s not so simple:
Traumatic events are almost impossible to put into words. This is true for all of
us, not just for people who suffer from PTSD. The initial imprints of the events of
September 11 were not stories but images: frantic people running down the street,
their faces covered with ash; an airplane smashing into Tower One of the World Trade
Center; the distant specks that were people jumping hand in hand. Those images were
replayed over and over, in our minds and on the TV screen, until Mayor Giuliani and
the media helped us create a narrative we could share with one another.

In Seven Pillars of Wisdom T. E.
Lawrence wrote of his war experiences: “We learned that there were pangs too
sharp, griefs too deep, ecstasies too high for our finite selves to register. When
emotion reached this pitch the mind choked; and memory went white till the
circumstances were humdrum once more.”[3] While trauma keeps us dumbfounded, the
path out of it is paved with words, carefully assembled, piece by piece, until the
whole story can be revealed.

BREAKING THE SILENCE

Activists in the early campaign for AIDS
awareness created a powerful slogan: “Silence = Death.” Silence about
trauma also leads to death—the death of the soul. Silence reinforces the godforsaken
isolation of trauma. Being able to say aloud to another human being, “I was
raped” or “I was battered by my husband” or “My parents
called it discipline, but it was abuse” or “I’m not making it
since I got back from Iraq,” is a sign that healing can begin.

We may think we can control our grief,
our terror, or our shame by remaining silent, but naming offers the possibility of a
different kind of control. When Adam was put in charge of the animal kingdom in the
Book of Genesis, his first act was to give a name to every living creature.

If you’ve been hurt, you need to
acknowledge and name what happened to you. I know that from personal experience: As
long as I had no place where I could let myself know what it was like when my father
locked me in the cellar of our house for various three-year-old offenses, I was
chronically preoccupied with being exiled and abandoned. Only when I could talk
about how that little boy felt, only when I could forgive him for having been as
scared and submissive as he was, did I start to enjoy the pleasure of my own
company. Feeling listened to and understood changes our physiology; being able to
articulate a complex feeling, and having our feelings recognized, lights up our
limbic brain and creates an “aha moment.” In contrast, being met by
silence and incomprehension kills the spirit. Or, as John Bowlby so memorably put
it: “What can not be spoken to the [m]other cannot be told to the
self.”

If you hide from yourself the fact that
an uncle molested you when you were young, you are vulnerable to react to triggers
like an animal in a thunderstorm: with a full-body response to the hormones that
signal “danger.” Without language and context, your awareness may be
limited to: “I’m scared.” Yet, determined to stay in control, you
are likely to avoid anybody or anything that reminds you even vaguely of your
trauma. You may also alternate between
being inhibited and being uptight or reactive and explosive—all without knowing
why.

As long as you keep secrets and suppress
information, you are fundamentally at war with yourself. Hiding your core feelings
takes an enormous amount of energy, it saps your motivation to pursue worthwhile
goals, and it leaves you feeling bored and shut down. Meanwhile, stress hormones
keep flooding your body, leading to headaches, muscle aches, problems with your
bowels or sexual functions—and irrational behaviors that may embarrass you and hurt
the people around you. Only after you identify the source of these responses can you
start using your feelings as signals of problems that require your urgent
attention.

Ignoring inner reality also eats away at
your sense of self, identity, and purpose. Clinical psychologist Edna Foa and her
colleagues developed the Posttraumatic Cognitions Inventory to assess how patients
think about themselves.[4] Symptoms of PTSD often include statements like “I feel
dead inside,” “I will never be able to feel normal emotions
again,” “I have permanently changed for the worse,” “I feel
like an object, not like a person,” “I have no future,” and
“I feel like I don’t know myself anymore.”

The critical issue is allowing yourself
to know what you know. That takes an enormous amount of courage. In What It Is
Like to Go to War, Vietnam veteran Karl Marlantes grapples with his
memories of belonging to a brilliantly effective Marine combat unit and confronts
the terrible split he discovered inside himself:

For years I was unaware of the need
to heal that split, and there was no one, after I returned, to point this out to
me. … Why did I assume there was only one person inside
me? … There’s a part of me that just loves maiming, killing, and
torturing. This part of me isn’t all of me. I have other elements that
indeed are just the opposite, of which I am proud. So am I a killer? No, but
part of me is. Am I a torturer? No, but part of me is. Do I feel horror and
sadness when I read in the newspapers of an abused child? Yes. But am I
fascinated?[5]

Marlantes tells us that his road to
recovery required learning to tell the truth, even if that truth was brutally
painful.

Death, destruction, and sorrow need to
be constantly justified in the absence of some overarching meaning for the
suffering. Lack of this overarching meaning encourages making things up, lying, to
fill the gap in meaning.[6]

I’d never been able to tell
anyone what was going on inside. So I forced these images back, away, for years.
I began to reintegrate that split-off part of my experience only after I
actually began to imagine that kid as a kid, my kid perhaps. Then, out came this
overwhelming sadness—and healing. Integrating the feelings of sadness, rage, or
all of the above with the action should be standard operating procedure for all
soldiers who have killed face-to-face. It requires no sophisticated
psychological training. Just form groups under a fellow squad or platoon member
who has had a few days of group leadership training and encourage people to
talk.[7]

Getting perspective on your terror and
sharing it with others can reestablish the feeling that you are a member of the
human race. After the Vietnam veterans I treated joined a therapy group where they
could share the atrocities they had witnessed and committed, they reported beginning
to open their hearts to their girlfriends.

THE MIRACLE OF SELF-DISCOVERY

Discovering your Self in language is
always an epiphany, even if finding the words to describe your inner reality can be
an agonizing process. That is why I find Helen Keller’s account of how she was
“born into language”[8] so inspiring.

When Helen was nineteen months old and
just starting to talk, a viral infection robbed her of her sight and hearing. Now
deaf, blind, and mute, this lovely, lively child turned into an untamed, isolated
creature. After five desperate years her family invited a partially blind teacher,
Anne Sullivan, to come from Boston to their home in rural Alabama as Helen’s
tutor. Anne began immediately to teach Helen the manual alphabet, spelling words
into her hand letter by letter, but it took ten weeks of trying to connect with this
wild child before the breakthrough occurred. It came as Anne spelled the word
“water” into one of Helen’s hands while she held the other under
the water pump.

Helen later recalled that moment in
The Story of My Life: “Water! That word startled my soul, and it
awoke, full of the spirit of the morning. … Until that day my mind had
been like a darkened chamber, waiting for words to enter and light the lamp, which
is thought. I learned a great many words that day.”

Learning the names of things enabled the
child not only to create an inner representation of the invisible and inaudible
physical reality around her but also to
find herself: Six months later she started to use the firstperson
“I.”

Helen’s story reminds me of the
abused, recalcitrant, uncommunicative kids we see in our residential treatment
programs. Before she acquired language, she was bewildered and self-centered—looking
back, she called that creature “Phantom.” And indeed, our kids come
across as phantoms until they can discover who they are and feel safe enough to
communicate what is going on with them.

In a later book, The World I Live
In, Keller again described her birth into self hood: “Before my
teacher came to me, I did not know that I am. I lived in a world that was a
no-world. … I had neither will nor intellect. … I can remember
all this, not because I knew that it was so, but because I have tactual memory. It
enables me to remember that I never contracted my forehead in the act of
thinking.”[9]

Helen’s “tactual”
memories—memories based only on touch—could not be shared. But language opened up
the possibility of joining a community. At age eight, when Helen went with Anne to
the Perkins Institution for the Blind in Boston (where Sullivan herself had
trained), she became able to communicate with other children for the first time:
“Oh, what happiness!” she wrote. “To talk freely with other
children! To feel at home in the great world!”

Helen’s discovery of language with
the help of Anne Sullivan captures the essence of a therapeutic relationship:
finding words where words were absent before and, as a result, being able to share
your deepest pain and deepest feelings with another human being. This is one of most
profound experiences we can have, and such resonance, in which hitherto unspoken
words can be discovered, uttered, and received, is fundamental to healing the
isolation of trauma—especially if other people in our lives have ignored or silenced
us. Communicating fully is the opposite of being traumatized.

KNOWING YOURSELF OR TELLING YOUR
STORY? OUR DUAL AWARENESS SYSTEM

Anyone who enters talk therapy, however,
almost immediately confronts the limitations of language. This was true of my own
psychoanalysis. While I talk easily and can tell interesting tales, I quickly
realized how difficult it was to feel my feelings deeply and simultaneously report
them to someone else. When I got in touch with the most intimate, painful, or
confusing moments of my life, I often found myself faced with a choice: I could
either focus on reliving old scenes in my mind’s eye and let myself feel what
I had felt back then, or I could tell my
analyst logically and coherently what had transpired. When I chose the latter, I
would quickly lose touch with myself and start to focus on his opinion of
what I was telling him. The slightest hint of doubt or judgment would shut me down,
and I would shift my attention to regaining his approval.

Since then neuroscience research has
shown that we possess two distinct forms of self-awareness: one that keeps track of
the self across time and one that registers the self in the present moment. The
first, our autobiographical self, creates connections among experiences and
assembles them into a coherent story. This system is rooted in language. Our
narratives change with the telling, as our perspective changes and as we incorporate
new input.

The other system, moment-to-moment
self-awareness, is based primarily in physical sensations, but if we feel safe and are
not rushed, we can find words to communicate that experience as well. These two ways
of knowing are localized in different parts of the brain that are largely
disconnected from each other.[10] Only the system devoted to
self-awareness, which is based in the medial prefrontal cortex, can change the
emotional brain.

In the groups I used to lead for
veterans, I could sometimes see these two systems working side by side. The soldiers
told horrible tales of death and destruction, but I noticed that their bodies often
simultaneously radiated a sense of pride and belonging. Similarly, many patients
tell me about the happy families they grew up in while their bodies are slumped over
and their voices sound anxious and uptight. One system creates a story for public
consumption, and if we tell that story often enough, we are likely to start
believing that it contains the whole truth. But the other system registers a
different truth: how we experience the situation deep inside. It is this second
system that needs to be accessed, befriended, and reconciled.

Just recently at my teaching hospital, a
group of psychiatric residents and I interviewed a young woman with temporal lobe
epilepsy who was being evaluated following a suicide attempt. The residents asked
her standard questions about her symptoms, the medications she was taking, how old
she was when the diagnosis was made, what had made her try to kill herself. She
responded in a flat, matter-of-fact voice: She’d been five when she was
diagnosed. She’d lost her job; she knew she’d been faking it; she felt
worthless. For some reason one of the residents asked whether she had been sexually
abused. That question surprised me: She had given us no indication that she had had
problems with intimacy or sexuality, and I wondered if the doctor was pursuing a
private agenda.

Yet the story our patient told did not
explain why she had fallen apart after losing her job. So I asked her what it had
been like for that five-year-old girl to be told that something was wrong with her
brain. That forced her to check in with herself, as she had no ready-made script for
that question. In a subdued tone of voice she told us that the worst part of her
diagnosis was that afterward her father wanted nothing more to do with her:
“He just saw me as a defective child.” Nobody had supported her, she
said, so she basically had to manage by herself.

I then asked her how she felt now about
that little girl with newly diagnosed epilepsy who was left on her own. Instead of
crying for her loneliness or being angry about the lack of support, she said
fiercely: “She was stupid, whiny, and dependent. She should have stepped up to
the plate and sucked it up.” That passion obviously came from the part of her
that had valiantly tried to cope with her distress, and I acknowledged that it
probably had helped her survive back then. I asked her to allow that frightened,
abandoned girl to tell her what it had been like to be all alone, her illness
compounded by family rejection. She started to sob and kept quiet for a long time
until finally she said: “No, she did not deserve that. She should
have been supported; somebody should have looked after her.” Then she shifted
again and proudly told me about her accomplishments—how much she’d achieved
despite that lack of support. Public story and inner experience finally met.

THE BODY IS THE BRIDGE

Trauma stories lessen the isolation of
trauma, and they provide an explanation for why people suffer the way they
do. They allow doctors to make diagnoses, so that they can address problems like
insomnia, rage, nightmares, or numbing. Stories can also provide people with a
target to blame. Blaming is a universal human trait that helps people feel good
while feeling bad, or, as my old teacher Elvin Semrad used to say: “Hate makes
the world go round.” But stories also obscure a more important issue, namely,
that trauma radically changes people: that in fact they no longer are
“themselves.”

It is excruciatingly difficult to put
that feeling of no longer being yourself into words. Language evolved primarily to
share “things out there,” not to communicate our inner feelings, our
interiority. (Again, the language center of the brain is about as far removed from
the center for experiencing one’s self as is geographically possible.) Most of
us are better at describing someone else than we are at describing ourselves. As I
once heard Harvard psychologist Jerome Kagan say: “The task of describing most
private experiences can be likened to
reaching down to a deep well to pick up small fragile crystal figures while you are
wearing thick leather mittens.”[11]

We can get past the slipperiness of
words by engaging the self-observing, body-based self system, which speaks through
sensations, tone of voice, and body tensions. Being able to perceive visceral
sensations is the very foundation of emotional awareness.[12] If a patient tells me
that he was eight when his father deserted the family, I am likely to stop and ask
him to check in with himself: What happens inside when he tells me about that boy
who never saw his father again? Where is it registered in his body? When you
activate your gut feelings and listen to your heartbreak—when you follow the
interoceptive pathways to your innermost recesses—things begin to change.

WRITING TO YOURSELF

There are other ways to access your inner
world of feelings. One of the most effective is through writing. Most of us have
poured out our hearts in angry, accusatory, plaintive, or sad letters after people
have betrayed or abandoned us. Doing so almost always makes us feel better, even if
we never send them. When you write to yourself, you don’t have to worry about
other people’s judgment—you just listen to your own thoughts and let their
flow take over. Later, when you reread what you wrote, you often discover surprising
truths.

As functioning members of society,
we’re supposed to be “cool” in our day-to-day interactions and
subordinate our feelings to the task at hand. When we talk with someone with whom we
don’t feel completely safe, our social editor jumps in on full alert and our
guard is up. Writing is different. If you ask your editor to leave you alone for a
while, things will come out that you had no idea were there. You are free to go into
a sort of a trance state in which your pen (or keyboard) seems to channel whatever
bubbles up from inside. You can connect those self-observing and narrative parts of
your brain without worrying about the reception you’ll get.

In the practice called free writing, you
can use any object as your own personal Rorschach test for entering a stream of
associations. Simply write the first thing that comes to your mind as you look at
the object in front of you and then keep going without stopping, rereading, or
crossing out. A wooden spoon on the counter may trigger memories of making tomato
sauce with your grandmother—or of being beaten as a child. The teapot that’s
been passed down for generations may take you meandering to the furthest reaches of
your mind to the loved ones you’ve lost or family holidays that were a mix of love and conflict. Soon an image
will emerge, then a memory, and then a paragraph to record it. Whatever shows up on
the paper will be a manifestation of associations that are uniquely yours.

My patients often bring in fragments of
writing and drawings about memories that they may not yet be ready to discuss.
Reading the content out loud would probably overwhelm them, but they want me to be
aware of what they are wrestling with. I tell them how much I appreciate their
courage in allowing themselves to explore hitherto hidden parts of themselves and in
entrusting me with them. These tentative communications guide my treatment plan—for
example, by helping me to decide whether to add somatic processing, neurofeedback,
or EMDR to our current work.

As far as I’m aware, the first
systematic test of the power of language to relieve trauma was done in 1986, when
James Pennebaker at the University of Texas in Austin turned his introductory
psychology class into an experimental laboratory. Pennebaker started off with a
healthy respect for the importance of inhibition, of keeping things to yourself,
which he viewed as the glue of civilization.[13] But he also assumed that people pay a
price for trying to suppress being aware of the elephant in the room.

He began by asking each student to
identify a deeply personal experience that they’d found very stressful or
traumatic. He then divided the class into three groups: One would write about what
was currently going on in their lives; the second would write about the details of
the traumatic or stressful event; and the third would recount the facts of the
experience, their feelings and emotions about it, and what impact they thought this
event had had on their lives. All of the students wrote continuously for fifteen
minutes on four consecutive days while sitting alone in a small cubicle in the
psychology building.

The students took the study very
seriously; many revealed secrets that they had never told anyone. They often cried
as they wrote, and many confided in the course assistants that they’d become
preoccupied with these experiences. Of the two hundred participants, sixty-five
wrote about a childhood trauma. Although the death of a family member was the most
frequent topic, 22 percent of the women and 10 percent of the men reported
sexual trauma prior to the age of seventeen.

The researchers asked the students about
their health and were surprised how often the students spontaneously reported
histories of major and minor health problems: cancer, high blood pressure, ulcers,
flu, headaches, and earaches.[14] Those who reported a traumatic sexual
experience in childhood had been
hospitalized an average of 1.7 days in the previous year—almost twice the rate of
the others.

The team then compared the number of
visits to the student health center participants had made during the month prior to
the study to the number in the month following it. The group that had written about
both the facts and the emotions related to their trauma clearly benefited the most:
They had a 50 percent drop in doctor visits compared with the other two groups.
Writing about their deepest thoughts and feelings about traumas had improved their
mood and resulted in a more optimistic attitude and better physical health.

When the students themselves were asked
to assess the study, they focused on how it had increased their self-understanding:
“It helped me think about what I felt during those times. I never realized how
it affected me before.” “I had to think and resolve past experiences.
One result of the experiment was peace of mind. To have to write about emotions and
feelings helped me understand how I felt and why.”[15]

In a subsequent study Pennebaker asked
half of a group of seventy-two students to talk into a tape recorder about the most
traumatic experience of their lives; the other half discussed their plans for the
rest of the day. As they spoke, researchers monitored their physiological reactions:
blood pleasure, heart rate, muscle tension, and hand temperature.[16] This study had
similar results: Those who allowed themselves to feel their emotions showed
significant physiological changes, both immediate and long term. During their
confessions blood pressure, heart rate, and other autonomic functions increased, but
afterward their arousal fell to levels below where they had been at the start of the
study. The drop in blood pressure could still be measured six weeks after the
experiment ended.

It is now widely accepted that stressful
experiences—whether divorce or final exams or loneliness—have a negative effect on
immune function, but this was a highly controversial notion at the time of
Pennebaker’s study. Building on his protocols, a team of researchers at the
Ohio State University College of Medicine compared two groups of students who wrote
either about a personal trauma or about a superficial topic.[17] Again, those who wrote
about personal traumas had fewer visits to the student health center, and their
improved health correlated with improved immune function, as measured by the action
of T lymphocytes (natural killer cells) and other immune markers in the blood. This
effect was most obvious directly after the experiment, but it could still be detected six weeks later. Writing experiments from around the world, with grade
school students, nursing home residents,
medical students, maximum-security prisoners, arthritis sufferers, new mothers, and
rape victims, consistently show that writing about upsetting events improves
physical and mental health.

Another aspect of Pennebaker’s
studies caught my attention: When his subjects talked about intimate or difficult
issues, they often changed their tone of voice and speaking style. The differences
were so striking that Pennebaker wondered if he had mixed up his tapes. For example,
one woman described her plans for the day in a childlike, high-pitched voice, but a
few minutes later, when she described stealing one hundred dollars from an open cash
register, both the volume and pitch of her voice became so much lower that she
sounded like an entirely different person. Alterations in emotional states were also
reflected in the subjects’ handwriting. As participants changed topics, they
might move from cursive to block letters and back to cursive; there were also
variations in the slant of the letters and in the pressure of their pens.

Such changes are called
“switching” in clinical practice, and we see them often in individuals
with trauma histories. Patients activate distinctly different emotional and
physiological states as they move from one topic to another. Switching manifests not
only as remarkably different vocal patterns but also in different facial expressions and body movements. Some
patients even appear to change their personal identity, from timid to forceful and
aggressive or from anxiously compliant to starkly seductive. When they write about
their deepest fears, their handwriting often becomes more childlike and
primitive.

If patients who present in such
dramatically different states are treated as fakes, or if they are told to stop
showing their unpredictably annoying parts, they are likely to become mute. They
probably will continue to seek help, but after they have been silenced they will
transmit their cries for help not by talking but by acting: with suicide attempts,
depression, and rage attacks. As we will see in chapter
17, they will improve only if both patient and therapist appreciate the
roles that these different states have played in their survival.

ART, MUSIC, AND DANCE

There are thousands of art, music, and
dance therapists who do beautiful work with abused children, soldiers suffering from
PTSD, incest victims, refugees, and torture survivors, and numerous accounts attest
to the effectiveness of expressive therapies.[18] However, at this point we know very
little about how they work or about the specific aspects of traumatic stress they
address, and it would present an enormous logistical and financial challenge to do
the research necessary to establish their value scientifically.

The capacity of art, music, and dance to
circumvent the speechlessness that comes with terror may be one reason they are used
as trauma treatments in cultures around the world. One of the few systematic studies
to compare nonverbal artistic expression with writing was done by James Pennebaker
and Anne Krantz, a San Francisco dance and movement therapist.[19] One-third of a group of
sixty-four students was asked to disclose a personal traumatic experience through
expressive body movements for at least ten minutes a day for three consecutive days
and then to write about it for another ten minutes. A second group danced but did
not write about their trauma, and a third group engaged in a routine exercise
program. Over the three following months members of all groups reported that they
felt happier and healthier. However, only the expressive movement group that also
wrote showed objective evidence: better physical health and an improved grade-point
average. (The study did not evaluate specific PTSD symptoms.) Pennebaker and Krantz
concluded: “The mere expression of the trauma is not sufficient. Health does
appear to require translating experiences into language.”

However, we still do not know whether
this conclusion—that language is essential to healing—is, in fact, always true.
Writing studies that have focused on PTSD symptoms (as opposed to general health)
have been disappointing. When I discussed this with Pennebaker, he cautioned me that
most writing studies of PTSD patients have been done in group settings where
participants were expected to share their stories. He reiterated the point
I’ve made above—that the object of writing is to write to yourself, to let
your self know what you have been trying to avoid.

THE LIMITS OF LANGUAGE

Trauma overwhelms listeners as well as
speakers. In The Great War in Modern Memory, his masterful study of World
War I, Paul Fussell comments brilliantly on the zone of silence that trauma
creates:

One of the cruxes of
war … is the collision between events and the language available—or
thought appropriate—to describe them. … Logically there is no reason
why the English language could not perfectly well render the actuality
of … warfare: it is rich in terms like blood,
terror, agony, madness, shit,
cruelty, murder, sell-out, pain and
hoax, as well as phrases like legs blown off,
intestines gushing out over his hands, screaming all
night, bleeding to death from the rectum, and the
like. … The problem was less one of “language” than of
gentility and
optimism. … The real reason [that soldiers fall silent] is that
soldiers have discovered that no one is very interested in the bad news they
have to report. What listener wants to be torn and shaken when he doesn’t
have to be? We have made unspeakable mean indescribable: it really
means nasty.[20]

Talking about painful events
doesn’t necessarily establish community—often quite the contrary. Families and
organizations may reject members who air the dirty laundry; friends and family can
lose patience with people who get stuck in their grief or hurt. This is one reason
why trauma victims often withdraw and why their stories become rote narratives,
edited into a form least likely to provoke rejection.

It is an enormous challenge to find safe
places to express the pain of trauma, which is why survivor groups like Alcoholics
Anonymous, Adult Children of Alcoholics, Narcotics Anonymous, and other support
groups can be so critical. Finding a responsive community in which to tell your
truth makes recovery possible. That is also why survivors need professional
therapists who are trained to listen to the agonizing details of their lives. I
recall the first time a veteran told me about killing a child in Vietnam. I had a
vivid flashback to when I was about seven years old and my father told me that a
child next door had been beaten to death by Nazi soldiers in front of our house for
showing a lack of respect. My reaction to the veteran’s confession was too
much to bear, and I had to end the session. That is why therapists need to have done
their own intensive therapy, so they can take care of themselves and remain
emotionally available to their patients, even when their patients’ stories
arouse feelings of rage or revulsion.

A different problem arises when trauma
victims themselves become literally speechless—when the language area of the brain
shuts down.[21]
I have seen this shutdown in the courtroom in many immigration cases and also in a
case brought against a perpetrator of mass slaughter in Rwanda. When asked to
testify about their experiences, victims often become so overwhelmed that they are
barely able to speak or are hijacked into such panic that they can’t clearly
articulate what happened to them. Their testimony is often dismissed as being too
chaotic, confused, and fragmented to be credible.

Others try to recount their history in a
way that keeps them from being triggered. This can make them come across as evasive
and unreliable witnesses. I have seen dozens of legal cases dismissed because asylum
seekers were unable to give coherent accounts of their reasons for fleeing.
I’ve also known numerous veterans whose claims were denied by the Veterans Administration because they could not
tell precisely what had happened to them.

Confusion and mutism are routine in
therapy offices: We fully expect that our patients will become overwhelmed if we
keep pressing them for the details of their story. For that reason we’ve
learned to “pendulate” our approach to trauma, to use a term coined by
my friend Peter Levine. We don’t avoid confronting the details, but we teach
our patients how to safely dip one toe in the water and then take it out again, thus
approaching the truth gradually.

We start by establishing inner
“islands of safety” within the body.[22] This means helping patients identify
parts of the body, postures, or movements where they can ground themselves whenever
they feel stuck, terrified, or enraged. These parts usually lie outside the reach of
the vagus nerve, which carries the messages of panic to the chest, abdomen, and
throat, and they can serve as allies in integrating the trauma. I might ask a
patient if her hands feel okay, and if she says yes, I’ll ask her to move
them, exploring their lightness and warmth and flexibility. Later, if I see her
chest tighten and her breath almost disappear, I can stop her and ask her to focus
on her hands and move them, so that she can feel herself as separate from the
trauma. Or I might ask her to focus on her out breath and notice how she can change
it, or ask her to lift her arms up and down with each breath—a qigong movement.

For some patients tapping acupressure
points is a good anchor.[23] I ask others to feel the weight of their body in the chair or
to plant their feet on the floor. I might ask a patient who is collapsing into
silence to see what happens when he sits up straight. Some patients discover their
own islands of safety—they begin to “get” that they can create body
sensations to counterbalance feeling out of control. This sets the stage for trauma
resolution: pendulating between states of exploration and safety, between language
and body, between remembering the past and feeling alive in the present.

DEALING WITH REALITY

Dealing with traumatic memories is,
however, just the beginning of treatment. Numerous studies have found that people
with PTSD have more general problems with focused attention and with learning new
information.[24] Alexander McFarlane did a simple test: He asked a group of people
to name as many words beginning with the letter B as they could in one
minute. Normal subjects averaged fifteen words; those with PTSD averaged three or
four. Normal subjects hesitated when they saw threatening words like
“blood,” “wound,” or “rape”;
McFarlane’s PTSD subjects reacted just as hesitantly to ordinary words like
“wool,” “ice cream,” and “bicycle.”[25]

After a while most people with PTSD
don’t spend a great deal of time or effort on dealing with the past—their
problem is simply making it through the day. Even traumatized patients who are
making real contributions in teaching, business, medicine, or the arts and who are
successfully raising their children expend a lot more energy on the everyday tasks
of living than do ordinary mortals.

Yet another pitfall of language is the
illusion that our thinking can easily be corrected if it doesn’t “make
sense.” The “cognitive” part of cognitive behavioral therapy
focuses on changing such “dysfunctional thinking.” This is a top-down
approach to change in which the therapist challenges or “reframes”
negative cognitions, as in “Let’s compare your feelings that
you are to blame for your rape with the actual facts of the matter” or
“Let’s compare your terror of driving with the statistics about road
safety today.”

I’m reminded of the distraught
woman who once came to our clinic asking for help with her two-month-old because the
baby was “so selfish.” Would she have benefited from a fact sheet on
child development or an explanation of the concept of altruism? Such information
would be unlikely to help her until she gained access to the frightened, abandoned
parts of herself—the parts expressed by her terror of dependence.

There is no question traumatized people
have irrational thoughts: “I was to blame for being so sexy.” “The
other guys weren’t afraid—they’re real men.” “I should have
known better than to walk down that street.” It’s best to treat those
thoughts as cognitive flashbacks—you don’t argue with them any more than you
would argue with someone who keeps having visual flashbacks of a terrible accident.
They are residues of traumatic incidents: thoughts they were thinking when, or
shortly after, the traumas occurred that are reactivated under stressful conditions.
A better way to treat them is with EMDR, the subject of the following chapter.

BECOMING SOME BODY

The reason people become overwhelmed by
telling their stories, and the reason they have cognitive flashbacks, is that their
brains have changed. As Freud and Breuer observed, trauma does not simply act as a
releasing agent for symptoms. Rather, “the psychical trauma—or more precisely
the memory of the trauma—acts like a foreign body which long after its entry must
continue to be regarded as an agent that still is at work.”[26] Like a splinter that
causes an infection, it is the
body’s response to the foreign object that becomes the problem more than the
object itself.

Modern neuroscience solidly supports
Freud’s notion that many of our conscious thoughts are complex
rationalizations for the flood of instincts, reflexes, motives, and deep-seated
memories that emanate from the unconscious. As we have seen, trauma interferes with
the proper functioning of brain areas that manage and interpret experience.
A robust sense of self—one that allows a person to state confidently, “This is
what I think and feel” and “This is what is going on with
me”—depends on a healthy and dynamic interplay among these areas.

Almost every brain-imaging study of
trauma patients finds abnormal activation of the insula. This part of the brain
integrates and interprets the input from the internal organs—including our muscles,
joints, and balance (proprioceptive) system—to generate the sense of being embodied.
The insula can transmit signals to the amygdala that trigger fight/fight responses.
This does not require any cognitive input or any conscious recognition that
something has gone awry—you just feel on edge and unable to focus or, at worst, have
a sense of imminent doom. These powerful feelings are generated deep inside the
brain and cannot be eliminated by reason or understanding.

Being constantly assaulted by, but
consciously cut off from, the origin of bodily sensations produces alexithymia: not
being able to sense and communicate what is going on with you. Only by getting in
touch with your body, by connecting viscerally with your self, can you regain a
sense of who you are, your priorities and values. Alexithymia, dissociation, and
shutdown all involve the brain structures that enable us to focus, know what we
feel, and take action to protect ourselves. When these essential structures are
subjected to inescapable shock, the result may be confusion and agitation, or it may
be emotional detachment, often accompanied by out-of-body experiences—the feeling
you’re watching yourself from far away. In other words trauma makes people
feel like either some body else, or like no body. In order to
overcome trauma, you need help to get back in touch with your body, with
your Self.

There is no question that language is
essential: Our sense of Self depends on being able to organize our memories into a
coherent whole.[27] This requires well-functioning connections between the conscious
brain and the self system of the body—connections that often are damaged by trauma.
The full story can be told only after those structures are repaired and after the
groundwork has been laid: after no body becomes some body.

CHAPTER 15

Letting Go of the Past: Emdr

Was it a vision, or a waking dream?
Fled
is that music;—Do I wake or sleep?

—John Keats

David, a middle-aged contractor, came to
see me because his violent rage attacks were making his home a living hell. During
our first session he told me a story about something that had happened to him the
summer he was twenty-three. He was working as a lifeguard, and one afternoon a group
of kids were roughhousing in the pool and drinking beer. David told them alcohol was
not allowed. In response the boys attacked him, and one of them took out his left
eye with a broken beer bottle. Thirty years later he still had nightmares and
flashbacks about the stabbing.

He was merciless in his criticisms of
his own teenage son and often yelled at him for the slightest infraction, and he
simply could not bring himself to show any affection toward his wife. On some level
he felt that the tragic loss of his eye gave him permission to abuse other people,
but he also hated the angry, vengeful person he had become. He had noticed that his
efforts to manage his rage made him chronically tense, and he wondered if his fear
of losing control had made love and friendship impossible.

During his second visit I introduced a
procedure called eye movement desensitization and reprocessing (EMDR). I asked David
to go back to the details of his assault and bring to mind his images of the attack,
the sounds he had heard, and the
thoughts that had gone through his mind. “Just let those moments come
back,” I told him.

I then asked him to follow my index
finger as I moved it slowly back and forth about twelve inches from his right eye.
Within seconds a cascade of rage and terror came to the surface, accompanied by
vivid sensations of pain, blood running down his cheek, and the realization that he
couldn’t see. As he reported these sensations, I made an occasional
encouraging sound and kept moving my finger back and forth. Every few minutes I
stopped and asked him to take a deep breath. Then I asked him to pay attention to
what was now on his mind, which was a fight he had had in school. I told him to
notice that and to stay with that memory. Other memories emerged, seemingly at
random: looking for his assailants everywhere, wanting to hurt them, getting into
barroom brawls. Each time he reported a new memory or sensation, I urged him to
notice what was coming to mind and resumed the finger movements.

At the end of that visit he looked
calmer and visibly relieved. He told me that the memory of the stabbing had lost its
intensity—it was now something unpleasant that had happened a long time ago.
“It really sucked,” he said thoughtfully, “and it kept me
off-kilter for years, but I’m surprised what a good life I eventually was able
to carve out for myself.”

Our third session, the following week,
dealt with the aftermath of the trauma: how he had used drugs and alcohol for years
to cope with his rage. As we repeated the EMDR sequences, still more memories arose.
David remembered talking with a prison guard he knew about having his incarcerated
assailant killed and then changing his mind. Recalling this decision was profoundly
liberating: He had come to see himself as a monster who was barely in control, but
realizing that he’d turned away from revenge put him back in touch with a
mindful, generous side of himself.

Next he spontaneously realized he was
treating his son the way he had felt toward his teenaged attackers. As our session
ended, he asked if I could meet with him and his family so he could tell his son
what had happened and ask for his forgiveness. At our fifth and final session he
reported that he was sleeping better and said that for the first time in his life he
felt a sense of inner peace. A year later he called to report not only that he
and wife had grown closer and had started to practice yoga together but also that he
laughed more and took real pleasure in his gardening and woodworking.

LEARNING ABOUT EMDR

My experience with David is one of many I
have had over the past two decades in which EMDR helped to make painful re-creations
of the trauma a thing of the past. My introduction to this method came through
Maggie, a spunky young psychologist who ran a halfway house for sexually abused
girls. Maggie got into one confrontation after another, clashing with nearly
everybody—except the thirteen- and fourteen-year-old girls she cared for. She did
drugs, had dangerous and often violent boyfriends, had frequent altercations with
her bosses, and moved from place to place because she could not tolerate her
roommates (nor they her). I never understood how she had mobilized enough stability
and concentration to earn a PhD in psychology from a reputable graduate school.

Maggie had been referred to a therapy
group I was running for women with similar problems. During her second meeting she
told us that her father had raped her twice, once when she was five years old and
once when she was seven. She was convinced it had been her fault. She loved her
daddy, she explained, and she must have been so seductive that he could not control
himself. Listening to her I thought, “She might not blame her father, but she
sure is blaming just about everybody else”—including her previous therapists
for not helping her get better. Like many trauma survivors, she told one story with
words and another in her actions, in which she kept replaying various aspects of her
trauma.

Then one day Maggie came to the group
eager to discuss a remarkable experience she’d had the previous weekend at an
EMDR training for professionals. At that time I’d heard only that EMDR was a
new fad in which therapists wiggled their fingers in front of patients’ eyes.
To me and my academic colleagues, it sounded like yet another of the crazes that
have always plagued psychiatry, and I was convinced that this would turn out to be
another of Maggie’s misadventures.

Maggie told us that during her EMDR
session she had vividly remembered her father’s rape when she was
seven—remembered it from inside her child’s body. She could feel physically
how small she was; she could feel her father’s huge body on top of her and
could smell the alcohol on his breath. And yet, she told us, even as she relived the
incident she was able to observe it from the point of view of her
twenty-nine-year-old self. She burst into tears: “I was such a little girl.
How could a huge man do this to a little girl?” She cried for a while and then
said: “It’s over now. I now know what happened. It wasn’t my
fault. I was a little girl and there was nothing I could do to keep him from
molesting me.”

I was astounded. I had been looking for a
long time for a way to help people revisit their traumatic past without becoming
retraumatized. It seemed that Maggie had had an experience as lifelike as a
flashback and yet had not been hijacked by it. Could EMDR make it safe for people to
access the imprints of trauma? Could it then transform them into memories of events
that had happened far in the past?

Maggie had a few more EMDR sessions and
remained in our group long enough for us to see how she changed. She was much less
angry, but she kept that sardonic sense of humor that I enjoyed so much. A few
months later she got involved with a very different kind of man than she’d
ever been attracted to before. She left the group, announcing that she’d
resolved her trauma, and I decided it was time for me to get trained in EMDR.

EMDR: FIRST EXPOSURES

Like many scientific advances, EMDR
originated with a chance observation. One day in 1987 psychologist Francine Shapiro
was walking through a park, preoccupied with some painful memories, when she noticed
that rapid eye movements produced a dramatic relief from her distress. How could a
major treatment modality grow from such a brief experience? How is it possible that
such a simple process had not been noted before? Initially skeptical about her
observation she subjected her method to years of experimentation and research,
gradually building it into a standardized procedure that could be taught and tested
in controlled studies.[1]

I arrived for my first EMDR training in
need of some trauma processing myself. A few weeks earlier the Jesuit priest who was
chair of my department at Massachusetts General Hospital had suddenly shut down the
Trauma Clinic, leaving us scrambling for a new site and new funds to treat our
patients, train our students, and conduct our research. At around the same time, my
friend Frank Putnam, who was doing the long-term study of sexually abused girls that
I discussed in chapter 10, was fired from the
National Institutes of Health and Rick Kluft, the country’s foremost expert on
dissociation, lost his unit at the Institute of the Pennsylvania Hospital. It might
have all been a coincidence, but it felt as if my whole world was under attack.

My distress about the Trauma Clinic
seemed like a good test for my EMDR trial. While I was following my partner’s
fingers with my eyes, a rapid succession of fuzzy childhood scenes came to mind:
intense family dinner-table conversations, confrontations with schoolmates during
recess, throwing pebbles at a shed window with my older brother—all of them the sort of vivid, floating,
“hypnopompic” images we experience when we slumber late on a Sunday
morning, then forget the moment we fully awaken.

After about half an hour my fellow
trainee and I revisited the scene in which my boss told me that he was closing my
clinic. Now I felt resigned: “Okay, it happened, and now it’s time to
move on.” I never looked back; the clinic later reconstituted itself and has
thrived ever since. Was EMDR the sole reason I was able to let go of my anger and
distress? Of course I’ll never know for certain, but my mental journey—through
unrelated childhood scenes to putting the episode to rest—was unlike anything I had
experienced in talk therapy.

What happened next, when it was my turn
to administer EMDR, was even more intriguing. We rotated to a different group, and
my new fellow student, whom I’d never met before, told me he wanted to address
some painful childhood incidents involving his father, but he did not want to
discuss them. I had never worked on anybody’s trauma without knowing
“the story,” and I was annoyed and flustered by his refusal to share any
details. While I was moving my fingers in front of his eyes, he looked intensely
distressed—he began sobbing, and his breathing became rapid and shallow. But each
time I asked him the questions that the protocol called for, he refused to tell me
what came to his mind.

At the end of our forty-five-minute
session, the first thing my colleague said was that he’d found dealing with me
so unpleasant that he would never refer a patient to me. Otherwise, he remarked, the
EMDR session had resolved the matter of his father’s abuse. While I
was skeptical and suspected that his rudeness toward me was a carryover from
unresolved feelings toward his father, there was no question that he appeared much
more relaxed.

I turned to my EMDR trainer, Gerald Puk,
and told him how flummoxed I was. This man clearly did not like me, and had looked
profoundly distressed during the EMDR session, but now he was telling me that his
long-standing misery was gone. How could I possibly know what he had or had not
resolved if he was unwilling to tell me what had happened during the session?

Gerry smiled and asked if by chance I
had become a mental health professional in order to solve some of my own personal
issues. I confirmed that most people who knew me thought that might be the case.
Then he asked if I found it meaningful when people told me their trauma stories.
Again, I had to agree with him. Then he said: “You know, Bessel, maybe you
need to learn to put your voyeuristic tendencies on hold. If it’s important
for you to hear trauma stories, why don’t you go to a bar, put a couple of
dollars on the table, and say to your neighbor, ‘I’ll buy you a drink if
you tell me your trauma story.’ But you really need to know the difference between your
desire to hear stories and your patient’s internal process of healing.”
I took Gerry’s admonition to heart and ever since have enjoyed repeating it to
my students.

I left my EMDR training preoccupied with
three issues that fascinate me to this day:

- EMDR loosens up something in the
mind/brain that gives people rapid access to loosely associated memories and
images from their past. This seems to help them put the traumatic experience
into a larger context or perspective.

- People may be able to heal from trauma without
talking about it. EMDR enables them to observe their experiences in a new way,
without verbal give-and-take with another person.

- EMDR can help even if the patient and the
therapist do not have a trusting relationship. This was particularly intriguing
because trauma, understandably, rarely leaves people with an open, trusting
heart.

In the years since, I have done EMDR
with patients who spoke Swahili, Mandarin, and Breton, all languages in which I can
say only, “Notice that,” the key EMDR instruction. (I always had a
translator available, but primarily to explain the steps of the process.) Because
EMDR doesn’t require patients to speak about the intolerable or explain to a
therapist why they feel so upset, it allows them to stay fully focused on their
internal experience, with sometimes extraordinary results.

STUDYING EMDR

The Trauma Clinic was saved by a manager
at the Massachusetts Department of Mental Health who had followed our work with
children and now asked us to take on the task of organizing the community trauma
response team for the Boston area. That was enough to cover our basic operations,
and the rest was supplied by an energetic staff who loved what we were
doing—including the newly discovered power of EMDR to cure some of the patients whom
we’d been unable to help before.

My colleagues and I began to show one
another videotapes of our EMDR sessions with PTSD patients, which enabled us to
observe dramatic week-by-week improvements. We then started to formally measure
their progress on a standard PTSD rating scale. We also arranged with Elizabeth
Matthew, a young neuroimaging specialist at the New England Deaconess Hospital, to have twelve
patients’ brains scanned before and after their treatment. After only three
EMDR sessions eight of the twelve had shown a significant decrease in their PTSD
scores. On their scans we could see a sharp increase in prefrontal lobe activation
after treatment, as well as much more activity in the anterior cingulate and the
basal ganglia. This shift could account for the difference in how they now
experienced their trauma.

One man reported: “I remember it
as though it was a real memory, but it was more distant. Typically, I drowned in it,
but this time I was floating on top. I had the feeling that I was in control.”
A woman told us: “Before, I felt each and every step of it. Now it is like a
whole, instead of fragments, so it is more manageable.” The trauma had lost
its immediacy and become a story about something that happened a long time ago.

We subsequently secured funding from the
National Institutes of Mental Health to compare the effects of EMDR with standard
doses of Prozac or a placebo.[2] Of our eighty-eight subjects thirty
received EMDR, twenty-eight Prozac, and the rest the sugar pill. As often happens,
the people on placebo did well. After eight weeks their 42 percent improvement was
greater than that for many other treatments that are promoted as “evidence
based.”

The group on Prozac did slightly better
than the placebo group, but barely so. This is typical of most studies of drugs for
PTSD: Simply showing up brings about a 30 percent to 42 percent improvement; when
drugs work, they add an additional 5 percent to 15 percent. However, the patients on
EMDR did substantially better than those on either Prozac or the placebo: After
eight EMDR sessions one in four were completely cured (their PTSD scores had dropped
to negligible levels), compared with one in ten of the Prozac group. But the real
difference occurred over time: When we interviewed our subjects eight months later,
60 percent of those who had received EMDR scored as being completely cured. As the
great psychiatrist Milton Erickson said, once you kick the log, the river will start
flowing. Once people started to integrate their traumatic memories, they
spontaneously continued to improve. In contrast, all those who had taken Prozac
relapsed when they went off the drug.

This study was significant because it
demonstrated that a focused, trauma-specific therapy for PTSD like EMDR could be
much more effective than medication. Other studies have confirmed that if patients
take Prozac or related drugs like Celexa, Paxil, and Zoloft, their PTSD symptoms
often improve, but only as long as they keep taking them. This makes drug treatment
much more expensive in the long run. (Interestingly, despite Prozac’s status
as a major antidepressant, in our study EMDR also produced a greater reduction in
depression scores than taking the antidepressant.)

Another key finding of our study: Adults
with histories of childhood trauma responded very differently to EMDR from those who
were traumatized as adults. At the end of eight weeks, almost half of the
adult-onset group that received EMDR scored as completely cured, while only 9
percent of the child-abuse group showed such pronounced improvement. Eight months
later the cure rate was 73 percent for the adult-onset group, compared with 25
percent for those with histories of child abuse. The child-abuse group had small but
consistently positive responses to Prozac.

These results reinforce the findings
that I reported in chapter 9: Chronic childhood abuse
causes very different mental and biological adaptations than discrete traumatic
events in adulthood. EMDR is a powerful treatment for stuck traumatic memories, but
it doesn’t necessarily resolve the effects of the betrayal and abandonment
that accompany physical or sexual abuse in childhood. Eight weeks of therapy of any
kind is rarely sufficient to resolve the legacy of long-standing trauma.

As of 2014 our EMDR study had the most
positive outcome of any published study of people who developed their PTSD in
reaction to a traumatic event as an adult. But despite these results, and those of
dozens of other studies, many of my colleagues continue to be skeptical about
EMDR—perhaps because it seems too good to be true, too simple to be so powerful. I
surely can understand that sort of skepticism—EMDR is an unusual procedure.
Interestingly, in the first solid scientific study using EMDR in combat veterans
with PTSD, EMDR was expected to do so poorly that it was included as the control
condition for comparison with biofeedback-assisted relaxation therapy. To the
researchers’ surprise, twelve sessions of EMDR turned out to be the more
effective treatment.[3] EMDR has since become one of the treatments for PTSD sanctioned
by the Department of Veterans Affairs.

IS EMDR A FORM OF EXPOSURE
THERAPY?

Some psychologists have hypothesized that
EMDR actually desensitizes people to the traumatic material and thus is related to
exposure therapy. A more accurate description would be that it integrates
the traumatic material. As our research showed, after EMDR people thought of the
trauma as a coherent event in the past, instead of experiencing sensations and
images divorced from any context.

Memories evolve and change. Immediately
after a memory is laid down, it undergoes a lengthy process of integration and
reinterpretation—a process that automatically happens in the mind/brain without any
input from the conscious self. When the
process is complete, the experience is integrated with other life events and stops
having a life of its own.[4] As we have seen, in PTSD this process fails and the memory
remains stuck—undigested and raw.

Unfortunately, few psychologists are
taught during their training how the memory-processing system in the brain works.
This omission can lead to misguided approaches to treatment. In contrast to phobias
(such as a spider phobia, which is based on a specific irrational fear),
posttraumatic stress is the result of a fundamental reorganization of the central
nervous system based on having experienced an actual threat of annihilation, (or
seeing someone else being annihilated), which reorganizes self experience (as
helpless) and the interpretation of reality (the entire world is a dangerous
place).

During exposure patients initially
become extremely upset. As they revisit the traumatic experience, they show sharp
increases in their heart rate, blood pressure, and stress hormones. But if they
manage to stay with the treatment and keep reliving their trauma, they slowly become
less reactive and less prone to disintegrate when they recall the event. As a
result, they get lower scores on their PTSD ratings. However, as far as we know,
simply exposing someone to the old trauma does not integrate the memory into the
overall context of their lives, and it rarely restores them to the level of joyful
engagement with people and pursuits they had prior to the trauma.

In contrast, EMDR, as well as the
treatments discussed in subsequent chapters—internal family systems, yoga,
neurofeedback, psychomotor therapy, and theater—focus not only on regulating the
intense memories activated by trauma but also on restoring a sense of agency,
engagement, and commitment through ownership of body and mind.

PROCESSING TRAUMA WITH EMDR

Kathy was a twenty-one-year-old student
at a local university. When I first met her, she looked terrified. She had been in
psychotherapy for three years with a therapist whom she trusted and felt understood
by but with whom she was not making any progress. After her third suicide attempt
her university health service referred her to me, hoping that the new technique
I’d told them about could help her.

Like several of my other traumatized
patients, Kathy was able to become completely absorbed in her studies: When she read
a book or wrote a research paper, she could block out everything else about her
life. This enabled her to be a competent
student, even when she had no idea how to establish a loving relationship with
herself, let alone with an intimate partner.

Kathy told me that her father had used
her for many years for child prostitution, which would normally have made me think
of using EMDR only as an adjunctive therapy. However, she turned out to be an EMDR
virtuoso and recovered completely after eight sessions, the shortest time thus far
in my experience for someone with a history of severe childhood abuse. Those
sessions took place fifteen years ago, and I recently met with her to discuss the
pros and cons of her adopting a third child. She was a delight: smart, funny, and
joyfully engaged with her family and her work as an assistant professor of child
development.

I’d like to share my notes on
Kathy’s fourth EMDR treatment, not only to demonstrate what typically happens
in such a session but also to reveal the human mind in action as it integrates a
traumatic experience. No brain scan, blood test, or rating scale can measure this,
and even a video recording can convey only a shadow of how EMDR can unleash the
imaginative powers of the mind.

Kathy sat with her chair at a
forty-five-degree angle to mine, so that we were about four feet apart. I asked her
to bring a particularly painful memory to mind and encouraged her to recall what she
had heard, saw, thought, and felt in her body as it took place. (My records do not
show whether she told me what the particular memory was; my guess is probably not,
since I did not write it down.)

I asked her whether she was now
“in the memory,” and when she said yes, I asked her how real it felt on
a scale of one to ten. About a nine, she said. Then I asked her to follow my moving
finger with her eyes. From time to time, after completing a set of about twenty-five
eye movements, I might say: “Take a deep breath,” followed by:
“What do you get now?” or “What comes to mind now?” Kathy
would then tell me what she was thinking. Whenever her tone of voice, facial
expression, body movements, or breathing patterns indicated that this was an
emotionally significant theme, I would say, “Notice that,” and start
another set of eye movements, during which she did not speak. Other than uttering
those few words, I remained silent for the next forty-five minutes.

Here is the association Kathy reported
after the first eye-movement sequence: “I realize that I have scars—from when
he tied my hands behind my back. The other scar is when he marked me to claim me as
his, and there [she points] are bite marks.” She looked stunned but
surprisingly calm as she recalled, “I remember being doused in gasoline—he
took Polaroid pictures of me—and then I was submerged in water. I was gang raped by
my father and two of his friends; I was
tied to a table; I remember them raping me with Budweiser bottles.”

My stomach was clenching, but I
didn’t comment beyond asking Kathy to keep those memories in mind. After about
thirty more back-and-forth movements I stopped when I saw that she was smiling. When
I asked what she was thinking, she said, “I was in a karate class; it was
great! I really kicked butt! I saw them backing off. I yelled, ‘Don’t
you see you are hurting me? I am not your girlfriend.’” I said,
“Stay there,” and began the next sequence. When it ended, Kathy said:
“I have an image of two me’s—this smart, pretty little
girl … and that little slut. All these women who could not take care of
themselves or me or their men—leaving it up to me to service all these men.”
She started to sob during the next sequence, and when we stopped, she said: “I
saw how little I was—the brutalization of the little girl. It was not my
fault.” I nodded and said, “That’s right—stay there.” The
next round ended with Kathy reporting: “I’m picturing my life now—my big
me holding my little me—saying, ‘You are safe now.’” I nodded
encouragingly and continued.

The images kept coming: “I have
pictures of a bulldozer flattening the house I grew up in. It’s over!”
Then Kathy started on a different track: “I am thinking about how much I like
Jeffrey [a boy in one of her classes]. Thinking that he might not want to hang out
with me. Thinking I can’t handle it. I have never been someone’s
girlfriend before and I don’t know how.” I asked her what she thought
she needed to know and began the next sequence. “Now, there is a person who
just wants to be with me—it is too simple. I don’t know how to just be myself
around men. I am petrified.”

As she tracked my finger, Kathy started
to sob. When I stopped, she told me: “I had an image of Jeffrey and me sitting
in the coffeehouse. My father comes in the door. He starts screaming at the top of
his lungs and he is wielding an ax; he says, ‘I told you that you belong to
me.’ He puts me on top of the table—then he rapes me, and then he
rapes Jeffrey.” She was crying hard now. “How can you be open with
somebody when you have visions of your dad raping you and then raping us
both?” I wanted to comfort her, but I knew it was more important to keep her
associations moving. I asked her to focus on what she felt in her body: “I
feel it in my forearms, in my shoulders, and my right chest. I just want to be
held.” We continued the EMDR and when we stopped, Kathy looked relaxed.
“I heard Jeffrey say it’s okay, that he was sent here to take care of
me. And that it was not anything that I did and that he just wants to be with me for
my sake.” Again I asked what she felt in her body. “I feel really
peaceful. A little bit shaky—like when you’re using new muscles. Some
relief. Jeffrey knows all this already. I feel like I’m alive and that it is
all over. But I am afraid that my father
has another little girl, and that makes me very, very sad. I want to save
her.”

But as we continued the trauma returned,
together with other thoughts and images: “I need to throw up. … I
have intrusions of lots of smells—bad cologne, alcohol, vomit.” A few
minutes later Kathy was crying profusely: “I really feel my mom here now. It
feels like she wants me to forgive her. I have the sense that the same thing
happened to her—she is apologizing to me over and over. She’s telling
me that this happened to her—that it was my grandfather. She’s also
telling me that my grandmother is really sorry for not being there to protect
me.” I kept asking her to take deep breaths and stay with whatever was coming
up.

At the end of the next sequence Kathy
said: “I feel like it’s over. I felt my grandmother holding me at my
current age—telling me that she is so sorry she married my grandfather.
That she and my mom are making sure that it stops here.” After one final EMDR
sequence Kathy was smiling: “I have an image of pushing my father out of the
coffeehouse and Jeffrey locking the door behind him. He stands outside. You can see
him through the glass—everybody’s making fun of him.”

With the help of EMDR Kathy was able to
integrate the memories of her trauma and call on her imagination to help her lay
them to rest, arriving at a sense of completion and control. She did so with minimal
input from me and without any discussion of the particulars of her experiences. (I
never felt a reason to question their accuracy; her experiences were real to her,
and my job was to help her deal with them in the present.) The process freed
something in her mind/brain to activate new images, feelings, and thoughts; it was
as if her life force emerged to create new possibilities for her future.[5]

As we’ve seen, traumatic memories
persist as split-off, unmodified images, sensations, and feelings. To my mind the
most remarkable feature of EMDR is its apparent capacity to activate a series of
unsought and seemingly unrelated sensations, emotions, images, and thoughts in
conjunction with the original memory. This way of reassembling old information into
new packages may be just the way we integrate ordinary, nontraumatic day-to-day
experiences.

EXPLORING THE SLEEP CONNECTION

Shortly after learning about EMDR I was
asked to speak about my work at the sleep laboratory headed by Allan Hobson at the
Massachusetts Mental Health Center. Hobson (together with his teacher, Michel
Jouvet)[6]
was famous for discovering where dreams
are generated in the brain, and one of his research assistants, Robert Stickgold,
was just then beginning to explore the function of dreams. I showed the group a
videotape of a patient who had suffered from severe PTSD for thirteen years after a
terrible car accident and who, in only two sessions of EMDR, had transformed from a
helpless panicked victim into a confident, assertive woman. Bob was fascinated.

A few weeks later a friend of
Stickgold’s family became so depressed after the death of her cat that she had
to be hospitalized. The attending psychiatrist concluded that the cat’s death
had triggered unresolved memories of the death of the woman’s mother when she
was twelve, and he connected her with Roger Solomon, a well-known EMDR trainer, who
treated her successfully. Afterward she called Stickgold and said, “Bob, you
have to study this. It’s really strange—it has to do with your brain,
not your mind.”

Soon afterward an article appeared in
the journal Dreaming suggesting that EMDR was related to rapid eye movement
(REM) sleep—the phase of sleep in which dreaming occurs.[7] Research had already
shown that sleep, and dream sleep in particular, plays a major role in mood
regulation. As the article in Dreaming pointed out, the eyes move rapidly
back and forth in REM sleep, just as they do in EMDR. Increasing our time in REM
sleep reduces depression, while the less REM sleep we get, the more likely we are to
become depressed.[8]

Of course, PTSD is notoriously
associated with disturbed sleep, and self-medication with alcohol or drugs further
disrupts REM sleep. During my time at the VA my colleagues and I had found that the
veterans with PTSD frequently woke themselves up soon after going into REM sleep[9]—probably
because they had activated a trauma fragment during a dream.[10] Other researchers have
also noticed this phenomenon, but thought that it was irrelevant to understanding
PTSD.[11]

Today we know that both deep sleep and
REM sleep play important roles in how memories change over time. The sleeping brain
reshapes memory by increasing the imprint of emotionally relevant information while
helping irrelevant material fade away.[12] In a series of elegant studies
Stickgold and his colleagues showed that the sleeping brain can even make sense out
of information whose relevance is unclear while we are awake and integrate it into
the larger memory system.[13]

Dreams keep replaying, recombining, and
reintegrating pieces of old memories for months and even years.[14] They constantly update
the subterranean realities that determine what our waking minds pay attention to.
And perhaps most relevant to EMDR, in REM sleep we activate more distant associations than in either non-REM
sleep or the normal waking state. For example, when subjects are wakened from
non-REM sleep and given a word-association test, they give standard responses:
hot/cold, hard/soft, etc. Wakened from REM sleep, they make less conventional
connections, such as thief/wrong.[15] They also solve simple anagrams more
easily after REM sleep. This shift toward activation of distant associations could
explain why dreams are so bizarre.[16]

Stickgold, Hobson, and their colleagues
thus discovered that dreams help to forge new relationships between apparently
unrelated memories.[17] Seeing novel connections is the cardinal feature of
creativity; as we’ve seen, it’s also essential to healing. The inability
to recombine experiences is also one of the striking features of PTSD. While Noam in
chapter 4 could imagine a trampoline to save
future victims of terrorism, traumatized people are trapped in frozen associations:
Anybody who wears a turban will try to kill me; any man who finds me attractive
wants to rape me.

Finally, Stickgold suggests a clear link
between EMDR and memory processing in dreams: “If the bilateral stimulation of
EMDR can alter brain states in a manner similar to that seen during REM sleep then
there is now good evidence that EMDR should be able to take advantage of
sleep-dependent processes, which may be blocked or ineffective in PTSD sufferers, to
allow effective memory processing and trauma resolution.”[18] The basic EMDR
instruction, “Hold that image in your mind and just watch my fingers moving
back and forth,” may very well reproduce what happens in the dreaming brain.
As this book is going to press Ruth Lanius and I are studying how the brain reacts,
both while remembering a traumatic event and an ordinary experience, to saccadic eye
movements as subjects lie in an fMRI scanner. Stay tuned.

ASSOCIATION AND INTEGRATION

Unlike conventional exposure treatment,
EMDR spends very little time revisiting the original trauma. The trauma itself is
certainly the starting point, but the focus is on stimulating and opening up the
associative process. As our Prozac/EMDR study showed, drugs can blunt the images and
sensations of terror, but they remain embedded in the mind and body. In contrast
with the subjects who improved on Prozac—whose memories were merely blunted, not
integrated as an event that happened in the past, and still caused considerable
anxiety—those who received EMDR no longer experienced the distinct imprints of the
trauma: It had become a story of a terrible event that had happened a long time ago. As one of my patients
said, making a dismissive hand gesture: “It’s over.”

While we don’t yet know precisely
how EMDR works, the same is true of Prozac. Prozac has an effect on serotonin, but
whether its levels go up or down, and in which brain cells, and why that makes
people feel less afraid, is still unclear. We likewise don’t know precisely
why talking to a trusted friend gives such profound relief, and I am surprised how
few people seem eager to explore that question.[19]

Clinicians have only one obligation: to
do whatever they can to help their patients get better. Because of this, clinical
practice has always been a hotbed for experimentation. Some experiments fail, some
succeed, and some, like EMDR, dialectical behavior therapy, and internal family
systems therapy, go on to change the way therapy is practiced. Validating all these
treatments takes decades and is hampered by the fact that research support generally
goes to methods that have already been proven to work. I am much comforted by
considering the history of penicillin: Almost four decades passed between the
discovery of its antibiotic properties by Alexander Fleming in 1928 and the final
elucidation of its mechanisms in 1965.

CHAPTER 16

Learning to Inhabit Your Body:
Yoga

As we begin to re-experience a visceral
reconnection with the needs of our bodies, there is a brand new capacity to warmly
love the self. We experience a new quality of authenticity in our caring, which
redirects our attention to our health, our diets, our energy, our time management.
This enhanced care for the self arises spontaneously and naturally, not as a
response to a “should.” We are able to experience an immediate and
intrinsic pleasure in self-care.

—Stephen Cope, Yoga and the Quest for the True Self

The first time I saw Annie she was
slumped over in a chair in my waiting room, wearing faded jeans and a purple Jimmy
Cliff T-shirt. Her legs were visibly shaking, and she kept staring at the floor even
after I invited her in. I had very little information about her, other than that she
was forty-seven years old and taught special-needs children. Her body communicated
clearly that she was too terrified to engage in conversation—or even to provide
routine information about her address or insurance plan. People who are this scared
can’t think straight, and any demand to perform will only make them shut down
further. If you insist, they’ll run away and you’ll never see them
again.

Annie shuffled into my office and
remained standing, barely breathing, looking like a frozen bird. I knew we
couldn’t do anything until I could help her quiet down. Moving to within six
feet of her and making sure she had unobstructed access to the door, I encouraged her to
take slightly deeper breaths. I breathed with her and asked her to follow my
example, gently raising my arms from my sides as she inhaled and lowering them as I
exhaled, a qigong technique that one of my Chinese students had taught me. She
stealthily followed my movements, her eyes still fixed on the floor. We spent about
half an hour this way. From time to time I quietly asked her to notice how her feet
felt against the floor and how her chest expanded and contracted with each breath.
Her breath gradually became slower and deeper, her face softened, her spine
straightened a bit, and her eyes lifted to about the level of my Adam’s apple.
I began to sense the person behind that overwhelming terror. Finally she looked more
relaxed and showed me the glimmer of a smile, a recognition that we both were in the
room. I suggested that we stop there for now—I’d made enough demands on
her—and asked whether she would like to come back a week later. She nodded and
muttered, “You sure are weird.”

As I got to know Annie, I inferred from
the notes she wrote and the drawings she gave me that she had been dreadfully abused
by both her father and her mother as a very young child. The full story was only
gradually revealed, as she slowly learned to call up some of the things that had
happened to her without her body being hijacked into uncontrollable anxiety.

I learned that Annie was extraordinarily
skilled and caring in her work with special-needs kids. (I tried out quite a few of
the techniques she told me about with the children in our own clinic and found them
extremely helpful). She would talk freely about the children she taught but would
clam up immediately if we verged on her relationships with adults. I knew she was
married, but she barely mentioned her husband. She often coped with disagreements
and confrontations by making her mind disappear. When she felt overwhelmed
she’d cut her arms and breasts with a razor blade. She had spent years in
various forms of therapy and had tried many different medications, which had done
little to help her deal with the imprints of her horrendous past. She had also been
admitted to several psychiatric hospitals to manage her self-destructive behaviors,
again without much apparent benefit.

In our early therapy sessions, because
Annie could only hint at what she was feeling and thinking before she would shut
down and freeze, we focused on calming the physiological chaos within. We used every
technique that I had learned over the years, like breathing with a focus on the out
breath, which activates the relaxing parasympathetic nervous system. I also taught
her to use her fingers to tap a sequence of acupressure points on various parts of her body, a practice often taught
under the name EFT (Emotional Freedom Technique), which has been shown to help
patients stay within the window of tolerance and often has positive effects on PTSD
symptoms.[1]

THE LEGACY OF INESCAPABLE SHOCK

Because we can now identify the brain
circuits involved in the alarm system, we know, more or less, what was happening in
Annie’s brain as she sat that first day in my waiting room: Her smoke
detector, her amygdala, had been rewired to interpret certain situations as
harbingers of life-threatening danger, and it was sending urgent signals to her
survival brain to fight, freeze, or flee. Annie had all these reactions
simultaneously—she was visibly agitated and mentally shut down.

As we’ve seen, broken alarm
systems can manifest in various ways, and if your smoke detector malfunctions, you
cannot trust the accuracy of your perceptions. For example, when Annie started to
like me she began to look forward to our meetings, but she would arrive at my office
in an intense panic. One day she had a flashback of feeling excited that her father
was coming home soon—but later that evening he molested her. For the first time, she
realized that her mind automatically associated excitement about seeing someone she
loved with the terror of being molested.

Small children are particularly adept at
compartmentalizing experience, so that Annie’s natural love for her father and
her dread of his assaults were held in separate states of consciousness. As an adult
Annie blamed herself for her abuse, because she believed that the loving, excited
little girl she once was had led her father on—that she had brought the molestation
upon herself. Her rational mind told her this was nonsense, but this belief emanated
from deep within her emotional, survival brain, from the basic wiring of her limbic
system. It would not change until she felt safe enough within her body to mindfully
go back into that experience and truly know how that little girl had felt and acted
during the abuse.

THE NUMBING WITHIN

One of the ways the memory of
helplessness is stored is as muscle tension or feelings of disintegration in the
affected body areas: head, back, and limbs in accident victims, vagina and rectum in
victims of sexual abuse. The lives of many trauma survivors come to revolve around
bracing against and neutralizing unwanted sensory experiences, and most people I see
in my practice have become experts in
such self-numbing. They may become serially obese or anorexic or addicted to
exercise or work. At least half of all traumatized people try to dull their
intolerable inner world with drugs or alcohol. The flip side of numbing is sensation
seeking. Many people cut themselves to make the numbing go away, while others try
bungee jumping or high-risk activities like prostitution and gambling. Any of these
methods can give them a false and paradoxical feeling of control.

When people are chronically angry or
scared, constant muscle tension ultimately leads to spasms, back pain, migraine
headaches, fibromyalgia, and other forms of chronic pain. They may visit multiple
specialists, undergo extensive diagnostic tests, and be prescribed multiple
medications, some of which may provide temporary relief but all of which fail to
address the underlying issues. Their diagnosis will come to define their reality
without ever being identified as a symptom of their attempt to cope with trauma.

The first two years of my therapy with
Annie focused on helping her learn to tolerate her physical sensations for what they
were—just sensations in the present, with a beginning, a middle, and an end. We
worked on helping her stay calm enough to notice what she felt without judgment, so
she could observe these unbidden images and feelings as residues of a terrible past
and not as unending threats to her life today.

Patients like Annie continuously
challenge us to find new ways of helping people regulate their arousal and control
their own physiology. That is how my Trauma Center colleagues and I stumbled upon
yoga.

FINDING OUR WAY TO YOGA: BOTTOM-UP
REGULATION

Our involvement with yoga started in 1998
when Jim Hopper and I first heard about a new biological marker, heart rate
variability (HRV), that had recently been discovered to be a good measure of how
well the autonomic nervous system is working. As you’ll recall from chapter 5, the autonomic nervous system is our
brain’s most elementary survival system, its two branches regulating arousal
throughout the body. Roughly speaking, the sympathetic nervous system (SNS) uses
chemicals like adrenaline to fuel the body and brain to take action, while the
parasympathetic nervous system (PNS) uses acetylcholine to help regulate basic body
functions like digestion, wound healing, and sleep and dream cycles. When
we’re at our best, these two systems work closely together to keep us in an
optimal state of engagement with our environment and with ourselves.

Heart rate variability measures the
relative balance between the sympathetic and the parasympathetic systems. When we
inhale, we stimulate the SNS, which results in an increase in heart rate.
Exhalations stimulate the PNS, which decreases how fast the heart beats. In healthy
individuals inhalations and exhalations produce steady, rhythmical fluctuations in
heart rate: Good heart rate variability is a measure of basic well-being.

Why is HRV important? When our autonomic
nervous system is well balanced, we have a reasonable degree of control over our
response to minor frustrations and disappointments, enabling us to calmly assess
what is going on when we feel insulted or left out. Effective arousal modulation
gives us control over our impulses and emotions: As long as we manage to stay calm,
we can choose how we want to respond. Individuals with poorly modulated autonomic
nervous systems are easily thrown off balance, both mentally and physically. Since
the autonomic nervous system organizes arousal in both body and brain, poor HRV—that
is, a lack of fluctuation in heart rate in response to breathing—not only has
negative effects on thinking and feeling but also on how the body responds to
stress. Lack of coherence between breathing and heart rate makes people vulnerable
to a variety of physical illnesses, such as heart disease and cancer, in addition to
mental problems such as depression and PTSD.[2]

In order to study this issue further, we
acquired a machine to measure HRV and started to put bands around the chests of
research subjects with and without PTSD to record the depth and rhythm of their
breathing while little monitors attached to their earlobes picked up their pulse.
After we’d tested about sixty subjects, it became clear that people with PTSD
have unusually low HRV. In other words, in PTSD the sympathetic and parasympathetic
nervous systems are out of sync.[3] This added a new twist to the
complicated trauma story: We confirmed that yet another brain regulatory system was
not functioning as it should.[4] Failure to keep this system in balance
is one explanation why traumatized people like Annie are so vulnerable to
overrespond to relatively minor stresses: The biological systems that are meant to
help us cope with the vagaries of life fail to meet the challenge.

Our next scientific question was: Is
there a way for people to improve their HRV? I had a personal incentive to explore
this question, as I had discovered that my own HRV was not nearly robust enough to
guarantee long-term physical health. An Internet search turned up studies showing
that marathon running markedly increased HRV. Sadly, that was of little use, since
neither I nor our patients were good candidates for the Boston Marathon. Google also listed seventeen thousand
yoga sites claiming that that yoga improved HRV, but we were unable to find any
supporting studies. Yogis may have developed a wonderful method to help people find
internal balance and health, but back in 1998 not much work had been done on
evaluating their claims with the tools of the Western medical tradition.

Heart rate variability (HRV) In a
well-regulated person. The rising and falling black lines represent
breathing, in this case slow and regular inhalations and exhalations. The gray area
shows fluctuations in heart rate. whenever this individual inhales, his heart rate
goes up; during exhalations the heart slows down. This pattern of heart rate
variability reflects excellent physiological health.

Responding to upset. When
someone remembers an upsetting experience, breathing speeds up and becomes
irregular, as does heart rate. Heart and breath no longer stay perfectly in sync.
This is a normal response.

HRV in PTSD. Breathing is
rapid and shallow. Heart rate is slow and out of synch with the breath. This is a
typical pattern of a shut-down person with chronic PTSD.

A person with chronic PTSD reliving a
trauma memory. Breathing initially is labored and deep, typical of a
panic reaction. The heart races out of synch with the breath. This is followed by
rapid, shallow breathing and slow heart rate, signs that the person is shutting
down.

Since then, however, scientific methods
have confirmed that changing the way one
breathes can improve problems with anger, depression, and anxiety[5] and that yoga can
positively affect such wide-ranging medical problems as high blood pressure,
elevated stress hormone secretion,[6] asthma, and lowback pain.[7] However, no
psychiatric journal had published a scientific study of yoga for PTSD until our own
work appeared in 2014.[8]

As it happened, a few days after our
Internet search a lanky yoga teacher named David Emerson walked through the front
door of the Trauma Center. He told us that he’d developed a modified form of
hatha yoga to deal with PTSD and that he’d been holding classes for veterans
at a local vet center and for women in the Boston Area Rape Crisis Center. Would we
be interested in working with him? Dave’s visit eventually grew into a very
active yoga program, and in due course we received the first grant from the National
Institutes of Health to study the effects of yoga on PTSD. Dave’s work also
contributed to my developing my own regular yoga practice and becoming a frequent
teacher at Kripalu, a yoga center in the Berkshire Mountains in western
Massachusetts. (Along the way, my own HRV pattern improved as well.)

In choosing to explore yoga to improve
HRV we were taking an expansive approach to the problem. We could simply have used
any of a number of reasonably priced handheld devices that train people to slow
their breathing and synchronize it with their heart rate, resulting in a state of
“cardiac coherence” like the pattern shown in the first illustration
above.[9]
Today there are a variety of apps that can help improve HRV with the aid of a
smartphone.[10] In our clinic we have workstations where patients can train their
HRV, and I urge all my patients who, for one reason or another, cannot practice
yoga, martial arts, or qigong to train themselves at home. (See Resources for more
information.)

EXPLORING YOGA

Our decision to study yoga led us deeper
into trauma’s impact on the body. Our first experimental yoga classes met in a
room generously donated by a nearby studio. David Emerson and his colleagues Dana
Moore and Jodi Carey volunteered as instructors, and my research team figured out
how we could best measure yoga’s effects on psychological functioning. We put
flyers in neighborhood supermarkets and laundromats to advertise our classes and
interviewed dozens of people who called in response. Ultimately we selected
thirty-seven women who had severe trauma histories and who had already received many years of therapy without
much benefit. Half the volunteers were selected at random for the yoga group, while
the others would receive a well-established mental health treatment, dialectical
behavior therapy (DBT), which teaches people how to apply mindfulness to stay calm
and in control. Finally, we commissioned an engineer at MIT to build us a
complicated computer that could measure HRV simultaneously in eight different
people. (In each study group there were multiple classes, each with no more than
eight participants.) While yoga significantly improved arousal problems in PTSD and
dramatically improved our subjects’ relationships to their bodies (“I
now take care of my body”; “I listen to what my body needs”),
eight weeks of DBT did not affect their arousal levels or PTSD symptoms. Thus, our
interest in yoga gradually evolved from a focus on learning whether yoga can change
HRV (which it can)[11] to helping traumatized people learn to comfortably inhabit their
tortured bodies.

Over time we also started a yoga program
for marines at Camp Lejeune and have worked successfully with various other programs
to implement yoga programs for veterans with PTSD. Even though we have no formal
research data on the veterans, it looks as if yoga is at least as effective for them
as it has been for the women in our studies.

All yoga programs consist of a
combination of breath practices (pranayama), stretches or postures
(asanas), and meditation. Different schools of yoga emphasize
variations in intensity and focus within these core components. For example,
variations in the speed and depth of breathing and use of the mouth, nostrils, and
throat all produce different results, and some techniques have powerful effects on
energy.[12]
In our classes we keep the approach simple. Many of our patients are barely aware of
their breath, so learning to focus on the in and out breath, to notice whether the
breath was fast or slow, and to count breaths in some poses can be a significant
accomplishment.[13]

We gradually introduce a limited number
of classic postures. The emphasis is not on getting the poses “right”
but on helping the participants notice which muscles are active at different times.
The sequences are designed to create a rhythm between tension and
relaxation—something we hope they will begin to perceive in their day-to-day
lives.

We do not teach meditation as such, but
we do foster mindfulness by encouraging students to observe what is happening in
different parts of the body from pose to pose. In our studies we keep seeing how
difficult it is for traumatized people to feel completely relaxed and physically
safe in their bodies. We measure our
subjects’ HRV by placing tiny monitors on their arms during
shavasana, the pose at the end of most classes during which practitioners
lie face up, palms up, arms and legs relaxed. Instead of relaxation we picked up too
much muscle activity to get a clear signal. Rather than going into a state of quiet
repose, our students’ muscles often continue to prepare them to fight unseen
enemies. A major challenge in recovering from trauma remains being able to achieve a
state of total relaxation and safe surrender.

LEARNING SELF-REGULATION

After seeing the success of our pilot
studies, we established a therapeutic yoga program at the Trauma Center. I thought
that this might be an opportunity for Annie to develop a more caring relationship
with her body, and I urged her to try it. The first class was difficult. Merely
being given an adjustment by the instructor was so terrifying that she went home and
slashed herself—her malfunctioning alarm system interpreted even a gentle touch on
her back as an assault. At the same time Annie realized that yoga might offer her a
way to liberate herself from the constant sense of danger that she felt in her body.
With my encouragement she returned the following week.

Annie had always found it easier to
write about her experiences than to talk about them. After her second yoga class she
wrote to me: “I don’t know all of the reasons that yoga terrifies me so
much, but I do know that it will be an incredible source of healing for me and that
is why I am working on myself to try it. Yoga is about looking inward instead of
outward and listening to my body, and a lot of my survival has been geared around
never doing those things. Going to the class today my heart was racing and part of
me really wanted to turn around, but then I just kept putting one foot in front of
the other until I got to the door and went in. After the class I came home and slept
for four hours. This week I tried doing yoga at home and the words came to me
‘Your body has things to say.’ I said back to myself, ‘I will try
and listen.’”

A few days later Annie wrote:
“Some thoughts during and after yoga today. It occurred to me how disconnected
I must be from my body when I cut it. When I was doing the poses I noticed that my
jaw and the whole area from where my legs end to my bellybutton is where I am tight,
tense and holding the pain and memories. Sometimes you have asked me where I feel things and I can’t
even begin to locate them, but today I felt those places very clearly and it made me
want to cry in a gentle kind of way.”

The following month both of us went on
vacation and, invited to stay in touch, Annie wrote to me again: “I’ve
been doing yoga on my own in a room that overlooks the lake. I’m continuing to
read the book you lent me [Stephen Cope’s wonderful Yoga and the Quest for
the True Self ]. It’s really interesting to think about how much I
have been refusing to listen to my body, which is such an important part of who I
am. Yesterday when I did yoga I thought about letting my body tell me the story it
wants to tell and in the hip opening poses there was a lot of pain and sadness. I
don’t think my mind is going to let really vivid images come up as long as I
am away from home, which is good. I think now about how unbalanced I have been and
about how hard I have tried to deny the past, which is a part of my true self. There
is so much I can learn if I am open to it and then I won’t have to fight
myself every minute of every day.”

One of the hardest yoga positions for
Annie to tolerate was one that’s often called Happy Baby, in which you lie on
your back with your knees deeply bent and the soles of your feet pointing to the
ceiling, while holding your toes with your hands. This rotates the pelvis into a
wide-open position. It’s easy to understand why this would make a rape victim
feel extremely vulnerable. Yet, as long as Happy Baby (or any posture that resembles
it) precipitates intense panic, it is difficult to be intimate. Learning how to
comfortably assume Happy Baby is a challenge for many patients in our yoga
classes.

GETTING TO KNOW ME: CULTIVATING
INTEROCEPTION

One of the clearest lessons from
contemporary neuroscience is that our sense of ourselves is anchored in a vital
connection with our bodies.[14] We do not truly know ourselves unless
we can feel and interpret our physical sensations; we need to register and act on
these sensations to navigate safely through life.[15] While numbing (or compensatory
sensation seeking) may make life tolerable, the price you pay is that you lose
awareness of what is going on inside your body and, with that, the sense of being
fully, sensually alive.

In chapter
6 I discussed alexithymia, the technical term for not being able to identify
what is going on inside oneself.[16] People who suffer from alexithymia tend to feel physically
uncomfortable but cannot describe exactly what the problem is. As a result they
often have multiple vague and distressing physical complaints that doctors
can’t diagnose. In addition, they can’t figure out for themselves what
they’re really feeling about any given situation or what makes them feel
better or worse. This is the result of numbing, which keeps them from anticipating
and responding to the ordinary demands of their bodies in quiet, mindful ways. At
the same time, it muffles the everyday sensory delights of experiences like music,
touch, and light, which imbue life with value. Yoga turned out to be a terrific way
to (re)gain a relationship with the interior world and with it a caring, loving,
sensual relationship to the self.

If you are not aware of what your body
needs, you can’t take care of it. If you don’t feel hunger, you
can’t nourish yourself. If you mistake anxiety for hunger, you may eat too
much. And if you can’t feel when you’re satiated, you’ll keep
eating. This is why cultivating sensory awareness is such a critical aspect of
trauma recovery. Most traditional therapies downplay or ignore the moment-to-moment
shifts in our inner sensory world. But these shifts carry the essence of the
organism’s responses: the emotional states that are imprinted in the
body’s chemical profile, in the viscera, in the contraction of the striated
muscles of the face, throat, trunk, and limbs.[17] Traumatized people need to learn that
they can tolerate their sensations, befriend their inner experiences, and cultivate
new action patterns.

In yoga you focus your attention on your
breathing and on your sensations moment to moment. You begin to notice the
connection between your emotions and your body—perhaps how anxiety about doing a
pose actually throws you off balance. You begin to experiment with changing the way
you feel. Will taking a deep breath relieve that tension in your shoulder? Will
focusing on your exhalations produce a sense of calm?[18]

Simply noticing what you feel fosters
emotional regulation, and it helps you to stop trying to ignore what is going on
inside you. As I often tell my students, the two most important phrases in therapy,
as in yoga, are “Notice that” and “What happens next?” Once
you start approaching your body with curiosity rather than with fear, everything
shifts.

Body awareness also changes your sense
of time. Trauma makes you feel as if you are stuck forever in a helpless state of
horror. In yoga you learn that sensations rise to a peak and then fall. For example,
if an instructor invites you to enter a particularly challenging position, you may
at first feel a sense of defeat or resistance, anticipating that you won’t be
able to tolerate the feelings brought up
by this particular position. A good yoga teacher will encourage you to just notice
any tension while timing what you feel with the flow of your breath:
“We’ll be holding this position for ten breaths.” This helps you
anticipate the end of discomfort and strengthens your capacity to deal with physical
and emotional distress. Awareness that all experience is transitory changes your
perspective on yourself.

This is not to say that regaining
interoception isn’t potentially upsetting. What happens when a newly accessed
feeling in your chest is experienced as rage, or fear, or anxiety? In our first yoga
study we had a 50 percent dropout rate, the highest of any study we’d ever
done. When we interviewed the patients who’d left, we learned that they had
found the program too intense: Any posture that involved the pelvis could
precipitate intense panic or even flashbacks to sexual assaults. Intense physical
sensations unleashed the demons from the past that had been so carefully kept in
check by numbing and inattention. This taught us to go slow, often at a
snail’s pace. That approach paid off: In our most recent study only one out of
thirty-four participants did not finish.

Effects of a weekly yoga
class. After twenty weeks, chronically traumatized women developed
increased activation of critical brain structures involved in self-regulation: the
insula and the medial prefrontal cortex.

YOGA AND THE NEUROSCIENCE OF
SELF-AWARENESS

During the past few years brain
researchers such as my colleagues Sara Lazar and Britta Hölzel at Harvard have shown
that intensive meditation has a positive effect on exactly those brain areas that
are critical for physiological self-regulation.[19] In our latest yoga study, with six
women with histories of profound early trauma, we also found the first indications
that twenty weeks of yoga practice increased activation of the basic self-system,
the insula and the medial prefrontal cortex (see chapter
6). This research needs much more work, but it opens up new perspectives on
how actions that involve noticing and befriending the sensations in our bodies can
produce profound changes in both mind and brain that can lead to healing from
trauma.

After each of our yoga studies, we asked
the participants what effect the classes had had on them. We never mentioned the
insula or interoception; in fact, we kept the discussion and explanation to a
minimum so that they could focus inward.

Here is a sample of their responses:

- “My emotions feel more powerful.
Maybe it’s just that I can recognize them now.”

- “I can express my feelings more because I
can recognize them more. I feel them in my body, recognize them, and address
them.”

- “I now see choices, multiple paths. I can
decide and I can choose my life, it doesn’t have to be repeated or be
experienced like a child.”

- “I was able to move my body and be in
my body in a safe place and without hurting myself/getting hurt.”

LEARNING TO COMMUNICATE

People who feel safe in their bodies can
begin to translate the memories that previously overwhelmed them into language.
After Annie had been practicing yoga three times a week for about a year, she
noticed that she was able to talk much more freely to me about what had happened to
her. She thought this almost miraculous. One day, when she knocked over a glass of
water, I got up from my chair and approached her with a Kleenex box, saying,
“Let me clean that up.” This precipitated a brief, intense panic
reaction. She was quickly able to contain herself, though, and explained why those
particular words were so upsetting to her—they were what her father would say after
he’d raped her. Annie wrote to me after that session: “Did you notice
that I have been able to say the words out loud? I didn’t have to write them
down to tell you what was happening. I didn’t lose trust in you because you
said words that triggered me. I understood that the words were a trigger and not
terrible words that no one should say.”

Annie continues to practice yoga and to
write to me about her experiences: “Today I went to a morning yoga class at my
new yoga studio. The teacher talked about breathing to the edge of where we can and
then noticing that edge. She said that if we notice our breath we are in the present
because we can’t breathe in the future or the past. It felt so amazing to me
to be practicing breathing in that way after we had just talked about it, like I had
been given a gift. Some of the poses can be triggering for me. Two of them were
today, one where your legs are up frog like and one where you are doing really deep
breathing into your pelvis. I felt the beginning of panic, especially in the
breathing pose, like oh no that’s not a part of my body I want to feel. But
then I was able to stop myself and just say, notice that this part of your body is
holding experiences and then just let it go. You don’t have to stay there but
you don’t have to leave either, just use it as information. I don’t know
that I have ever been able to do that in such a conscious way before. It made me
think that if I notice without being so afraid, it will be easier for me to believe
myself.”

In another message, Annie reflected on
the changes in her life: “I slowly learned to just have my feelings, without
being hijacked by them. Life is more manageable: I am more attuned to my day and
more present in the moment. I am more tolerant of physical touch. My husband and I
are enjoying watching movies cuddled together in bed … a huge step. All
this helped me finally feel intimate with my husband.”

CHAPTER 17

Putting the Pieces Together:
Self-Leadership

This being human is a guest house. Every
morning is a new arrival. A joy, a depression, a meanness, some momentary awareness
comes as an unexpected visitor. … Welcome and entertain them all. Treat
each guest honorably. The dark thought, the shame, the malice, meet them at the door
laughing, and invite them in. Be grateful for whoever comes, because each has been
sent as a guide from beyond.

—Rumi

A man has as many social selves as there are
individuals who recognize him.

—William James, The Principles of Psychology

It was early in my career, and I had been
seeing Mary, a shy, lonely, and physically collapsed young woman, for about three
months in weekly psychotherapy, dealing with the ravages of her terrible history of
early abuse. One day I opened the door to my waiting room and saw her standing there
provocatively, dressed in a miniskirt, her hair dyed flaming red, with a cup of
coffee in one hand and a snarl on her face. “You must be Dr. van der
Kolk,” she said. “My name is Jane, and I came to warn you not to believe
any of the lies that Mary has been telling you. Can I come in and tell you about
her?” I was stunned but fortunately kept myself from confronting
“Jane” and instead heard her
out. Over the course of our session I met not only Jane but also a hurt little girl
and an angry male adolescent. That was the beginning of a long and productive
treatment.

Mary was my first encounter with
dissociative identity disorder (DID), which at that time was called multiple
personality disorder. As dramatic as its symptoms are, the internal splitting and
emergence of distinct identities experienced in DID represent only the extreme end
of the spectrum of mental life. The sense of being inhabited by warring impulses or
parts is common to all of us but particularly to traumatized people who had to
resort to extreme measures in order to survive. Exploring—even befriending—those
parts is an important component of healing.

DESPERATE TIMES REQUIRE DESPERATE
MEASURES

We all know what happens when we feel
humiliated: We put all our energy into protecting ourselves, developing whatever
survival strategies we can. We may repress our feelings; we may get furious and plot
revenge. We may decide to become so powerful and successful that nobody can ever
hurt us again. Many behaviors that are classified as psychiatric problems, including
some obsessions, compulsions, and panic attacks, as well as most self-destructive
behaviors, started out as strategies for self-protection. These adaptations to
trauma can so interfere with the capacity to function that health-care providers and
patients themselves often believe that full recovery is beyond reach. Viewing these
symptoms as permanent disabilities narrows the focus of treatment to finding the
proper drug regimen, which can lead to lifelong dependence—as though trauma
survivors were like kidney patients on dialysis.[1]

It is much more productive to see
aggression or depression, arrogance or passivity as learned behaviors: Somewhere
along the line, the patient came to believe that he or she could survive only if he
or she was tough, invisible, or absent, or that it was safer to give up. Like
traumatic memories that keep intruding until they are laid to rest, traumatic
adaptations continue until the human organism feels safe and integrates all the
parts of itself that are stuck in fighting or warding off the trauma.

Every trauma survivor I’ve met is
resilient in his or her own way, and every one of their stories inspires awe at how
people cope. Knowing how much energy the sheer act of survival requires keeps me
from being surprised at the price they
often pay: the absence of a loving relationship with their own bodies, minds, and
souls.

Coping takes its toll. For many children
it is safer to hate themselves than to risk their relationship with their caregivers
by expressing anger or by running away. As a result, abused children are likely to
grow up believing that they are fundamentally unlovable; that was the only way their
young minds could explain why they were treated so badly. They survive by denying,
ignoring, and splitting off large chunks of reality: They forget the abuse; they
suppress their rage or despair; they numb their physical sensations. If you were
abused as a child, you are likely to have a childlike part living inside you that is
frozen in time, still holding fast to this kind of self-loathing and denial. Many
adults who survive terrible experiences are caught in the same trap. Pushing away
intense feelings can be highly adaptive in the short run. It may help you preserve
your dignity and independence; it may help you maintain focus on critical tasks like
saving a comrade, taking care of your kids, or rebuilding your house.

The problems come later. After seeing a
friend blown up, a soldier may return to civilian life and try to put the experience
out of his mind. A protective part of him knows how to be competent at his job and
how to get along with colleagues. But he may habitually erupt in rage at his
girlfriend or become numb and frozen when the pleasure of surrendering to her touch
makes him feel he is losing control. He probably will not be aware that his mind
automatically associates passive surrender with the paralysis he felt when his
friend was killed. So another protective part steps in to create a diversion: He
gets angry and, having no idea what set him off, he thinks he’s mad about
something his girlfriend did. Of course, if he keeps blowing up at her (and
subsequent girlfriends), he will become more and more isolated. But he may never
realize that a traumatized part is triggered by passivity and that another part, an
angry manager, is stepping in to protect that vulnerable part. Helping these parts
to give up their extreme beliefs is how therapy can save people’s lives.

As we saw in chapter 13, a central task for recovery from trauma is to learn to live
with the memories of the past without being overwhelmed by them in the present. But
most survivors, including those who are functioning well—even brilliantly—in some
aspects of their lives, face another, even greater challenge: reconfiguring a
brain/mind system that was constructed to cope with the worst. Just as we need to
revisit traumatic memories in order to integrate them, we need to revisit the parts
of ourselves that developed the defensive habits that helped us to survive.

THE MIND IS A MOSAIC

We all have parts. Right now a part of me
feels like taking a nap; another part wants to keep writing. Still feeling injured
by an offensive e-mail message, a part of me wants to hit “reply” on a
stinging put-down, while a different part wants to shrug it off. Most people who
know me have seen my intense, sincere, and irritable parts; some have met the little
snarling dog that lives inside me. My children reminisce about going on family
vacations with my playful and adventurous parts.

When you walk into the office in the
morning and see the storm clouds over your boss’s head, you know precisely
what is coming. That angry part has a characteristic tone of voice, vocabulary, and
body posture—so different from yesterday, when you shared pictures of your kids.
Parts are not just feelings but distinct ways of being, with their own beliefs,
agendas, and roles in the overall ecology of our lives.

How well we get along with ourselves
depends largely on our internal leadership skills—how well we listen to our
different parts, make sure they feel taken care of, and keep them from sabotaging
one another. Parts often come across as absolutes when in fact they represent only
one element in a complex constellation of thoughts, emotions, and sensations. If
Margaret shouts, “I hate you!” in the middle of an argument, Joe
probably thinks she despises him—and in that moment Margaret might agree. But in
fact only a part of her is angry, and that part temporarily obscures her generous
and affectionate feelings, which may well return when she sees the devastation on
Joe’s face.

Every major school of psychology
recognizes that people have subpersonalities and gives them different names.[2] In 1890
William James wrote: “[I]t must be admitted that … the total
possible consciousness may be split into parts which coexist, but mutually ignore
each other, and share the objects of knowledge between them.”[3] Carl Jung
wrote: “The psyche is a self-regulating system that maintains its equilibrium
just as the body does,”[4] “The natural state of the human
psyche consists in a jostling together of its components and in their contradictory
behavior,”[5] and “The reconciliation of these opposites is a major
problem. Thus, the adversary is none other than ‘the other in
me.’”[6]

Modern neuroscience has confirmed this
notion of the mind as a kind of society. Michael Gazzaniga, who conducted pioneering
split-brain research, concluded that the mind is composed of semiautonomous
functioning modules, each of which has a special role.[7] In his book The Social
Brain (1985) he writes,
“But what of the idea that the self is not a unified being, and there may
exist within us several realms of consciousness? … From our [split-brain]
studies the new idea emerges that there are literally several selves, and they do
not necessarily ‘converse’ with each other internally.”[8] MIT scientist
Marvin Minsky, a pioneer of artificial intelligence, declared: “The legend of
the single Self can only divert us from the target of that inquiry.[9] … [I]t can make sense to think there exists, inside your
brain, a society of different minds. Like members of a family, the different minds
can work together to help each other, each still having its own mental experiences
that the others never know about.”[10]

Therapists who are trained to see people
as complex human beings with multiple characteristics and potentialities can help
them explore their system of inner parts and take care of the wounded facets of
themselves. There are several such treatment approaches, including the structural
dissociation model developed by my Dutch colleagues Onno van der Hart and Ellert
Nijenhuis and Atlanta-based Kathy Steel, that is widely practiced in Europe and
Richard Kluft’s work in the United States.[11]

Twenty years after working with Mary, I
met Richard Schwartz, the developer of internal family systems therapy (IFS). It was
through his work that Minsky’s “family” metaphor truly came to
life for me and offered a systematic way to work with the split-off parts that
result from trauma. At the core of IFS is the notion that the mind of each of us is
like a family in which the members have different levels of maturity, excitability,
wisdom, and pain. The parts form a network or system in which change in any one part
will affect all the others.

The IFS model helped me realize that
dissociation occurs on a continuum. In trauma the self-system breaks down, and parts
of the self become polarized and go to war with one another. Self-loathing coexists
(and fights) with grandiosity; loving care with hatred; numbing and passivity with
rage and aggression. These extreme parts bear the burden of the trauma.

In IFS a part is considered not just a
passing emotional state or customary thought pattern but a distinct mental system
with its own history, abilities, needs, and worldview.[12] Trauma injects parts with
beliefs and emotions that hijack them out of their naturally valuable state. For
example, we all have parts that are childlike and fun. When we are abused, these are
the parts that are hurt the most, and they become frozen, carrying the pain, terror,
and betrayal of abuse. This burden makes them toxic—parts of ourselves that we need
to deny at all costs. Because they are locked away inside, IFS calls them the
exiles.

At this point other parts organize to
protect the internal family from the exiles. These protectors keep the toxic parts away, but
in so doing they take on some of the energy of the abuser. Critical and
perfectionistic managers can make sure we never get close to anyone or
drive us to be relentlessly productive. Another group of protectors, which IFS calls
firefighters, are emergency responders, acting impulsively whenever an
experience triggers an exiled emotion.

Each split-off part holds different
memories, beliefs, and physical sensations; some hold the shame, others the rage,
some the pleasure and excitement, another the intense loneliness or the abject
compliance. These are all aspects of the abuse experience. The critical insight is
that all these parts have a function: to protect the self from feeling the full
terror of annihilation.

Children who act out their pain rather
than locking it down are often diagnosed with “oppositional defiant
behavior,” “attachment disorder,” or “conduct
disorder.” But these labels ignore the fact that rage and withdrawal are only
facets of a whole range of desperate attempts at survival. Trying to control a
child’s behavior while failing to address the underlying issue—the abuse—leads
to treatments that are ineffective at best and harmful at worst. As they grow up,
their parts do not spontaneously integrate into a coherent personality but continue
to lead a relatively autonomous existence.

Parts that are “out” may be
entirely unaware of the other parts of the system.[13] Most of the men I evaluated with
regard to their childhood molestation by Catholic priests took anabolic steroids and
spent an inordinate amount of time in the gym pumping iron. These compulsive
bodybuilders lived in a masculine culture of sweat, football, and beer, where
weakness and fear were carefully concealed. Only after they felt safe with me did I
meet the terrified kids inside.

Patients may also dislike the parts that
are out: the parts that are angry, destructive, or critical. But IFS offers a
framework for understanding them—and, also important, talking about them in a
nonpathologizing way. Recognizing that each part is stuck with burdens from the past
and respecting its function in the overall system makes it feel less threatening or
overwhelming.

As Schwartz states: “If one
accepts the basic idea that people have an innate drive toward nurturing their own
health, this implies that, when people have chronic problems, something gets in the
way of accessing inner resources. Recognizing this, the role of therapists is to
collaborate rather than to teach, confront, or fill holes in your psyche.”[14] The first
step in this collaboration is to assure the internal system that all parts are
welcome and that all of them—even those
that are suicidal or destructive—were formed in an attempt to protect the
self-system, no matter how much they now seem to threaten it.

SELF-LEADERSHIP

IFS recognizes that the cultivation of
mindful self-leadership is the foundation for healing from trauma. Mindfulness not
only makes it possible to survey our internal landscape with compassion and
curiosity but can also actively steer us in the right direction for self-care. All
systems—families, organizations, or nations—can operate effectively only if they
have clearly defined and competent leadership. The internal family is no different:
All facets of our selves need to be attended to. The internal leader must wisely
distribute the available resources and supply a vision for the whole that takes all
the parts into account.

As Richard Schwartz explains:

The internal system of an abuse victim differs from the non-abuse system
with regard to the consistent absence of effective leadership, the extreme
rules under which the parts function, and the absence of any consistent
balance or harmony. Typically, the parts operate around outdated assumptions
and beliefs derived from the childhood abuse, believing, for example, that
it is still extremely dangerous to reveal secrets about childhood
experiences which were endured.

[15]

What happens when the self is no longer
in charge? IFS calls this “blending”: a condition in which the Self
identifies with a part, as in “I want to kill myself” or “I hate
you.” Notice the difference from “A part of me wishes that I were
dead” or “A part of me gets triggered when you do that and makes me want
to kill you.”

Schwartz makes two assertions that
extend the concept of mindfulness into the realm of active leadership. The first is
that this Self does not need to be cultivated or developed. Beneath the surface of
the protective parts of trauma survivors there exists an undamaged essence, a Self
that is confident, curious, and calm, a Self that has been sheltered from
destruction by the various protectors that have emerged in their efforts to ensure
survival. Once those protectors trust that it is safe to separate, the Self will
spontaneously emerge, and the parts can be enlisted in the healing process.

The second assumption is that, rather
than being a passive observer, this mindful Self can help reorganize the inner system and
communicate with the parts in ways that help those parts trust that there is someone
inside who can handle things. Again neuroscience research shows that this is not
just a metaphor. Mindfulness increases activation of the medial prefrontal cortex
and decreases activation of structures like the amygdala that trigger our emotional
responses. This increases our control over the emotional brain.

Even more than encouraging a
relationship between a therapist and a helpless patient, IFS focuses on cultivating
an inner relationship between the Self and the various protective parts. In this
model of treatment the Self doesn’t only witness or passively observe, as in
some meditation traditions; it has an active leadership role. The Self is like an
orchestra conductor who helps all the parts to function harmoniously as a symphony
rather than a cacophony.

GETTING TO KNOW THE INTERNAL
LANDSCAPE

The task of the therapist is to help
patients separate this confusing blend into separate entities, so that they are able
to say: “This part of me is like a little child, and that part of me is more
mature but feels like a victim.” They might not like many of these parts, but
identifying them makes them less intimidating or overwhelming. The next step is to
encourage patients to simply ask each protective part as it emerges to “stand
back” temporarily so that we can see what it is protecting. When this is done
again and again, the parts begin to unblend from the Self and make space for mindful
self-observation. Patients learn to put their fear, rage, or disgust on hold and
open up into states of curiosity and self-reflection. From the stable perspective of
Self they can begin constructive inner dialogues with their parts.

Patients are asked to identify the part
involved in the current problem, like feeling worthless, abandoned, or obsessed with
vengeful thoughts. As they ask themselves, “What inside me feels that
way?” an image may come to mind.[16] Maybe the depressed part looks like
an abandoned child, or an aging man, or an overwhelmed nurse taking care of the
wounded; a vengeful part might appear as a combat marine or a member of a street
gang.

Next the therapist asks, “How do
you feel toward that (sad, vengeful, terrified) part of you?” This sets the
stage for mindful self-observation by separating the “you” from the part
in question. If the patient has an extreme response like “I hate it,”
the therapist knows that there is another protective part blended with Self. He or
she might then ask, “See if the part that hates it would step back.”
Then the protective part is often thanked for its vigilance and assured that it can return anytime that it is
needed. If the protective part is willing, the follow-up question is: “How do
you feel toward the (previously rejected) part now?” The patient is likely to
say something like “I wonder why it is so (sad, vengeful etc.).” This
sets the stage for getting to know the part better—for example, by inquiring how old
it is and how it came to feel the way it does.

Once a patient manifests a critical mass
of Self, this kind of dialogue begins to take place spontaneously. At this point
it’s important for the therapist to step aside and just keep an eye out for
other parts that might interfere, or make occasional empathic comments, or ask
questions like “What do you say to the part about that?” or “Where
do you want to go now?” or “What feels like the right next step?”
as well as the ubiquitous Self-detecting question, “How do you feel toward the
part now?”

A LIFE IN PARTS

Joan came to see me to help her manage
her uncontrollable temper tantrums and to deal with her guilt about her numerous
affairs, most recently with her tennis coach. As she put it in our first session:
“I go from being a kick-ass professional woman to a whimpering child, to a
furious bitch, to a pitiless eating machine in the course of ten minutes. I have no
idea which of these I really am.”

By this point in the session, Joan had
already critiqued the prints on my wall, my rickety furniture, and my messy desk.
Offense was her best defense. She was preparing to get hurt again—I’d probably
let her down, as so many people had before. She knew that for therapy to work,
she’d have to make herself vulnerable, so she had to find out if I could
tolerate her anger, fear, and sorrow. I realized that the only way to counter her
defensiveness was by showing a high level of interest in the details of her life,
demonstrating unwavering support for the risk she took in talking with me, and
accepting the parts she was most ashamed of.

I asked Joan if she had noticed the part
of herself that was critical. She acknowledged that she had, and I asked her how she
felt toward that critic. This key question allowed her to begin to separate from
that part and to access her Self. Joan responded that she hated the critic, because
it reminded her of her mother. When I asked her what that critical part might be
protecting, her anger subsided, and she became more curious and thoughtful: “I
wonder why she finds it necessary to call me some of the same names that my mother
used to call me, and worse.” She talked about how scared she had been of her
mom growing up and how she felt that she never could do anything right. The critic was obviously a manager: Not
only was it protecting Joan from me, but it was trying to preempt her mother’s
criticism.

Over the next few weeks Joan told me
that she had been sexually molested by her mother’s boyfriend, probably around
the time she was in the first or second grade. She thought she’d been
“ruined” for intimate relationships. While she was demanding and
critical of her husband, for whom she lacked any sexual desire, she was passionate
and reckless in her love affairs. But the affairs always ended in a similar way: In
the middle of a lovemaking session, she would suddenly become terrified and curl up
into a ball, whimpering like a little girl. These scenes left her confused and
disgusted, and afterward she could not bear to have anything more to do with her
lover.

Like Marilyn in chapter 8, Joan told me that she had learned to make
herself disappear when she was being molested, floating above the scene as if it
were happening to some other girl. Pushing the molestation out of her mind had
enabled Joan to have a normal school life of sleepovers, girlfriends, and team
sports. The trouble began in adolescence, when she developed her pattern of frigid
contempt for boys who treated her well and having casual sex that left her
humiliated and ashamed. She told me that bulimia for her was what orgasms must be
for other people, and having sex with her husband for her was what vomiting must be
for others. While specific memories of her abuse were split off (dissociated), she
unwittingly kept reenacting it.

I did not try to explain to her why she
felt so angry, guilty, or shut down—she already thought of herself as damaged goods.
In therapy, as in memory processing, pendulation—the gradual approach that I
discussed in chapter 13—is central. For Joan to be
able to deal with her misery and hurt, we would have to recruit her own strength and
self-love, enabling her to heal herself.

This meant focusing on her many inner
resources and reminding myself that I could not provide her with the love and caring
she had missed as a child. If, as a therapist, teacher, or mentor, you try to fill
the holes of early deprivation, you come up against the fact that you are the wrong
person, at the wrong time, in the wrong place. The therapy would focus on
Joan’s relationship with her parts rather than with me.

MEETING THE MANAGERS

As Joan’s treatment progressed, we
identified many different parts that were in charge at different times: an
aggressive childlike part that threw tantrums, a promiscuous adolescent part, a
suicidal part, an obsessive manager, a prissy moralist, and so on. As usual, we met
the managers first. Their job was to prevent humiliation and abandonment and to keep her
organized and safe. Some managers may be aggressive, like Joan’s critic, while
others are perfectionistic or reserved, careful not to draw too much attention to
themselves. They may tell us to turn a blind eye to what is going on and keep us
passive to avoid risk. Internal managers also control how much access we have to
emotions, so that the self-system doesn’t get overwhelmed.

It requires an enormous amount of energy
to keep the system under control. A single flirtatious comment may trigger several
parts simultaneously: one that becomes intensely sexually aroused, another filled
with self-loathing, a third that tries to calm things down by self-cutting. Other
managers create obsessions and distractions or deny reality altogether. But each
part should be approached as an internal protector who maintains an important
defensive position. Managers carry huge burdens of responsibility and usually are in
over their heads.

Some managers are extremely competent.
Many of my patients hold responsible positions, do outstanding professional jobs,
and can be superbly attentive parents. Joan’s critical manager undoubtedly
contributed to her success as an ophthalmologist. I have had numerous patients who
were highly skilled teachers or nurses. While their colleagues may have experienced
them as a bit distant or reserved, they would probably have been astonished to
discover that their exemplary coworkers engaged in self-mutilation, eating
disorders, or bizarre sexual practices.

Gradually Joan started to realize that
it is normal to simultaneously experience conflicting feelings or thoughts, which
gave her more confidence to face the task ahead. Instead of believing that hate
consumed her entire being, she learned that only a part of her felt paralyzed by it.
However, after a negative evaluation at work Joan went into a tailspin, berating
herself for not protecting herself, then feeling clingy, weak, and powerless. When I
asked her to see where that powerless part was located in her body and how she felt
toward it, she resisted. She told me she couldn’t stand that whiny,
incompetent girl who made her feel embarrassed and contemptuous of herself. I
suspected that this part held much of the memory of her abuse, and I decided not to
pressure her at this point. She left my office withdrawn and upset.

The next day she raided the refrigerator
and then spent hours vomiting up her food. When she returned to my office, she told
me she wanted to kill herself and was surprised that I seemed genuinely curious and
nonjudgmental and that I did not condemn her for either her bulimia or her
suicidality. When I asked her what parts were involved, the critic came back and
blurted out, “She is disgusting.” When she asked that part to step back,
the next part said: “Nobody will
ever love me,” followed again by the critic, who told me that the best way to
help her would be to ignore all that noise and to increase her medications.

Clearly, in their desire to protect her
injured parts, these managers were unintentionally doing her harm. So I kept asking
them what they thought would happen if they stepped back. Joan answered:
“People will hate me” and “I will be all alone and out in the
street.” This was followed by a memory: Her mother had told her that if she
disobeyed, she would be put up for adoption and never see her sisters or her dog
again. When I asked her how she felt about that scared girl inside, she cried and
said that she felt bad for her. Now her Self was back, and I was confident that we
had calmed the system down, but this session turned out to be too much too soon.

PUTTING OUT THE FLAMES

The following week Joan missed her
appointment. We had triggered her exiles, and her firefighters went on a rampage. As
she told me later, the evening after we talked about her terror of being put into
foster care, she felt as if she were going to blast out of herself. She went to a
bar and picked up a guy. Coming home late, drunk, and disheveled, she refused to
talk to her husband and fell asleep in the den. The next morning she acted as if
nothing had happened.

Firefighters will do anything to make
emotional pain go away. Aside from sharing the task of keeping the exiles locked up,
they are the opposite of managers: Managers are all about staying in control, while
firefighters will destroy the house in order to extinguish the fire. The struggle
between uptight managers and out-of-control firefighters will continue until the
exiles, which carry the burden of the trauma, are allowed to come home and be cared
for.

Anyone who deals with survivors will
encounter those firefighters. I’ve met firefighters who shop, drink, play
computer games addictively, have impulsive affairs, or exercise compulsively. A
sordid encounter can blunt the abused child’s horror and shame, if only for a
couple of hours.

It is critical to remember that, at
their core, firefighters are also desperately trying to protect the system. Unlike
managers, who are usually superficially cooperative during therapy, firefighters
don’t hold back: They hurl insults and storm out of the room. Firefighters are
frantic, and if you ask them what would happen if they stopped doing their job, you
discover that they believe the exiled feelings would crash the entire self-system.
They are also oblivious to the idea that there are better ways to guarantee physical
and emotional safety, and even if behaviors like bingeing or cutting stop, firefighters often find other methods
of self-harm. These cycles will come to an end only when the Self is able to take
charge and the system feels safe.

THE BURDEN OF TOXICITY

Exiles are the toxic waste dump of the
system. Because they hold the memories, sensations, beliefs, and emotions associated
with trauma, it is hazardous to release them. They contain the “Oh, my God,
I’m done for” experience—the essence of inescapable shock—and with it,
terror, collapse, and accommodation. Exiles may reveal themselves in the form of
crushing physical sensations or extreme numbing, and they offend both the
reasonableness of the managers and the bravado of the firefighters.

Like most incest survivors, Joan hated
her exiles, particularly the little girl who had responded to her abuser’s
sexual demands and the terrified child who whimpered alone in her bed. When exiles
overwhelm managers, they take us over—we are nothing but that rejected, weak,
unloved, and abandoned child. The Self becomes “blended” with the
exiles, and every possible alternative for our life is eclipsed. Then, as Schwartz
points out, “We see ourselves, and the world, through their eyes and believe
it is ‘the’ world. In this state it won’t occur to us that we have
been hijacked.”[17]

Keeping the exiles locked up, however,
stamps out not only memories and emotions but also the parts that hold them—the
parts that were hurt the most by the trauma. In Schwartz’s words:
“Usually those are your most sensitive, creative, intimacy-loving, lively,
playful and innocent parts. By exiling them when they get hurt, they suffer a double
whammy—the insult of your rejection is added to their original injury.”[18] As Joan
discovered, keeping the exiles hidden and despised was condemning her to a life
without intimacy or genuine joy.

UNLOCKING THE PAST

Several months into Joan’s
treatment we again accessed the exiled girl who carried the humiliation, confusion,
and shame of Joan’s molestation. By then she had come to trust me enough and
had developed enough sense of Self to be able to tolerate observing herself as a
child, with all her long-buried feelings of terror, excitement, surrender, and
complicity. She did not say very much during this process, and my main job was to
keep her in a state of calm self-observation. She often had the impulse to pull away
in disgust and horror, leaving this unacceptable child alone in her misery. At these
points I asked her protectors to step
back so that she could keep listening to what her little girl wanted her to
know.

Finally, with my encouragement, she was
able to rush into the scene and take the girl away with her to a safe place. She
firmly told her abuser that she would never let him get close to her again. Instead
of denying the child, she played an active role in liberating her. As in EMDR the
resolution of the trauma was the result of her ability to access her imagination and
rework the scenes in which she had become frozen so long ago. Helpless passivity was
replaced by determined Self-led action.

Once Joan started to own her impulses
and behaviors, she recognized the emptiness of her relationship with her husband,
Brian, and began to insist on change. I invited her to ask Brian to meet with us,
and she was present for eight sessions before he began to see me individually.

Schwartz observes that IFS can help
family members “mentor” each other as they learn to observe how one
person’s parts interact with another’s. I witnessed this firsthand with
Joan and Brian. Brian was initially quite proud of having put up with Joan’s
behavior for so long; feeling that she really needed him had kept him from even
considering divorce. But now that she wanted more intimacy, he felt pressured and
inadequate—revealing a panicked part that blanked out and put up a wall against
feeling.

Gradually Brian began to talk about
growing up in an alcoholic family where behaviors like Joan’s were common and
largely ignored, punctuated by his father’s stays in detox centers and his
mother’s long hospitalizations for depression and suicide attempts. When I
asked his panicked part what would happen if it allowed Brian to feel anything, he
revealed his fear of being overwhelmed by pain—the pain of his childhood added to
the pain of his relationship with Joan.

Over the next few weeks other parts
emerged. First came a protector that was frightened of women and determined never to
let Brian become vulnerable to their manipulations. Then we discovered a strong
caretaker part that had looked after his mother and his younger siblings. This part
gave Brian a feeling of self-worth and purpose and a way of dealing with his own
terror. Finally, Brian was ready to meet his exile, the scared, essentially
motherless child who’d had no one to care for him.

This is a very short version of a long
exploration, which involved many diversions, as when Joan’s critic reemerged
from time to time. But from the beginning IFS helped Joan and Brian hear themselves
and each other from the perspective of an objective, curious, and compassionate
Self. They were no longer locked in the past, and a whole range of new possibilities
opened up for them.

THE POWER OF SELF-COMPASSION: IFS IN
THE TREATMENT OF RHEUMATOID ARTHRITIS

Nancy Shadick is a rheumatologist at
Boston’s Brigham and Women’s Hospital who combines medical research on
rheumatoid arthritis (RA) with a strong interest in her patients’ personal
experience of their illness. When she discovered IFS at a workshop with Richard
Schwartz, she decided to incorporate the therapy into a study of psychosocial
intervention with RA patients.

RA is an autoimmune disease that causes
inflammatory disorders throughout the body, causing chronic pain and disability.
Medication can delay its progress and relieve some of the pain, but there is no
cure, and living with RA can lead to depression, anxiety, isolation, and overall
impaired quality of life. I followed this study with particular interest because of
the link I’d observed between trauma and autoimmune disease.

Working with senior IFS therapist Nancy
Sowell, Dr. Shadick created a nine-month randomized study in which one group of RA
patients would receive both group and individual instruction in IFS while a control
group received regular mailings and phone calls regarding disease symptoms and
management. Both groups continued with their regular medications, and they were
assessed periodically by rheumatologists who were not informed which group they
belonged to.

The goal of the IFS group was to teach
patients how to accept and understand their inevitable fear, hopelessness, and anger
and to treat those feelings as members of their own “internal family.”
They would learn the inner dialogue skills that would enable them to recognize their
pain, identify the accompanying thoughts and emotions, and then approach these
internal states with interest and compassion.

A basic problem emerged early. Like so
many trauma survivors, the RA patients were alexithymic. As Nancy Sowell later told
me, they never complained about their pain or disability unless they were totally
overwhelmed. Asked how they were feeling, they almost always replied,
“I’m fine.” Their stoic parts clearly helped them cope, but these
managers also kept them in a state of denial. Some shut out their bodily sensations
and emotions to the extent that they could not collaborate effectively with their
doctors.

To get things moving, the leaders
introduced the IFS parts dramatically, rearranging furniture and props to represent
managers, exiles, and firefighters. Over the course of several weeks, group members
began to talk about the managers who told them to “grin and bear it”
because no one wanted to hear about their pain anyway. Then, as they asked the stoic
parts to step back, they started to
acknowledge the angry part that wanted to yell and wreak havoc, the part that wanted
stay in bed all the time, and the exile who felt worthless because she wasn’t
allowed to talk. It emerged that, as children, nearly all of them were supposed to
be seen and not heard—safety meant keeping their needs under wraps.

Individual IFS therapy helped patients
apply the language of parts to daily issues. For example, one woman felt trapped by
conflicts at her job, where a manager part insisted the only way out was to overwork
until her RA flared up. With the therapist’s help she realized that she could
care for her needs without making herself sick.

The two groups, IFS and controls, were
evaluated three times during the nine-month study period and then again one year
later. At the end of nine months, the IFS group showed measurable improvements in
self-assessed joint pain, physical function, self-compassion, and overall pain
relative to the education group. They also showed significant improvements in
depression and self-efficacy. The IFS group’s gains in pain perception and
depressive symptoms were sustained one year later, although objective medical tests
could no longer detect measurable improvements in pain or function. In other words,
what had changed most was the patients’ ability to live with their disease. In
their conclusions, Shadick and Sowell emphasized IFS’s focus on
self-compassion as a key factor.

This was not the first study to show
that psychological interventions can help RA patients. Cognitive behavioral
therapies and mindfulness-based practices have also been shown to have a positive
impact on pain, joint inflammation, physical disability, and depression.[19] However,
none of these studies has asked a crucial question: Are increased psychological
safety and comfort reflected in a better-functioning immune system?

LIBERATING THE EXILED CHILD

Peter ran an oncology service at a
prestigious academic medical center that was consistently rated as one of the best
in the country. As he sat in my office, in perfect physical shape because of his
regular squash practice, his confidence had crossed the line into arrogance. This
man certainly did not seem to suffer from PTSD. He told me he just wanted to know
how he could help his wife to be less “touchy.” She had threatened to
leave him unless he did something about what she termed his callous behavior. Peter
assured me that her perception was warped, because he obviously had no problem being
empathic with sick people.

He loved talking about his work, proud of
the fact that residents and fellows competed fiercely to be on his service and also
of scuttlebutt he’d heard about his staff being terrified of him. He described
himself as brutally honest, a real scientist, someone who just looked at the facts
and—with a meaningful glance in my direction—did not suffer fools gladly. He had
high standards, but no higher than he had for himself, and he assured me that he
didn’t need anybody’s love, just their respect.

Peter also told me that his psychiatry
rotation in med school had convinced him that psychiatrists still practiced
witchcraft, and his one stint in couples’ therapy had further confirmed that
opinion. He expressed contempt for people who blamed their parents or society for
their problems. Even though he had had his own share of misery as a child, he was
determined never to think of himself as a victim.

While Peter’s toughness and his
love for precision appealed to me, I could not help but wonder if we would discover
something I’d seen all too often: that internal managers who are obsessed with
power are usually created as a bulwark against feeling helpless.

When I asked him about his family, Peter
told me that his father ran a manufacturing business. He was a Holocaust survivor
who could be brutal and exacting, but he also had a tender and sentimental side that
had kept Peter connected with him and that had inspired Peter to become a physician.
As he told me about his mother, he realized for the first time that she had
substituted rigorous housekeeping for genuine care, but Peter denied that this
bothered him. He went to school and got straight As. He had vowed to build a life
free of rejection and humiliation, but, ironically, he lived with death and
rejection every day—death on the oncology ward and the constant struggle to get his
research funded and published.

Peter’s wife joined us for the
next meeting. She described how he criticized her incessantly—her taste in clothes,
her child-rearing practices, her reading habits, her intelligence, her friends. He
was rarely at home and never emotionally available. Because he had so many important
obligations, and because he was so explosive, his family always tiptoed around him.
She was determined to leave him and start a new life unless he made some radical
changes. At that point, for the first time, I saw Peter become obviously distressed.
He assured me and his wife that he wanted to work things out.

At our next session I asked him to let
his body relax, close his eyes, focus his attention inside, and ask that critical
part—the one his wife had identified—what it was afraid would
happen if he stopped his ruthless judging. After about thirty seconds he said he
felt stupid talking to himself. He
didn’t want to try some new age gimmick—he’d come to me looking for
“empirically verified therapy.” I assured him that, like him, I was at
the forefront of empirically based therapies and that this was one of them. He was
silent for perhaps a minute before he whispered: “I would get hurt.” I
urged him to ask the critic what that meant. Still with his eyes closed, Peter
replied: “If you criticize others, they don’t dare to hurt you.”
Then: “If you are perfect, nobody can criticize you.” I asked him to
thank his critic for protecting him against hurt and humiliation, and as he became
silent again, I could see his shoulders relax and his breathing become slower and
deeper.

He next told me that he was aware that
his pomposity was affecting his relationships with his colleagues and students; he
felt lonely and despised during staff meetings and uncomfortable at hospital
parties. When I asked him if he wanted to change the way that angry part threatened
people, he replied that he did. I then asked him where it was located in his body,
and he found it in the middle of his chest. Keeping his focus inside, I asked him
how he felt toward it. He said it made him scared.

Next I asked him to stay focused on it
and see how he felt toward it now. He said he was curious to know more about it. I
asked him how old it was. He said about seven. I asked him to have his critic show
him what he protected. After a lengthy silence, still with his eyes closed, he told
me that he was witnessing a scene from his childhood. His father was beating a
little boy, him, and he was standing to one side thinking how stupid that kid was to
provoke his dad. When I asked him how he felt about the boy who was getting hurt, he
told me that he despised him. He was a weakling and a whiner; after showing even the
least bit of defiance to his dad’s high-handed ways, he inevitably capitulated
and whimpered that he would be a good little boy. He had no guts, no fire in his
belly. I asked the critic if he would be willing to step aside so we could see what
was going on with that boy. In response the critic appeared in full force and called
him names like “wimp” and “sissy.” I asked Peter again if
the critic would be willing to step aside and give the boy a chance to speak. He
shut down completely and left the session saying that he was unlikely ever to set
foot in my office again.

But the following week he was back: As
she had threatened, his wife had gone to a lawyer and filed for divorce. He was
devastated and no longer looked anything like the perfectly put-together doctor whom
I’d come to know and, in many ways, dread. Faced with the loss of his family,
he became unhinged and felt comforted by the idea that if things got too bad he
could take his life in his own hands.

We went inside again and identified the
part that was terrified of abandonment. Once he was in his mindful Self-state, I
urged him to ask that terrified boy to show him the burdens he was carrying. Again,
his first reaction was disgust at the boy’s weakness, but after I asked him to
get that part to step back, he saw an image of himself as a young boy in his
parents’ house, alone in his room, screaming in terror. Peter watched this
scene for several minutes, weeping silently through much of it. I asked him if the
boy had told him everything he wanted him to know. No, there were other scenes, like
running to embrace his father at the door and getting slapped for having disobeyed
his mother.

From time to time he would interrupt the
process by explaining why his parents couldn’t have done any better than they
had, their being Holocaust survivors and all that implied. Again I suggested he find
the protective parts that were interrupting the witnessing of the boy’s pain
and request that they move temporarily to another room. And each time he was able to
return to his grief.

I asked Peter to tell the boy that he
now understood how bad the experience had been. He sat in a long, sad silence. Then
I asked him to show the boy that he cared about him. After some coaxing he put his
arms around the boy. I was surprised that this seemingly harsh and callous man knew
exactly how to take care of him.

Then, after some time, I urged Peter to
go back into the scene and take the boy away with him. Peter imagined himself
confronting his dad as a grown man, telling him: “If you ever mess with that
boy again, I’ll come and kill you.” He then, in his imagination, took
the child to a beautiful campground he knew, where the boy could play and frolic
with ponies while he watched over him.

Our work was not done. After his wife
rescinded her threat of divorce, some of his old habits returned, and we had to
revisit that isolated boy from time to time to make sure that Peter’s wounded
parts were taken care of, especially when he felt hurt by something that happened at
home or on the job. This is the stage IFS calls “unburdening,” and it
corresponds to nursing those exiled parts back to health. With each new unburdening
Peter’s once scathing inner critic relaxed, as little by little it became more
like a mentor than a judge, and he began to repair his relationships with his family
and colleagues. He also stopped suffering from tension headaches.

One day he told me that he’d spent
his adulthood trying to let go of his past, and he remarked how ironic it was that
he had to get closer to it in order to let it go.

CHAPTER 18

Filling in the Holes: Creating
Structures

The greatest discovery of my generation is that
human beings can alter their lives by altering their attitudes of mind.

—William James

It is not that something different is seen, but
that one sees differently. It is as though the spatial act of seeing were changed by
a new dimension.

—Carl Jung

It is one thing to process memories of
trauma, but it is an entirely different matter to confront the inner void—the holes
in the soul that result from not having been wanted, not having been seen, and not
having been allowed to speak the truth. If your parents’ faces never lit up
when they looked at you, it’s hard to know what it feels like to be loved and
cherished. If you come from an incomprehensible world filled with secrecy and fear,
it’s almost impossible to find the words to express what you have endured. If
you grew up unwanted and ignored, it is a major challenge to develop a visceral
sense of agency and self-worth.

The research that Judy Herman, Chris
Perry, and I had done (see chapter 9) showed that
people who felt unwanted as children, and those who did not remember feeling safe
with anyone while growing up, did not fully benefit from conventional psychotherapy,
presumably because they could not activate old traces of feeling cared for.

I could see this even in some of my most
committed and articulate patients. Despite their hard work in therapy and their
share of personal and professional accomplishments, they could not erase the
devastating imprints of a mother who was too depressed to notice them or a father
who treated them like he wished they’d never been born. It was clear that
their lives would change fundamentally only if they could reconstruct those implicit
maps. But how? How can we help people become viscerally acquainted with feelings
that were lacking early in their lives?

I glimpsed a possible answer when I
attended the founding conference of the United States Association for Body
Psychotherapy in June 1994 at a small college in Beverley on the rocky Massachusetts
coast. Ironically, I had been asked to represent mainstream psychiatry at the
meeting and to speak on using brain scans to visualize mental states. But as soon as
I walked into the lobby where attendees had gathered for morning coffee, I realized
this was a different crowd from my usual psychopharmacology or psychotherapy
gatherings. The way they talked to one another, their postures and gestures,
radiated vitality and engagement—the sort of physical reciprocity that is the
essence of attunement.

I soon struck up a conversation with
Albert Pesso, a stocky former dancer with the Martha Graham Dance Company who was
then in his early seventies. Underneath his bushy eyebrows he exuded kindness and
confidence. He told me that he had found a way of fundamentally changing
people’s relationship to their core, somatic selves. His enthusiasm was
infectious, but I was skeptical and asked him if he was certain he could change the
settings of the amygdala. Unfazed by the fact that nobody had ever tested his method
scientifically, he confidently assured me that he could.

Pesso was about to conduct a workshop in
“PBSP psychomotor therapy,”[1] and he invited me to attend. It was
unlike any group work I had ever seen. He took a low chair opposite a woman named
Nancy, whom he called a “protagonist,” with the other participants
seated on pillows around them. He then invited Nancy to talk about what was
troubling her, occasionally using her pauses to “witness” what he was
observing—as in “A witness can see how crestfallen you are when you talk about
your father deserting the family.” I was impressed by how carefully he tracked
subtle shifts in body posture, facial expression, tone of voice, and eye gaze, the
nonverbal expressions of emotion. (This is called “microtracking” in
psychomotor therapy).

Each time Pesso made a “witness
statement,” Nancy’s face and body relaxed a bit, as if she felt
comforted by being seen and validated. His quiet comments seemed to bolster her
courage to continue and go deeper. When Nancy started to cry, he observed that nobody should
have to bear so much pain all by herself, and he asked if she would like to choose
someone to sit next to her. (He called this a “contact person.”) Nancy
nodded and, after carefully scanning the room, pointed to a kind-looking middle-aged
woman. Pesso asked Nancy where she would like her contact person to sit.
“Right here,” Nancy said decisively, indicating a pillow immediately to
her right.

I was fascinated. People process spatial
relations with the right hemisphere of the brain, and our neuroimaging research had
shown that the imprint of trauma is principally on the right hemisphere as well (see
chapter 3). Caring, disapproval, and indifference
all are primarily conveyed by facial expression, tone of voice, and physical
movements. According to recent research, up to 90 percent of human communication
occurs in the nonverbal, right-hemisphere realm,[2] and this was where Pesso’s work
seemed primarily to be directed. As the workshop went on, I was also struck by how
the contact person’s presence seemed to help Nancy tolerate the painful
experiences she was dredging up.[3]

But what was most unusual was how Pesso
created tableaus—or as he called them, “structures”—of the
protagonists’ past. As the narratives unfolded, group participants were asked
to play the roles of significant people in the protagonists’ lives, such as
parents and other family members, so that their inner world began to take form in
three-dimensional space. Group members were also enlisted to play the ideal,
wished-for parents who would provide the support, love, and protection that had been
lacking at critical moments. Protagonists became the directors of their own plays,
creating around them the past they never had, and they clearly experienced profound
physical and mental relief after these imaginary scenarios. Could this technique
instill imprints of safety and comfort alongside those of terror and abandonment,
decades after the original shaping of mind and brain?

Intrigued with the promise of
Pesso’s work, I eagerly accepted his invitation to visit his hilltop farmhouse
in southern New Hampshire. After lunch beneath an ancient oak tree, Al asked me to
join him in his red clapboard barn, now a studio, to do a structure. I’d spent
several years in psychoanalysis, so I did not expect any major revelations. I was a
settled professional man in my forties with my own family, and I thought of my
parents as two elderly people who were trying to create a decent old age for
themselves. I certainly did not think they still had a major influence on me.

Since there were no other people
available for role-play, Al began by asking me to select an object or a piece of
furniture to represent my father. I chose a gigantic black leather couch and asked
Al to put it upright about eight feet in
front of me, slightly to the left. Then he asked if I’d like to bring my
mother into the room as well, and I chose a heavy lamp, approximately the same
height as the upright couch. As the session continued, the space became populated
with the important people in my life: my best friend, a tiny Kleenex box to my
right; my wife, a small pillow next to him; my two children, two more tiny
pillows.

After a while I surveyed the projection
of my internal landscape: two hulking, dark, and threatening objects representing my
parents and an array of minuscule objects representing my wife, children, and
friends. I was astounded; I had re-created my inner image of my stern Calvinistic
parents from the time I was a little boy. My chest felt tight, and I’m sure
that my voice sounded even tighter. I could not deny what my spatial brain was
revealing: The structure had allowed me to visualize my implicit map of the
world.

When I told Al what I had just
uncovered, he nodded and asked if I would allow him to change my perspective. I felt
my skepticism return, but I liked Al and was curious about his method, so I
hesitantly agreed. He then interposed his body directly between me and the couch and
lamp, making them disappear from my line of sight. Instantaneously I felt a deep
release in my body—the constriction in my chest eased and my breathing became
relaxed. That was the moment I decided to become Pesso’s student.[4]

RESTRUCTURING INNER MAPS

Projecting your inner world into the
three-dimensional space of a structure enables you to see what’s happening in
the theater of your mind and gives you a much clearer perspective on your reactions
to people and events in the past. As you position placeholders for the important
people in your life, you may be surprised by the unexpected memories, thoughts, and
emotions that come up. You then can experiment with moving the pieces around on the
external chessboard that you’ve created and see what effect it has on you.

Although the structures involve
dialogue, psychomotor therapy does not explain or interpret the past. Instead, it
allows you to feel what you felt back then, to visualize what you saw, and to say
what you could not say when it actually happened. It’s as if you could go back
into the movie of your life and rewrite the crucial scenes. You can direct the
role-players to do things they failed to do in the past, such as keeping your father
from beating up your mom. These tableaus can stimulate powerful emotions. For
example, as you place your “real mother” in the corner, cowering in
terror, you may feel a deep longing to protect her and realize how powerless you
felt as a child. But if you then create
an ideal mother, who stands up to your father and who knows how to avoid getting
trapped in abusive relationships, you may experience a visceral sense of
relief and an unburdening of that old guilt and helplessness. Or you might confront
the brother who brutalized you as a child and then create an ideal brother who
protects you and becomes your role model.

The job of the
director/therapist and other group members is to provide
protagonists with the support they need to delve into whatever they have been too
afraid to explore on their own. The safety of the group allows you to notice things
that you have hidden from yourself—usually the things you are most ashamed of. When
you no longer have to hide, the structure allows you to place the shame where it
belongs—on the figures right in front of you who represent those who hurt you and
made you feel helpless as a child.

Feeling safe means you can say things to
your father (or, rather, the placeholder who represents him) that you wish you could
have said as a five-year-old. You can tell the placeholder for your depressed and
frightened mother how terrible you felt about not being able to take care of her.
You can experiment with distance and proximity and explore what happens as you move
placeholders around. As an active participant, you can lose yourself in a scene in a
way you cannot when you simply tell a story. And as you take charge of representing
the reality of your experience, the witness keeps you company, reflecting the
changes in your posture, facial expression, and tone of voice.

In my experience, physically
reexperiencing the past in the present and then reworking it in a safe and
supportive “container” can be powerful enough to create new,
supplemental memories: simulated experiences of growing up in an attuned,
affectionate setting where you are protected from harm. Structures do not erase bad
memories, or even neutralize them the way EMDR does. Instead, a structure offers
fresh options—an alternative memory in which your basic human needs are met and your
longings for love and protection are fulfilled.

REVISING THE PAST

Let me give an example from a workshop I
led not long ago at the Esalen Institute in Big Sur, California.

Maria was a slender, athletic Filipina
in her midforties who had been pleasant and accommodating during our first two days,
which had been devoted to exploring the long-term impact of trauma and teaching
self-regulation techniques. But now, seated on her pillow about six feet away from
me, she looked scared and collapsed.
I wondered to myself if she had volunteered as a protagonist mainly to please the
girlfriend who had accompanied her to the workshop.

I began by encouraging her to notice
what was going on inside her and to share whatever came to mind. After a long
silence she said: “I can’t really feel anything in my body, and my mind
is blank.” Mirroring her inner tension, I replied: “A witness can see
how worried you are that your mind is blank and you don’t feel anything after
volunteering to do a structure. Is that right?” “Yes!” she
answered, sounding slightly relieved.

The “witness figure” enters
the structure at the very beginning and takes the role of an accepting,
nonjudgmental observer who joins the protagonist by reflecting his or her emotional
state and noting the context in which that state has emerged (as when I mentioned
Maria’s “volunteering to do a structure”). Being validated by
feeling heard and seen is a precondition for feeling safe, which is critical when we
explore the dangerous territory of trauma and abandonment. A neuroimaging study has
shown that when people hear a statement that mirrors their inner state, the right
amygdala momentarily lights up, as if to underline the accuracy of the
reflection.

I encouraged Maria to keep focusing on
her breath, one of the exercises we had been practicing together, and to notice what
she was feeling in her body. After another long silence she hesitantly began to
speak: “There is always a sense of fear in everything I do. It doesn’t
look like I am afraid, but I am always pushing myself. It is really difficult for me
to be up here.” I reflected, “A witness can see how uncomfortable you
feel pushing yourself to be here,” and she nodded, slightly straightening her
spine, signaling that she felt understood. She continued: “I grew up thinking
that my family was normal. But I always was terrified of my dad. I never felt cared
for by him. He never hit me as hard as he did my siblings, but I have a pervasive
sense of fear.” I noted that a witness could see how afraid she looked as she
spoke of her father, and then I invited her to select a group member to represent
him.

Maria scanned the room and chose Scott,
a gentle video producer who had been a lively and supportive member of the group. I
gave Scott his script: “I enroll as your real father, who terrified you when
you were a little girl,” which he repeated. (Note that this work is not about
improvisation but about accurately enacting the dialogue and directions provided by
the witness and protagonist.) I then asked Maria where she would like her real
father to be positioned, and she instructed Scott to stand about twelve feet away,
slightly to her right and facing away from her. We were beginning to create the
tableau, and every time I conduct a structure I’m impressed by how precise the
outward projections of the right
hemisphere are. Protagonists always know exactly where the various characters in
their structures should be located.

It also surprises me, again and again,
how the placeholders representing the significant people in the protagonist’s
past almost immediately assume a virtual reality: The people who enroll seem to
become the people he or she had to deal with back then—not only to the
protagonist but often to the other participants as well. I encouraged Maria to take
a good, long look at her real father, and as she gazed at him standing there, we
could witness how her emotions shifted between terror and a deep sense of compassion
for him. She tearfully reflected on how difficult his life had been—how, as a child
during World War II, he had seen people beheaded; how he had been forced to eat
rotten fish infested with maggots. Structures promote one of the essential
conditions for deep therapeutic change: a trancelike state in which multiple
realities can live side by side—past and present, knowing that you’re an adult
while feeling the way you did as a child, expressing your rage or terror to someone
who feels like your abuser while being fully aware that you are talking to Scott,
who is nothing like your real father, and experiencing simultaneously the complex
emotions of loyalty, tenderness, rage, and longing that kids feel with their
parents.

As Maria began to speak about their
relationship when she was a little girl, I continued to mirror her expressions. Her
father had brutalized her mother, she said. He was relentlessly critical of her
diet, her body, her housekeeping, and she was always afraid for her mother when he
berated her. Maria described her mother as loving and warm; she could not have
survived without her. She would always be there to comfort Maria after her father
lashed out at her, but she didn’t do anything to protect her children from
their father’s rage. “I think my mom had a lot of fear herself. I have a
sense that she didn’t protect us because she felt trapped.”

At this point I suggested that it was
time to call Maria’s real mother into the room. Maria scanned the group and
smiled brightly as she asked Kristin, a blonde, Scandinavian-looking artist, to play
the part of her real mother. Kristin accepted in the formal words of the structure:
“I enroll as your real mother, who was warm and loving and without whom you
would not have survived but who failed to protect you from your abusive
father.” Maria had her sit on a pillow to her right, much closer than her real
father.

I encouraged Maria to look at Kristin
and then I asked, “So what happens when you look at her?” Maria angrily
said, “Nothing.” “A witness would see how you stiffen as you look
at your real mom and angrily say that you feel nothing,” I noted. After a long
silence I asked again, “So what happens now?” Maria looked slightly more collapsed and repeated,
“Nothing.” I asked her, “Is there something you want to say to
your mom?” Finally Maria said, “I know you did the best you
could,” and then, moments later: “I wanted you to protect me.”
When she began to cry softly, I asked her, “What is happening inside?”
“Holding my chest, my heart feels like it is pounding really hard,”
Maria said. “My sadness goes out to my mom; how incapable she was of standing
up to my father and protecting us. She just shuts down, pretending
everything’s okay, and in her mind it probably is, and that makes me mad
today. I want to say to her: ‘Mom, when I see you react to dad when he is
being mean … when I see your face, you look disgusted and I don’t
know why you don’t say, “Fuck off.” You don’t know how to
fight—you are such a pushover—there is a part of you that is not good and not alive.
I don’t even know what I want you to say. I just want you to be
different—nothing you do is right, like you accept everything when it is totally not
okay.’” I noted, “A witness would see how fierce you are as you
want your mother to stand up to your dad.” Maria then talked about how she
wanted her mother to run off with the kids and take them away from her terrifying
father.

I then suggested enrolling another group
member to represent her ideal mother. Maria scanned the room again and chose Ellen,
a therapist and martial artist. Maria placed her on a pillow to her right between
her real mother and herself and asked Ellen to put her arm around her. “What
do you want your ideal mother to say to your dad?” I asked. “I want her
to say, ‘If you are going to talk like that, I am going to leave you and take
the kids,’” she answered. “‘We are not going to sit here and
listen to this shit.’” Ellen repeated Maria’s words. Then I asked:
“What happens now?” Maria responded: “I like it. I have a little
pressure in my head. My breath is free. I have a subtle energetic dance in my body
now. Sweet.” “A witness can see how delighted you are when you hear your
mother saying that she is not taking this shit from your dad anymore and that she
will take you away from him,” I told her. Maria began to sob and said,
“I would have been able to be a safe, happy little girl.” Out of the
corner of my eye I could see several group members weeping silently—the possibility
of growing up safe and happy clearly resonated with their own longings.

After a while I suggested that it was
time to summon Maria’s ideal father. I could clearly see the delight in
Maria’s eyes as she scanned the group, imagining her ideal father. She finally
chose Danny. I gave him his script, and he gently told her: “I enroll as your
ideal father, who would have loved you and cared for you and who would not have
terrified you.” Maria instructed him to take a seat near her on her left and
beamed. “My healthy mom and dad!” she exclaimed. I responded: “Allow yourself to
feel that joy as you look at an ideal dad who would have cared for you.” Maria
cried, “It’s beautiful,” and threw her arms around Danny, smiling
at him through her tears. “I am remembering a really tender moment with my
dad, and that is what this feels like. I would love to have my mom next to me
too.” Both ideal parents tenderly responded and cradled her. I left them there
for a while so that they could fully internalize the experience.

We finished with Danny saying: “If
I had been your ideal dad back then, I would have loved you just like this and not
have inflicted my cruelty,” while Ellen added, “If I had been your ideal
mom, I would have stood up for you and me and protected you and not let any harm
come to you.” All the characters then made final statements, deenrolling from
the roles they had played, and formally resumed being themselves.

RESCRIPTING YOUR LIFE

Nobody grows up under ideal
circumstances—as if we even know what ideal circumstances are. As my late friend
David Servan-Schreiber once said: every life is difficult in its own way. But we do
know that, in order to become self-confident and capable adults, it helps enormously
to have grown up with steady and predictable parents; parents who delighted in you,
in your discoveries and explorations; parents who helped you organize your comings
and goings; and who served as role models for self-care and getting along with other
people.

Defects in any of these areas are likely
to manifest themselves later in life. A child who has been ignored or chronically
humiliated is likely to lack self-respect. Children who have not been allowed to
assert themselves will probably have difficulty standing up for themselves as
adults, and most grown-ups who were brutalized as children carry a smoldering rage
that will take a great deal of energy to contain.

Our relationships will suffer as well.
The more early pain and deprivation we have experienced, the more likely we are to
interpret other people’s actions as being directed against us and the less
understanding we will be of their struggles, insecurities, and concerns. If we
cannot appreciate the complexity of their lives, we may see anything they do as a
confirmation that we are going to get hurt and disappointed.

In the chapters on the biology of trauma
we saw how trauma and abandonment disconnect people from their body as a source of
pleasure and comfort, or even as a part of themselves that needs care and
nurturance. When we cannot rely on our
body to signal safety or warning and instead feel chronically overwhelmed by
physical stirrings, we lose the capacity to feel at home in our own skin and, by
extension, in the world. As long as their map of the world is based on trauma,
abuse, and neglect, people are likely to seek shortcuts to oblivion. Anticipating
rejection, ridicule, and deprivation, they are reluctant to try out new options,
certain that these will lead to failure. This lack of experimentation traps people
in a matrix of fear, isolation, and scarcity where it is impossible to welcome the
very experiences that might change their basic worldview.

This is one reason the highly structured
experiences of psychomotor therapy are so valuable. Participants can safely project
their inner reality into a space filled with real people, where they can explore the
cacophony and confusion of the past. This leads to concrete aha moments: “Yes,
that is what it was like. That is what I had to deal with. And that is what it would
have felt like back then if I had been cherished and cradled.” Acquiring a
sensory experience of feeling treasured and protected as a three-year-old in the
trancelike container of a structure allows people to rescript their inner
experience, as in “I can spontaneously interact with other people without
having to be afraid of being rejected or getting hurt.”

Structures harness the extraordinary
power of the imagination to transform the inner narratives that drive and confine
our functioning in the world. With the proper support the secrets that once were too
dangerous to be revealed can be disclosed not just to a therapist, a latter-day
father confessor, but, in our imagination, to the people who actually hurt and
betrayed us.

The three-dimensional nature of the
structure transforms the hidden, the forbidden, and the feared into visible,
concrete reality. In this it is somewhat similar to IFS, which we explored in the
previous chapter. IFS calls forth the split-off parts that you created in order to
survive and enables you to identify and talk with them, so that your undamaged Self
can emerge. In contrast, a structure creates a three-dimensional image of whom and
what you had to deal with and gives you a chance to create a different outcome.

Most people are hesitant to go into past
pain and disappointment—it only promises to bring back the intolerable. But as they
are mirrored and witnessed, a new reality begins to take shape. Accurate mirroring
feels completely different from being ignored, criticized, and put down. It gives
you permission to feel what you feel and know what you know—one of
the essential foundations of recovery.

Trauma causes people to remain stuck in
interpreting the present in light of an unchanging past. The scene you re-create in
a structure may or may not be precisely
what happened, but it represents the structure of your inner world: your internal
map and the hidden rules that you have been living by.

DARING TO TELL THE TRUTH

I recently led another group structure
with a twenty-six-year-old man named Mark, who at age thirteen had accidentally
overheard his father having phone sex with his aunt, his mother’s sister. Mark
felt confused, embarrassed, hurt, betrayed, and paralyzed by this knowledge, but
when he tried to talk with his father about it, he was met with rage and denial: he
was told that he had a filthy imagination and accused of trying to break up the
family. Mark never dared to tell his mom, but henceforth the family secrets and
hypocrisy contaminated every aspect of his home life and gave him a pervasive sense
that nobody could be trusted. After school, he spent his isolated adolescence
hanging around neighborhood basketball courts or in his room watching TV. When he
was twenty-one his mother died—of a broken heart, Mark says—and his father married
the aunt. Mark was not invited to either the funeral or the wedding.

Secrets like these become inner
toxins—realities that you are not allowed to acknowledge to yourself or to others
but that nevertheless become the template of your life. I knew none of this history
when Mark joined the group, but he stood out by his emotional distance, and during
check-ins he acknowledged that he felt separated from everyone by a dense fog. I was
quite worried about what would be revealed once we started to look behind his
frozen, expressionless exterior.

When I invited Mark to talk about his
family, he said a few words and then seemed to shut down even more. So I encouraged
him to ask for a “contact figure” to support him. He chose a
white-haired group member, Richard, and placed Richard on a pillow next to him,
touching his shoulder. Then, as he began to tell his story, Mark placed Joe, as his
real father, ten feet in front of him, and directed Carolyn, representing his
mother, to crouch in a corner with her face hidden. Mark next asked Amanda to play
his aunt, telling her to stand defiantly to one side, arms crossed over her
chest—representing all the calculating, ruthless, and devious women who are after
men.

Surveying the tableau he had created,
Mark sat up straight, eyes wide open; clearly the fog had lifted. I said: “A
witness can see how startled you are seeing what you had to deal with.” Mark
nodded appreciatively and remained silent and somber for some time. Then, looking at
his “father,” he burst out:
“You asshole, you hypocrite, you ruined my life.” I invited Mark to tell
his “father” all the things that he had wanted to tell him but never
could. A long list of accusations followed. I directed the “father” to
respond physically as if he had been punched, so that Mark could see that that his
blows had landed. It did not surprise me when Mark spontaneously said that
he’d always worried that his rage would get out of control and that this fear
had kept him from standing up for himself in school, at work, and in other
relationships.

After Mark had confronted his
“father,” I asked if he would like Richard to assume a new role: that of
his ideal father. I instructed Richard to look Mark directly in the eye and to say:
“If I had been your ideal father back then, I would have listened to you and
not accused you of having a filthy imagination.” When Richard repeated this,
Mark started to tremble. “Oh my God, life would have been so different if I
could have trusted my father and talked about what was going on. I could have
had a father.” I then told Richard to say: “If I had been
your ideal father back then, I would have welcomed your anger and you would have had
a father you could have trusted.” Mark visibly relaxed and said that would
have made all the difference in the world.

Then Mark addressed the stand-in for his
aunt. The group was visibly stunned as he unleashed a torrent of abuse on her:
“You conniving whore, you backstabber. You betrayed your sister and ruined her
life. You ruined our family.” After he was done, Mark started to sob. He then
said he’d always been deeply suspicious of any woman who showed an interest in
him. The remainder of the structure took another half hour, in which we slowly set
up conditions for him to create two new women: the ideal aunt, who did not betray
her sister but who helped support their isolated immigrant family, and the ideal
mother, who kept her husband’s interest and devotion and so did not die of
heartbreak. Mark ended the structure quietly surveying the scene he had created with
a contented smile on his face.

For the remainder of the workshop Mark
was an open and valuable member of the group, and three months later he sent me an
e-mail saying that this experience had changed his life. He had recently moved in
with his first girlfriend, and although they’d had some heated discussions
about their new arrangement, he’d been able to take in her point of view
without clamming up defensively, going back to his fear or rage, or feeling that she
was trying to pull a fast one. He was amazed that he felt okay disagreeing with her
and that he was able to stand up for himself. He then asked for the name of a
therapist in his community to help with the huge changes he was making in his life,
and I fortunately had a colleague I could refer him to.

ANTIDOTES TO PAINFUL MEMORIES

Like the model mugging classes that I
discussed in chapter 13, the structures in
psychomotor therapy hold out the possibility of forming virtual memories that live
side by side with the painful realities of the past and provide sensory experiences
of feeling seen, cradled, and supported that can serve as antidotes to memories of
hurt and betrayal. In order to change, people need to become viscerally familiar
with realities that directly contradict the static feelings of the frozen or
panicked self of trauma, replacing them with sensations rooted in safety, mastery,
delight, and connection. As we saw in the chapter on EMDR, one of the functions of
dreaming is to create associations in which the frustrating events of the day are
interwoven with the rest of one’s life. Unlike our dreams,
psychomotor structures are still subject to the laws of physics, but they too can
reweave the past.

Of course we can never undo what
happened, but we can create new emotional scenarios intense and real enough to
defuse and counter some of those old ones. The healing tableaus of structures offer
an experience that many participants have never believed was possible for them: to
be welcomed into a world where people delight in them, protect them, meet their
needs, and make you feel at home.

CHAPTER 19

Rewiring the Brain:
Neurofeedback

Is it a fact—or have I dreamt it—that by means
of electricity, the world of matter has become a great nerve, vibrating thousands of
miles in a breathless point of time?

—Nathaniel Hawthorne

The faculty of voluntarily bringing back a
wandering attention, over and over again, is the very root of the judgment,
character, and will.

—William James

The summer after my first year of medical
school, I worked as a part-time research assistant in Ernest Hartmann’s sleep
laboratory at Boston State Hospital. My job was to prepare and monitor the study
participants and to analyze their EEG—electroencephalogram, or brain wave—tracings.
Subjects would show up in the evening; I would paste an array of wires onto their
scalps and another set of electrodes around their eyes to register the rapid eye
movements that occur during dreaming. Then I would walk them to their bedrooms, bid
them good night, and start the polygraph, a bulky machine with thirty-two pens that
transmitted their brain activity onto a continuous spool of paper.

Even though our subjects were fast
asleep, the neurons in their brains kept up their frenzied internal communication,
which was transmitted to the polygraph throughout the night. I’d settle down
to pore over the previous night’s EEGs, stopping from time to time to pick up
baseball scores on my radio, and use the
intercom to wake subjects whenever the polygraph showed a REM sleep cycle. I would
ask what they had dreamed about and write down what they reported and then in the
morning help them fill out a questionnaire about sleep quality and send them on
their way.

Those quiet nights at Hartmann’s
lab documented a great deal about REM sleep and contributed to building the basic
understanding of sleep processes, which paved the way for the crucial discoveries
that I discussed in chapter 15. However, until
recently, the long-standing hope that the EEG would help us better understand how
electrical brain activity contributes to psychiatric problems remained largely
unrealized.

MAPPING THE ELECTRICAL CIRCUITS OF
THE BRAIN

Before the advent of the pharmacological
revolution, it was widely understood that brain activity depends on both chemical
and electrical signals. The subsequent dominance of pharmacology almost obliterated
interest in the electrophysiology of the brain for several decades.

The first recording of the brain’s
electrical activity was made in 1924 by the German psychiatrist Hans Berger. This
new technology was initially met with skepticism and ridicule by the medical
establishment, but electroencephalography gradually became an indispensable tool for
diagnosing seizure activity in patients with epilepsy. Berger discovered that
different brain-wave patterns reflected different mental activities. (For example,
trying to solve a math problem resulted in bursts at a moderately fast frequency
band known as beta.) He hoped that eventually science would be able to correlate
different psychiatric problems with specific EEG irregularities. This expectation
was fueled by the first reports on EEG patterns in “behavior problem
children” in 1938.[1] Most of these hyperactive and impulsive children had
slower-than-normal waves in their frontal lobes. This finding has been reproduced
innumerable times since then, and in 2013 slow-wave prefrontal activity was
certified by the Food and Drug Administration as a biomarker for ADHD. Slow frontal
lobe electrical activity explains why these kids have poor executive functioning:
Their rational brains lack proper control over their emotional brains, which also
occurs when abuse and trauma have made the emotional centers hyperalert to danger
and organized for fight or flight.

Early in my career I also hoped that the
EEG might help us to make better diagnoses, and between 1980 and 1990 I sent many of
my patients to get EEGs to determine if
their emotional instability was rooted in neurological abnormalities. The reports
usually came back with the phrase: “nonspecific temporal lobe
abnormalities.”[2] This told me very little, and because at that time the only way
we could change these ambiguous patterns was with drugs that had more side effects
than benefits, I gave up doing routine EEGs on my patients.

Then, in 2000, a study by my friend
Alexander McFarlane and his associates (researchers in Adelaide, Australia)
rekindled my interest, as it documented clear differences in information processing
between traumatized subjects and a group of “normal” Australians. The
researchers used a standardized test called “the oddball paradigm” in
which subjects are asked to detect the item that doesn’t fit in a series of
otherwise related images (like a trumpet in a group of tables and chairs). None of
the images was related to trauma.

In the “normal” group key
parts of the brain worked together to produce a coherent pattern of filtering,
focus, and analysis. (See left image below.) In contrast, the brain waves of
traumatized subjects were more loosely coordinated and failed to come together into
a coherent pattern. Specifically, they did not generate the brain-wave pattern that
helps people pay attention on the task at hand by filtering out irrelevant
information (the upward curve, labeled N200). In addition, the core
information-processing configuration of the brain (the downward peak, P300) was
poorly defined; the depth of the wave determines how well we are able to take in and
analyze new data. This was important new information about how traumatized people
process non-traumatic information that has profound implications for understanding
day-to-day information processing. These brain-wave patterns could explain why so
many traumatized people have trouble learning from experience and fully engaging in
their daily lives. Their brains are not organized to pay careful attention to what
is going on in the present moment.

Normal versus PTSD. Patterns
of attention. Milliseconds after the brain is presented with input it starts
organizing the meaning of the incoming information. Normally, all regions of the
brain collaborate in a synchronized pattern (left), while the brainwaves in PTSD are
less well coordinated; the brain has trouble filtering out irrelevant information,
and has problems attending to the stimulus at hand.

Sandy McFarlane’s study reminded me
of what Pierre Janet had said back in 1889: “Traumatic stress is an illness of
not being able to be fully alive in the present.” Years later, when I saw the
movie The Hurt Locker, which dealt with the experiences of soldiers in
Iraq, I immediately recalled Sandy’s study: As long as they were coping with
extreme stress, these men performed with pinpoint focus; but back in civilian life
they were overwhelmed having to make simple choices in a supermarket. We are now
seeing alarming statistics about the number of returning combat veterans who enroll
in college on the GI Bill but do not complete their degrees. (Some estimates are
over 80 percent.) Their well-documented problems with focusing and attention are
surely contributing to these poor results.

McFarlane’s study clarified a
possible mechanism for the lack of focus and attention in PTSD, but it also
presented a whole new challenge: Was there any way to change these dysfunctional
brain-wave patterns? It was seven years before I learned that there might be ways to
do that.

In 2007 I met Sebern Fisher at a
conference on attachment-disordered children. Sebern was the former clinical
director of a residential treatment center for severely disturbed adolescents, and
she told me that she’d been using neurofeedback in her private practice for
about ten years. She showed me before-and-after drawings made by a ten-year-old.
This boy had had such severe temper tantrums, learning disabilities, and overall
difficulties with self-organization that he could not be handled in school.[3]

His first family portrait (on the left
opposite), drawn before treatment started, was at the developmental level of a
three-year-old. Less than five weeks later, after twenty sessions of neurofeedback,
his tantrums had decreased and his drawing showed a marked improvement in
complexity. Ten weeks and another twenty sessions later, his drawing took another
leap in complexity and his behavior normalized.

I had never come across a treatment that
could produce such a dramatic change in mental functioning in so brief a period of
time. So when Sebern offered to give me a neurofeedback demonstration, I eagerly
accepted.

SEEING THE SYMPHONY OF THE
BRAIN

At Sebern’s office in Northampton,
Massachusetts, she showed me her neurofeedback equipment—two desktop computers and a
small amplifier—and some of the data she had collected. She then pasted one
electrode on each side of my skull and
another on my right ear. Soon the computer in front of me was displaying rows of
brain waves like the ones I’d seen on the sleep-lab polygraph three decades
earlier. Sebern’s tiny laptop could detect, record, and display the electrical
symphony of my brain faster and more precisely than what had probably been a million
dollars’ worth of equipment in Hartmann’s lab.

From stick figures to clearly defined
human beings. After four months of neurofeedback, a ten-year-old
boy’s family drawings show the equivalent of six years of mental
development.

As Sebern explained, feedback provides
the brain with a mirror of its own function: the oscillations and rhythms that
underpin the currents and crosscurrents of the mind. Neurofeedback nudges the brain
to make more of some frequencies and less of others, creating new patterns that
enhance its natural complexity and its bias toward self-regulation.[4] “In
effect,” she told me, “we may be freeing up innate but stuck oscillatory
properties in the brain and allowing new ones to develop.”

Sebern adjusted some settings, “to
set the reward and inhibit frequencies,” as she explained, so that the
feedback would reinforce selected brain-wave patterns while discouraging others. Now
I was looking at something like a video game featuring three spaceships of different
colors. The computer was emitting irregular tones, and the spaceships were moving
quite randomly. I discovered that when I blinked my eyes they stopped, and when I
calmly stared at the screen they moved in tandem, accompanied by regular beeps.
Sebern then encouraged me to make the green spaceship move ahead of the
others. I leaned forward to concentrate, but the harder I tried, the
more the green spaceship fell behind. She smiled and told me that I’d do much
better if I’d just relax and let my brain take in the feedback that the
computer was generating. So I sat back, and after a while the tones grew steadier
and the green spaceship started pulling ahead of the others. I felt calm and
focused—and my spaceship was winning.

In some ways neurofeedback is similar to
watching someone’s face during a conversation. If you see smiles or slight
nods, you’re rewarded, and you go on telling your story or making your point.
But the moment your conversation partner looks bored or shifts her gaze,
you’ll start to wrap up or change the topic. In neurofeedback the reward is a
tone or movement on the screen instead of a smile, and the inhibition is far more
neutral than a frown—it’s simply an undesired pattern.

Next Sebern introduced another feature
of neurofeedback: its ability to track circuitry in specific parts of the brain. She
moved the electrodes from my temples to my left brow, and I started to feel sharp
and focused. She told me she was rewarding beta waves in my frontal cortex, which
accounted for my alertness. When she moved the electrodes to the crown of my head, I
felt more detached from the computer images and more aware of the sensations in my
body. Afterward she showed me a summary graph that recorded how my brain waves had
changed as I experienced subtle shifts in my mental state and physical
sensations.

How could neurofeedback be used to help
to treat trauma? As Sebern explained: “With neurofeedback we hope to intervene
in the circuitry that promotes and sustains states of fear and traits of
fearfulness, shame, and rage. It is the repetitive firing of these circuits that
defines trauma.” Patients need help to change the habitual brain patterns
created by trauma and its aftermath. When the fear patterns relax, the brain becomes
less susceptible to automatic stress reactions and better able to focus on ordinary
events. After all, stress is not an inherent property of events themselves—it is a
function of how we label and react to them. Neurofeedback simply stabilizes the
brain and increases resiliency, allowing
us to develop more choices in how to respond.

THE BIRTH OF NEUROFEEDBACK

Neurofeedback was not a new technology in
2007. As early as the late 1950s University of Chicago psychology professor Joe
Kamiya, who was studying the phenomenon of internal perception, had discovered that
people could learn through feedback to tell when they were producing alpha waves,
which are associated with relaxation. (It took some subjects only four days to reach
100 percent accuracy.) He then demonstrated that they could also enter voluntarily
into an alpha state in response to a simple sound cue.

In 1968 an article about Kamiya’s
work was published in the popular magazine Psychology Today, and the idea
that alpha training could relieve stress and stress-related conditions became widely
known.[5]
The first scientific work showing that neurofeedback could have an effect on
pathological conditions was done by Barry Sterman at UCLA. The National Aeronautics
and Space Administration had asked Sterman to study the toxicity of a rocket fuel,
monomethylhydrazine (MMH), which was known to cause hallucinations, nausea, and
seizures. Sterman had previously trained some cats to produce a specific EEG
frequency known as the sensorimotor rhythm. (In cats this alert, focused state is
associated with waiting to be fed.) He discovered that while his ordinary lab cats
developed seizures after exposure to MMH, the cats that had received neurofeedback
did not. The training had somehow stabilized their brains.

In 1971 Sterman attached his first human
subject, twenty-three-year-old Mary Fairbanks, to a neurofeedback device. She had
suffered from epilepsy since the age of eight, with grand mal seizures two or more
times a month. She trained for an hour a day twice a week. At the end of three
months she was virtually seizure free. Sterman subsequently received a grant from
the National Institutes of Health to conduct a more systematic study, and the
impressive results were published in the journal Epilepsia in 1978.[6]

This period of experimentation and huge
optimism about the potential of the human mind came to an end in the middle 1970s
with newly discovered psychiatric drugs. Psychiatry and brain science adopted a
chemical model of mind and brain, and other treatment approaches were relegated to
the back burner.

Since then the field of neurofeedback
has grown by fits and starts, with much of the scientific groundwork being done in
Europe, Russia, and Australia. Even
though there are about ten thousand neurofeedback practitioners in the United
States, the practice has not been able to garner the research funding necessary to
gain widespread acceptance. One reason may be that there are multiple competing
neurofeedback systems; another is that the commercial potential is limited. Only a
few applications are covered by insurance, which makes neurofeedback expensive for
consumers and prevents practitioners from amassing the resources necessary to do
large-scale studies.

FROM A HOMELESS SHELTER TO THE
NURSING STATION

Sebern had arranged for me to speak with
three of her patients. All told remarkable stories, but as I listened to
twenty-seven-year-old Lisa, who was studying nursing at a nearby college, I felt
myself truly awakening to the stunning potential of this treatment. Lisa possessed
the greatest single resilience factor humans can have: She was an appealing
person—engaging, curious, and obviously intelligent. She made great eye contact, and
she was eager to share what she had learned about herself. Best of all, like so many
survivors I’ve known, she had a wry sense of humor and a delicious take on
human folly.

Based on what I knew about her
background, it was a miracle that she was so calm and self-possessed. She had spent
years in group homes and mental hospitals, and she was a familiar presence in the
emergency rooms of western Massachusetts—the girl who regularly arrived by
ambulance, half dead from prescription drug overdoses or bloody from self-inflicted
wounds.

Here is how she began her story:
“I used to envy the kids who knew what would happen when their parents got
drunk. At least they could predict the havoc. In my home there was no pattern.
Anything could set my mother off—eating dinner, watching TV, coming home from
school, getting dressed—and I never knew what she was going to do or how she would
hurt me. It was so random.”

Her father had abandoned the family when
Lisa was three years old, leaving her at the mercy of her psychotic mother.
“Torture” is not too strong a word to describe the abuse she endured.
“I lived up in the attic room,” she told me, “and there was
another room up there where I would go and piss on the carpet because I was too
scared to go downstairs to the bathroom. I would take all the clothes off my dolls
and drive pencils into them and put them up in my window.”

When she was twelve years old, Lisa ran
away from home and was picked up by the police and returned. After she ran away
again, child protective services stepped
in, and she spent the next six years in mental hospitals, shelters, group homes,
foster families, and on the street. No placement lasted, because Lisa was so
dissociated and self-destructive that she terrified her caretakers. She would attack
herself or destroy furniture and afterward she would not remember what she had done,
which earned her a reputation as a manipulative liar. In retrospect, Lisa told me,
she simply lacked the language to communicate what was going on with her.

When she turned eighteen, she
“matured out” of child protective services and started an independent
life, one without family, education, money, or skills. But shortly after discharge
she ran into Sebern, who had just acquired her first neurofeedback equipment and
remembered Lisa from the residential treatment center where she had once worked.
She’d always had a soft spot for this lost girl, and she invited Lisa to try
out her new gizmo.

As Sebern recalled: “When Lisa
first came to see me, it was fall. She walked around with a vacant stare, carrying a
pumpkin wherever she went. There just wasn’t a there there. I wasn’t
ever sure that I had gotten to any organizing self.” Any form of talk therapy
was impossible for Lisa. Whenever Sebern asked her about anything stressful, she
would shut down or go into a panic. In Lisa’s words: “Every time we
tried to talk about what had happened to me growing up, I would have a breakdown. I
would wake up with cuts and burns and I wouldn’t be able to eat. I
wouldn’t be able to sleep.”

Her sense of terror was omnipresent:
“I was afraid all the time. I didn’t like to be touched. I was always
jumpy and nervous. I couldn’t close my eyes if another person was around.
There was no convincing me that someone wasn’t going to kick me the second I
closed my eyes. That makes you feel crazy. You know you’re in a room with
someone you trust, you know intellectually that nothing’s going to happen to
you, but then there’s the rest of your body and you can’t ever relax. If
someone put their arm around me, I would just check out.” She was stuck in a
state of inescapable shock.

Lisa recalled dissociating when she was
a little girl, but things got worse after puberty: “I started waking up with
cuts, and people at school would know me by different names. I couldn’t have a
steady boyfriend because I would date other guys when I was dissociated and then not
remember. I was blacking out a lot and opening my eyes into some pretty
strange situations.” Like many severely traumatized people, Lisa could not
recognize herself in a mirror.[7] I had never heard anyone describe so
articulately what it was like to lack a continuous sense of self.

There was no one to confirm her reality.
“When I was seventeen and living
in the group home for severely disturbed adolescents, I cut myself up really badly
with the lid of a tin can. They took me to the emergency room, but I couldn’t
tell the doctor what I had done to cut myself—I didn’t have any memory of it.
The ER doctor was convinced that dissociative identity disorder didn’t
exist. … A lot of people involved in mental health tell you it
doesn’t exist. Not that you don’t have it, but that it doesn’t
exist.”

The first thing Lisa did after she aged
out of her residential treatment program was to go off her medications:
“This doesn’t work for everybody,” she acknowledged, “but it
turned out to be personally the right choice. I know people who need meds, but that
was not the case for me. After going off them and starting neurofeedback, I became
much clearer.”

When she invited Lisa to do
neurofeedback, Sebern had little idea what to expect, as Lisa would be the first
dissociative patient she tried it on. They met twice a week and started by rewarding
more coherent brain patterns in the right temporal lobe, the fear center of the
brain. After a few weeks Lisa noticed she was wasn’t as uptight around people,
and she no longer dreaded the basement laundry room in her building. Then came a
bigger breakthrough: She stopped dissociating. “I’d always had a
constant hum of low-level conversations in my head,” she recalled. “I
was scared I was schizophrenic. After half a year of neurofeedback I stopped hearing
those noises. I integrated, I guess. Everything just came together.”

As Lisa developed a more continuous
sense of self, she became able to talk about her experiences: “I now can
actually talk about things like my childhood. For the first time I started being
able to do therapy. Up till then I didn’t have enough distance and I
couldn’t calm down enough. If you’re still in it, it’s hard to
talk about it. I wasn’t able to attach in the way that you need to attach and
open up in the way that you need to open up in order to have any type of
relationship with a therapist.” This was a stunning revelation: So many
patients are in and out of treatment, unable to meaningfully connect because they
are still “in it.” Of course, when people don’t know who they are,
they can’t possibly see the reality of the people around them.

Lisa went on: “There was so much
anxiety around attachment. I would go into a room and try to memorize every possible
way to get out, every detail about a person. I was trying desperately to keep track
of everything that could hurt me. Now I know people in a different way. It’s
not based on memorizing them out of fear. When you’re not afraid of being
hurt, you can know people differently.”

This articulate young woman had emerged
from the depths of despair and confusion
with a degree of clarity and focus I had never seen before. It was clear that we had
to explore the potential of neurofeedback at the Trauma Center.

GETTING STARTED IN
NEUROFEEDBACK

First we had to decide which of five
different existing neurofeedback systems to adopt, and then find a long weekend to
learn the principles and practice on one another.[8] Eight staff members and three trainers
volunteered their time to explore the complexities of EEGs, electrodes, and
computer-generated feedback. On the second morning of the training, when I was
partnered with my colleague Michael, I placed an electrode on the right side of his
head, directly over the sensorimotor strip of his brain, and rewarded the frequency
of eleven to fourteen hertz. Shortly after the session ended, Michael asked for the
attention of the group. He’d just had a remarkable experience, he told us. He
had always felt somewhat on edge and unsafe in the presence of other people, even
colleagues like us. Although nobody seemed to notice—he was, after all, a
well-respected therapist—he lived with a chronic, gnawing sense of danger. That
feeling was now gone, and he felt safe, relaxed, and open. Over the next three years
Michael emerged from his habitual low profile to challenge the group with his
insights and opinions, and he became one of the most valuable contributors to our
neurofeedback program.

With the help of the ANS Foundation we
started our first study with a group of seventeen patients who had not responded to
previous treatments. We targeted the right temporal area of the brain, the location
that our early brain-scan studies (described in chapter
3)[9]
had shown to be excessively activated during traumatic stress, and gave them twenty
neurofeedback sessions over ten weeks.

Because most of these patients suffered
from alexithymia, it was not easy for them to report their response to the
treatments. But their actions spoke for them: They consistently showed up on time
for their appointments, even if they had to drive through snowstorms. None of them
dropped out, and at the end of the full twenty sessions, we could document
significant improvements not only in their PTSD scores,[10] but also in their
interpersonal comfort, emotional balance, and self-awareness.[11] They were less frantic,
they slept better, and they felt calmer and more focused.

In any case, self-reports can be
unreliable; objective changes in behavior are much better indicators of how well
treatment works. The first patient I treated with neurofeedback was a good example.
He was a professional man in his early fifties who defined himself as heterosexual, but he
compulsively sought homosexual contact with strangers whenever he felt abandoned and
misunderstood. His marriage had broken up around this issue, and he had become HIV
positive; he was desperate to gain control over his behavior. During a previous
therapy he had talked extensively about his sexual abuse by an uncle at around the
age of eight. We assumed that his compulsion was related to that abuse, but making
that connection had made no difference in his behavior. After more than a year of
regular psychotherapy with a competent therapist, nothing had changed.

A week after I started to train his
brain to produce slower waves in his right temporal lobe, he had a distressing
argument with a new girlfriend, and instead of going to his habitual cruising spot
to find sex he decided to go fishing. I attributed that response to chance. However,
over the next ten weeks, in the midst of his tumultuous relationship, he continued
to find solace in fishing and began to renovate a lakeside cabin. When we skipped
three weeks of neurofeedback because of our vacations schedules, his compulsion
suddenly returned, suggesting that his brain had not yet stabilized its new pattern.
We trained for six more months, and now, four years later, I see him about every six
months for a checkup. He has felt no further impulse to engage in his dangerous
sexual activities.

How did his brain come to derive comfort
from fishing rather than from compulsive sexual behavior? At this point we simply
don’t know. Neurofeedback changes brain connectivity patterns; the mind
follows by creating new patterns of engagement.

BRAIN-WAVE BASICS FROM SLOW TO
FAST

Each line on an EEG charts the activity
in a different part of the brain: a mixture of different rhythms, ranged on a scale
from slow to fast.[12] The EEG consists of measurements of varying heights (amplitude)
and wavelengths (frequency). Frequency refers to the number of times a waveform
rises and falls in one second, and it is measured in hertz (Hz), or cycles per
second (cps). Every frequency on the EEG is relevant to understanding and treating
trauma, and the basics are relatively easy to grasp.

Delta waves, the slowest frequencies
(2–5 Hz) are seen most often during sleep. The brain is in an idling state, and the
mind is turned inward. If people have too much slow-wave activity while
they’re awake, their thinking is foggy and they exhibit poor judgment and poor
impulse control. Eighty percent of children with ADHD and many individuals diagnosed
with PTSD have excessive slow waves in their frontal lobes.

The Electroencephalogram
(EEG). While there is no typical signature for PTSD, many traumatized
people have sharply increased activity in the temporal lobes, as this patient does
(T_3, T_4, T_5). Neurofeedback can normalize these
abnormal brain patterns and thereby increase emotional stability.

THE RATE OF BRAINWAVE FIRING IS
RELATED TO OUR STATE OF AROUSAL

Dreaming speeds up brain waves. Theta
frequencies (5–8 Hz) predominate at the edge of sleep, as in the floating
“hypnopompic” state I described in chapter
15 on EMDR; they are also characteristic of hypnotic trance states. Theta
waves create a frame of mind unconstrained by logic or by the ordinary demands of
life and thus open the potential for making novel connections and associations. One
of the most promising EEG neurofeedback treatments for PTSD, alpha/theta training,
makes use of that quality to loosen frozen associations and facilitate new learning.
On the downside, theta frequencies also occur when we’re “out of
it” or depressed.

Alpha waves (8–12 Hz) are accompanied by
a sense of peace and calm.[13] They are familiar to anyone who has
learned mindfulness meditation. (A patient once told me that neurofeedback
worked for him “like meditation on steroids.”) I use alpha training most often in my
practice to help people who are either too numb or too agitated to achieve a state
of focused relaxation. Walter Reed National Military Medical Center recently
introduced alpha-training instruments to treat soldiers with PTSD, but at the time
of this writing the results are not yet available.

Beta waves are the fastest frequencies
(13–20 Hz). When they dominate, the brain is oriented to the outside world. Beta
enables us to engage in focused attention while performing a task. However, high
beta (over 20 Hz) is associated with agitation, anxiety, and body tenseness—in
effect, we are constantly scanning the environment for danger.

HELPING THE BRAIN TO FOCUS

Neurofeedback training can improve
creativity, athletic control, and inner awareness, even in people who already are
highly accomplished.[14] When we started to study neurofeedback, we discovered that
sports medicine was the only department in Boston University that had any
familiarity with the subject. One of my earliest teachers in brain physiology was
the sports psychologist Len Zaichkowsky, who soon left Boston to train the Vancouver
Canucks with neurofeedback.[15]

Neurofeedback has probably been studied
more thoroughly for performance enhancement than for psychiatric problems. In Italy
the trainer for the soccer club AC Milan used it to help players remain relaxed and
focused as they watched videos of their errors. Their increased mental and
physiological control paid off when several players joined the Italian team that won
the 2006 World Cup—and when AC Milan won the European championship the following
year.[16]
Neurofeedback was also included in the science and technology component of Own the
Podium, a $117 million, five-year plan engineered to help Canada dominate the 2010
Winter Olympics in Vancouver. The Canadians won the most gold medals and came in
third overall.

Musical performance has been shown to
benefit as well. A panel of judges from Britain’s Royal College of Music found
that students who were trained with ten sessions of neurofeedback by John Gruzelier
of the University of London had a 10 percent improvement in the performance of a
piece of music, compared with students who had not received neurofeedback. This
represents a huge difference in such a competitive field.[17]

Given its enhancement of focus,
attention, and concentration, it’s not surprising that neurofeedback drew the
attention of specialists in attention-deficit/hyperactivity disorder (ADHD). At
least thirty-six studies have shown that
neurofeedback can be an effective and time-limited treatment for ADHD—one
that’s about as effective as conventional drugs.[18] Once the brain has been
trained to produce different patterns of electrical communication, no further
treatment is necessary, in contrast to drugs, which do not change fundamental brain
activity and work only as long as the patient keeps taking them.

WHERE IS THE PROBLEM IN MY
BRAIN?

Sophisticated computerized EEG analysis,
known as the quantitative EEG (qEEG), can trace brain-wave activity millisecond by
millisecond, and its software can convert that activity into a color map that shows
which frequencies are highest or lowest in key areas of the brain.[19] The qEEG can also
show how well brain regions are communicating or working together. Several large
qEEG databases of both normal and abnormal patterns are available, which allows us
to compare a patient’s qEEG with those of thousands of other people with
similar issues. Last but not least, in contrast to fMRIs and related scans, the qEEG
is both relatively inexpensive and portable.

The qEEG provides compelling evidence of
the arbitrary boundaries of current DSM diagnostic categories. DSM labels for mental
illness are not aligned with specific patterns of brain activation. Mental states
that are common to many diagnoses, such as confusion, agitation, or feeling
disembodied, are associated with specific patterns on the qEEG. In general, the more
problems a patient has, the more abnormalities show up in the qEEG.[20]

Our patients find it very helpful to be
able to see the patterns of localized electrical activity in their brains. We can
show them the patterns that seem to be responsible for their difficulty focusing or
for their lack of emotional control. They can see why different brain areas need to
be trained to generate different frequencies and communication patterns. These
explanations help them shift from self-blaming attempts to control their behavior to
learning to process information differently.

As Ed Hamlin, who trained us in
interpreting the qEEG, recently wrote to me: “Many people respond to the
training, but the ones that respond best and quickest are those that can see how the
feedback is related to something they are doing. For example, if I’m
attempting to help someone increase their ability to be present, we can see how
they’re doing with it. Then the benefit really begins to accumulate. There is
something very empowering about having the experience of changing your brain’s
activity with your mind.”

HOW DOES TRAUMA CHANGE BRAIN
WAVES?

In our neurofeedback lab we see
individuals with long histories of traumatic stress who have only partially
responded to existing treatments. Their qEEGs show a variety of different patterns.
Often there is excessive activity in the right temporal lobe, the fear center of the
brain, combined with too much frontal slow-wave activity. This means that their
hyperaroused emotional brains dominate their mental life. Our research showed that
calming the fear center decreases trauma-based problems and improves executive
functioning. This is reflected not only in a significant decrease in patients’
PTSD scores but also in improved mental clarity and an increased ability to regulate
how upset they become in response to relatively minor provocations.[21]

Other traumatized patients show patterns
of hyperactivity the moment they close their eyes: Not seeing what is going on
around them makes them panic and their brain waves go wild. We train them to produce
more relaxed brain patterns. Yet another group overreacts to sounds and light, a
sign that the thalamus has difficulty filtering out irrelevant information. In those
patients we focus on changing communication patterns at the back of the brain.

While our center is focused on finding
optimal treatments for long-standing traumatic stress, Alexander McFarlane is
studying how exposure to combat changes previously normal brains. The Australian
Department of Defence asked his research group to measure the effects of deployment
to combat duty in Iraq and Afghanistan on mental and biological functioning,
including brain-wave patterns. In the initial phase McFarlane and his colleagues
measured the qEEG in 179 combat troops four months prior to and four months after
each successive deployment to the Middle East.

They found that the total number of
months in combat over a three-year period was associated with progressive decreases
in alpha power at the back of the brain. This area, which monitors the
state of the body and regulates such elementary processes as sleep and hunger,
ordinarily has the highest level of alpha waves of any region in the brain,
particularly when people close their eyes. As we have seen, alpha is associated with
relaxation. The decrease in alpha power in these soldiers reflects a state of
persistent agitation. At the same time the brain waves at the front of the brain,
which normally have high levels of beta, show a progressive slowing with each
deployment. The soldiers gradually develop frontal-lobe activity that resembles that
of children with ADHD, which interferes with their executive functioning and
capacity for focused attention.

The net effect is that arousal, which is
supposed to provide us with the energy needed to engage in day-to-day tasks, no
longer helps these soldiers to focus on
ordinary tasks. It simply makes them agitated and restless. At this stage of
McFarlane’s study, it is too early to know if any of these soldiers will
develop PTSD, and only time will tell to what degree these brains will readjust to
the pace of civilian life.

NEUROFEEDBACK AND LEARNING
DISABILITIES

Chronic abuse and neglect in childhood
interfere with the proper wiring of sensory-integration systems. In some cases this
results in learning disabilities, which include faulty connections between the
auditory and word-processing systems, and poor hand-eye coordination. As long as
they are frozen or explosive, it is difficult to see how much trouble the
adolescents in our residential treatment programs have processing day-to-day
information, but once their behavioral problems have been successfully treated,
their learning disabilities often become manifest. Even if these traumatized kids
could sit still and pay attention, many of them would still be handicapped by their
poor learning skills.[22]

Lisa described how trauma had interfered
with the proper wiring of basic processing functions. She told me she “always
got lost” going places, and she recalled having a marked auditory delay that
kept her from being able to follow the instructions from her teachers.
“Imagine being in a classroom,” she said, “and the teacher comes
in and says, ‘Good morning. Turn to page two-seventy-two. Do problems one to
five.’ If you’re even a fraction of a second off, it’s just a
jumble. It was impossible to concentrate.”

Neurofeedback helped her to reverse
these learning disabilities. “I learned to keep track of things; for example,
to read maps. Right after we started therapy, there was this memorable time when I
was going from Amherst to Northampton [less than ten miles] to meet Sebern. I was
supposed to take a couple of buses, but I ended up walking along the highway for a
couple miles. I was that disorganized—I couldn’t read the schedule; I
couldn’t keep track of the time. I was too jacked up and nervous, which made
me tired all the time. I couldn’t pay attention and keep it together. I just
couldn’t organize my brain around it.”

That statement defines the challenge for
brain and mind science: How can we help people learn to organize time and space,
distance and relationships, capacities that are laid down in the brain during the
first few years of life, if early trauma has interfered with their development?
Neither drugs nor conventional therapy have been shown to activate the
neuroplasticity necessary to bring those capacities online after the critical
periods have passed. Now is the time to study whether neurofeedback can succeed
where other interventions have failed.

ALPHA-THETA TRAINING

Alpha-theta training is a particularly
fascinating neurofeedback procedure, because it can induce the sorts of hypnagogic
states—the essence of hypnotic trance—that are discussed in chapter 15.[23] When theta waves predominate in the
brain, the mind’s focus is on the internal world, a world of free-floating
imagery. Alpha brain waves may act as a bridge from the external world to the
internal, and vice versa. In alpha-theta training these frequencies are alternately
rewarded.

The challenge in PTSD is to open the
mind to new possibilities, so that the present is no longer interpreted as a
continuous reliving of the past. Trance states, during which theta activity
dominates, can help to loosen the conditioned connections between particular stimuli
and responses, such as loud cracks signaling gunfire, a harbinger of death. A new
association can be created in which that same crack can come to be linked to Fourth
of July fireworks at the end of a day at the beach with loved ones.

In the twilight states fostered by
alpha/theta training, traumatic events may be safely reexperienced and new
associations fostered. Some patients report unusual imagery and/or deep insights
about their life; others simply become more relaxed and less rigid. Any state in
which people can safely experience images, feelings, and emotions that are
associated with dread and helplessness is likely to create fresh potential and a
wider perspective.

Can alpha-theta reverse hyperarousal
patterns? The accumulated evidence is promising. Eugene Peniston and Paul Kulkosky,
researchers at the VA Medical Center in Fort Lyon, Colorado, used neurofeedback to
treat twenty-nine Vietnam veterans with a twelve- to- fifteen-year history of
chronic combat-related PTSD. Fifteen of the men were randomly assigned to the EEG
alpha-theta training and fourteen to a control group that received standard medical
care, including psychotropic drugs and individual and group therapy. On average,
participants in both groups had been hospitalized more than five times for their
PTSD. The neurofeedback facilitated twilight states of learning by rewarding both
alpha and theta waves. As the men lay back in a recliner with their eyes closed,
they were coached to allow the neurofeedback sounds to guide them into deep
relaxation. They were also asked to use positive mental imagery (for example, being
sober, living confidently and happily) as they moved toward the trancelike
alpha-theta state.

This study, published in 1991, had one
of the best outcomes ever recorded for PTSD. The neurofeedback group had a
significant decrease in their PTSD symptoms, as well as in physical complaints,
depression, anxiety, and paranoia. After the treatment phase the veterans and their
family members were contacted monthly
for a period of thirty months. Only three of the fifteen neurofeedback-treated
veterans reported disturbing flashbacks and nightmares. All three chose to undergo
ten booster sessions; only one needed to return to the hospital for further
treatment. Fourteen out of fifteen were using significantly less medication.

In contrast, every vet in the comparison
group experienced an increase in PTSD symptoms during the follow-up period, and all
of them required at least two further hospitalizations. Ten of the comparison group
also increased their medication use.[24] This study has been replicated by
other researchers, but it has received surprisingly little attention outside the
neurofeedback community.[25]

NEUROFEEDBACK, PTSD, AND
ADDICTION

Approximately one-third to one-half of
severely traumatized people develop substance abuse problems.[26] Since the time of Homer,
soldiers have used alcohol to numb their pain, irritability, and depression. In one
recent study half of motor vehicle accident victims developed problems with drugs or
alcohol. Alcohol abuse makes people careless and thus increases their chances of
being traumatized again (although being drunk during an assault actually decreases
the likelihood of developing PTSD).

There is a circular relationship between
PTSD and substance abuse: While drugs and alcohol may provide temporary relief from
trauma symptoms, withdrawing from them increases hyperarousal, thereby intensifying
nightmares, flashbacks, and irritability. There are only two ways to end this
vicious cycle: by resolving the symptoms of PTSD with methods such as EMDR or by
treating the hyperarousal that is part of both PTSD and withdrawal from drugs or
alcohol. Drugs such as naltrexone are sometimes prescribed to reduce hyperarousal,
but this treatment helps in only some cases.

One of the first women I trained with
neurofeedback had a long-standing cocaine addiction, in addition to a horrendous
childhood history of sexual abuse and abandonment. Much to my surprise, her cocaine
habit cleared after the first two sessions and on follow-up five years later had not
returned. I had never seen anyone recover this quickly from severe drug abuse, so I
turned to the existing scientific literature for guidance.[27] Most of the studies on
this subject were done more than two decades ago; in recent years, very few
neurofeedback studies for the treatment of addiction have been published, at least
in the United States.

Between 75 percent and 80 percent of
patients who are admitted for detox and
alcohol and drug abuse treatment will relapse. Another study by Peniston and
Kulkosky—on the effects of neurofeedback training with veterans who had dual
diagnoses of alcoholism and PTSD[28]—focused on this problem.
Fifteen veterans received alpha-theta training, while the control group received
standard treatment without neurofeedback. The subjects were followed up regularly
for three years, during which eight members of neurofeedback group stopped drinking
completely and one got drunk once but became sick and didn’t drink again. Most
of them were markedly less depressed. As Peniston put it, the changes reported
corresponded to being “more warmhearted, more intelligent, more emotionally
stable, more socially bold, more relaxed and more satisfied.”[29] In contrast,
all of those given standard treatment were readmitted to the hospital within
eighteen months.[30] Since that time a number of studies on neurofeedback for
addictions have been published,[31] but this important application needs
much more research to establish its potential and limitations.

THE FUTURE OF NEUROFEEDBACK

In my practice I use neurofeedback
primarily to help with the hyperarousal, confusion, and concentration problems of
people who suffer from developmental trauma. However, it has also shown good results
for numerous issues and conditions that go beyond the scope of this book, including
relieving tension headaches, improving cognitive functioning following a traumatic
brain injury, reducing anxiety and panic attacks, learning to deepen meditation
states, treating autism, improving seizure control, self-regulation in mood
disorders, and more. As of 2013 neurofeedback is being used in seventeen military
and VA facilities to treat PTSD,[32] and scientific documentation of its
efficacy in recent combat vets is just beginning to be assessed. Frank Duffy, the
director of the clinical neurophysiology and developmental neurophysiology
laboratories of Boston Children’s Hospital, has commented: “The
literature, which lacks any negative study, suggests that neurofeedback plays a
major therapeutic role in many different areas. In my opinion, if any medication had
demonstrated such a wide spectrum of efficacy it would be universally accepted and
widely used.”[33]

Many questions remain to be answered
about treatment protocols for neurofeedback, but the scientific paradigm is
gradually shifting in a direction that invites a deeper exploration of these
questions. In 2010 Thomas Insel, director of the National Institute of Mental
Health, published an article in Scientific American entitled “Faulty
Circuits,” in which he called for a return to understanding mind and brain in
terms of the rhythms and patterns of electrical communication: “Brain regions that
function together to carry out normal (and abnormal) mental operations can be
thought of as analogous to electrical circuits—the latest research shows that the
malfunctioning of entire circuits may underlie many mental disorders.”[34] Three years
later Insel announced that NIMH was “re-orienting its research away from DSM
categories”[35] and focusing instead on “disorders of the human
connectome.”[36]

As explained by Francis Collins,
director of the National Institutes of Health (of which NIMH is a part), “The
connectome refers to the exquisitely interconnected network of neurons (nerve cells)
in your brain. Like the genome, the microbiome, and other exciting ‘ome’
fields, the effort to map the connectome and decipher the electrical signals that
zap through it to generate your thoughts, feelings, and behaviors has become
possible through development of powerful new tools and technologies.”[37] The
connectome is now being mapped in detail under the auspices of NIMH.

As we await the results of this
research, I’d like to give the last word to Lisa, the survivor who introduced
me to the enormous potential of neurofeedback. When I asked her to summarize what
the treatment had done for her, she said: “It calmed me down. It stopped the
dissociation. I can use my feelings; I’m not running away from them. I’m
not held hostage by them. I can’t turn them off and on, but I can put them
away. I may be sad about the abuse I went through, but I can put it away. I can call
a friend and not talk about it if I don’t want to talk about it, or I
can do homework or clean my apartment. Emotions mean something now. I’m not
anxious all the time, and when I am anxious, I can reflect on it. If the
anxiety’s coming from the past, I can find it there, or I can look at how it
relates to my life now. And it’s not just negative emotions, like anger and
anxiety—I can reflect on love and intimacy or sexual attraction. I’m not in
fight-or-flight all the time. My blood pressure is down. I’m not physically
prepared to take off at any moment or defend myself against an attack. Neurofeedback
made it possible for me to have a relationship. Neurofeedback freed me up to live my
life the way I want to, because I’m not always in the thrall of how I was hurt
and what it did to me.”

Four years after I met her and recorded
our conversations, Lisa graduated near the top of her nursing school class, and she
now works full time as a nurse at a local hospital.

CHAPTER 20

Finding Your Voice: Communal Rhythms
and Theater

Acting is not about putting on a character but
discovering the character within you: you are the character, you just have to find
it within yourself—albeit a very expanded version of yourself.

—Tina Packer

Many scientists I know were inspired by
their children’s health problems to find new ways of understanding mind,
brain, and therapy. My own son’s recovery from a mysterious illness that, for
lack of a better name, we call chronic fatigue syndrome, convinced me of the
therapeutic possibilities of theater.

Nick spent most of seventh and eighth
grade in bed, bloated by allergies and medications that left him too exhausted to go
to school. His mother and I saw him becoming entrenched in his identity as a
self-hating and isolated kid, and we were desperate to help him. When his mother
realized that he picked up a little energy round 5:00 p.m., we signed him up for an
evening class in improvisational theater where he would at least have a chance to
interact with other boys and girls his age. He took to the group and to the acting
exercises and soon landed his first role, as Action in West Side Story, a
tough kid who’s always ready to fight and has the lead in singing “Gee,
Officer Krupke.” One day at home I caught him walking with a swagger,
practicing what it was like to be somebody with clout. Was he developing a physical sense of pleasure, imagining
himself as a strong guy who commands respect?

Then he was cast as the Fonz in
Happy Days. Being adored by girls and keeping an audience spellbound
became the real tipping point in his recovery. Unlike his experience with the
numerous therapists who had talked with him about how bad he felt, theater gave him
a chance to deeply and physically experience what it was like to be someone other
than the learning-disabled, oversensitive boy that he had gradually become. Being a
valued contributor to a group gave him a visceral experience of power and
competence. I believe that this new embodied version of himself set him on the road
to becoming the creative, loving adult he is today.

Our sense of agency, how much we feel in
control, is defined by our relationship with our bodies and its rhythms: Our waking
and sleeping and how we eat, sit, and walk define the contours of our days. In order
to find our voice, we have to be in our bodies—able to breathe fully and
able to access our inner sensations. This is the opposite of dissociation, of being
“out of body” and making yourself disappear. It’s also the
opposite of depression, lying slumped in front of a screen that provides passive
entertainment. Acting is an experience of using your body to take your place in
life.

THE THEATER OF WAR

Nick’s transformation was not the
first time I’d witnessed the benefits of theater. In 1988 I was still treating
three veterans with PTSD whom I’d met at the VA, and when they showed a sudden
improvement in their vitality, optimism, and family relationships, I attributed it
to my growing therapeutic skills. Then I discovered that all three were involved in
a theatrical production.

Wanting to dramatize the plight of
homeless veterans, they had persuaded playwright David Mamet, who was living nearby,
to meet weekly with their group to develop a script around their experiences. Mamet
then recruited Al Pacino, Donald Sutherland, and Michael J. Fox to come to Boston
for an evening called Sketches of War, which raised money to convert the VA
clinic where I’d met my patients into a shelter for homeless veterans.[1] Standing on a
stage with professional actors, speaking about their memories of the war, and
reading their poetry was clearly a more transformative experience than any therapy
could have offered them.

Since time immemorial human beings have
used communal rituals to cope with their
most powerful and terrifying feelings. Ancient Greek theater, the oldest of which we
have written records, seems to have grown out of religious rites that involved
dancing, singing, and reenacting mythical stories. By the fifth century BCE, theater
played a central role in civic life, with the audience seated in a horseshoe around
the stage, which enabled them to see one another’s emotions and reactions.

Greek drama may have served as a ritual
reintegration for combat veterans. At the time Aeschylus wrote the Oresteia
trilogy, Athens was at war on six fronts; the cycle of tragedy is set in motion when
the returning warrior king Agamemnon is murdered by his wife, Clytemnestra, for
having sacrificed their daughter before sailing to the Trojan War. Military service
was required of every adult citizen of Athens, so audiences were undoubtedly
composed of combat veterans and active-duty soldiers on leave. The performers
themselves must have been citizen-soldiers.

Sophocles was a general officer in
Athens’s wars against the Persians, and his play Ajax, which ends
with the suicide of one of the Trojan War’s greatest heroes, reads like a
textbook description of traumatic stress. In 2008 writer and director Bryan Doerries
arranged a reading of Ajax for five hundred marines in San Diego and was
stunned by the reception it received. (Like many of us who work with trauma,
Doerries’s inspiration was personal; he had studied classics in college and
turned to the Greek texts for comfort when he lost a girlfriend to cystic fibrosis.)
His project “The Theater of War” evolved from that first event, and with
funding from the U.S. Department of Defense, this 2,500-year-old play has since been
performed more than two hundred times here and abroad to give voice to the plight of
combat veterans and foster dialogue and understanding in their families and
friends.[2]

Theater of War performances are followed
by a town hall–style discussion. I attended a reading of Ajax in Cambridge,
Massachusetts, shortly after the news media had publicized a 27 percent increase in
suicides among combat veterans over the previous three years. Some forty
people—Vietnam veterans, military wives, recently discharged men and women who had
served in Iraq and Afghanistan—lined up behind the microphone. Many of them quoted
lines from the play as they spoke about their sleepless nights, drug addiction, and
alienation from their families. The atmosphere was electric, and afterward the
audience huddled in the foyer, some holding each other and crying, others in deep
conversation.

As Doerries later said: “Anyone
who has come into contact with extreme pain, suffering or death has no trouble
understanding Greek drama. It’s all about bearing witness to the stories of
veterans.”[3]

KEEPING TOGETHER IN TIME

Collective movement and music create a
larger context for our lives, a meaning beyond our individual fate. Religious
rituals universally involve rhythmic movements, from davening at the Wailing Wall in
Jerusalem to the sung liturgy and gestures of the Catholic Mass to moving meditation
in Buddhist ceremonies and the rhythmic prayer rituals performed five times a day by
devout Muslims.

Music was a backbone of the civil rights
movement in the United States. Anyone alive at that time will not forget the lines
of marchers, arms linked, singing “We Shall Overcome” as they walked
steadily toward the police who were massed to stop them. Music binds together people
who might individually be terrified but who collectively become powerful advocates
for themselves and others. Along with language, dancing, marching, and singing are
uniquely human ways to install a sense of hope and courage.

I observed the force of communal rhythms
in action when I watched Archbishop Desmond Tutu conduct public hearings for the
Truth and Reconciliation Commission in South Africa in 1996. These events were
framed by collective singing and dancing. Witnesses recounted the unspeakable
atrocities that had been inflicted on them and their families. When they became
overwhelmed, Tutu would interrupt their testimony and lead the entire audience in
prayer, song, and dance until the witnesses could contain their sobbing and halt
their physical collapse. This enabled participants to pendulate in and out of
reliving their horror and eventually to find words to describe what had happened to
them. I fully credit Tutu and the other member of the commission with averting what
might have been an orgy of revenge, as is so common when victims are finally set
free.

A few years ago I discovered Keeping
Together in Time,[4] written by the great historian William
H. McNeill near the end of his career. This short book examines the historical role
of dance and military drill in creating what McNeill calls “muscular
bonding” and sheds a new light on the importance of theater, communal dance,
and movement. It also solved a long-standing puzzle in my own mind. Having been
raised in the Netherlands, I had always wondered how a group of simple Dutch
peasants and fishermen had won their liberation from the mighty Spanish empire. The
Eighty Years’ War, which lasted from the late sixteenth to the midseventeenth
century, began as a series of guerrilla actions, and it seemed destined to remain
that way, since the ill-disciplined, ill-paid soldiers regularly fled under volleys
of musket fire.

This changed when Prince Maurice of
Orange became the leader of the Dutch
rebels. Still in his early twenties, he had recently completed his schooling in
Latin, which enabled him to read 1,500-year-old Roman manuals on military tactics.
He learned that the Roman general Lycurgus had introduced marching in step to the
Roman legions and that the historian Plutarch had attributed their invincibility to
this practice: “It was at once a magnificent and terrible sight, to see them
march on to the tune of their flutes, without any disorder in their ranks, any
discomposure in their minds or change in their countenances, calmly and cheerfully
moving with music to the deadly fight.”[5]

Prince Maurice instituted close-order
drill, accompanied by drums, flutes, and trumpets, in his ragtag army. This
collective ritual not only provided his men with a sense of purpose and solidarity,
but also made it possible for them to execute complicated maneuvers. Close-order
drill subsequently spread across Europe, and to this day the major services of the
U.S. military spend liberally on their marching bands, even though fifes and drums
no longer accompany troops into battle.

Neuroscientist Jaak Panksepp, who was
born in the tiny Baltic country of Estonia, told me the remarkable story of
Estonia’s “Singing Revolution.” In June 1987, on one of those
endless sub-Arctic summer evenings, more than ten thousand concertgoers at the
Tallinn Song Festival Grounds linked hands and began to sing patriotic songs that
had been forbidden during half a century of Soviet occupation. These songfests and
protests continued, and on September 11, 1988, three hundred thousand people, about
a quarter of the population of Estonia, gathered to sing and make a public demand
for independence. By August 1991 the Congress of Estonia had proclaimed the
restoration of the Estonian state, and when Soviet tanks attempted to intervene,
people acted as human shields to protect Tallinn’s radio and TV stations. As a
columnist noted in the New York Times: “Imagine the scene in
Casablanca in which the French patrons sing “La
Marseillaise” in defiance of the Germans, then multiply its power by a factor
of thousands, and you’ve only begun to imagine the force of the Singing
Revolution.”[6]

TREATING TRAUMA THROUGH THEATER

It is surprising how little research
exists on how collective ceremonies affect the mind and brain and how they might
prevent or alleviate trauma. Over the past decade, however, I have had a chance to
observe and study three different programs for treating trauma through theater:
Urban Improv in Boston[7]
and the Trauma Drama program it inspired
in the Boston public schools and in our residential centers;[8] the Possibility Project,
directed by Paul Griffin in New York City;[9] and Shakespeare & Company, in
Lenox, Massachusetts, which runs a program for juvenile offenders called Shakespeare
in the Courts.[10] In this chapter, I’ll focus on these three groups, but there
are many excellent therapeutic drama programs in the United States and abroad,
making theater a widely available resource for recovery.

Despite their differences, all of these
programs share a common foundation: confrontation of the painful realities of life
and symbolic transformation through communal action. Love and hate, aggression and
surrender, loyalty and betrayal are the stuff of theater and the stuff of trauma. As
a culture we are trained to cut ourselves off from the truth of what we’re
feeling. In the words of Tina Packer, the charismatic founder of Shakespeare &
Company: “Training actors involves training people to go against that
tendency—not only to feel deeply, but to convey that feeling at every moment to the
audience, so the audience will get it—and not close off against it.”

Traumatized people are terrified to feel
deeply. They are afraid to experience their emotions, because emotions lead to loss
of control. In contrast, theater is about embodying emotions, giving voice to them,
becoming rhythmically engaged, taking on and embodying different roles.

As we’ve seen, the essence of
trauma is feeling godforsaken, cut off from the human race. Theater involves a
collective confrontation with the realities of the human condition. As Paul Griffin,
discussing his theater program for foster-care children, told me: “The stuff
of tragedy in theater revolves around coping with betrayal, assault, and
destruction. These kids have no trouble understanding what Lear, Othello, Macbeth,
or Hamlet are all about.” In Tina Packer’s words: “Everything is
about using the whole body and having other bodies resonate with your feelings,
emotions and thoughts.” Theater gives trauma survivors a chance to connect
with one another by deeply experiencing their common humanity.

Traumatized people are afraid of
conflict. They fear losing control and ending up on the losing side once again.
Conflict is central to theater—inner conflicts, interpersonal conflicts, family
conflicts, social conflicts, and their consequences. Trauma is about trying to
forget, hiding how scared, enraged, or helpless you are. Theater is about finding
ways of telling the truth and conveying deep truths to your audience. This requires
pushing through blockages to discover your own truth, exploring and examining your
own internal experience so that it can emerge in your voice and body on stage.

MAKING IT SAFE TO ENGAGE

These theater programs are not for
aspiring actors but for angry, frightened, and obstreperous teenagers or withdrawn,
alcoholic, burned-out veterans. When they come to rehearsal, they slump into their
chairs, fearful that others will immediately see what failures they are. Traumatized
adolescents are a jumble: inhibited, out of tune, inarticulate, uncoordinated, and
purposeless. They are too hyperaroused to notice what is going on around them. They
are easily triggered and rely on action rather than words to discharge their
feelings.

All the directors I’ve worked with
agree that the secret is to go slow and engage them bit by bit. The initial
challenge is simply to get participants to be more present in the room. Here’s
Kevin Coleman, director of Shakespeare in the Courts, describing his work with teens
when I interviewed him: “First we get them up and walking around the room.
Then we start to create a balance in the space, so they’re not walking
aimlessly, but become aware of other people. Gradually, with little prompts, it
becomes more complex: Just walk on your toes, or on your heels, or walk backwards.
Then, when you bump into someone, scream and fall down. After maybe thirty prompts,
they’re out there waving their arms in the air, and we get to a full-body warm
up, but it’s incremental. If you take too big a jump, you’ll see them
hit the wall.

“You have to make it safe for them
to notice each other. Once their bodies are a little more free, I might use the
prompt: ‘Don’t make eye contact with anyone—just look at the
floor.’ Most of them are thinking: ‘Great, I’m doing that
already,’ but then I say ‘Now begin to notice people as you go by, but
don’t let them see you looking.’ And next: ‘Just make eye contact
for a second.’ Then: ‘Now, no eye contact … now,
contact … now, no contact. Now, make eye contact and hold
it … too long. You’ll know when it’s too long because
you’ll either want to start dating that person or to have a fight with them.
That’s when it’s too long.’

“They don’t make that kind
of extended eye contact in their normal lives, not even with a person they’re
talking to. They don’t know if that person is safe or not. So what
you’re doing is making it safe for them not to disappear when they make eye
contact, or when someone looks at them. Bit by bit, by bit, by bit …”

Traumatized adolescents are noticeably
out of sync. In the Trauma Center’s Trauma Drama program, we use mirroring
exercises to help them to get in tune with one another. They move their right arm
up, and their partner mirrors it; they twirl, and their partner twirls in response.
They begin to observe how body movements
and facial expressions change, how their own natural movements differ from those of
others, and how unaccustomed movements and expressions make them feel. Mirroring
loosens their preoccupation with what other people think of them and helps them
attune viscerally, not cognitively, to someone else’s experience. When
mirroring ends in giggles, it’s a sure indication that our participants feel
safe.

In order to become real partners, they
also need to learn to trust one another. An exercise in which one person is
blindfolded while his partner leads him by the hand is especially tough for our
kids. It’s often as terrifying for them to be the leader, to be trusted by
someone vulnerable, as it is to be blindfolded and led. At first they may last for
only ten or twenty seconds, but we gradually work them up to five minutes. Afterward
some of them have to go off by themselves for a while, because it is so emotionally
overwhelming to feel these connections.

The traumatized kids and veterans we
work with are embarrassed to be seen, afraid to be in touch with what they are
feeling, and they keep one another at arm’s length. The job of any director,
like that of any therapist, is to slow things down so the actors can establish a
relationship with themselves, with their bodies. Theater offers a unique way to
access a full range of emotions and physical sensations that not only put them in
touch with the habitual “set” of their bodies, but also let them explore
alternative ways of engaging with life.

URBAN IMPROV

My son loved his theater group, which was
run by Urban Improv (UI), a long-standing Boston arts institution. He stayed with
them through high school and then volunteered to work with them the summer after his
freshman year in college. It was then that he learned that UI’s violence
prevention program, which has run hundreds of workshops in local schools since 1992,
had received a research grant to assess its efficacy—and that they were looking for
someone to head the study. Nick suggested to the directors, Kippy Dewey and Cissa
Campion, that his dad would be the ideal person for the job. Luckily for me, they
agreed.

I began to visit schools with UI’s
multicultural ensemble, which included a director, four professional
actor-educators, and a musician. Urban Improv creates scripted skits depicting the
kinds of problems that students face every day: exclusion from peer groups,
jealousy, rivalry and anger, and family strife. Skits for older students also
address issues like dating, STDs, homophobia, and peer violence. In a typical presentation the
professional actors might portray a group of kids excluding a newcomer from a lunch
table in the cafeteria. As the scene approaches a choice point—for example, the new
student responds to their put-downs—the director freezes the action. A member of the
class is then invited to replace one of the actors and show how he or she would feel
and behave in this situation. These scenarios enable the students to observe
day-to-day problems with some emotional distance while experimenting with various
solutions: Will they confront the tormenters, talk to a friend, call the homeroom
teacher, tell their parents what happened?

Another volunteer is then asked to try a
different approach, so that students can see how other choices might play out. Props
and costumes help the participants take risks in new roles, as do the playful
atmosphere and the support from the actors. In the discussion groups afterward
students respond to questions like “How was this scene similar or different
from what happens in your school?” “How do you get the respect that you
need?” and “How do you settle your differences?” These discussions
become lively exchanges as many students volunteer their thoughts and ideas.

Our Trauma Center team evaluated this
program at two grade levels in seventeen participating schools. Classrooms that
participated in the UI program were compared with similar nonparticipating
classrooms. At the fourth-grade level, we found a significant positive response. On
standardized rating scales for aggression, cooperation, and self-control, students
in the UI group showed substantially fewer fights and angry outbursts, more
cooperation and self-assertion with peers, and more attentiveness and engagement in
the classroom.[11]

Much to our surprise, these results were
not matched by the eighth graders. What had happened in the interim that affected
their responses? At first we had only our personal impressions to go on. When
I’d visited the fourth-grade classes, I’d been struck by their wide-eyed
innocence and their eagerness to participate. The eighth graders, in contrast, were
often sullen and defensive and as a group seemed to have lost their spontaneity and
enthusiasm. Onset of puberty was one obvious factor for the change, but might there
be others?

When we delved further, we found that
the older children had experienced more than twice as much trauma as the younger
ones: Every single eighth grader in these typical American inner-city schools had
witnessed serious violence. Two-thirds had observed five or more incidents,
including stabbings, gunfights, killings, and domestic assaults. Our data showed
that eighth graders with such high levels of exposure to violence were significantly
more aggressive than students
without these histories and that the program made no significant difference in their
behavior.

The Trauma Center team decided to see if
we could turn this situation around with a longer and more intensive program that
focused on team building and emotion-regulation exercises, using scripts that dealt
directly with the kinds of violence these kids experienced. For several months
members of our staff, led by Joseph Spinazzola, met weekly with the UI actors to
work on script development. The actors taught our psychologists improvisation,
mirroring, and precise physical attunement so they could credibly portray melting
down, confronting, cowering, or collapsing. We taught the actors about trauma
triggers and how to recognize and deal with trauma reenactments.[12]

During the winter and spring of 2005, we
tested the resulting program at a specialized day school run jointly by the Boston
Public Schools and the Massachusetts Department of Correction. This was a chaotic
environment in which students often shuttled back and forth between school and jail.
All of them came from high-crime neighborhoods and had been exposed to horrendous
violence; I had never seen such an aggressive and sullen group of kids. We got a
glimpse into the lives of the innumerable middle school and high school teachers who
deal daily with students whose first response to new challenges is to lash out or go
into defiant withdrawal.

We were shocked to discover that, in
scenes where someone was in physical danger, the students always sided with the
aggressors. Because they could not tolerate any sign of weakness in themselves, they
could not accept it in others. They showed nothing but contempt for potential
victims, yelling things like, “Kill the bitch, she deserves it,” during
a skit about dating violence.

At first some of the professional actors
wanted to give up—it was simply too painful to see how mean these kids were—but they
stuck it out, and I was amazed to see how they gradually got the students to
experiment, however reluctantly, with new roles. Toward the end of the program, a
few students were even volunteering for parts that involved showing vulnerability or
fear. When they received their certificate of completion, several shyly gave the
actors drawings to express their appreciation. I detected a few tears, possibly even
in myself.

Our attempt to make Trauma Drama a
regular part of the eighth-grade curriculum in the Boston public schools
unfortunately ran into a wall of bureaucratic resistance. Nonetheless, it lives on
as an integral part of the residential treatment programs at the Justice Resource
Institute, while music, theater, art, and sports—timeless ways of fostering
competence and collective bonding—continue to disappear from our schools.

THE POSSIBILITY PROJECT

In Paul Griffin’s New York City
Possibility Project the actors are not presented with prepared scripts. Instead,
over a nine-month period they meet for three hours a week, write their own
full-length musical, and perform it for several hundred people. During its
twenty-year history the Possibility Project has accrued a stable staff and strong
traditions. Each production team is made up of recent graduates who, with the help
of professional actors, dancers, and musicians, organize scriptwriting, scenic
design, choreography, and rehearsals for the incoming class. These recent grads are
powerful role models. As Paul told me: “When they come into the program,
students believe they cannot make a difference; putting a program like this together
is a transforming experience for their future.”

In 2010 Paul started a new program
specifically for foster-care youth. This is a troubled population: Five years after
maturing out of care, some 60 percent will have been convicted of a crime, 75
percent will be on public assistance, and only 6 percent will have completed even a
community college degree.

The Trauma Center treats many foster
care kids, but Griffin gave me a new way to see their lives: “Understanding
foster care is like learning about a foreign country. If you’re not from
there, you don’t speak the language. Life is upside down for foster-care
youth.” The security and love that other children take for granted they have
to create for themselves. When Griffin says, “Life is upside down,” he
means that if you treat kids in foster care with love or generosity, they often
don’t know what to make of it or how to respond. Rudeness feels more familiar;
cynicism they understand.

As Griffin points out,
“Abandonment makes it impossible to trust, and kids who have gone through
foster care understand abandonment. You can have no impact until they trust
you.” Foster-care children often answer to multiple people in charge. If they
want to switch schools, for example, they have to deal with foster parents, school
officials, the foster-care agency, and sometimes a judge. This tends to make them
politically savvy, and they learn all too well how to play people.

In the foster-care world,
“permanency” is a big buzzword. The motto is “One caring
adult—that’s all you need.” However, it is natural for teenagers to pull
away from adults, and Griffin remarks that the best form of permanency for teens is
a steady group of friends—which the program is designed to provide. Another
foster-care buzzword is “independence,” which Paul counters with
“interdependence.” “We’re all
interdependent,” he points out. “The idea that we’re asking our young people
to go out in the world completely alone and call themselves independent is crazy. We
need to teach them how to be interdependent, which means teaching them how to have
relationships.”

Paul found that foster-care youth are
natural actors. Playing tragic characters, you have to express emotions and create a
reality that comes from a place of depth and sorrow and hurt. Young people in foster
care? That’s all they know. It’s life and death every day for them. Over
time, collaboration helps the kids become important people in one another’s
lives. Phase one of the program is group building. The first rehearsal establishes
basic agreements: responsibility, accountability, respect; yes to expressions of
affection, no to sexual contact in the group. They then begin singing and moving
together, which gets them in sync.

Now comes phase two: sharing life
stories. They are now listening to one another, discovering shared experiences,
breaking through the loneliness and isolation of trauma. Paul gave me a film that
shows how this happened in one group. When the kids are first asked to say or do
something to introduce themselves, they freeze, their faces expressionless, their
eyes cast down, doing anything they can to become invisible.

As they begin to talk, as they discover
a voice in which they themselves are central, they also begin to create their own
show. Paul makes it clear the production depends on their input: “If you could
write a musical or play, what would you put in it? Punishment? Revenge? Betrayal?
Loss? This is your show to write.” Everything they say is written down, and
some of them start to put their own words on paper. As a script emerges, the
production team incorporates the students’ precise words into the songs and
dialogue. The group will learn that if they can embody their experiences well
enough, other people will listen. They will learn to feel what they feel and know
what they know.

The focus changes naturally as
rehearsals begin. The foster kids’ history of pain, alienation, and fear is no
longer central, and the emphasis shifts to “How can I become the best actor,
singer, dancer, choreographer, or lighting and set designer I can possibly
be?” Being able to perform becomes the critical issue: Competence is the best
defense against the helplessness of trauma.

This is, of course, true for all of us.
When the job goes bad, when a cherished project fails, when someone you count on
leaves you or dies, there are few things as helpful as moving your muscles and doing
something that demands focused attention. Inner-city schools and psychiatric
programs often lose sight of this. They want the kids to behave
“normally”—without building the competencies that will make them feel
normal.

Theater programs also teach cause and
effect. A foster kid’s life is completely unpredictable. Anything can happen
without notice: being triggered and having a meltdown; seeing a parent arrested or
killed; being moved from one home to another; getting yelled at for things that got
you approval in your last placement. In a theatrical production they see the
consequences of their decisions and actions laid out directly before their eyes.
“If you want to give them a sense of control, you have to give them power over
their destiny rather than intervene on their behalf,” Paul explains.
“You cannot help, fix, or save the young people you are working with. What you
can do is work side by side with them, help them to understand their vision, and
realize it with them. By doing that you give them back control. We’re healing
trauma without anyone ever mentioning the word.”

SENTENCED TO SHAKESPEARE

For the teenagers attending sessions of
Shakespeare in the Courts, there is no improvisation, no building scripts around
their own lives. They are all “adjudicated offenders” found guilty of
fighting, drinking, stealing, and property crimes, and a Berkshire County Juvenile
Court judge has sentenced them to six weeks, four afternoons a week, of intensive
acting study. Shakespeare is a foreign country for these actors. As Kevin Coleman
told me, when they first turn up—angry, suspicious, and in shock—they’re
convinced that they’d rather go to jail. Instead they’re going to learn
the lines of Hamlet, or Mark Antony, or Henry V and then go onstage in a condensed
performance of an entire Shakespeare play before an audience of family, friends, and
representatives of the juvenile justice system.

With no words to express the effects of
their capricious upbringing, these adolescents act out their emotions with violence.
Shakespeare calls for sword fighting, which, like other martial arts, gives them an
opportunity to practice contained aggression and expressions of physical power. The
emphasis is on keeping everyone safe. The kids love swordplay, but to keep one
another safe they have to negotiate and use language.

Shakespeare was writing at a time of
transition, when the world was moving from primarily oral to written
communication—when most people were still signing their name with an X.
These kids are facing their own period of transition; many are barely articulate,
and some struggle to read at all. If they rely on four-letter words, it’s not
only to show they’re tough but because they have no other language to
communicate who they are or what they
feel. When they discover the richness and the potential of language, they often have
a visceral experience of joy.

The actors first investigate what,
exactly, Shakespeare is saying, line by line. The director feeds the words one by
one into the actors’ ears, and they are instructed to say the line on the
outgoing breath. At the beginning of the process, many of these kids can barely get
a line out. Progress is slow, as each actor slowly internalizes the words. The words
gain depth and resonance as the voice changes in response to their associations. The
idea is to inspire the actors to sense their reactions to the words—and so to
discover the character. Rather than “I have to remember my lines,” the
emphasis is on “What do these words mean to me? What effect do
I have on my fellow actors? And what happens to me when I hear their
lines?”[13]

This can be a life-changing process, as
I witnessed in a workshop run by actors trained by Shakespeare & Company at the
VA Medical Center in Bath, New York. Larry, a fifty-nine-year-old Vietnam veteran
with twenty-seven detox hospitalizations during the previous year, had volunteered
to play the role of Brutus in a scene from Julius Caesar. As the rehearsal
began, he mumbled and hurried through his lines; he seemed to be terrified of what
people were thinking of him.

Remember March, the ides of March remember:

Did not great Julius bleed for justice’ sake?

What villain touch’d his body, that did stab,

And not for justice?

It seemed to take hours to rehearse the
speech that begins with these lines. At first he was just standing there, shoulders
slumped, repeating the words that the director whispered in his ear:
“Remember—what do you remember? Do you remember too much? Or not
enough? Remember. What don’t you want to remember? What is it like to
remember?” Larry’s voice cracked, eyes to the floor, sweat beading on
his forehead.

After a short break and a sip of water,
back to work. “Justice—did you receive justice? Did you ever bleed
for justice’s sake? What does justice mean to you? Struck. Have you
ever struck someone? Have you ever been struck? What was it like? What do you wish
you had done? Stab. Have you ever stabbed someone? Have you ever felt
stabbed in the back? Have you stabbed someone in the back?” At this point
Larry bolted from the room.

The next day he returned and we began
again—Larry standing there, perspiring, heart racing, having a million associations
going through his mind, gradually allowing himself to feel every word and learning
to own the lines that he uttered.

At the end of the program Larry started
his first job in seven years, and he was still working the last I heard, six months
later. Learning to experience and tolerate deep emotions is essential for recovery
from trauma.

In Shakespeare in the Courts, the
specificity of the language that is used in rehearsal extends to the students’
offstage speech. Kevin Coleman notes that their talk is riddled with the expression
“I feel like …” He goes on: “If you are confusing your
emotional experiences with your judgments, your work becomes vague. If you ask them,
‘How did that feel?’ they’ll immediately say: ‘It felt
good’ or ‘That felt bad.’ Both of those are judgments. So we never
say, ‘How did that feel?’ at the end of a scene, because it invites them
to go to the judgment part of their brain.”

Instead Coleman asks, “Did you
notice any specific feelings that came up for you doing that scene?” That way
they learn to name emotional experiences: “I felt angry when he said
that.” “I felt scared when he looked at me.” Becoming embodied
and, for lack of a better word, “en-languaged,” helps the actors realize
that they have many different emotions. The more they notice, the more curious they
get.

When rehearsals begin, the kids have to
learn to stand up straight and walk across a stage unselfconsciously. They have to
learn to speak so that they can be heard in all parts of the theater, which in
itself presents a huge challenge. The final performance means facing the community.
The kids step out onto the stage, experiencing another level of vulnerability,
danger, or safety, and they find out how much they can trust themselves. Gradually
the eagerness to succeed, to show that they can do it, takes over. Kevin told me the
story of a girl who played Ophelia in Hamlet. On the day of the performance he saw
her waiting backstage, ready to go on, with a wastebasket clutched to her belly.
(She explained that she was so nervous she was scared she’d throw up). She had
been a chronic runaway from her foster homes and also from Shakespeare in the
Courts. Because the program is committed to not throwing kids out if at all
possible, the police and truant officers had repeatedly brought her back. There must
have come a point when she began to realize that her role was essential to the
group, or perhaps she sensed the intrinsic value of the experience for herself. At
least for that day, she was choosing not to run.

THERAPY AND THEATER

I once heard Tina Packer declare to a
roomful of trauma specialists: “Therapy and theater are intuition at work.
They are the opposite of research, where one strives to step outside of one’s
own personal experience, even outside your patients’ experience, to test the
objective validity of assumptions. What makes therapy effective is deep, subjective
resonance and that deep sense of truth and veracity that lives in the body.” I
am still hoping that someday we will prove Tina wrong and combine the rigor of
scientific methods with the power of embodied intuition.

Edward, one of the Shakespeare &
Company teachers, told me about an experience he’d had as a young actor in
Packer’s advanced training workshop. The group had spent the morning doing
exercises aimed at getting the muscles of the torso to release, so that the breath
could drop in naturally and fully. Edward noticed that every time he rolled through
one section of his ribs, he’d feel a wave of sadness. The coach asked if
he’d ever been injured there, and he said no.

For Packer’s afternoon class
he’d prepared a speech from Richard II where the king is summoned to
give up his crown to the lord who has usurped him. During the discussion afterward,
he recalled that his mother had broken her ribs when she was pregnant with him and
that he’d always associated this with his premature birth.

As he recalled:

When I told
Tina this, she started asking me questions about my first few months. I said I
didn’t remember being in an incubator but that I remembered times later
when I stopped breathing, and being in the hospital in an oxygen tent. I
remembered being in my uncle’s car and him driving through red lights to
get me to the emergency room. It was like having sudden infant death syndrome at
the age of three.

Tina kept asking me questions,
and I started to get really frustrated and angry at her poking away at whatever
shield I had around that pain. Then she said, “Was it painful when the
doctors stuck all those needles in you?”

At that moment, I just started
screaming. I tried to leave the room, but two of the other actors—really big
guys—held me down. They finally got me to sit in a chair, and I was trembling
and shaking. Then Tina said, “You’re your mother and you’re
going to do this speech. You’re your mother and you’re giving birth
to yourself. And you’re telling yourself that you’re going to make it.
You’re not going to die. You must convince yourself. You must convince
that little newborn that you’re not going to die.”

This became my intention with
Richard’s speech. When I first brought the speech to class, I told myself
that I wanted to get the role right, not that something welling deep inside me
needed to say these words. When finally it did, it became so clear that my baby
was like Richard; I was not ready to give up my throne. It was like megatons of
energy and tension just left my body. Pathways opened up for expression that had
been blocked by this baby holding his breath and being so afraid that it was
going to die.

The genius of Tina was in having
me become my mother telling me I’d be okay. It was almost like going back
and changing the story. Being reassured that someday I would feel safe enough to
express my pain made it a precious part of my life.

That night I had the first
orgasm I’d ever had in the presence of another person. And I know
it’s because I released something—some tension in my body—that allowed me
to be more in the world.

Epilogue

Choices to be Made

We are on the verge of becoming a
trauma-conscious society. Almost every day one of my colleagues publishes another
report on how trauma disrupts the workings of mind, brain, and body. The ACE study
showed how early abuse devastates health and social functioning, while James Heckman
won a Nobel Prize for demonstrating the vast savings produced by early intervention
in the lives of children from poor and troubled families: more high school
graduations, less criminality, increased employment, and decreased family and
community violence. All over the world I meet people who take these data seriously
and who work tirelessly to develop and apply more effective interventions, whether
devoted teachers, social workers, doctors, therapists, nurses, philanthropists,
theater directors, prison guards, police officers, or meditation coaches. If you
have come this far with me in The Body Keeps the Score, you have also
become part of this community.

Advances in neuroscience have given us a
better understanding of how trauma changes brain development, self-regulation, and
the capacity to stay focused and in tune with others. Sophisticated imaging
techniques have identified the origins of PTSD in the brain, so that we now
understand why traumatized people become disengaged, why they are bothered by sounds
and lights, and why they may blow up or withdraw in response to the slightest
provocation. We have learned how, throughout life, experiences change the structure
and function of the brain—and even affect the genes we pass on to our children.
Understanding many of the fundamental processes that underlie traumatic stress opens
the door to an array of interventions that can bring the brain areas related to
self-regulation, self-perception, and attention back online. We know not only how to treat trauma but
also, increasingly, how to prevent it.

And yet, after attending another wake
for a teenager who was killed in a drive-by shooting in the Blue Hill Avenue section
of Boston or after reading about the latest school budget cuts in impoverished
cities and towns, I find myself close to despair. In many ways we seem to be
regressing, with measures like the callous congressional elimination of food stamps
for kids whose parents are unemployed or in jail; with the stubborn opposition to
universal health care in some quarters; with psychiatry’s obtuse refusal to
make connection between psychic suffering and social conditions; with the refusal to
prohibit the sale or possession of weapons whose only purpose is to kill large
numbers of human beings; and with our tolerance for incarcerating a huge segment of
our population, wasting their lives as well as our resources.

Discussions of PTSD still tend to focus
on recently returned soldiers, victims of terrorist bombings, or survivors of
terrible accidents. But trauma remains a much larger public health issue, arguably
the greatest threat to our national well-being. Since 2001 far more Americans have
died at the hands of their partners or other family members than in the wars in Iraq
and Afghanistan. American women are twice as likely to suffer domestic violence as
breast cancer. The American Academy of Pediatrics estimates that firearms kill twice
as many children as cancer does. All around Boston I see signs advertising the Jimmy
Fund, which fights children’s cancer, and for marches to fund research on
breast cancer and leukemia, but we seem too embarrassed or discouraged to mount a
massive effort to help children and adults learn to deal with the fear, rage, and
collapse, the predictable consequences of having been traumatized.

When I give presentations on trauma and
trauma treatment, participants sometimes ask me to leave out the politics and
confine myself to talking about neuroscience and therapy. I wish I could separate
trauma from politics, but as long as we continue to live in denial and treat only
trauma while ignoring its origins, we are bound to fail. In today’s world your
ZIP code, even more than your genetic code, determines whether you will lead a safe
and healthy life. People’s income, family structure, housing, employment, and
educational opportunities affect not only their risk of developing traumatic stress
but also their access to effective help to address it. Poverty, unemployment,
inferior schools, social isolation, widespread availability of guns, and substandard
housing all are breeding grounds for trauma. Trauma breeds further trauma; hurt
people hurt other people.

My most profound experience with healing
from collective trauma was witnessing the work of the South African Truth and
Reconciliation Commission, which was based on the central guiding principle of
Ubuntu, a Xhosa word that denotes sharing what you have, as in
“My humanity is inextricably bound up in yours.” Ubuntu recognizes that
true healing is impossible without recognition of our common humanity and our common
destiny.

We are fundamentally social
creatures—our brains are wired to foster working and playing together. Trauma
devastates the social-engagement system and interferes with cooperation, nurturing,
and the ability to function as a productive member of the clan. In this book we have
seen how many mental health problems, from drug addiction to self-injurious
behavior, start off as attempts to cope with emotions that became unbearable because
of a lack of adequate human contact and support. Yet institutions that deal with
traumatized children and adults all too often bypass the emotional-engagement system
that is the foundation of who we are and instead focus narrowly on correcting
“faulty thinking” and on suppressing unpleasant emotions and troublesome
behaviors.

People can learn to control and change
their behavior, but only if they feel safe enough to experiment with new solutions.
The body keeps the score: If trauma is encoded in heartbreaking and gut-wrenching
sensations, then our first priority is to help people move out of fight-or-flight
states, reorganize their perception of danger, and manage relationships. Where
traumatized children are concerned, the last things we should be cutting from school
schedules are the activities that can do precisely that: chorus, physical education,
recess, and anything else that involves movement, play, and other forms of joyful
engagement.

As we’ve seen, my own profession
often compounds, rather than alleviates, the problem. Many psychiatrists today work
in assembly-line offices where they see patients they hardly know for fifteen
minutes and then dole out pills to relieve pain, anxiety, or depression. Their
message seems to be “Leave it to us to fix you; just be compliant and take
these drugs and come back in three months—but be sure not to use alcohol or
(illegal) drugs to relieve your problems.” Such shortcuts in treatment make it
impossible to develop self-care and self-leadership. One tragic example of this
orientation is the rampant prescription of painkillers, which now kill more people
each year in the United States than guns or car accidents.

Our increasing use of drugs to treat
these conditions doesn’t address the real issues: What are these patients
trying to cope with? What are their internal or external resources? How do they calm
themselves down? Do they have caring
relationships with their bodies, and what do they do to cultivate a physical sense
of power, vitality, and relaxation? Do they have dynamic interactions with other
people? Who really knows them, loves them, and cares about them? Whom can they count
on when they’re scared, when their babies are ill, or when they are sick
themselves? Are they members of a community, and do they play vital roles in the
lives of the people around them? What specific skills do they need to focus, pay
attention, and make choices? Do they have a sense of purpose? What are they good at?
How can we help them feel in charge of their lives?

I like to believe that once our society
truly focuses on the needs of children, all forms of social support for families—a
policy that remains so controversial in this country—will gradually come to seem not
only desirable but also doable. What difference would it make if all American
children had access to high-quality day care where parents could safely leave their
children as they went off to work or school? What would our school systems look like
if all children could attend well-staffed preschools that cultivated cooperation,
self-regulation, perseverance, and concentration (as opposed to focusing on passing
tests, which will likely happen once children are allowed to follow their natural
curiosity and desire to excel, and are not shut down by hopelessness, fear, and
hyperarousal)?

I have a family photograph of myself as
a five-year-old, perched between my older (obviously wiser) and younger (obviously
more dependent) siblings. In the picture I proudly hold up a wooden toy boat,
grinning from ear to ear: “See what a wonderful kid I am and see what an
incredible boat I have! Wouldn’t you love to come and play with me?” All
of us, but especially children, need such confidence—confidence that others will
know, affirm, and cherish us. Without that we can’t develop a sense of agency
that will enable us to assert: “This is what I believe in; this is what I
stand for; this is what I will devote myself to.” As long as we feel safely
held in the hearts and minds of the people who love us, we will climb mountains and
cross deserts and stay up all night to finish projects. Children and adults will do
anything for people they trust and whose opinion they value.

But if we feel abandoned, worthless, or
invisible, nothing seems to matter. Fear destroys curiosity and playfulness. In
order to have a healthy society we must raise children who can safely play and
learn. There can be no growth without curiosity and no adaptability without being
able to explore, through trial and error, who you are and what matters to you.
Currently more than 50 percent of the children served by Head Start have had three
or more adverse childhood experiences like those included in the ACE study:
incarcerated family members, depression,
violence, abuse, or drug use in the home, or periods of homelessness.

People who feel safe and meaningfully
connected with others have little reason to squander their lives doing drugs or
staring numbly at television; they don’t feel compelled to stuff themselves
with carbohydrates or assault their fellow human beings. However, if nothing they do
seems to make a difference, they feel trapped and become susceptible to the lure of
pills, gang leaders, extremist religions, or violent political movements—anybody and
anything that promises relief. As the ACE study has shown, child abuse and neglect
is the single most preventable cause of mental illness, the single most common cause
of drug and alcohol abuse, and a significant contributor to leading causes of death
such as diabetes, heart disease, cancer, stroke, and suicide.

My colleagues and I focus much of our
work where trauma has its greatest impact: on children and adolescents. Since we
came together to establish the National Child Traumatic Stress Network in 2001, it
has grown into a collaborative network of more than 150 centers nationwide, each of
which has created programs in schools, juvenile justice systems, child welfare
agencies, homeless shelters, military facilities, and residential group
homes.

The Trauma Center is one of
NCTSN’s Treatment Development and Evaluation sites. My colleagues Joe
Spinazzola, Margaret Blaustein, and I have developed comprehensive programs for
children and adolescents that we, with the help of trauma-savvy colleagues in
Hartford, Chicago, Houston, San Francisco, Anchorage, Los Angeles, and New York, are
now implementing. Our team selects a particular area of the country to work in every
two years, relying on local contacts to identify organizations that are energetic,
open, and well respected; these will eventually serve as new nodes for treatment
dissemination. For example, I collaborated for one two-year period with colleagues
in Missoula, Montana, to help develop a culturally sensitive trauma program on
Blackfoot Indian reservations.

The greatest hope for traumatized,
abused, and neglected children is to receive a good education in schools where they
are seen and known, where they learn to regulate themselves, and where they can
develop a sense of agency. At their best, schools can function as islands of safety
in a chaotic world. They can teach children how their bodies and brains work and how
they can understand and deal with their emotions. Schools can play a significant
role in instilling the resilience necessary to deal with the traumas of
neighborhoods or families. If parents are forced to work two jobs to eke out a
living, or if they are too impaired, overwhelmed, or depressed to be attuned to the needs of their kids, schools by
default have to be the places where children are taught self-leadership and an
internal locus of control.

When our team arrives at a school, the
teachers’ initial response is often some version of “If I’d wanted
to be a social worker, I would have gone to social work school. But I came here to
be a teacher.” Many of them have already learned the hard way, however, that
they cannot teach if they have a classroom filled with students whose alarm bells
are constantly going off. Even the most committed teachers and school systems often
come to feel frustrated and ineffective because so many of their kids are too
traumatized to learn. Focusing only on improving test scores won’t make any
difference if teachers can’t effectively address the behavior problems of
these students. The good news is that the basic principles of trauma-focused
interventions can be translated into practical day-to-day routines and approaches
that can transform the entire culture of a school.

Most teachers we work with are intrigued
to learn that abused and neglected students are likely to interpret any deviation
from routine as danger and that their extreme reactions usually are expressions of
traumatic stress. Children who defy the rules are unlikely to be brought to reason
by verbal reprimands or even suspension—a practice that has become epidemic in
American schools. Teachers’ perspectives begin to change when they realize
that these kids’ disturbing behaviors started out as frustrated attempts to
communicate distress and as misguided attempts to survive.

More than anything else, being able to
feel safe with other people defines mental health; safe connections are fundamental
to meaningful and satisfying lives. The critical challenge in a classroom setting is
to foster reciprocity: truly hearing and being heard; really seeing and being seen
by other people. We try to teach everyone in a school community—office staff,
principals, bus drivers, teachers, and cafeteria workers—to recognize and understand
the effects of trauma on children and to focus on the importance of fostering
safety, predictability, and being known and seen. We make certain that the children
are greeted by name every morning and that teachers make face-to-face contact with
each and every one of them. Just as in our workshops, group work, and theater
programs, we always start the day with checkins: taking the time to share
what’s on everybody’s mind.

Many of the children we work with have
never been able to communicate successfully with language, as they are accustomed to
adults who yell, command, sulk, or put earbuds in their ears. One of our first steps
is to help their teachers model new ways of talking about feelings, stating
expectations, and asking for help. Instead of yelling, “Stop!” when a
child is throwing a tantrum or making
her sit alone in the corner, teachers are encouraged to notice and name the
child’s experience, as in “I can see how upset you are”; to give
her choices, as in “Would you like to go to the safe spot or sit on my
lap?”; and to help her find words to describe her feelings and begin to find
her voice, as in: “What will happen when you get home after class?” It
may take many months for a child to know when it is safe to speak the truth (because
it will never be universally safe), but for children, as for adults, identifying the
truth of an experience is essential to healing from trauma.

It is standard practice in many schools
to punish children for tantrums, spacing out, or aggressive outbursts—all of which
are often symptoms of traumatic stress. When that happens, the school, instead of
offering a safe haven, becomes yet another traumatic trigger. Angry confrontations
and punishment can at best temporarily halt unacceptable behaviors, but since the
underlying alarm system and stress hormones are not laid to rest, they are certain
to erupt again at the next provocation.

In such situations the first step is
acknowledging that a child is upset; then the teacher should calm him, then explore
the cause and discuss possible solutions. For example, when a first-grader melts
down, hitting his teacher and throwing objects around, we encourage his teacher to
set clear limits while gently talking to him: “Would you like to wrap
that blanket around you to help you calm down?” (The kid is likely to scream,
“No!” but then curl up under the blanket and settle down.)
Predictability and clarity of expectations are critical; consistency is essential.
Children from chaotic backgrounds often have no idea how people can effectively work
together, and inconsistency only promotes further confusion. Trauma-sensitive
teachers soon realize that calling a parent about an obstreperous kid is likely to
result in a beating and further traumatization.

Our goal in all these efforts is to
translate brain science into everyday practice. For example, calming down enough to
take charge of ourselves requires activating the brain areas that notice our inner
sensations, the self-observing watchtower discussed in chapter 4. So a teacher might say: “Shall we take some deep breaths
or use the breathing star?” (This is a colorful breathing aid made out of file
folders.) Another option might be having the child sit in a corner wrapped in a
heavy blanket while listening to some soothing music through headphones. Safe areas
can help kids calm down by providing stimulating sensory awareness: the texture of
burlap or velvet; shoe boxes filled with soft brushes and flexible toys. When the
child is ready to talk again, he is encouraged to tell someone what is going on
before he rejoins the group.

Kids as young as three can blow soap
bubbles and learn that when they slow down their breathing to six breaths per minute
and focus on the out breath as it flows over their upper lip, they will feel more
calm and focused. Our team of yoga teachers works with children nearing adolescence
specifically to help them “befriend” their bodies and deal with
disruptive physical sensations. We know that one of the prime reasons for habitual
drug use in teens is that they cannot stand the physical sensations that signal
fear, rage, and helplessness.

Self-regulation can be taught to many
kids who cycle between frantic activity and immobility. In addition to reading,
writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and
communication as part of their core curriculum. Just as we teach history and
geography, we need to teach children how their brains and bodies work. For adults
and children alike, being in control of ourselves requires becoming familiar with
our inner world and accurately identifying what scares, upsets, or delights us.

Emotional intelligence starts with
labeling your own feelings and attuning to the emotions of the people around you. We
begin very simply: with mirrors. Looking into a mirror helps kids to be aware of
what they look like when they are sad, angry, bored, or disappointed. Then we ask
them, “How do you feel when you see a face like that?” We teach them how
their brains are built, what emotions are for, and where they are registered in
their bodies, and how they can communicate their feelings to the people around them.
They learn that their facial muscles give clues about what they are feeling and then
experiment with how their facial expressions affect other people.

We also strengthen the brain’s
watchtower by teaching them to recognize and name their physical sensations. For
example, when their chest tightens, that probably means that they are nervous; their
breathing becomes shallow and they feel uptight. What does anger feel like, and what
can they do to change that sensation in their body? What happens if they take a deep
breath or take time out to jump rope or hit a punching bag? Does tapping acupressure
points help? We try to provide children, teachers, and other care providers with a
toolbox of ways to take charge of their emotional reactions.

To promote reciprocity, we use other
mirroring exercises, which are the foundation of safe interpersonal communication.
Kids practice imitating one another’s facial expressions. They proceed to
imitating gestures and sounds and then get up and move in sync. To play well, they
have to pay attention to really seeing and hearing one another. Games like Simon
Says lead to lots of sniggering and giggling—signs of safety and relaxation. When
teenagers balk at these “stupid
games,” we nod understandingly and enlist their cooperation by asking them to
demonstrate games to the little kids, who “need their help.”

Teachers and leaders learn that an
activity as simple as trying to keep a beach ball in the air as long as possible
helps groups become more focused, cohesive, and fun. These are inexpensive
interventions. For older children some schools have installed workstations costing
less than two hundred dollars where students can play computer games to help them
focus and to improve their heart rate variability (HRV) (discussed in chapter 16), just as we do in our own clinic.

Children and adults alike need to
experience how rewarding it is to work at the edge of their abilities. Resilience is
the product of agency: knowing that what you do can make a difference. Many
of us remember what playing team sports, singing in the school choir, or playing in
the marching band meant to us, especially if we had coaches or directors who
believed in us, pushed us to excel, and taught us we could be better than we thought
was possible. The children we reach need this experience.

Athletics, playing music, dancing, and
theatrical performances all promote agency and community. They also engage kids in
novel challenges and unaccustomed roles. In a devastated postindustrial New England
town, my friends Carolyn and Eli Newberger are teaching El Sistema, an orchestral
music program that originated in Venezuela. Several of my students run an
after-school program in Brazilian capoeira in a high-crime area of Boston,
and my colleagues at the Trauma Center continue the Trauma Drama program. Last year
I spent three weeks helping two boys prepare a scene from Julius Caesar. An
effeminate, shy boy was playing Brutus and had to summon up his full force to put
down Cassius, played by the class bully, who had to be coached to play a corrupt
general begging for mercy. The scene came to life only after the bully talked about
his father’s violence and his own vow never to show weakness to anyone. (Most
bullies have themselves been bullied, and they despise kids who remind them of their
own vulnerability.) Brutus’s powerful voice, on the other hand, emerged after
he realized that he’d made himself invisible to deal with his own family
violence.

These intense communal efforts force
kids to collaborate, compromise, and stay focused on the task at hand. Tensions
often run high, but the kids stick with it because they want to earn the respect of
their coaches or directors and don’t want to let down the team—all feelings
that are opposite to the vulnerability of being subjected to arbitrary abuse, the
invisibility of neglect, and the godforsaken isolation of trauma.

Our NCTSN programs are working: Kids
become less anxious and emotionally reactive and are less aggressive or withdrawn;
they get along better and their school performance improves; their attention
deficit, hyperactivity, and “oppositional defiant” problems decrease;
and parents report that their children are sleeping better. Terrible things still
happen to them and around them, but they are now able to talk about these events;
they have built up the trust and resources to seek the help they need. Interventions
are successful if they draw on our natural wellsprings of cooperation and on our
inborn responses to safety, reciprocity, and imagination.

Trauma constantly confronts us with our
fragility and with man’s inhumanity to man but also with our extraordinary
resilience. I have been able to do this work for so long because it drew me to
explore our sources of joy, creativity, meaning, and connection—all the things that
make life worth living. I can’t begin to imagine how I would have coped with
what many of my patients have endured, and I see their symptoms as part of their
strength—the ways they learned to survive. And despite all their suffering many have
gone on to become loving partners and parents, exemplary teachers, nurses,
scientists, and artists.

Most great instigators of social change
have intimate personal knowledge of trauma. Oprah Winfrey comes to mind, as do Maya
Angelou, Nelson Mandela, and Elie Wiesel. Read the life history of any visionary,
and you will find insights and passions that came from having dealt with
devastation.

The same is true of societies. Many of
our most profound advances grew out of experiencing trauma: the abolition of slavery
from the Civil War, Social Security in response to the Great Depression, and the GI
Bill, which produced our once vast and prosperous middle class, from World War II.
Trauma is now our most urgent public health issue, and we have the knowledge
necessary to respond effectively. The choice is ours to act on what we know.

Appendix

Consensus Proposed Criteria for
Developmental Trauma Disorder

The goal of introducing the diagnosis of
Developmental Trauma Disorder is to capture the reality of the clinical
presentations of children and adolescents exposed to chronic interpersonal trauma
and thereby guide clinicians to develop and utilize effective interventions and for
researchers to study the neurobiology and transmission of chronic interpersonal
violence. Whether or not they exhibit symptoms of PTSD, children who have developed
in the context of ongoing danger, maltreatment, and inadequate caregiving systems
are ill-served by the current diagnostic system, as it frequently leads to no
diagnosis, multiple unrelated diagnoses, an emphasis on behavioral control without
recognition of interpersonal trauma and lack of safety in the etiology of symptoms,
and a lack of attention to ameliorating the developmental disruptions that underlie
the symptoms.

The Consensus Proposed Criteria for
Developmental Trauma Disorder were devised and put forward in February 2009 by a
National Child Traumatic Stress Network (NCTSN)-affiliated Task Force led by Bessel
A. van der Kolk, MD and Robert S. Pynoos, MD, with the participation of Dante
Cicchetti, PhD, Marylene Cloitre, PhD, Wendy D’Andrea, PhD, Julian D. Ford, PhD, Alicia F. Lieberman, PhD, Frank W.
Putnam, MD, Glenn Saxe, MD, Joseph Spinazzola, PhD, Bradley C. Stolbach, PhD, and
Martin Teicher, MD, PhD. The consensus proposed criteria are based on extensive
review of empirical literature, expert clinical wisdom, surveys of NCTSN clinicians,
and preliminary analysis of data from thousands of children in numerous clinical and
child service system settings, including NCTSN treatment centers, state child
welfare systems, inpatient psychiatric settings, and juvenile detention centers.
Because their validity, prevalence, symptom thresholds, or clinical utility have yet
to be examined through prospective data collection or analysis, these proposed
criteria should not be viewed as a formal diagnostic category to be incorporated
into the DSM as written here. Rather, they are intended to describe the most
clinically significant symptoms exhibited by many children and adolescents following
complex trauma. These proposed criteria have guided the Developmental Trauma
Disorder field trials that began in 2009 and continue to this day.

CONSENSUS PROPOSED CRITERIA FOR
DEVELOPMENTAL TRAUMA DISORDER

A. Exposure. The child or
adolescent has experienced or witnessed multiple or prolonged adverse events over a
period of at least one year beginning in childhood or early adolescence,
including:

A. 1. Direct experience or witnessing of
repeated and severe episodes of interpersonal violence; and

A. 2. Significant disruptions of protective
caregiving as the result of repeated changes in primary caregiver; repeated
separation from the primary caregiver; or exposure to severe and persistent
emotional abuse

B. Affective and Physiological
Dysregulation. The child exhibits impaired normative developmental competencies
related to arousal regulation, including at least two of the following:

B. 1. Inability to modulate, tolerate, or
recover from extreme affect states (e.g., fear, anger, shame), including
prolonged and extreme tantrums, or immobilization

B. 2. Disturbances in regulation in bodily
functions (e.g. persistent disturbances in sleeping, eating, and elimination;
over-reactivity or under-reactivity
to touch and sounds; disorganization during routine transitions)

B. 3. Diminished awareness/dissociation of
sensations, emotions and bodily states

B. 4. Impaired capacity to describe emotions
or bodily states

C. Attentional and Behavioral
Dysregulation: The child exhibits impaired normative developmental competencies
related to sustained attention, learning, or coping with stress, including at least
three of the following:

C. 1. Preoccupation with threat, or impaired
capacity to perceive threat, including misreading of safety and danger cues

C. 2. Impaired capacity for self-protection,
including extreme risk-taking or thrill-seeking

C. 3. Maladaptive attempts at self-soothing
(e.g., rocking and other rhythmical movements, compulsive masturbation)

C. 4. Habitual (intentional or automatic) or
reactive self-harm

C. 5. Inability to initiate or sustain
goal-directed behavior

D. Self and Relational
Dysregulation. The child exhibits impaired normative developmental competencies in
their sense of personal identity and involvement in relationships, including at
least three of the following:

D. 1. Intense preoccupation with safety of
the caregiver or other loved ones (including precocious caregiving) or
difficulty tolerating reunion with them after separation

D. 2. Persistent negative sense of self,
including self-loathing, helplessness, worthlessness, ineffectiveness, or
defectiveness

D. 3. Extreme and persistent distrust,
defiance or lack of reciprocal behavior in close relationships with adults or
peers

D. 4. Reactive physical or verbal aggression
toward peers, caregivers, or other adults

D. 5. Inappropriate (excessive or
promiscuous) attempts to get intimate contact (including but not limited to
sexual or physical intimacy) or excessive reliance on peers or adults for safety
and reassurance

D. 6. Impaired capacity to regulate empathic
arousal as evidenced by lack of empathy for, or intolerance of, expressions of
distress of others, or excessive responsiveness to the distress of others

E. Posttraumatic Spectrum
Symptoms. The child exhibits at least one symptom in at least two of the three PTSD
symptom clusters B, C, & D.

F. Duration of disturbance (symptoms in DTD Criteria B, C,
D, and E) at least 6 months.

G. Functional Impairment. The
disturbance causes clinically significant distress or impairment in at least two of
the following areas of functioning:

• Scholastic

• Familial

• Peer Group

• Legal

• Health

• Vocational (for youth involved in,
seeking or referred for employment, volunteer work or job training)

B. A. van der Kolk, “Developmental
Trauma Disorder: Toward A Rational Diagnosis For ChildrenWith Complex Trauma
Histories,” Psychiatric Annals, 35, no. 5 (2005): 401-408.

Resources

GENERAL INFORMATION ABOUT TRAUMA AND
ITS TREATMENT

- The Trauma Center at JRI. This is the
website of the Trauma Center of which I am the medical director, which has
numerous resources for special populations, various treatment approaches,
lectures and courses: www.traumacenter.org.

- David Baldwin’s Trauma Information Pages
provide information for clinicians and researchers in the traumatic-stress
field: http://www.trauma-pages.com/.

- National Child Traumatic Stress Network
(NCTSN). Effective treatments for youth, trauma training,
and education measures; reviews of measures examining trauma for parents,
educators, judges, child welfare agencies, military personnel, and therapists:
http://www.nctsnet.org/.

- American Psychological Association. Resource
guide for traumatized people and their loved ones: http://www.apa.org/topics/trauma/.

- Averse Childhood Experiences. Several websites
are devoted to the ACE study and its consequences: http://acestoohigh.com/got-your-ace-score/; http://www.cdc.gov/violenceprevention/acesstudy/[URL inactive]; http://acestudy.org/.

- Gift from Within PTSD Resources for Survivors
and Caregivers: giftfromwithin.org.

- There & Back Again is a nonprofit
organization that supports the well-being of service-members. Its mission is to
provide reintegration support services to combat veterans of all conflicts: http://thereandbackagain.org/.

- HelpPRO Therapist Finder. Comprehensive listings
of local therapists specializing in trauma and other concerns, serving specific
age groups, accepting payment options and more: http://www.helppro.com/.

- Sidran Foundation includes traumatic memories
and general information about dealing with trauma: www.sidran.org.

- Traumatology. Green Cross Academy of
Traumatology electronic journal, edited by Charles Figley: www.greencross.org/.

- PILOTS database at Dartmouth is a
searchable database of the world’s literature on post-traumatic stress
disorder, produced by the National Center for PTSD: http://search.proquest.com/pilots/?accountid=28179.

GOVERNMENT RESOURCES

- National Center for PTSD includes links to
the PTSD Research Quarterly and National Center divisions, including
behavioral science division, clinical neuroscience division, and women’s
health sciences division: http://www.ptsd.va.gov/.

- Office for Victims of Crime in the Department
of Justice. Provides a variety of resources for victims of crime in the United
States and internationally, including the National Directory of Victim
Assistance Funding Opportunities which lists, by state and territory, the
contact names, mailing addresses, telephone numbers, and e-mail addresses for
the federal grant programs that provide assistance to crime victims: http://ojp.gov/ovc/.

- National Institutes of Mental Health: http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml.

WEBSITES SPECIFICALLY DEALING WITH
TRAUMA AND MEMORY

- Jim Hopper.com. Info on the stages of recovery, recovered memories, and
comprehensive literature review on remembering trauma.

- The Recovered Memory Project. Archive
compiled by Ross Cheit at Brown University: http://www.brown.edu/academics/taubman-center/.

MEDICATIONS

- About Medications for Combat PTSD.
Jonathan Shay, MD, PhD, staff psychiatrist, Boston VA Outpatient Clinic: http://www.dr-bob.org/tips/ptsd.html[URL inactive]. webMD http://www.webmd.com/drugs/condition=1020-post+traumatic+stress+disorderaspx?diseaseid=10200diseasename=post+traumatic+stress+disorder

PROFESSIONAL ORGANIZATIONS FOCUSED ON
GENERAL TRAUMA RESEARCH AND DISSEMINATION

- International Society for Traumatic Stress
Studies: www.istss.com[URL inactive].

- European Society for Traumatic Stress Studies:
www.estss.org.

- International Society for the Study of
Trauma and Dissociation (ISSTD): http://www.isst-d.org/.

PROFESSIONAL ORGANIZATIONS DEALING
WITH PARTICULAR TREATMENT METHODS

- The EMDR International Association
(EMDRIA): http://www.emdria.org/.

- Sensorimotor Institute (founded by Pat Ogden):
http://www.sensorimotorpsychotherapy.org/home/index.html.

- Somatic experiencing (founded by Peter Levine):
http://www.traumahealing.com/somatic-experiencing/index.html[URL inactive].

- Internal family systems therapy: http://www.selfleadership.org/.

- Pesso Boyden system psychomotor therapy: PBSP.com.

THEATER PROGRAMS (A SAMPLE OF
PROGRAMS FOR TRAUMATIZED YOUTH)

- Urban Improv uses improvisational theater
workshops to teach violence prevention, conflict resolution, and decision
making: http://www.urbanimprov.org/.

- The Possibility Project. Based in NYC: http://the-possibility-project.org/.

- Shakespeare in the Courts: http://www.shakespeare.org/education/for-youth/shakespeare-courts/.

YOGA AND MINDFULNESS

- http://givebackyoga.org/.

- http://www.kripalu.org/.

- http://www.mindandlife.org/.

Further Reading

DEALING WITH TRAUMATIZED
CHILDREN

- Blaustein, Margaret, and Kristine
Kinniburgh. Treating Traumatic Stress in Children and Adolescents: How to
Foster Resilience through Attachment, Self-Regulation, and Competency.
New York: Guilford, 2012.

- Hughes, Daniel. Building the Bonds of
Attachment. New York: Jason Aronson, 2006.

- Perry, Bruce, and Maia Szalavitz. The Boy
Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s
Notebook. New York: Basic Books, 2006.

- Terr, Lenore. Too Scared to Cry: Psychic
Trauma in Childhood. Basic Books, 2008.

- Terr, Lenore C. Working with Children to
Heal Interpersonal Trauma: The Power of Play. Ed., Eliana Gil. New
York: Guilford Press, 2011.

- Saxe, Glenn, Heidi Ellis, and Julie Kaplow.
Collaborative Treatment of Traumatized Children and Teens: The Trauma
Systems Therapy Approach. New York: Guilford Press, 2006.

- Lieberman, Alicia, and Patricia van Horn.
Psychotherapy with Infants and Young Children: Repairing the Effects of
Stress and Trauma on Early Attachment. New York: Guilford Press,
2011.

PSYCHOTHERAPY

- Siegel, Daniel J. Mindsight: The New
Science of Personal Transformation. New York: Norton, 2010.

- Fosha D., M. Solomon, and D. J. Siegel. The
Healing Power of Emotion: Affective Neuroscience, Development and Clinical
Practice (Norton Series on Interpersonal Neurobiology). New York:
Norton, 2009.

- Siegel, D., and M. Solomon: Healing Trauma:
Attachment, Mind, Body and Brain (Norton Series on Interpersonal
Neurobiology). New York: Norton, 2003.

- Courtois, Christine, and Julian Ford.
Treating Complex Traumatic Stress Disorders (Adults): Scientific
Foundations and Therapeutic Models. New York: Guilford, 2013.

- Herman, Judith. Trauma and Recovery:
The Aftermath of Violence—from Domestic Abuse to Political Terror. New
York: Basic Books, 1992.

NEUROSCIENCE OF TRAUMA

- Panksepp, Jaak, and Lucy Biven. The
Archaeology of Mind: Neuroevolutionary Origins of Human Emotions
(Norton Series on Interpersonal Neurobiology). New York: Norton, 2012.

- Davidson, Richard, and Sharon Begley. The
Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You
Think, Feel, and Live—and How You Can Change Them. New York: Hachette,
2012.

- Porges, Stephen. The Polyvagal Theory:
Neurophysiological Foundations of Emotions, Attachment, Communication, and
Self-regulation (Norton Series on Interpersonal Neurobiology). New
York: Norton, 2011.

- Fogel, Alan. Body Sense: The Science and
Practice of Embodied Self-Awareness (Norton Series on Interpersonal
Neurobiology). New York: Norton, 2009.

- Shore, Allan N. Affect Regulation and the
Origin of the Self: The Neurobiology of Emotional Development. New
York: Psychology Press, 1994.

- Damasio, Antonio R. The Feeling of What
Happens: Body and Emotion in the Making of Consciousness. Houghton
Mifflin Harcourt, 2000.

BODY-ORIENTED APPROACHES

- Cozzolino, Louis. The Neuroscience of
Psychotherapy: Healing the Social Brain, second edition (Norton Series
on Interpersonal Neurobiology). New York: Norton, 2010.

- Ogden, Pat, and Kekuni Minton. Trauma and
the Body: A Sensorimotor Approach to Psychotherapy (Norton Series on
Interpersonal Neurobiology). New York: Norton, 2008.

- Levine, Peter A. In an Unspoken Voice: How
the Body Releases Trauma and Restores Goodness. Berkeley: North
Atlantic, 2010.

- Levine, Peter A., and Ann Frederic. Waking
the Tiger: Healing Trauma. Berkeley: North Atlantic, 2012

- Curran, Linda. 101 Trauma-Informed
Interventions: Activities, Exercises and Assignments to Move the Client and
Therapy Forward. PESI, 2013.

EMDR

- Parnell, Laura. Attachment-Focused
EMDR: Healing Relational Trauma. New York: Norton, 2013.

- Shapiro, Francine. Getting Past Your Past:
Take Control of Your Life with
Self-Help Techniques from EMDR Therapy. Emmaus, PA: Rodale, 2012.

- Shapiro, Francine, and Margot Silk Forrest.
EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming
Anxiety, Stress, and Trauma. New York: Basic Books, 2004.

WORKING WITH DISSOCIATION

- Schwartz, Richard C. Internal Family
Systems Therapy (The Guilford Family Therapy Series). New York:
Guilford, 1997.

- O. van der Hart, E. R. Nijenhuis, and F.
Steele. The Haunted Self: Structural Dissociation and the Treatment of
Chronic Traumatization. New York: Norton, 2006.

COUPLES

- Gottman, John. The Science of Trust:
Emotional Attunement for Couples. New York: Norton, 2011.

YOGA

- Emerson, David, and Elizabeth Hopper.
Overcoming Trauma through
Yoga: Reclaiming Your Body. Berkeley: North Atlantic, 2012.

- Cope, Stephen. Yoga and the Quest for
the True Self. New York: Bantam Books, 1999.

NEUROFEEDBACK

- Fisher, Sebern. Neurofeedback in the
Treatment of Developmental
Trauma: Calming the Fear-Driven Brain. New York: Norton, 2014.

- Demos, John N. Getting Started with
Neurofeedback. New York: Norton, 2005.

- Evans, James R. Handbook of
Neurofeedback: Dynamics and Clinical
Applications. CRC Press, 2013.

PHYSICAL EFFECTS OF TRAUMA

- Mate, Gabor When the Body Says No:
Understanding the Stress-Disease
Connection. New York: Random House, 2011.

- Sapolsky, Robert. Why Zebras
Don’t Get Ulcers: The Acclaimed Guide to
Stress, Stress-Related Diseases, and Coping. New York: Macmillan
2004.

MEDITATION AND MINDFULNESS

- Zinn, Jon Kabat and Thich Nat Hanh.
Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain, and Illness, revised edition. New York: Random
House, 2009.

- Kornfield, Jack. A Path
with Heart: A Guide Through The Perils and
Promises of Spiritual Life. New York: Random House, 2009.

- Goldstein, Joseph, and Jack Kornfield.
Seeking the Heart of Wisdom: The
Path of Insight Meditation. Shambhala Publications, 2001.

PSYCHOMOTOR THERAPY

- Pesso, Albert, and John S. Crandell.
Moving Psychotherapy: Theory and
Application of Pesso System-Psychomotor Therapy. Brookline Books,
1991.

- Pesso, Albert. Experience In Action: A
Psychomotor Psychology, New York: New York University Press, 1969.

Notes

PROLOGUE

1. V. Felitti, et al. “Relationship of
Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in
Adults: The Adverse Childhood Experiences (ACE) Study.” American Journal
of Preventive Medicine 14, no. 4 (1998): 245–58.

CHAPTER 1: LESSONS FROM VIETNAM
VETERANS

1. A. Kardiner, The Traumatic Neuroses of
War (New York: P. Hoeber, 1941). Later I discovered that numerous textbooks
on war trauma were published around both the First and Second World Wars, but as
Abram Kardiner wrote in 1947: “The subject of neurotic disturbances consequent
upon war has, in the past 25 years, been submitted to a good deal of capriciousness
in public interest and psychiatric whims. The public does not sustain its interest,
which was very great after World War I, and neither does psychiatry. Hence these
conditions are not subject to continuous study.”

2. Op cit, p. 7.

3. B. A. van der Kolk, “Adolescent
Vulnerability to Post Traumatic Stress Disorder,” Psychiatry 48
(1985): 365–70.

4. S. A. Haley, “When the Patient Reports
Atrocities: Specific Treatment Considerations of the Vietnam Veteran,”
Archives of General Psychiatry 30 (1974): 191–96.

5. E. Hartmann, B. A. van der Kolk, and M.
Olfield, “A Preliminary Study of the Personality of the Nightmare
Sufferer,” American Journal of Psychiatry 138 (1981): 794–97; B. A.
van der Kolk, et al., “Nightmares and Trauma: Life-long and Traumatic
Nightmares in Veterans,” American Journal of Psychiatry 141 (1984):
187–90.

6. B. A. van der Kolk and C. Ducey, “The
Psychological Processing of Traumatic Experience: Rorschach Patterns in PTSD,”
Journal of Traumatic Stress 2 (1989): 259–74.

7. Unlike normal memories, traumatic memories are more like
fragments of sensations, emotions, reactions, and images, that keep getting
reexperienced in the present. The studies of Holocaust memories at Yale by Dori Laub
and Nanette C. Auerhahn, as well as Lawrence L. Langer’s book Holocaust
Testimonies: The Ruins of Memory, and, most of all, Pierre Janet’s
1889, 1893, and 1905 descriptions of the nature of traumatic memories helped us
organize what we saw. That work will be discussed in the memory chapter.

8. D. J. Henderson, “Incest,” in
Comprehensive Textbook of Psychiatry, eds. A. M. Freedman and H. I.
Kaplan, 2nd ed. (Baltimore: Williams & Wilkins, 1974), 1536.

9. Ibid.

10. K. H. Seal, et al., “Bringing the
War Back Home: Mental Health Disorders Among 103,788 U.S. Veterans Returning from
Iraq and Afghanistan Seen at Department of Veterans Affairs Facilities,”
Archives of Internal Medicine 167, no. 5 (2007): 476–82; C. W. Hoge, J.
L. Auchterlonie, and C. S. Milliken, “Mental Health Problems, Use of Mental
Health Services, and Attrition from Military Service After Returning from Deployment
to Iraq or Afghanistan,” Journal of the American Medical Association
295, no. 9 (2006): 1023–32.

11. D. G. Kilpatrick and B. E. Saunders,
Prevalence and Consequences of Child Victimization: Results from the
National Survey of Adolescents: Final Report (Charleston, SC: National
Crime Victims Research and Treatment Center, Department of Psychiatry and Behavioral
Sciences, Medical University of South Carolina 1997).

12. U.S. Department of Health and Human
Services, Administration on Children, Youth and Families, Child Maltreatment
2007, 2009. See also U.S. Department of Health and Human Services,
Administration for Children and Families, Administration on Children, Youth and
Families, Children’s Bureau, Child Maltreatment
2010, 2011.

CHAPTER 2: REVOLUTIONS IN
UNDERSTANDING MIND AND BRAIN

1. G. Ross Baker, et al., “The Canadian
Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in
Canada,” Canadian Medical Association Journal 170, no. 11 (2004):
1678–86; A. C. McFarlane, et al., “Posttraumatic Stress Disorder in a General
Psychiatric Inpatient Population,” Journal of Traumatic Stress 14,
no. 4 (2001): 633–45; Kim T. Mueser, et al., “Trauma and Posttraumatic Stress
Disorder in Severe Mental Illness,” Journal of Consulting and Clinical
Psychology 66, no. 3 (1998): 493; National Trauma Consortium, www.national-traumaconsortium.org[URL inactive].

2. E. Bleuler, Dementia Praecox or the
Group of Schizophrenias, trans. J. Zinkin (Washington, DC:
International Universities Press, 1950), p. 227.

3. L. Grinspoon, J. Ewalt, and R. I. Shader,
“Psychotherapy and Pharmacotherapy in Chronic Schizophrenia,”
American Journal of Psychiatry 124, no. 12 (1968): 1645–52. See also L.
Grinspoon, J. Ewalt, and R. I. Shader, Schizophrenia: Psychotherapy and
Pharmacotherapy (Baltimore: Williams and Wilkins, 1972).

4. T. R. Insel, “Neuroscience: Shining Light on
Depression,” Science 317, no. 5839 (2007): 757–58. See also C. M.
France, P. H. Lysaker, and R. P. Robinson, “The ‘Chemical
Imbalance’ Explanation for Depression: Origins, Lay Endorsement, and Clinical
Implications,” Professional Psychology: Research and Practice 38
(2007): 411–20.

5. B. J. Deacon, and J. J. Lickel, “On
the Brain Disease Model of Mental Disorders,” Behavior Therapist 32,
no. 6 (2009).

6. J. O. Cole, et al., “Drug Trials in
Persistent Dyskinesia (Clozapine),” in Tardive Dyskinesia, Research and
Treatment, ed. R. C. Smith, J. M. Davis, and W. E. Fahn (New York: Plenum,
1979).

7. E. F. Torrey, Out of the Shadows:
Confronting America’s Mental Illness Crisis (New York: John Wiley
& Sons, 1997). However, other factors were equally important, such as President
Kennedy’s 1963 Community Mental Health Act, in which the federal government
took over paying for mental health care and which rewarded states for treating
mentally ill people in the community.

8. American Psychiatric Association, Committee
on Nomenclature. Work Group to Revise DSM-III. Diagnostic and Statistical Manual
of Mental Disorders (American Psychiatric Publishing, 1980).

9. S. F. Maier and M. E. Seligman,
“Learned Helplessness: Theory and Evidence,” Journal of Experimental
Psychology: General 105, no. 1 (1976): 3. See also M. E. Seligman, S. F.
Maier, and J. H. Geer, “Alleviation of Learned Helplessness in the Dog,”
Journal of Abnormal Psychology 73, no. 3 (1968): 256; and R.
L. Jackson, J. H. Alexander, and S. F. Maier, “Learned Helplessness,
Inactivity, and Associative Deficits: Effects of Inescapable Shock on Response
Choice Escape Learning,” Journal of Experimental Psychology: Animal
Behavior Processes 6, no. 1 (1980): 1.

10. G. A. Bradshaw and A. N. Schore,
“How Elephants Are Opening Doors: Developmental Neuroethology, Attachment and
Social Context,” Ethology 113 (2007): 426–36.

11. D. Mitchell, S. Koleszar, and R. A.
Scopatz, “Arousal and T-Maze Choice Behavior in Mice: A Convergent Paradigm
for Neophobia Constructs and Optimal Arousal Theory,” Learning and
Motivation 15 (1984): 287–301. See also D. Mitchell, E. W. Osborne, and M.
W. O’Boyle, “Habituation Under Stress: Shocked Mice Show Nonassociative
Learning in a T-maze,” Behavioral and Neural Biology 43 (1985):
212–17.

12. B. A. van der Kolk, et al.,
“Inescapable Shock, Neurotransmitters and Addiction to Trauma: Towards a
Psychobiology of Post Traumatic Stress,” Biological Psychiatry 20
(1985): 414–25.

13. C. Hedges, War Is a Force That Gives
Us Meaning (New York: Random House Digital, 2003).

14. B. A. van der Kolk, “The Compulsion
to Repeat Trauma: Revictimization, Attachment and Masochism,” Psychiatric
Clinics of North America 12 (1989): 389–411.

15. R. L. Solomon, “The Opponent-Process
Theory of Acquired Motivation: The Costs of Pleasure and the Benefits of
Pain,” American Psychologist 35 (1980): 691–712.

16. H. K. Beecher, “Pain in Men Wounded in
Battle,” Annals of Surgery 123, no. 1 (January 1946): 96–105.

17. B. A. van der Kolk, et al., “Pain
Perception and Endogenous Opioids in Post Traumatic Stress Disorder,”
Psychopharmacology Bulletin 25 (1989): 117–21. See also R. K. Pitman,
et al., “Naloxone Reversible Stress Induced Analgesia in Post Traumatic Stress
Disorder,” Archives of General Psychiatry 47 (1990): 541–47; and
Solomon, “Opponent-Process Theory of Acquired Motivation.”

18. J. A. Gray and N. McNaughton, “The
Neuropsychology of Anxiety: Reprise,” in Nebraska Symposium on
Motivation (University of Nebraska Press, 1996), 43, 61–134. See also C. G.
DeYoung and J. R. Gray, “Personality Neuroscience: Explaining Individual
Differences in Affect, Behavior, and Cognition, in The Cambridge Handbook of
Personality Psychology (2009), 323–46.

19. M. J. Raleigh, et al., “Social and
Environmental Influences on Blood Serotonin Concentrations in Monkeys,”
Archives of General Psychiatry 41 (1984): 505–10.

20. B. A. van der Kolk, et al.,
“Fluoxetine in Post Traumatic Stress,” Journal of Clinical
Psychiatry (1994): 517–22.

21. For the Rorschach aficionados among you,
it reversed the C + CF/FC ratio.

22. Grace E. Jackson, Rethinking
Psychiatric Drugs: A Guide for Informed Consent (AuthorHouse, 2005); Robert
Whitaker, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the
Astonishing Rise of Mental Illness in America (New York: Random House,
2011).

23. We will return to this issue in chapter 15, where we discuss our study comparing
Prozac with EMDR, in which EMDR had better long-term results than Prozac in treating
depression, at least in adult onset trauma.

24. J. M. Zito, et al., “Psychotropic
Practice Patterns for Youth: A 10-Year Perspective,” Archives of
Pediatrics and Adolescent Medicine 157 (January 2003): 17–25.

25. http://en.wikipedia.org/wiki/List_of_largest_selling_pharmaceutical_products.

26. Lucette Lagnado, “U.S. Probes Use of
Antipsychotic Drugs on Children,” Wall
Street Journal, August 11, 2013.

27. Katie Thomas, “J.&J. to Pay $2.2
Billion in Risperdal Settlement,” New York Times, November 4,
2013.

28. M. Olfson, et al., “Trends in
Antipsychotic Drug Use by Very Young, Privately Insured Children,” Journal
of the American Academy of Child & Adolescent Psychiatry 49,
no.1 (2010): 13–23.

29. M. Olfson, et al., “National Trends
in the Outpatient Treatment of Children and Adolescents with Antipsychotic
Drugs,” Archives of General Psychiatry 63, no. 6 (2006):
679.

30. A. J. Hall, et al., “Patterns of
Abuse Among Unintentional Pharmaceutical Overdose Fatalities,” Journal of
the American Medical Association 300, no. 22 (2008): 2613–20.

31. During the past decade two editors in
chief of the most prestigious professional medical journal in the United States, the
New England Journal of Medicine, Dr. Marcia Angell and Dr. Arnold Relman, have resigned from
their positions because of the excessive power of the pharmaceutical industry over
medical research, hospitals, and doctors. In a letter to the New York Times
on December 28, 2004, Angell and Relman pointed out that the previous year one drug
company had spent 28 percent of its revenues (more than $6 billion) on marketing and
administrative expenses, while spending only half that on research and development;
keeping 30 percent in net income was typical for the pharmaceutical industry. They
concluded: “The medical profession should break its dependence on the
pharmaceutical industry and educate its own.” Unfortunately, this is about as
likely as politicians breaking free from the donors that finance their election
campaigns.

CHAPTER 3: LOOKING INTO THE BRAIN:
THE NEUROSCIENCE REVOLUTION

1. B. Roozendaal, B. S. McEwen, and S.
Chattarji, “Stress, Memory and the Amygdala,” Nature Reviews
Neuroscience 10, no. 6 (2009): 423–33.

2. R. Joseph, The Right Brain and the
Unconscious (New York: Plenum Press, 1995).

3. The movie The Assault (based on
the novel of the same name by Harry Mulisch), which won the Oscar for Best Foreign
Language Film in 1986, is a good illustration of the power of deep early emotional
impressions in determining powerful passions in adults.

4. This is the essence of cognitive behavioral
therapy. See Foa, Friedman, and Keane, 2000 Treatment Guidelines for
PTSD.

CHAPTER 4: RUNNING FOR YOUR LIFE:
THE ANATOMY OF SURVIVAL

1. R. Sperry, “Changing
Priorities,” Annual Review of Neuroscience 4 (1981): 1–15.

2. A. A. Lima, et al., “The Impact of
Tonic Immobility Reaction on the Prognosis of Posttraumatic Stress Disorder,”
Journal of Psychiatric Research 44, no. 4 (March 2010): 224–28.

3. P. Janet, L’automatisme
psychologique (Paris: Félix Alcan, 1889).

4. R. R. Llinás, I of the Vortex: From
Neurons to Self (Cambridge, MA: MIT Press, 2002). See also R. Carter and C.
D. Frith, Mapping the Mind (Berkeley: University of California Press,
1998); R. Carter, The Human Brain Book (Penguin, 2009); and J. J. Ratey,
A User’s Guide to the Brain (New York: Pantheon Books, 2001),
179.

5. B. D. Perry, et al., “Childhood
Trauma, the Neurobiology of Adaptation, and Use Dependent Development of the Brain:
How States Become Traits,” Infant Mental Health Journal 16,
no. 4 (1995): 271–91.

6. I am indebted to my late friend David
Servan-Schreiber, who first made this distinction in his book The Instinct to
Heal.

7. E. Goldberg, The Executive Brain:
Frontal Lobes and the Civilized Mind (London, Oxford University Press,
2001).

8. G. Rizzolatti and L. Craighero “The
Mirror-Neuron System,” Annual Review of Neuroscience 27 (2004):
169–92. See also M. Iacoboni, et al., “Cortical Mechanisms of Human
Imitation,” Science 286, no. 5449 (1999): 2526–28; C. Keysers and V.
Gaz-zola, “Social Neuroscience: Mirror Neurons Recorded in Humans,”
Current
Biology 20, no. 8 (2010):
R353–54; J. Decety and P. L. Jackson, “The Functional Architecture of Human
Empathy,” Behavioral and Cognitive Neuroscience Reviews 3 (2004):
71–100; M. B. Schippers, et al., “Mapping the Information Flow from One Brain
to Another During Gestural Communication,” Proceedings of the National
Academy of Sciences of the United States of America 107, no. 20 (2010):
9388–93; and A. N. Meltzoff and J. Decety, “What Imitation Tells Us About
Social Cognition: A Rapprochement Between Developmental Psychology and Cognitive
Neuroscience,” Philosophical Transactions of the Royal Society,
London 358 (2003): 491–500.

9. D. Goleman, Emotional Intelligence
(New York: Random House, 2006). See also V. S. Ramachandran, “Mirror Neurons
and Imitation Learning as the Driving Force Behind ‘the Great Leap
Forward’ in Human Evolution,” Edge (May 31, 2000), http://edge.org/conversation/mirror-neurons-and-imitation-learning-as-the-driving-force-behind-the-great-leap-forward-in-human-evolution
(retrieved April 13, 2013).

10. G. M. Edelman, and J. A. Gally,
“Reentry: A Key Mechanism for Integration of Brain Function,”
Frontiers in Integrative Neuroscience 7 (2013).

11. J. LeDoux, “Rethinking the Emotional
Brain,” Neuron 73, no. 4 (2012): 653–76. See also J. S. Feinstein, et
al., “The Human Amygdala and the Induction and Experience of Fear,”
Current Biology 21, no. 1 (2011): 34–38.

12. The medial prefrontal cortex is the middle
part of the brain (neuroscientists call them “the midline structures”).
This area of the brain comprises a conglomerate of related structures: the
orbito-prefrontal cortex, the inferior and dorsal medial prefrontal cortex, and a
large structure called the anterior cingulate, all of which are involved in
monitoring the internal state of the organism and selecting the appropriate
response. See, e.g., D. Diorio, V. Viau, and M. J. Meaney, “The Role of the
Medial Prefrontal Cortex (Cingulate Gyrus) in the Regulation of
Hypothalamic-Pituitary-Adrenal Responses to Stress,” Journal of
Neuroscience 13, no. 9 (September 1993): 3839–47; J. P. Mitchell, M. R.
Banaji, and C. N. Macrae, “The Link Between Social Cognition and
Self-Referential Thought in the Medial Prefrontal Cortex,” Journal of
Cognitive Neuroscience 17, no. 8. (2005): 1306–15; A.
D’Argembeau, et al., “Valuing One’s Self: Medial Prefrontal
Involvement in Epistemic and Emotive Investments in Self-Views,” Cerebral
Cortex 22 (March 2012): 659–67; M. A. Morgan, L. M. Romanski, J. E. LeDoux,
“Extinction of Emotional Learning: Contribution of Medial Prefrontal
Cortex,” Neuroscience Letters 163 (1993):109–13; L. M. Shin, S. L.
Rauch, and R. K. Pitman, “Amygdala, Medial Prefrontal Cortex, and Hippocampal
Function in PTSD,” Annals of the New York Academy of Sciences 1071,
no. 1 (2006): 67–79; L. M. Williams, et al., “Trauma Modulates Amygdala and
Medial Prefrontal Responses to Consciously Attended Fear,” Neuroimage, 29, no.
2 (2006): 347–57; M. Koenig and J. Grafman, “Posttraumatic Stress Disorder:
The Role of Medial Prefrontal Cortex and Amygdala,” Neuroscientist
15, no. 5 (2009): 540–48; and M. R. Milad, I. Vidal-Gonzalez, and G. J. Quirk,
“Electrical Stimulation of Medial Prefrontal Cortex Reduces Conditioned Fear
in a Temporally Specific Manner,” Behavioral Neuroscience 118, no. 2
(2004): 389.

13. B. A. van der Kolk, “Clinical Implications of
Neuroscience Research in PTSD,” Annals of the New York Academy of
Sciences 1071 (2006): 277–93.

14. P. D. MacLean, The Triune Brain in
Evolution: Role in Paleocerebral Functions (New York, Springer, 1990).

15. Ute Lawrence, The Power of Trauma:
Conquering Post Traumatic Stress Disorder, iUniverse, 2009.

16. Rita Carter and Christopher D. Frith,
Mapping the Mind (Berkeley: University of California Press, 1998). See
also A. Bechara, et al., “Insensitivity to Future Consequences Following
Damage to Human Prefrontal Cortex,” Cognition 50, no. 1
(1994): 7–15; A. Pascual-Leone, et al., “The Role of the Dorsolateral
Prefrontal Cortex in Implicit Procedural Learning,” Experimental Brain
Research 107, no. 3 (1996): 479–85; and S. C. Rao, G. Rainer, and
E. K. Miller, “Integration of What and Where in the Primate Prefrontal
Cortex,” Science 276, no. 5313 (1997): 821–24.

17. H. S. Duggal, “New-Onset PTSD After
Thalamic Infarct,” American Journal of Psychiatry 159, no. 12 (2002):
2113-a. See also R. A. Lanius, et al., “Neural Correlates of Traumatic
Memories in Posttraumatic Stress Disorder: A Functional MRI Investigation,”
American Journal of Psychiatry 158, no. 11 (2001): 1920–22;
and I. Liberzon, et al., “Alteration of Corticothalamic Perfusion Ratios
During a PTSD Flashback,” Depression and Anxiety 4, no. 3
(1996): 146–50.

18. R. Noyes Jr. and R. Kletti,
“Depersonalization in Response to Life-Threatening Danger,”
Comprehensive Psychiatry 18, no. 4 (1977): 375–84. See also M. Sierra,
and G. E. Berrios, “Depersonalization: Neurobiological Perspectives,”
Biological Psychiatry 44, no. 9 (1998): 898–908.

19. D. Church, et al., “Single-Session
Reduction of the Intensity of Traumatic Memories in Abused Adolescents After EFT: A
Randomized Controlled Pilot Study,” Traumatology 18, no. 3 (2012):
73–79; and D. Feinstein and D. Church, “Modulating Gene Expression Through
Psychotherapy: The Contribution of Noninvasive Somatic Interventions,”
Review of General Psychology 14, no. 4 (2010): 283–95. See also www.vetcases.com.

CHAPTER 5: BODY-BRAIN
CONNECTIONS

1. C. Darwin, The Expression of the
Emotions in Man and Animals (London: Oxford University Press, 1998).

2. Ibid., 71.

3. Ibid.

4. Ibid., 71–72.

5. P. Ekman, Facial Action Coding System:
A Technique for the Measurement of Facial Movement (Palo Alto, CA:
Consulting Psychologists Press, 1978). See also C. E. Izard, The Maximally
Discriminative Facial Movement Coding System (MAX) (Newark, DE: University
of Delaware Instructional Resource Center, 1979).

6. S. W. Porges, The Polyvagal Theory:
Neurophysiological Foundations of Emotions, Attachment, Communication, and
Self-Regulation, Norton Series on Interpersonal Neurobiology (New York: WW
Norton & Company, 2011).

7. This is Stephen Porges’s and Sue Carter’s
name for the ventral vagal system. http://www.pesi.com/bookstore/A_Neural_Love_Code__The_Body_s_Need_to_Engage_and_Bond-details.aspx[URL inactive]

8. S. S. Tomkins, Affect, Imagery,
Consciousness (vol. 1, The Positive Affects) (New York: Springer,
1962); S. S. Tomkin, Affect, Imagery, Consciousness (vol. 2, The
Negative Affects) (New York: Springer, 1963).

9. P. Ekman, Emotions Revealed:
Recognizing Faces and Feelings to Improve Commu-nication and Emotional Life
(New York: Macmillan, 2007); P. Ekman, The Face of
Man: Expressions of Universal Emotions in a New Guinea Village (New York:
Garland STPM Press, 1980).

10. See, e.g., B. M. Levinson,
“Human/Companion Animal Therapy,” Journal of
Contemporary Psychotherapy 14, no. 2 (1984): 131–44; D. A. Willis,
“Animal Therapy,” Rehabilitation Nursing 22, no. 2 (1997):
78–81; and A. H. Fine, ed., Handbook on Animal-Assisted Therapy: Theoretical
Foundations and Guidelines for Practice (Academic Press, 2010).

11. P. Ekman, R. W. Levenson, and W. V.
Friesen, “Autonomic Nervous System Activity Distinguishes Between
Emotions,” Science 221 (1983): 1208–10.

12. J. H. Jackson, “Evolution and
Dissolution of the Nervous System,” in Selected Writings of John Hughlings
Jackson, ed. J. Taylor (London: Stapes Press, 1958), 45–118.

13. Porges pointed out this pet store analogy
to me.

14. S. W. Porges, J. A. Doussard-Roosevelt,
and A. K. Maiti, “Vagal Tone and the Physiological Regulation of
Emotion,” in The Development of Emotion Regulation: Biological and
Behavioral Considerations, ed. N. A. Fox, Monographs of the Society for
Research in Child Development, vol. 59 (2–3, serial no. 240) (1994), 167–86. http://www.amazon.com/The-Development-Emotion-Regulation-Considerations/dp/0226259404).

15. V. Felitti, et al., “Relationship of
Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in
Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal
of Preventive Medicine 14, no. 4 (1998): 245–58.

16. S. W. Porges, “Orienting in a
Defensive World: Mammalian Modifications of Our Evolutionary Heritage: A Polyvagal
Theory,” Psychophysiology 32 (1995): 301–18.

17. B. A. Van der Kolk, “The Body Keeps
the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress,”
Harvard Review of Psychiatry 1, no. 5 (1994): 253–65.

CHAPTER 6: LOSING YOUR BODY, LOSING
YOUR SELF

1. K. L. Walsh, et al., “Resiliency
Factors in the Relation Between Childhood Sexual Abuse and Adulthood Sexual Assault
in College-Age Women,” Journal of Child Sexual Abuse 16, no. 1
(2007): 1–17.

2. A. C. McFarlane, “The Long-Term Costs
of Traumatic Stress: Intertwined Physical and Psychological Consequences,”
World Psychiatry 9, no. 1 (2010): 3–10.

3. W. James, “What Is an Emotion?”
Mind 9: 188–205.

4. R. L. Bluhm, et al., “Alterations in
Default Network Connectivity in Posttraumatic Stress Disorder Related to Early-Life
Trauma,” Journal of Psychiatry & Neuroscience 34, no. 3 (2009):
187. See also J. K. Daniels, et al., “Switching Between Executive and Default
Mode Networks in Posttraumatic Stress Disorder: Alterations in Functional
Connectivity,” Journal of Psychiatry & Neuroscience 35, no. 4
(2010): 258.

5. A. Damasio, The Feeling of What
Happens: Body and Emotion in the Making of Consciousness (New York:
Hartcourt Brace, 1999). Damasio actually says, “Consciousness was invented so
that we could know life”, p. 31.

6. Damasio, Feeling of What Happens,
p. 28.

7. Ibid., p. 29.

8. A. Damasio, Self Comes to Mind:
Constructing the Conscious Brain (New York, Random House Digital, 2012),
17.

9. Damasio, Feeling of What Happens,
p. 256.

10. Antonio R. Damasio, et al.,
“Subcortical and Cortical Brain Activity During the Feeling of Self-Generated
Emotions.” Nature Neuroscience 3, vol. 10 (2000): 1049–56.

11. A. A. T. S. Reinders, et al., “One
Brain, Two Selves,” NeuroImage 20 (2003): 2119–25. See also E. R. S.
Nijenhuis, O. Van der Hart, and K. Steele, “The Emerging Psychobiology of
Trauma-Related Dissociation and Dissociative Disorders,” in Biological
Psychiatry, vol. 2., eds. H. A. H. D’Haenen, J. A. den Boer, and P.
Willner (West Sussex, UK: Wiley 2002), 1079–198; J. Parvizi and A. R. Damasio,
“Consciousness and the Brain Stem,” Cognition 79 (2001):
135–59; F. W. Putnam, “Dissociation and Disturbances of Self,” in
Dysfunctions of the Self, vol. 5, eds. D. Cicchetti and S. L. Toth (New
York: University of Rochester Press, 1994), 251–65; and F. W. Putnam,
Dissociation in Children and Adolescents: A Developmental Perspective
(New York: Guilford, 1997).

12. A. D’Argembeau, et al.,
“Distinct Regions of the Medial Prefrontal Cortex Are Associated with
Self-Referential Processing and Perspective Taking,” Journal of Cognitive
Neuroscience 19, no. 6 (2007): 935–44. See also N. A. Farb, et al.,
“Attending to the Present: Mindfulness Meditation Reveals Distinct Neural
Modes of Self-Reference,” Social Cognitive and Affective Neuroscience
2, no. 4 (2007): 313–22; and B. K. Hölzel, et al., “Investigation of
Mindfulness Meditation Practitioners with Voxel-Based Morphometry,” Social
Cognitive and Affective Neuroscience 3, no. 1 (2008): 55–61.

13. P. A. Levine, Healing Trauma: A
Pioneering Program for Restoring the Wisdom of Your Body (Berkeley: North
Atlantic Books, 2008); and P. A. Levine, In an Unspoken Voice: How the Body
Releases Trauma and Restores Goodness (Berkeley: North Atlantic Books,
2010).

14. P. Ogden and K. Minton,
“Sensorimotor Psychotherapy: One Method for Processing Traumatic
Memory,” Traumatology 6, no. 3 (2000): 149–73; and P. Ogden, K. Minton, and C. Pain, Trauma and the
Body: A Sensorimotor Approach to Psychotherapy, Norton Series on
Interpersonal Neurobiology (New York: WW Norton & Company, 2006).

15. D. A. Bakal, Minding the Body:
Clinical Uses of Somatic Awareness (New York: Guilford Press, 2001).

16. There are innumerable studies on the
subject. A small sample for further study: J. Wolfe, et al., “Posttraumatic
Stress Disorder and War-Zone Exposure as Correlates of Perceived Health in Female
Vietnam War Veterans,” Journal of Consulting and Clinical Psychology
62, no. 6 (1994): 1235–40; L. A. Zoellner, M. L. Goodwin, and E. B. Foa, “PTSD
Severity and Health Perceptions in Female Victims of Sexual Assault,”
Journal of Traumatic Stress 13, no. 4 (2000): 635–49; E. M. Sledjeski,
B. Speisman, and L. C. Dierker, “Does Number of Lifetime Traumas Explain the
Relationship Between PTSD and Chronic Medical Conditions? Answers from the National
Comorbidity Survey-Replication (NCS-R),” Journal of Behavioral Medicine
31 (2008): 341–49; J. A. Boscarino, “Posttraumatic Stress Disorder
and Physical Illness: Results from Clinical and Epidemiologic Studies,”
Annals of the New York Academy of Sciences 1032 (2004): 141–53; M.
Cloitre, et al., “Posttraumatic Stress Disorder and Extent of Trauma Exposure
as Correlates of Medical Problems and Perceived Health Among Women with Childhood
Abuse,” Women & Health 34, no. 3 (2001): 1–17; D. Lauterbach, R.
Vora, and M. Rakow, “The Relationship Between Posttraumatic Stress Disorder
and Self-Reported Health Problems,” Psychosomatic Medicine 67, no. 6
(2005): 939–47; B. S. McEwen, “Protective and Damaging Effects of Stress
Mediators,” New England Journal of Medicine 338, no. 3 (1998):
171–79; P. P. Schnurr and B. L. Green, Trauma and Health: Physical Health
Consequences of Exposure to Extreme Stress (Washington, DC: American
Psychological Association, 2004).

17. P. K. Trickett, J. G. Noll, and F. W.
Putnam, “The Impact of Sexual Abuse on Female Development: Lessons from a
Multigenerational, Longitudinal Research Study,” Development and
Psychopathology 23, no. 2 (2011): 453.

18. K. Kosten and F. Giller Jr.,
“Alexithymia as a Predictor of Treatment Response in Post-Traumatic Stress
Disorder,” Journal of Traumatic Stress 5, no. 4 (October 1992):
563–73.

19. G. J. Taylor and R. M. Bagby, “New
Trends in Alexithymia Research,” Psychotherapy and Psychosomatics 73,
no. 2 (2004): 68–77.

20. R. D. Lane, et al., “Impaired
Verbal and Nonverbal Emotion Recognition in Alexithymia,” Psychosomatic
Medicine 58, no. 3 (1996): 203–10.

21. H. Krystal and J. H. Krystal,
Integration and Self-Healing: Affect, Trauma, Alexithymia (New York:
Analytic Press, 1988).

22. P. Frewen, et al., “Clinical and
Neural Correlates of Alexithymia in Posttraumatic Stress Disorder,”
Journal of Abnormal Psychology 117, no. 1 (2008): 171–81.

23. D. Finkelhor, R. K. Ormrod, and H. A.
Turner, (2007). “Re-Victimization Patterns in a National Longitudinal Sample
of Children and Youth,” Child Abuse & Neglect 31, no. 5 (2007): 479-502; J. A. Schumm, S.
E. Hobfoll, and N. J. Keogh, “Revictimization and Interpersonal Resource Loss
Predicts PTSD Among Women in Substance-Use Treatment, Journal of Traumatic
Stress, 17, no. 2 (2004): 173–81; J. D. Ford, J. D. Elhai, D. F. Connor,
and B. C. Frueh, “Poly-Victimization and Risk of Posttraumatic, Depressive,
and Substance Use Disorders and Involvement in Delinquency in a National Sample of
Adolescents,” Journal of Adolescent Health, 46, no. 6 (2010):
545–52.

24. P. Schilder,
“Depersonalization,” in Introduction to a Psychoanalytic
Psychiatry, no. 50 (New York: International Universities Press, 196), p.
120.

25. S. Arzy, et al., “Neural Mechanisms
of Embodiment: Asomatognosia Due to Premotor Cortex Damage,” Archives of
Neurology 63, no. 7 (2006): 1022–25. See also S. Arzy et al.,
“Induction of an Illusory Shadow Person,” Nature 443, no. 7109
(2006): 287; S. Arzy et al., “Neural Basis of Embodiment: Distinct
Contributions of Temporoparietal Junction and Extrastriate Body Area,”
Journal of Neuroscience 26, no. 31 (2006): 8074–81; O. Blanke et al.,
“Out-of-Body Experience and Autoscopy of Neurological Origin,”
Brain 127, part 2 (2004): 243–58; and M. Sierra, et al.,
“Unpacking the Depersonalization Syndrome: An Exploratory Factor Analysis on
the Cambridge Depersonalization Scale,” Psychological Medicine 35
(2005): 1523–32.

26. A. A. T. Reinders, et al.,
“Psychobiological Characteristics of Dissociative Identity Disorder: A Symptom
Provocation Study,” Biological Psychiatry 60, no. 7 (2006):
730–40.

27. In his book Focusing, Eugene
Gendlin coined the term “felt sense”: “A felt sense is not a
mental experience but a physical one. A bodily awareness of a situation or person or
event; Focusing (New York, Random House Digital, 1982).

28. C. Steuwe, et al., “Effect of
Direct Eye Contact in PTSD Related to Interpersonal Trauma: An fMRI Study of
Activation of an Innate Alarm System,” Social Cognitive and Affective
Neuroscience 9, no. 1 (January 2012): 88–97.

CHAPTER 7: GETTING ON THE SAME
WAVELENGTH, ATTACHMENT AND ATTUNEMENT

1. N. Murray, E. Koby, and B. van der Kolk,
“The Effects of Abuse on Children’s Thoughts,” chapter 4 in Psychological Trauma
(Washington, DC: American Psychiatric Press, 1987).

2. The attachment researcher Mary Main told
six-year-olds a story about a child whose mother had gone away and asked them to
make up a story of what happened next. Most six-year-olds who, as infants, had been
found to have secure relationships with their mothers made up some imaginative tale
with a good ending, while the kids who five years earlier had been classified as
having a disorganized attachment relationship had a tendency toward catastrophic
fantasies and often gave frightened responses like “The parents will
die” or “The child will kill herself.” In Mary Main, Nancy Kaplan,
and Jude Cassidy. “Security in Infancy, Childhood, and Adulthood: A Move to
the Level of Representation,” Monographs of the Society for
Research in Child Development (1985).

3. J. Bowlby, Attachment and Loss, vol. 1,
Attachment (New York Random House, 1969); J. Bowlby, Attachment and
Loss, vol. 2, Separation: Anxiety and Anger (New York: Penguin,
1975); J. Bowlby, Attachment and Loss, vol. 3, Loss: Sadness and
Depression (New York: Basic, 1980); J. Bowlby, “The Nature of the
Child’s Tie to His Mother 1,” International Journal of
Psycho-Analysis, 1958, 39, 350–73.

4. C. Trevarthen, “Musicality and the
Intrinsic Motive Pulse: Evidence from Human Psychobiology and Rhythms, Musical
Narrative, and the Origins of Human Communication,” Muisae Scientiae,
special issue, 1999, 157–213.

5. A. Gopnik and A. N. Meltzoff, Words,
Thoughts, and Theories (Cambridge: MIT Press, 1997); A. N. Meltzoff and M.
K. Moore, “Newborn Infants Imitate Adult Facial Gestures,” Child
Development 54, no. 3 (June 1983): 702–9; A. Gopnik, A. N. Meltzoff, and P.
K. Kuhl, The Scientist in the Crib: Minds, Brains, and How Children Learn
(New York: HarperCollins, 2009).

6. E. Z. Tronick, “Emotions and
Emotional Communication in Infants,” American Psychologist 44, no. 2
(1989): 112. See also E. Tronick, The Neurobehavioral and Social-Emotional
Development of Infants and Children (New York, WW Norton & Company,
2007); E. Tronick and M. Beeghly, “Infants’ Meaning-Making and the
Development of Mental Health Problems,” American Psychologist 66, no.
2 (2011): 107; and A. V. Sravish, et al., “Dyadic Flexibility During the
Face-to-Face Still-Face Paradigm: A Dynamic Systems Analysis of Its Temporal
Organization,” Infant Behavior and Development 36, no. 3 (2013):
432–37.

7. M. Main, “Overview of the Field of
Attachment,” Journal of Consulting and Clinical Psychology 64, no. 2
(1996): 237–43.

8. D. W. Winnicott, Playing and
Reality (New York: Psychology Press, 1971). See also D. W. Winnicott,
“The Maturational Processes and the Facilitating Environment,” (1965);
and D. W. Winnicott, Through Paediatrics to Psycho-analysis: Collected
Papers (New York: Brunner/Mazel, 1975).

9. As we saw in chapter 6, and as Damasio has demonstrated, this sense of inner reality is,
at least in part, rooted in the insula, the brain structure that plays a central
role in body-mind communication, a structure that is often impaired in people with
histories of chronic trauma.

10. D. W. Winnicott, Primary Maternal
Preoccupation (London: Tavistock, 1956), 300–305.

11. S. D. Pollak, et al., “Recognizing
Emotion in Faces: Developmental Effects of Child Abuse and Neglect,”
Developmental Psychology 36, no. 5 (2000): 679.

12. P. M. Crittenden, “IV Peering into
the Black Box: An Exploratory Treatise on the Development of Self in Young
Children,” Disorders and Dysfunctions of the Self 5 (1994): 79; P. M.
Crittenden, and A. Landini, Assessing Adult Attachment: A Dynamic-Maturational
Approach to Discourse Analysis (New York: WW Norton & Company,
2011).

13. Patricia M. Crittenden,
“Children’s Strategies for Coping with Adverse Home Environments: An
Interpretation Using Attachment Theory,” Child Abuse & Neglect
16, no. 3 (1992): 329–43.

14. Main, 1990, op cit.

15. Main, 1990, op cit.

16. Ibid.

17. E. Hesse, and M. Main, “Frightened,
Threatening, and Dissociative Parental Behavior in Low-Risk Samples: Description,
Discussion, and Interpretations,” Development and Psychopathology 18,
no. 2 (2006): 309–343. See also E. Hesse and M. Main, “Disorganized Infant,
Child, and Adult Attachment: Collapse in Behavioral and Attentional
Strategies,” Journal of the American Psychoanalytic Association 48,
no. 4 (2000): 1097–127.

18. Main, “Overview of the Field of
Attachment,” op cit.

19. Hesse and Main, 1995, op cit, p. 310.

20. We looked at this from a biological point
of view when we discussed “immobilization without fear” in chapter 5. S. W. Porges, “Orienting in a
Defensive World: Mammalian Modifications of Our Evolutionary Heritage: A Polyvagal
Theory,” Psychophysiology 32 (1995): 301–318.

21. M. H. van Ijzendoorn, C. Schuengel, and
M. Bakermans-Kranenburg, “Disorganized Attachment in Early Childhood:
Meta-analysis of Precursors, Concomitants, and Sequelae,” Development and
Psychopathology 11 (1999): 225–49.

22. Ijzendoorn, op cit.

23. N. W. Boris, M. Fueyo, and C. H. Zeanah,
“The Clinical Assessment of Attachment in Children Under Five,”
Journal of the American Academy of Child & Adolescent Psychiatry,
36, no. 2 (1997): 291–93; K. Lyons-Ruth, “Attachment Relationships Among
Children with Aggressive Behavior Problems: The Role of Disorganized Early
Attachment Patterns,” Journal of Consulting and Clinical Psychology,
64, no. 1 (1996), 64.

24. Stephen W. Porges, et al., “Infant
Regulation of the Vagal ‘Brake’ Predicts Child Behavior Problems: A
Psychobiological Model of Social Behavior,” Developmental
Psychobiology 29, no. 8 (1996): 697–712.

25. Louise Hertsgaard, et al.,
“Adrenocortical Responses to the Strange Situation in Infants with
Disorganized/Disoriented Attachment Relationships,” Child Development
66, no. 4 (1995): 1100–6; Gottfried Spangler, and Klaus E. Grossmann,
“Biobehavioral Organization in Securely and Insecurely Attached
Infants,” Child
Development 64, no. 5 (1993): 1439–50.

26. Main and Hesse, 1990, op cit.

27. M. H. van Ijzendoorn, et al.,
“Disorganized Attachment in Early Childhood,” op cit.

28. B. Beebe, and F. M. Lachmann, Infant
Research and Adult Treatment: Co-constructing Interactions (New York:
Routledge, 2013); B. Beebe, F. Lachmann, and J. Jaffe (1997). Mother-Infant
Interaction Structures and Presymbolic Self- and Object Representations.
Psychoanalytic Dialogues, 7, no. 2 (1997): 133–82.

29. R. Yehuda, et al., “Vulnerability
to Posttraumatic Stress Disorder in Adult Offspring of Holocaust Survivors,”
American Journal of Psychiatry 155, no. 9 (1998): 1163–71. See also R.
Yehuda, et al., “Relationship Between Posttraumatic Stress Disorder
Characteristics of Holocaust Survivors and Their Adult Offspring,”
American Journal of
Psychiatry 155, no. 6 (1998):
841–43; R. Yehuda, et al., “Parental Posttraumatic Stress Disorder as a
Vulnerability Factor for Low Cortisol Trait in Offspring of Holocaust
Survivors,” Archives of General Psychiatry 64, no. 9 (2007): 1040 and
R. Yehuda, et al., “Maternal, Not Paternal, PTSD Is Related to Increased Risk
for PTSD in Offspring of Holocaust Survivors,” Journal of Psychiatric
Research 42, no. 13 (2008): 1104–11.

30. R. Yehuda, et al.,
“Transgenerational Effects of PTSD in Babies of Mothers Exposed to the WTC
Attacks During Pregnancy,” Journal of Clinical Endocrinology and
Metabolism 90 (2005): 4115–18.

31. G. Saxe, et al., “Relationship
Between Acute Morphine and the Course of PTSD in Children with Burns,”
Journal of the American Academy of Child & Adolescent Psychiatry
40, no. 8 (2001): 915–21. See also G. N. Saxe, et al., “Pathways to PTSD, Part
I: Children with Burns,” American Journal of Psychiatry 162, no. 7
(2005): 1299–304.

32. C. M. Chemtob, Y. Nomura, and R. A.
Abramovitz, “Impact of Conjoined Exposure to the World Trade Center Attacks
and to Other Traumatic Events on the Behavioral Problems of Preschool
Children,” Archives of Pediatrics and Adolescent Medicine 162, no. 2
(2008): 126. See also P. J. Landrigan, et al., “Impact of September 11 World
Trade Center Disaster on Children and Pregnant Women,” Mount Sinai Journal
of Medicine 75, no. 2 (2008): 129–34.

33. D. Finkelhor, R. K. Ormrod, and H. A.
Turner, “Polyvictimization and Trauma in a National Longitudinal
Cohort,” Development and Psychopathology 19, no. 1 (2007):
149–66; J. D. Ford, et al., “Poly-victimization and Risk of Posttraumatic,
Depressive, and Substance Use Disorders and Involvement in Delinquency in a National
Sample of Adolescents,” Journal of Adolescent Health 46, no.
6 (2010): 545–52; J. D. Ford, et al., “Clinical Significance of a Proposed
Development Trauma Disorder Diagnosis: Results of an International Survey of
Clinicians,” Journal of Clinical Psychiatry 74, no. 8
(2013): 841–49.

34. Family Pathways Project, http://www.challiance.org/academics/familypathwaysproject.aspx.

35. K. Lyons-Ruth and D. Block, “The
Disturbed Caregiving System: Relations Among Childhood Trauma, Maternal Caregiving,
and Infant Affect and Attachment,” Infant Mental Health Journal 17,
no. 3 (1996): 257–75.

36. K. Lyons-Ruth, “The Two-Person
Construction of Defenses: Disorganized Attachment Strategies, Unintegrated Mental
States, and Hostile/Helpless Relational Processes,” Journal of Infant,
Child, and Adolescent Psychotherapy 2 (2003): 105.

37. G. Whitmer, “On the Nature of
Dissociation,” Psychoanalytic Quarterly 70, no. 4 (2001): 807–37. See
also K. Lyons-Ruth, “The Two-Person Construction of Defenses: Disorganized
Attachment Strategies, Unintegrated Mental States, and Hostile/Helpless Relational
Processes,” Journal of Infant, Child, and Adolescent Psychotherapy 2,
no. 4 (2002): 107–19.

38. Mary S. Ainsworth and John Bowlby,
“An Ethological Approach to Personality Development,” American
Psychologist 46, no. 4 (April 1991): 333–41.

39. K. Lyons-Ruth and D. Jacobvitz, 1999; Main, 1993; K.
Lyons-Ruth, “Dissociation and the Parent-Infant Dialogue: A Longitudinal
Perspective from Attachment Research,” Journal of the American
Psychoanalytic Association 51, no. 3 (2003): 883–911.

40. L. Dutra, et al., “Quality of Early
Care and Childhood Trauma: A Prospective Study of Developmental Pathways to
Dissociation,” Journal of Nervous and Mental Disease 197, no. 6
(2009): 383. See also K. Lyons-Ruth, et al., “Borderline Symptoms and
Suicidality/Self-Injury in Late Adolescence: Prospectively Observed Relationship
Correlates in Infancy and Childhood,” Psychiatry Research 206, nos.
2–3 (April 30, 2013): 273–81.

41. For meta-analysis of the relative
contributions of disorganized attachment and child maltreatment, see C. Schuengel,
et al., “Frightening Maternal Behavior Linking Unresolved Loss and
Disorganized Infant Attachment,” Journal of Consulting and Clinical
Psychology 67, no. 1 (1999): 54.

42. K. Lyons-Ruth and D. Jacobvitz,
“Attachment Disorganization: Genetic Factors, Parenting Contexts, and
Developmental Transformation from Infancy to Adulthood,” in Handbook of
Attachment: Theory, Research, and Clinical Applications, 2nd ed., ed. J.
Cassidy and R. Shaver (New York: Guilford Press, 2008), 666–97. See also E.
O’connor, et al., “Risks and Outcomes Associated with
Disorganized/Controlling Patterns of Attachment at Age Three Years in the National
Institute of Child Health & Human Development Study of Early Child Care and
Youth Development,” Infant Mental Health Journal 32, no. 4 (2011):
450–72; and K. LyonsRuth, et al., “Borderline Symptoms and
Suicidality/Self-Injury.

43. At this point we have little information
about what factors affect the evolution of these early regulatory abnormalities, but
intervening life events, the quality of other relationships, and perhaps even
genetic factors are likely to modify them over time. It is obviously critical to
study to what degree consistent and concentrated parenting of children with early
histories of abuse and neglect can rearrange biological systems.

44. E. Warner, et al., “Can the Body
Change the Score? Application of Sensory Modulation Principles in the Treatment of
Traumatized Adolescents in Residential Settings,” Journal of Family
Violence 28, no. 7 (2003): 729–38.

CHAPTER 8: TRAPPED IN RELATIONSHIPS:
THE COST OF ABUSE AND NEGLECT

1. W. H. Auden, The Double Man (New
York: Random House, 1941),

2. S. N. Wilson, et al., “Phenotype of
Blood Lymphocytes in PTSD Suggests Chronic Immune Activation,”
Psychosomatics 40, no. 3 (1999): 222–25. See also M. Uddin, et
al., “Epigenetic and Immune Function Profiles Associated with Posttraumatic
Stress Disorder,” Proceedings of the National Academy of Sciences of the
United States of America 107, no. 20 (2010): 9470–75; M. Altemus,
M. Cloitre, and F. S. Dhabhar, “Enhanced Cellular Immune Response in Women
with PTSD Related to Childhood Abuse,” American Journal of Psychiatry
160, no. 9 (2003): 1705–7; and N. Kawamura, Y. Kim, and N. Asukai,
“Suppression of Cellular Immunity in Men with a Past History of Posttraumatic Stress
Disorder,” American Journal of Psychiatry 158, no. 3 (2001):
484–86.

3. R. Summit, “The Child Sexual Abuse
Accommodation Syndrome,” Child Abuse & Neglect 7 (1983):
177–93.

4. A study using fMRI at the University of
Lausanne in Switzerland showed that when people have these out-of-body experiences,
staring at themselves as if looking down from the ceiling, they are activating the
superior temporal cortex in the brain. O. Blanke, et al., “Linking Out-of-Body
Experience and Self Processing to Mental Own-Body Imagery at the Temporoparietal
Junction,” Journal of Neuroscience 25, no. 3 (2005): 550–57.
See also O. Blanke and T. Metzinger, “Full-Body Illusions and Minimal
Phenomenal Selfhood,” Trends in Cognitive Sciences 13, no. 1
(2009): 7–13.

5. When an adult uses a child for sexual
gratification, the child invariably is caught in a confusing situation and a
conflict of loyalties: By disclosing the abuse, she betrays and hurts the
perpetrator (who may be an adult on whom the child depends for safety and
protection), but by hiding the abuse, she compounds her shame and vulnerability.
This dilemma was first articulated by Sándor Ferenczi in 1933 in “The
Confusion of Tongues Between the Adult and the Child: The Language of Tenderness and
the Language of Passion,” International Journal of Psychoanalysis, 30
no. 4 (1949): 225–30, and has been explored by numerous subsequent authors.

CHAPTER 9: WHAT’S LOVE GOT TO
DO WITH IT?

1. Gary Greenberg, The Book of Woe: The
DSM and the Unmaking of Psychiatry (New York: Penguin, 2013).

2. http://www.thefreedictionary.com/diagnosis.

3. The TAQ can be accessed at the Trauma
Center Web site: www.traumacenter.org/products/instruments.php.

4. J. L. Herman, J. C. Perry, and B. A. van
der Kolk, “Childhood Trauma in Borderline Personality Disorder,”
American Journal of Psychiatry 146, no. 4 (April 1989): 490–95.

5. Teicher found significant changes in the
orbitofrontal cortex (OFC), a region of the brain that is involved in decision
making and the regulation of behavior involved in sensitivity to social demands. M.
H. Teicher, et al., “The Neurobiological Consequences of Early Stress and
Childhood Maltreatment,” Neuroscience & Biobehavioral Reviews
27, no. 1 (2003): 33–44. See also M. H. Teicher, “Scars That
Won’t Heal: The Neurobiology of Child Abuse,” Scientific
American 286, no. 3 (2002): 54–61; M. Teicher, et al.,
“Sticks, Stones, and Hurtful Words: Relative Effects of Various Forms of
Childhood Maltreatment,” American Journal of Psychiatry 163,
no. 6 (2006): 993–1000; A. Bechara, et al., “Insensitivity to Future
Consequences Following Damage to Human Prefrontal Cortex,” Cognition
50 (1994): 7–15. Impairment in this area of the brain results in excessive
swearing, poor social interactions, compulsive gambling, excessive alcohol/drug use
and poor empathic ability. M. L. Kringelbach and E. T. Rolls, “The Functional
Neuroanatomy of the Human Orbitofrontal
Cortex: Evidence from Neuroimaging and Neuropsychology,” Progress in
Neurobiology 72 (2004): 341–72. The other problematic area Teicher
identified was the precuneus, a brain area involved in understanding oneself and
being able to take perspective on how your perceptions may be different from someone
else’s. A. E. Cavanna and M. R. Trimble “The Precuneus: A
Review of Its Functional Anatomy and Behavioural Correlates,” Brain
129 (2006): 564–83.

6. S. Roth, et al., “Complex PTSD in
Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field Trial
for Posttraumatic Stress Disorder,” Journal of Traumatic Stress 10
(1997): 539–55; B. A. van der Kolk et al., “Dissociation, Somatization, and
Affect Dysregulation: The Complexity of Adaptation to Trauma,” American
Journal of Psychiatry 153 (1996): 83–93; D. Pelcovitz, et al.,
“Development of a Criteria Set and a Structured Interview for Disorders of
Extreme Stress (SIDES),” Journal of Traumatic Stress 10 (1997): 3–16;
S. N. Ogata, et al., “Childhood Sexual and Physical Abuse in Adult Patients
with Borderline Personality Disorder,” American Journal of Psychiatry
147 (1990): 1008–1013; M. C. Zanarini, et al., “Axis I Comorbidity of
Borderline Personality Disorder,” American Journal of Psychiatry 155,
no. 12. (December 1998): 1733–39; S. L. Shearer, et al., “Frequency and
Correlates of Childhood Sexual and Physical Abuse Histories in Adult Female
Borderline Inpatients,” American Journal of Psychiatry 147 (1990):
214–16; D. Westen, et al., “Physical and Sexual Abuse in Adolescent Girls with
Borderline Personality Disorder,” American Journal of Orthopsychiatry
60 (1990): 55–66; M. C. Zanarini, et al., “Reported Pathological Childhood
Experiences Associated with the Development of Borderline Personality
Disorder,” American Journal of Psychiatry 154 (1997): 1101–1106.

7. J. Bowlby, A Secure Base: Parent-Child
Attachment and Healthy Human Development (New York: Basic Books, 2008),
103.

8. B. A. van der Kolk, J. C. Perry, and J. L.
Herman, “Childhood Origins of Self-Destructive Behavior,” American
Journal of Psychiatry 148 (1991): 1665–71.

9. This notion found further support in the
work of the neuroscientist Jaak Panksepp, who found that young rats that were not
licked by their moms during the first week of their lives did not develop opioid
receptors in the anterior cingulate cortex, a part of the brain associated with
affiliation and a sense of safety. See E. E. Nelson and J. Panksepp, “Brain
Substrates of Infant-Mother Attachment: Contributions of Opioids, Oxytocin, and
Norepinephrine,” Neuroscience & Biobehavioral Reviews
22, no. 3 (1998): 437–52. See also J. Panksepp, et al.,
“Endogenous Opioids and Social Behavior,” Neuroscience &
Biobehavioral Reviews 4, no. 4 (1981): 473–87; and J. Panksepp, E.
Nelson, and S. Siviy, “Brain Opioids and Mother-Infant Social
Motivation,” Acta paediatrica 83, no. 397 (1994): 40–46.

10. The delegation to Robert Spitzer also
included Judy Herman, Jim Chu, and David Pelcovitz.

11. B. A. van der Kolk, et al.,
“Disorders of Extreme Stress: The Empirical Foundation of a Complex Adaptation
to Trauma,” Journal of Traumatic Stress 18, no. 5 (2005): 389–99. See also J. L. Herman,
“Complex PTSD: A Syndrome in Survivors of Prolonged and Repeated
Trauma,” Journal of Traumatic Stress 5, no. 3 (1992):
377–91; C. Zlotnick, et al., “The Long-Term Sequelae of Sexual Abuse: Support
for a Complex Posttraumatic Stress Disorder,” Journal of Traumatic
Stress 9, no. 2 (1996): 195–205; S. Roth, et al., “Complex
PTSD in Victims Exposed to Sexual and Physical Abuse: Results from the DSM-IV Field
Trial for Posttraumatic Stress Disorder,” Journal of Traumatic Stress
10, no. 4 (1997): 539–55; and D. Pelcovitz, et al., “Development
and Validation of the Structured Interview for Measurement of Disorders of Extreme
Stress,” Journal of Traumatic Stress 10 (1997): 3–16.

12. B. C. Stolbach, et al., “Complex
Trauma Exposure and Symptoms in Urban Traumatized Children: A Preliminary Test of
Proposed Criteria for Developmental Trauma Disorder,” Journal of Traumatic
Stress 26, no. 4 (August 2013): 483–91.

13. B. A. van der Kolk, et al.,
“Dissociation, Somatization and Affect Dysregulation: The Complexity of
Adaptation to Trauma,” American Journal of Psychiatry 153, suppl
(1996): 83–93. See also D. G. Kilpatrick, et al., “Posttraumatic Stress
Disorder Field Trial: Evaluation of the PTSD Construct—Criteria A Through E,”
in: DSM-IV
Sourcebook, vol. 4 (Washington: American Psychiatric Press, 1998), 803-844;
T. Luxenberg, J. Spinazzola, and B. A. van der Kolk, “Complex Trauma and
Disorders of Extreme Stress (DESNOS) Diagnosis, Part One: Assessment,”
Directions in Psychiatry 21, no. 25 (2001): 373–92; and B. A. van der
Kolk, et al., “Disorders of Extreme Stress: The Empirical Foundation of a
Compex Adaptation to Trauma,” Journal of Traumatic Stress 18, no. 5
(2005): 389–99.

14. These questions are available on the ACE
Web site: http://acestudy.org/.

15. http://www.cdc.gov/ace/findings.htm; http://acestudy.org/download; V. Felitti, et al., “Relationship of
Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in
Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal
of Preventive Medicine 14, no. 4 (1998): 245–58. See also R.
Reading, “The Enduring Effects of Abuse and Related Adverse Experiences in
Childhood: A Convergence of Evidence from Neurobiology and Epidemiology,”
Child: Care, Health and Development 32, no. 2 (2006): 253–56;
V. J. Edwards, et al., “Experiencing Multiple Forms of Childhood Maltreatment
and Adult Mental Health: Results from the Adverse Childhood Experiences (ACE)
Study,” American
Journal of Psychiatry 160, no. 8 (2003): 1453–60; S. R. Dube, et
al., “Adverse Childhood Experiences and Personal Alcohol Abuse as an
Adult,” Addictive Behaviors 27, no. 5 (2002): 713–25; S. R.
and S. R. Dube, et al., “Childhood Abuse, Neglect, and Household Dysfunction
and the Risk of Illicit Drug Use: The Adverse Childhood Experiences Study,”
Pediatrics 111, no. 3 (2003): 564–72.

16. S. A. Strassels, “Economic Burden
of Prescription Opioid Misuse and Abuse,” Journal of Managed Care
Pharmacy 15, no. 7 (2009): 556–62.

17. C. B. Nemeroff, et al.,
“Differential Responses to Psychotherapy Versus Pharmacotherapy in Patients
with Chronic Forms of Major Depression and Childhood Trauma,” Proceedings
of the National Academy of Sciences of the United States of
America 100, no. 24
(2003): 14293–96. See also C. Heim, P. M. Plotsky, and C. B. Nemeroff,
“Importance of Studying the Contributions of Early Adverse Experience to
Neurobiological Findings in Depression,” Neuropsychopharmacology
29, no. 4 (2004): 641–48.

18. B. E. Carlson, “Adolescent
Observers of Marital Violence,” Journal of Family Violence 5, no. 4
(1990): 285–99. See also B. E. Carlson, “Children’s Observations of
Interparental Violence,” in Battered Women and Their Families, ed. A.
R. Roberts (New York: Springer, 1984), 147–67; J. L. Edleson,
“Children’s Witnessing of Adult Domestic Violence,” Journal of
Interpersonal Violence 14, no. 8 (1999): 839–70; K. Henning, et al.,
“Long-Term Psychological and Social Impact of Witnessing Physical Conflict
Between Parents,” Journal of Interpersonal Violence 11, no. 1 (1996):
35–51; E. N. Jouriles, C. M. Murphy, and D. O’Leary, “Interpersonal
Aggression, Marital Discord, and Child Problems,” Journal of Consulting
and Clinical Psychology 57, no. 3 (1989): 453–55; J. R. Kolko, E. H.
Blakely, and D. Engelman, “Children Who Witness Domestic Violence: A Review of
Empirical Literature,” Journal of Interpersonal Violence 11, no. 2
(1996): 281–93; and J. Wolak and D. Finkelhor, “Children Exposed to Partner
Violence,” in Partner Violence: A Comprehensive Review of 20 Years of
Research, ed. J. L. Jasinski and L. Williams (Thousand Oaks, CA: Sage,
1998).

19. Most of these statements are based on
conversations with Vincent Felitti, amplified by J. E. Stevens, “The Adverse
Childhood Experiences Study—the Largest Public Health Study You Never Heard
Of,” Huffington Post, October 8, 2012, http://www.huffingtonpost.com/jane-ellen-stevens/the-adverse-childhood-exp_1_b_1943647.html.

20. Population attributable risk: the
proportion of a problem in the overall population whose problems can be attributed
to specific risk factors.

21. National Cancer Institute, “Nearly
800,000 Deaths Prevented Due to Declines in Smoking” (press release), March
14, 2012, available at http://www.cancer.gov/newscenter/newsfromnci/2012/TobaccoControlCISNET[URL inactive].

CHAPTER 10: DEVELOPMENTAL TRAUMA:
THE HIDDEN EPIDEMIC

1. These cases were part of the DTD field
trial, conducted jointly by Julian Ford, Joseph Spinazzola, and me.

2. H. J. Williams, M. J. Owen, and M. C.
O’Donovan, “Schizophrenia Genetics: New Insights from New
Approaches,” British Medical Bulletin 91 (2009): 61–74. See also P.
V. Gejman, A. R. Sanders, and K. S. Kendler, “Genetics of Schizophrenia: New
Findings and Challenges,” Annual Review of Genomics and Human
Genetics 12 (2011): 121–44; and A. Sanders, et al., “No Significant
Association of 14 Candidate Genes with Schizophrenia in a Large European Ancestry
Sample: Implications for Psychiatric Genetics,” American Journal of
Psychiatry 165, no. 4 (April 2008): 497–506.

3. R. Yehuda, et al., “Putative
Biological Mechanisms for the Association Between Early Life Adversity and the
Subsequent Development of PTSD,” Psychopharmacology
212, no. 3 (October 2010): 405–417; K.
C. Koenen, “Genetics of Posttraumatic Stress Disorder: Review and
Recommendations for Future Studies,” Journal of Traumatic Stress 20,
no. 5 (October 2007): 737–50; M. W. Gilbertson, et al., “Smaller Hippocampal
Volume Predicts Pathologic Vulnerability to Psychological Trauma,” Nature
Neuroscience 5 (2002): 1242–47.

4. Koenen, “Genetics of Posttraumatic
Stress Disorder.” See also R. F. P. Broekman, M. Olff, and F. Boer, “The
Genetic Background to PTSD,” Neuroscience & Biobehavioral Reviews
31, no. 3 (2007): 348–62.

5. M. J. Meaney and A. C. Ferguson-Smith,
“Epigenetic Regulation of the Neural Transcriptome: The Meaning of the
Marks,” Nature Neuroscience 13, no. 11 (2010): 1313–18. See
also M. J. Meaney, “Epigenetics and the Biological Definition of Gene ×
Environment Interactions,” Child Development 81, no. 1
(2010): 41–79; and B. M. Lester, et al., “Behavioral Epigenetics,”
Annals of the New York Academy of Sciences 1226, no. 1 (2011):
14–33.

6. M. Szyf, “The Early Life Social
Environment and DNA Methylation: DNA Methylation Mediating the Long-Term Impact of
Social Environments Early in Life,” Epigenetics 6, no. 8 (2011):
971–78.

7. Moshe Szyf, Patrick McGowan, and Michael
J. Meaney, “The Social Environment and the Epigenome,” Environmental
and Molecular Mutagenesis 49, no. 1 (2008): 46–60.

8. There now is voluminous evidence that life
experiences of all sorts changes gene expression. Some examples are: D. Mehta et
al., “Childhood Maltreatment Is Associated with Distinct Genomic and
Epigenetic Profiles in Posttraumatic Stress Disorder,” Proceedings of the
National Academy of Sciences of the United States of America 110, no. 20
(2013): 8302–7; P. O. McGowan, et al., “Epigenetic Regulation of the
Glucocorticoid Receptor in Human Brain Associates with Childhood Abuse,”
Nature Neuroscience 12, no. 3 (2009): 342–48; M. N. Davies, et al.,
“Functional Annotation of the Human Brain Methylome Identifies Tissue-Specific
Epigenetic Variation Across Brain and Blood,” Genome Biology 13, no.
6 (2012): R43; M. Gunnar and K. Quevedo, “The Neurobiology of Stress and
Development,” Annual Review of Psychology 58 (2007): 145–73; A.
Sommershof, et al., “Substantial Reduction of Naïve and Regulatory T Cells
Following Traumatic Stress,” Brain, Behavior, and Immunity 23, no. 8
(2009): 1117–24; N. Provençal, et al., “The Signature of Maternal Rearing in
the Methylome in Rhesus Macaque Prefrontal Cortex and T Cells,” Journal of
Neuroscience 32, no. 44 (2012): 15626–42; B. Labonté, et al.,
“Genome-wide Epigenetic Regulation by Early-Life Trauma,” Archives
of General Psychiatry 69, no. 7 (2012): 722–31; A. K. Smith, et al.,
“Differential Immune System DNA Methylation and Cytokine Regulation in
Post-traumatic Stress Disorder,” American Journal of Medical Genetics Part
B: Neuropsychiatric Genetics 156B, no. 6 (2011): 700–708; M. Uddin, et al.,
“Epigenetic and Immune Function Profiles Associated with Posttraumatic Stress
Disorder,” Proceedings of the National Academy of Sciences of the United
States of America 107, no. 20 (2010): 9470–75.

9. C. S. Barr, et al., “The Utility of the Non-human
Primate Model for Studying Gene by Environment Interactions in Behavioral
Research,” Genes, Brain and Behavior 2, no. 6 (2003):
336–40.

10. A. J. Bennett, et al., “Early
Experience and Serotonin Transporter Gene Variation Interact to Influence Primate
CNS Function,” Molecular Psychiatry 7, no. 1 (2002): 118–22.
See also C. S. Barr, et al., “Interaction Between Serotonin Transporter Gene
Variation and Rearing Condition in Alcohol Preference and Consumption in Female
Primates,” Archives of General Psychiatry 61, no. 11 (2004):
1146; and C. S. Barr, et al., “Serotonin Transporter Gene Variation Is
Associated with Alcohol Sensitivity in Rhesus Macaques Exposed to Early-Life
Stress,” Alcoholism: Clinical and Experimental Research 27,
no. 5 (2003): 812–17.

11. A. Roy, et al., “Interaction of
FKBP5, a Stress-Related Gene, with Childhood Trauma Increases the Risk for
Attempting Suicide,” Neuropsychopharmacology 35, no. 8
(2010): 1674–83. See also M. A. Enoch, et al., “The Influence of GABRA2,
Childhood Trauma, and Their Interaction on Alcohol, Heroin, and Cocaine
Dependence,” Biological Psychiatry 67 no. 1 (2010): 20–27; and A.
Roy, et al., “Two HPA Axis Genes, CRHBP and FKBP5, Interact with Childhood
Trauma to Increase the Risk for Suicidal Behavior,” Journal of Psychiatric
Research 46, no. 1 (2012): 72–79.

12. A. S. Masten and D. Cicchetti,
“Developmental Cascades,” Development and Psychopathology
22, no. 3 (2010): 491–95; S. L. Toth, et al., “Illogical Thinking
and Thought Disorder in Maltreated Children,” Journal of the American
Academy of
Child & Adolescent Psychiatry 50, no. 7 (2011): 659–68; J.
Willis, “Building a Bridge from Neuroscience to the Classroom,” Phi
Delta Kappan 89, no. 6 (2008): 424; I. M. Eigsti and D. Cicchetti,
“The Impact of Child Maltreatment on Expressive Syntax at 60 Months,”
Developmental Science 7, no. 1 (2004): 88–102.

13. J. Spinazzola, et al., “Survey
Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and
Adolescents,” Psychiatric Annals 35, no. 5 (2005): 433–39.

14. R. C. Kessler, C. B. Nelson, and K. A.
McGonagle, “The Epidemiology of Co-occuring Addictive and Mental
Disorders,” American Journal of Orthopsychiatry 66, no. 1 (1996):
17–31. See also Institute of Medicine of the National Academies, Treatment of
Posttraumatic Stress Disorder (Washington: National Academies Press, 2008);
and C. S. North, et al., “Toward Validation of the Diagnosis of Posttraumatic
Stress Disorder,” American Journal of Psychiatry 166, no. 1 (2009):
34–40.

15. Joseph Spinazzola, et al., “Survey
Evaluates Complex Trauma Exposure, Outcome, and Intervention Among Children and
Adolescents,” Psychiatric Annals (2005).

16. Our work group consisted of Drs. Bob
Pynoos, Frank Putnam, Glenn Saxe, Julian Ford, Joseph Spinazzola, Marylene Cloitre,
Bradley Stolbach, Alexander McFarlane, Alicia Lieberman, Wendy D’Andrea,
Martin Teicher, and Dante Cicchetti.

17. The proposed criteria for Developmental
Trauma Disorder can be found in the Appendix.

18. http://www.traumacenter.org/products/instruments.php.

19. Read more about Sroufe at www.cehd.umn.edu/icd/people/faculty/cpsy/sroufe.html and more about the
Minnesota Longitudinal Study of Risk and Adaptation and its publications at http://www.cehd.umn.edu/icd/research/parent-child/ and http://www.cehd.umn.edu/icd/research/parent-child/publications/. See also
L. A. Sroufe and W. A. Collins, The Development of the Person: The Minnesota
Study of Risk and Adaptation from Birth to Adulthood (New York: Guilford
Press, 2009); and L. A. Sroufe, “Attachment and Development: A Prospective,
Longitudinal Study from Birth to Adulthood,” Attachment & Human
Development 7, no. 4 (2005): 349–67.

20. L. A. Sroufe, The Development of the
Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood
(New York: Guilford Press, 2005). Harvard researcher Karlen Lyons-Ruth had similar
findings in a sample of children she followed for about eighteen years: Disorganized
attachment, role reversal, and lack of maternal communication at age three were the
greatest predictors of children being part of the mental health or social service
system at age eighteen.

21. D. Jacobvitz and L. A. Sroufe, “The
Early Caregiver-Child Relationship and Attention-Deficit Disorder with Hyperactivity
in Kindergarten: A Prospective Study,” Child Development 58, no. 6
(December 1987): 1496–504.

22. G. H. Elder Jr., T. Van Nguyen, and A.
Caspi, “Linking Family Hardship to Children’s Lives,” Child
Development 56, no. 2 (April 1985): 361–75.

23. For children who were physically abused,
the chance of being diagnosed with conduct disorder or oppositional defiant disorder
went up by a factor of three. Neglect or sexual abuse doubled the chance of
developing an anxiety disorder. Parental psychological unavailability or sexual
abuse doubled the chance of later developing PTSD. The chance of receiving multiple
diagnoses was 54 percent for children who suffered neglect, 60 percent for physical
abuse, and 73 percent for both sexual abuse.

24. This was a quote based on the work of
Emmy Werner, who has studied 698 children born on the island of Kauai for forty
years, starting in 1955. The study showed that most children who grew up in unstable
households grew up to experience problems with delinquency, mental and physical
health, and family stability. One-third of all high-risk children displayed
resilience and developed into caring, competent, and confident adults.
Protective factors were 1. being an appealing child, 2. a strong bond
with a nonparent caretaker (such as an aunt, a babysitter, or a teacher) and strong
involvement in church or community groups. E. E. Werner and R. S. Smith,
Overcoming the Odds: High Risk Children from Birth to Adulthood (Ithaca
and London: Cornell University Press, 1992).

25. P. K. Trickett, J. G. Noll, and F. W.
Putnam, “The Impact of Sexual Abuse on Female Development: Lessons from a
Multigenerational, Longitudinal Research Study,” Development and
Psychopathology 23 (2011): 453–76. See also J. G. Noll, P. K. Trickett, and
F. W. Putnam, “A Prospective Investigation of the Impact of Childhood Sexual
Abuse on the Development of Sexuality,” Journal of Consulting and
Clinical Psychology 71 (2003):
575–86; P. K. Trickett, C. McBride-Chang, and F. W. Putnam, “The Classroom
Performance and Behavior of Sexually Abused Females,” Development and
Psychopathology 6 (1994): 183–94; P. K. Trickett and F. W. Putnam,
Sexual Abuse of Females: Effects in Childhood (Washington: National
Institute of Mental Health, 1990–1993); F. W. Putnam and P. K. Trickett, The
Psychobiological Effects of Child Sexual Abuse (New York: W. T. Grant
Foundation, 1987).

26. In the sixty-three studies on disruptive
mood regulation disorder, nobody asked anything about attachment, PTSD, trauma,
child abuse, or neglect. The word “maltreatment” is used in passing in
just one of the sixty-three articles. There is nothing about parenting, family
dynamics, or about family therapy.

27. In the appendix at the back of the DSM,
you can find the so-called V-codes, diagnostic labels without official standing that
are not eligible for insurance reimbursement. There you will see listings for
childhood abuse, childhood neglect, childhood physical abuse, and childhood sexual
abuse.

28. Ibid., p 121.

29. At the time of this writing, the DSM-5 is
number seven on Amazon’s best-seller list. The APA earned $100 million on the
previous edition of the DSM. The publication of the DSM constitutes, with
contributions from the pharmaceutical industry and membership dues, the APA’s
major source of income.

30. Gary Greenberg, The Book of Woe: The
DSM and the Unmaking of Psychiatry (New York: Penguin, 2013), 239.

31. In an open letter to the APA David
Elkins, the chairman of one of the divisions of the American Psychological
Association, complained that DSM-V was based on shaky evidence, carelessness with
the public health, and the conceptualizations of mental disorder as primarily
medical phenomena.” His letter attracted nearly five thousand signatures. The
president of the American Counseling Association sent a letter on behalf of its
115,000 DSM-buying members to the president of the APA, also objecting to the
quality of the science behind DSM-5—and “urge(d) the APA to make public the
work of the scientific review committee it had appointed to review the proposed
changes, as well as to allow an evaluation of “all evidence and data by
external, independent groups of experts.”

32. Thomas Insel had formerly done research
on the attachment hormone oxytocin in non-human primates.

33. National Institute of Mental Health,
“NIMH Research Domain Criteria (RDoC),” http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml.

34. The Development of the Person: The
Minnesota Study of Risk and Adaptation from
Birth to Adulthood (New York: Guilford Press, 2005).

35. B. A. van der Kolk, “Developmental
Trauma Disorder: Toward a Rational Diagnosis for Children with Complex Trauma
Histories,” Psychiatric Annals 35, no. 5 (2005): 401–8; W.
D’Andrea, et al., “Understanding Interpersonal Trauma in Children: Why We Need a Developmentally
Appropriate Trauma Diagnosis,” American Journal of Orthopsychiatry 82
(2012): 187–200. J. D. Ford, et al., “Clinical Significance of a Proposed
Developmental Trauma Disorder Diagnosis: Results of an International Survey of
Clinicians,” Journal of Clinical Psychiatry 74, no. 8 (2013):
841–849. Up-to-date results from the Developmental Trauma Disorder field trial study
are available on our Web site: www.traumacenter.org.

36. J. J. Heckman, “Skill Formation and
the Economics of Investing in Disadvantaged Children,” Science
312, no. 5782 (2006): 1900–2.

37. D. Olds, et al., “Long-Term Effects
of Nurse Home Visitation on Children’s Criminal and Antisocial Behavior:
15-Year Follow-up of a Randomized Controlled Trial,” JAMA 280, no. 14
(1998): 1238–44. See also J. Eckenrode, et al., “Preventing Child Abuse and
Neglect with a Program of Nurse Home Visitation: The Limiting Effects of Domestic
Violence,” JAMA 284, no. 11 (2000): 1385–91; D. I. Lowell, et al.,
“A Randomized Controlled Trial of Child FIRST: A Comprehensive Home-Based
Intervention Translating Research into Early Childhood Practice,” Child
Development 82, no. 1 (January/February 2011): 193–208; S. T. Harvey and J.
E. Taylor, “A Meta-Analysis of the Effects of Psychotherapy with Sexually
Abused Children and Adolescents, Clinical Psychology Review 30, no. 5 (July
2010): 517–35; J. E. Taylor and S. T. Harvey, “A Meta-Analysis of the Effects
of Psychotherapy with Adults Sexually Abused in Childhood,” Clinical
Psychology Review 30, no. 6 (August 2010): 749–67; Olds, Henderson,
Chamberlin, & Tatelbaum, 1986; B. C. Stolbach, et al., “Complex Trauma
Exposure and Symptoms in Urban Traumatized Children: A Preliminary Test of Proposed
Criteria for Developmental Trauma Disorder,” Journal of Traumatic
Stress 26, no. 4 (August 2013): 483–91.

CHAPTER 11: UNCOVERING SECRETS: THE
PROBLEM OF TRAUMATIC MEMORY

1. Unlike clinical consultations, in which
doctor-patient confidentiality applies, forensic evaluations are public documents to
be shared with lawyers, courts, and juries. Before doing a forensic evaluation I
inform clients of that and warn them that nothing they tell me can be kept
confidential.

2. K. A. Lee, et al., “A 50-Year
Prospective Study of the Psychological Sequelae of World War II Combat,”
American Journal of Psychiatry 152, no. 4 (April 1995):
516–22.

3. J. L. McGaugh and M. L. Hertz, Memory
Consolidation (San Fransisco: Albion Press, 1972); L. Cahill and J. L.
McGaugh, “Mechanisms of Emotional Arousal and Lasting Declarative
Memory,” Trends in Neurosciences 21, no. 7 (1998): 294–99.

4. A. F. Arnsten, et al., “α-1
Noradrenergic Receptor Stimulation Impairs Prefrontal Cortical Cognitive
Function,” Biological Psychiatry 45, no. 1 (1999): 26–31.
See also A. F. Arnsten, “Enhanced: The Biology of Being Frazzled,”
Science 280, no. 5370 (1998): 1711–12; S. Birnbaum, et al.,
“A Role for Norepinephrine in StressInduced Cognitive Deficits:
α-1-adrenoceptor Mediation in the Prefrontal Cortex,” Biological
Psychiatry 46, no. 9 (1999): 1266–74.

5. Y. D. Van Der Werf, et al. “Special Issue:
Contributions of Thalamic Nuclei to Declarative Memory Functioning,”
Cortex 39 (2003): 1047–62. See also B. M. Elzinga and J. D. Bremner,
“Are the Neural Substrates of Memory the Final Common Pathway in Posttraumatic
Stress Disorder (PTSD)?” Journal of Affective Disorders 70 (2002):
1–17; L. M. Shin et al., “A Functional Magnetic Resonance Imaging Study of
Amygdala and Medial Prefrontal Cortex Responses to Overtly Presented Fearful Faces
in Posttraumatic Stress Disorder,” Archives of General Psychiatry 62
(2005): 273–81; L. M. Williams et al., “Trauma Modulates Amygdala and Medial
Prefrontal Responses to Consciously Attended Fear,” Neuroimage 29
(2006): 347–57; R. A. Lanius et al., “Brain Activation During Script-Driven
Imagery Induced Dissociative Responses in PTSD: A Functional Magnetic Resonance
Imaging Investigation,” Biological Psychiatry 52 (2002): 305–311; H.
D Critchley, C. J. Mathias, and R. J. Dolan, “Fear Conditioning in Humans: The
Influence of Awareness and Autonomic Arousal on Functional Neuroanatomy,”
Neuron 33 (2002): 653–63; M. Beauregard, J. Levesque, and P. Bourgouin,
“Neural Correlates of Conscious Self-Regulation of Emotion,” Journal
of Neuroscience 21 (2001): RC165; K. N. Ochsner et al., “For Better
or for Worse: Neural Systems Supporting the Cognitive Downand Up-Regulation of
Negative Emotion,” NeuroImage 23 (2004): 483–99; M. A. Morgan, L. M.
Romanski, and J. E. LeDoux, et al., “Extinction of Emotional Learning:
Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163
(1993): 109–13; M. R. Milad and G. J. Quirk, “Neurons in Medial Prefrontal
Cortex Signal Memory for Fear Extinction,” Nature 420 (2002): 70–74;
and J. Amat, et al., “Medial Prefrontal Cortex Determines How Stressor
Controllability Affects Behavior and Dorsal Raphe Nucleus,” Nature
Neuroscience 8 (2005): 365–71.

6. B. A. Van der Kolk and R. Fisler,
“Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and
Exploratory Study,” Journal of Traumatic Stress 8, no. 4 (1995):
505–25.

7. Hysteria as defined by Free Dictionary, http://www.thefreedictionary.com/hysteria.

8. A. Young, The Harmony of Illusions:
Inventing Post-traumatic Stress Disorder (Princeton University Press,
1997). See also H. F. Ellenberger, The Discovery of the Unconscious: The History
and Evolution of Dynamic Psychiatry (Basic Books, 2008).

9. T. Ribot, Diseases of Memory
(Appleton, 1887), 108–9; Ellenberger, Discovery of the
Unconscious.

10. J. Breuer and S. Freud, “The
Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of
the Complete Psychological Works of Sigmund Freud (London: Hogarth Press,
1893).

11. A. Young, Harmony of
Illusions.

12. J. L. Herman, Trauma and
Recovery (New York: Basic Books, 1997), 15.

13. A. Young, Harmony of Illusions.
See also J. M. Charcot, Clinical Lectures on Certain Diseases of the Nervous
System, vol. 3 (London: New Sydenham Society, 1888).

14. http://en.wikipedia.org/wiki/File:Jean-Martin_Charcot_chronophotography.jpg

15. P. Janet, L’Automatisme psychologique
(Paris: Félix Alcan, 1889).

16. Onno van der Hart introduced me to the
work of Janet and probably is the greatest living scholar of his work. I had the
good fortune of closely collaborating with Onno on summarizing Janet’s
fundamental ideas. B. A. van der Kolk and O. van der Hart, “Pierre Janet and
the Breakdown of Adaptation in Psychological Trauma,” American Journal of
Psychiatry 146 (1989): 1530–40; B. A. van der Kolk and O. van der Hart,
“The Intrusive Past: The Flexibility of Memory and the Engraving of
Trauma,” Imago 48 (1991): 425–54.

17. P. Janet, “L’amnésie et la
dissociation des souvenirs par l’emotion” [Amnesia and the dissociation
of memories by emotions], Journal de Psychologie 1 (1904): 417–53.

18. P. Janet, Psychological Healing
(New York: Macmillan, 1925); p 660.

19. P. Janet, L’Etat mental des
hystériques, 2nd ed. (Paris: Félix Alcan, 1911; repr. Marseille, France:
Lafitte Reprints, 1983). P. Janet, The Major Symptoms of Hysteria (London
and New York: Macmillan, 1907; repr. New York: Hafner, 1965); P. Janet,
L’evolution de la memoire et de la notion du temps (Paris: A.
Chahine, 1928).

20. J. L. Titchener, “Post-traumatic
Decline: A Consequence of Unresolved Destructive Drives,” Trauma and Its
Wake 2 (1986): 5–19.

21. J. Breuer, and S. Freud, “The
Physical Mechanisms of Hysterical Phenomena.”

22. S. Freud and J. Breuer, “The
Etiology of Hysteria,” in the Standard Edition of the Complete
Psychological Works of Sigmund Freud, vol. 3, ed. J. Strachy (London:
Hogarth Press, 1962): 189–221.

23. S. Freud, “Three Essays on the
Theory of Sexuality,” in the Standard Edition of the
Complete Psychological Works of Sigmund Freud, vol. 7 (London: Hogarth
Press, 1962): 190: The reappearance of sexual activity is determined by internal
causes and external contingencies … I shall have to speak presently of the
internal causes; great and lasting importance attaches at this period to the
accidental external [Freud’s emphasis] contingencies. In the
foreground we find the effects of seduction, which treats a child as a sexual
object prematurely and teaches him, in highly emotional circumstances, how
to obtain satisfaction from his genital zones, a satisfaction which he is then
usually obliged to repeat again and again by masturbation. An influence of this kind
may originate either from adults or from other children. I cannot admit that in
my paper on ‘The Aetiology of Hysteria’ (1896c) I exaggerated the
frequency or importance of that influence, though I did not then know that
persons who remain normal may have had the same experiences in their childhood, and
though I consequently overrated the importance of seduction in comparison with the
factors of sexual constitution and development. Obviously seduction is not required
in order to arouse a child’s sexual life; that can also come about
spontaneously from internal causes. S. Freud “Introductory Lectures in
Psycho-analysis in Stand ard Edition (1916), 370: Phantasies of being
seduced are of particular interest, because so often they are not phantasies but
real memories.

24. S. Freud, Inhibitions Symptoms and
Anxiety (1914), 150. See also Strachey, Standard Edition of the
Complete Psychological Works.

25. B. A. van der Kolk, Psychological Trauma
(Washington, D: American Psychiatric Press, 1986).

26. B. A. Van der Kolk, “The Compulsion
to Repeat the Trauma,” Psychiatric Clinics of
North America 12, no. 2 (1989): 389–411.

CHAPTER 12: THE UNBEARABLE HEAVINESS
OF REMEMBERING

1. A. Young, The Harmony of Illusions:
Inventing Post-traumatic Stress Disorder (Princeton, NJ: Princeton
University Press, 1997), 84.

2. F. W. Mott, “Special Discussion on
Shell Shock Without Visible Signs of Injury,” Proceedings of the Royal
Society of Medicine 9 (1916): i–xliv. See also C. S. Myers, “A
Contribution to the Study of Shell Shock,” Lancet 1 (1915): 316–20;
T. W. Salmon, “The Care and Treatment of Mental Diseases and War Neuroses
(“Shell Shock”) in the British Army,” Mental Hygiene 1
(1917): 509–47; and E. Jones and S. Wessely, Shell Shock to PTSD: Military
Psychiatry from 1900 to the Gulf (Hove, UK: Psychology Press, 2005).

3. J. Keegan, The First World War
(New York: Random House, 2011).

4. A. D. Macleod, “Shell Shock, Gordon
Holmes and the Great War.” Journal of the Royal Society of Medicine
97, no. 2 (2004): 86–89; M. Eckstein, Rites of Spring: The Great War and the
Birth of the Modern Age (Boston: Houghton Mifflin, 1989).

5. Lord Southborough, Report of the War
Office Committee of Enquiry into “Shell-Shock” (London: His
Majesty’s Stationery Office, 1922).

6. Booker Prize winner Pat Barker has written
a moving trilogy about the work of army psychiatrist W. H. R. Rivers: P. Barker,
Regeneration (London: Penguin UK, 2008); P. Barker, The Eye in the
Door (New York: Penguin, 1995); P. Barker, The Ghost Road (London:
Penguin UK, 2008). Further discussions of the aftermath of World War I can be found
in A. Young, Harmony of Illusions; and B. Shephard, A War of Nerves,
Soldiers and Psychiatrists 1914–1994 (London: Jonathan Cape, 2000).

7. J. H. Bartlett, The Bonus March and
the New Deal (1937); R. Daniels, The Bonus
March: An Episode of the Great Depression (1971).

8. E. M. Remarque, All Quiet on the
Western Front, trans. A. W. Wheen (London: GP Putnam’s Sons,
1929).

9. Ibid., pp. 192–93.

10. For an account, see http://motlc.wiesenthal.com/site/pp.asp?c=gvKVLcMVIuG&b=395007.

11. C. S. Myers, Shell Shock in France
1914–1918 (Cambridge UK, Cambridge University Press, 1940).

12. A. Kardiner, The Traumatic Neuroses
of War (New York: Hoeber, 1941).

13. http://en.wikipedia.org/wiki/Let_There_Be_Light_(film).

14. G. Greer and J. Oxenbould, Daddy, We
Hardly Knew You (London: Penguin, 1990).

15. A. Kardiner and H. Spiegel, War
Stress and Neurotic Illness (Oxford, England: Hoeber, 1947).

16. D. J. Henderson, “Incest,” in
Comprehensive Textbook of Psychiatry, 2nd ed., eds. A. M. Freedman and
H. I. Kaplan (Baltimore: Williams & Wilkins, 1974), p. 1536.

17. W. Sargent and E. Slater, “Acute
War Neuroses,” The Lancet 236, no. 6097 (1940): 1–2. See also G.
Debenham, et al., “Treatment of War Neurosis,” The Lancet 237,
no. 6126 (1941): 107–9; and W. Sargent and E. Slater, “Amnesic Syndromes in
War,” Proceedings of the Royal Society of Medicine (Section of
Psychiatry) 34, no. 12 (October 1941): 757–64.

18. Every single scientific study of memory
of childhood sexual abuse, whether prospective or retrospective, whether studying
clinical samples or general population samples, finds that a certain percentage of
sexually abused individuals forget, and later remember, their abuse. See, e.g., B.
A. van der Kolk and R. Fisler, “Dissociation and the Fragmentary Nature of
Traumatic Memories: Overview and Exploratory Study,” Journal of Traumatic
Stress 8 (1995): 505–25; J. W. Hopper and B. A. van der Kolk,
“Retrieving, Assessing, and Classifying Traumatic Memories: A Preliminary
Report on Three Case Studies of a New Standardized Method,” Journal of
Aggression, Maltreatment & Trauma 4 (2001): 33–71; J. J. Freyd and A.
P. DePrince, eds., Trauma and Cognitive Science (Binghamton, NY: Haworth
Press, 2001), 33–71; A. P. DePrince and J. J. Freyd, “The Meeting of Trauma
and Cognitive Science: Facing Challenges and Creating Opportunities at the
Crossroads,” Journal of Aggression, Maltreatment & Trauma 4, no.
2 (2001): 1–8; D. Brown, A. W. Scheflin, and D. Corydon Hammond, Memory, Trauma
Treatment and the Law (New York: Norton, 1997); K. Pope and L. Brown,
Recovered Memories of Abuse: Assessment, Therapy, Forensics
(Washington: American Psychological Association, 1996); and L. Terr, Unchained
Memories: True Stories of Traumatic Memories, Lost and Found (New York:
Basic Books, 1994).

19. E. F. Loftus, S. Polonsky, and M. T.
Fullilove, “Memories of Childhood Sexual Abuse: Remembering and
Repressing,” Psychology of Women Quarterly 18, no. 1 (1994): 67–84.
L. M. Williams, “Recall of Childhood Trauma: A Prospective Study of
Women’s Memories of Child Sexual Abuse,” Journal of Consulting and
Clinical Psychology 62, no. 6 (1994): 1167–76.

20. L. M. Williams, “Recall of
Childhood Trauma.”

21. L. M. Williams, “Recovered Memories
of Abuse in Women with Documented Child Sexual Victimization Histories,”
Journal of Traumatic Stress 8, no. 4 (1995): 649–73.

22. The prominent neuroscientist Jaak
Panksepp states in his most recent book: “Abundant preclinical work with
animal models has now shown that memories that are retrieved tend to return to their
memory banks with modifications.” J. Panksepp and L. Biven, The
Archaeology of Mind: Neuroevolutionary Origins of Human Emotions, Norton
Series on Interpersonal Neurobiology (New York: WW Norton, 2012).

23. E. F. Loftus, “The Reality of
Repressed Memories,” American Psychologist 48, no. 5 (1993):
518–37. See also E. F. Loftus and K. Ketcham, The Myth of Repressed
Memory: False Memories and
Allegations of Sexual Abuse (New York: Macmillan, 1996).

24. J. F. Kihlstrom, “The Cognitive
Unconscious,” Science 237, no. 4821 (1987): 1445–52.

25. E. F. Loftus, “Planting
Misinformation in the Human Mind: A 30-Year Investigation of the Malleability of
Memory,” Learning & Memory 12, no. 4 (2005): 361–66.

26. B. A. Van der Kolk and R. Fisler,
“Dissociation and the Fragmentary Nature of Traumatic Memories: Overview and
Exploratory Study,” Journal of Traumatic Stress 8, no. 4
(1995): 505–25.

27. We will explore this further in chapter 14.

28. L. L. Langer, Holocaust Testimonies:
The Ruins of Memory (New Haven: Yale University Press, 1991).

29. Ibid., p.5.

30. L. L. Langer, op cit., p. 21.

31. L. L. Langer, op cit., p. 34.

32. J. Osterman and B. A. van der Kolk,
“Awareness during Anaesthesia and Posttraumatic Stress Disorder,”
General Hospital Psychiatry 20 (1998): 274-81. See also K. Kiviniemi,
“Conscious Awareness and Memory During General Anesthesia,” Journal
of the American Association of Nurse Anesthetists 62 (1994): 441–49; A. D.
Macleod and E. Maycock, “Awareness During Anaesthesia and Post Traumatic
Stress Disorder,” Anaesthesia and Intensive Care 20, no. 3
(1992) 378–82; F. Guerra, “Awareness and Recall: Neurological and
Psychological Complications of Surgery and Anesthesia,” in International
Anesthesiology Clinics, vol. 24. ed. B. T Hindman (Boston: Little
Brown, 1986), 75–99; J. Eldor and D. Z. N. Frankel, “Intra-anesthetic
Awareness,” Resuscitation 21 (1991): 113–19; J. L. Breckenridge and
A. R. Aitkenhead, “Awareness During Anaesthesia: A Review,” Annals
of the Royal College of Surgeons of England 65, no. 2 (1983), 93.

CHAPTER 13: HEALING FROM TRAUMA:
OWNING YOUR SELF

1. “Self-leadership” is the term
used by Dick Schwartz in internal family system therapy, the topic of chapter 17.

2. The exceptions are Pesso’s and
Schwartz’s work, detailed in chapters 17 and 18, which I practice, and from which I have
personally benefited, but which I have not studied scientifically—at least not
yet.

3. A. F. Arnsten, “Enhanced: The
Biology of Being Frazzled,” Science 280, no. 5370 (1998): 1711–12; A.
Arnsten, “Stress Signalling Pathways That Impair Prefrontal Cortex Structure
and Function,” Nature Reviews Neuroscience 10, no. 6 (2009):
410–22.

4. D. J. Siegel, The Mindful Therapist: A
Clinician’s Guide to Mindsight and Neural
Integration (New York: WW Norton, 2010).

5. J. E. LeDoux, “Emotion Circuits in
the Brain,” Annual Review of Neuroscience 23, no. 1 (2000): 155–84.
See also M. A. Morgan, L. M. Romanski, and J. E. LeDoux, “Extinction of
Emotional Learning: Contribution of Medial Prefrontal Cortex,” Neuroscience Letters 163, no. 1
(1993): 109–113; and J. M. Moscarello and J. E. LeDoux, “Active Avoidance
Learning Requires Prefrontal Suppression of Amygdala-Mediated Defensive
Reactions,” Journal of Neuroscience 33, no. 9 (2013): 3815–23.

6. S. W. Porges, “Stress and
Parasympathetic Control,” Stress Science: Neuroendocrinology 306
(2010). See also S. W. Porges, “Reciprocal Influences Between Body and Brain
in the Perception and Expression of Affect,” in The Healing Power of
Emotion: Affective Neuroscience, Development & Clinical Practice,
Norton Series on Interpersonal Neurobiology (New York: WW Norton, 2009), 27.

7. B. A. van der Kolk, et al., “Yoga As
an Adjunctive Treatment for PTSD.” Journal of
Clinical Psychiatry 75, no. 6 (June 2014): 559–65.

8. Sebern F. Fisher, Neurofeedback in the
Treatment of Developmental Trauma: Calming the Fear-Driven Brain. (New
York: WW Norton & Company, 2014).

9. R. P. Brown and P. L. Gerbarg,
“Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and
Depression—Part II: Clinical Applications and Guidelines,” Journal of
Alternative & Complementary Medicine 11, no. 4 (2005): 711–17. See also
C. L. Mandle, et al., “The Efficacy of Relaxation Response Interventions with
Adult Patients: A Review of the Literature,” Journal of Cardiovascular
Nursing 10 (1996): 4–26; and M. Nakao, et al., “Anxiety Is a Good
Indicator for Somatic Symptom Reduction Through Behavioral Medicine Intervention in
a Mind/Body Medicine Clinic,” Psychotherapy and Psychosomatics 70
(2001): 50–57.

10. C. Hannaford, Smart Moves: Why
Learning Is Not All in Your Head (Arlington, VA: Great Ocean Publishers,
1995), 22207–3746.

11. J. Kabat-Zinn, Full Catastrophe
Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and
Illness (New York: Bantam Books, 2013). See also D. Fosha, D. J. Siegel,
and M. Solomon, eds., The Healing Power of Emotion: Affective Neuroscience,
Development & Clinical Practice, Norton Series on Interpersonal
Neurobiology (New York: WW Norton, 2011); and B. A. van der Kolk,
“Posttraumatic Therapy in the Age of Neuroscience,” Psychoanalytic
Dialogues 12, no. 3 (2002): 381–92.

12. As we have seen in chapter 5, brain scans of people suffering from PTSD
show altered activation in areas associated with the default network, which is
involved with autobiographical memory and a continuous sense of self.

13. P. A. Levine, In an Unspoken Voice:
How the Body Releases Trauma and Restores
Goodness (Berkeley: North Atlantic, 2010).

14. P. Ogden, Trauma and the Body
(New York: Norton, 2009). See also A. Y. Shalev, “Measuring Outcome in
Posttraumatic Stress Disorder,” Journal of Clinical Psychiatry 61,
supp. 5 (2000): 33–42.

15. I. Kabat-Zinn, Full Catastrophe
Living. p. xx

16. S. G. Hofmann, et al., “The Effect
of Mindfulness-Based Therapy on Anxiety and Depression: A Meta-Analytic
Review,” Journal of Consulting and Clinical Psychology 78, no.2
(2010): 169–83; J. D. Teasdale, et al., “Prevention of Relapse/Recurrence in Major Depression by
Mindfulness-Based Cognitive Therapy,” Journal of Consulting and Clinical
Psychology 68 (2000): 615–23. See also Britta K. Hölzel, et al., “How
Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual
and Neural Perspective.” Perspectives on Psychological Science 6, no.
6 (2011): 537–59; and P. Grossman, et al., “Mindfulness-Based Stress Reduction
and Health Benefits: A Meta-Analysis,” Journal of Psychosomatic
Research 57, no. 1 (2004): 35–43.

17. The brain circuits involved in
mindfulness meditation have been well established, and improve attention regulation
and has a positive effect on the interference of emotional reactions with
attentional performance tasks. See L. E. Carlson, et al., “One Year Pre-Post
Intervention Follow-up of Psychological, Immune, Endocrine and Blood Pressure
Outcomes of Mindfulness-Based Stress Reduction (MBSR) in Breast and Prostate Cancer
Outpatients,” Brain, Behavior, and Immunity 21, no. 8 (2007):
1038–49; and R. J. Davidson, et al., “Alterations in Brain and Immune Function
Produced by Mindfulness Meditation,” Psychosomatic Medicine 65, no. 4 (2003):
564–70.

18. Britta Hölzel and her colleagues have
done extensive research on meditation and brain function and have shown that it
involves the dorsomedial PFC, ventrolateral PFC, and rostral anterior congulate
(ACC). See B. K. Hölzel, et al., “Stress Reduction Correlates with Structural
Changes in the Amygdala,” Social Cognitive and Affective Neuroscience
5 (2010): 11–17; B. K. Hölzel, et al., “Mindfulness Practice Leads to
Increases in Regional Brain Gray Matter Density,” Psychiatry Research
191, no. 1 (2011): 36–43; B. K. Hölzel, et al., “Investigation of Mindfulness
Meditation Practitioners with Voxel-Based Morphometry,” Social Cognitive
and Affective Neuroscience 3, no. 1 (2008): 55–61; and B. K. Hölzel, et
al., “Differential Engagement of Anterior Cingulate and Adjacent Medial
Frontal Cortex in Adept Meditators and Non-meditators,” Neuroscience
Letters 421, no. 1 (2007): 16–21.

19. The main brain structure involved in body
awareness is the anterior insula. See A. D. Craig, “Interoception: The Sense
of the Physiological Condition of the Body,” Current Opinion on
Neurobiology 13 (2003): 500–505; Critchley, Wiens, Rotshtein, Ohman, and
Dolan, 2004; N. A. S Farb, Z. V. Segal, H. Mayberg, J. Bean, D. McKeon, Z. Fatima,
et al., “Attending to the Present: Mindfulness Meditation Reveals Distinct
Neural Modes of Self-Reference,” Social Cognitive and Affective
Neuroscience 2 (2007): 313–22.; J. A. Grant, J. Courtemanche, E. G.
Duerden, G. H. Duncan, and P. Rainville, (2010). “Cortical Thickness and Pain
Sensitivity in Zen Meditators,” Emotion 10, no. 1 (2010): 43–53.

20. S. J. Banks, et al.,
“Amygdala-Frontal Connectivity During Emotion-Regulation,” Social
Cognitive and Affective Neuroscience 2, no. 4 (2007): 303–12. See also M.
R. Milad, et al., “Thickness of Ventromedial Prefrontal Cortex in Humans Is
Correlated with Extinction Memory,” Proceedings of the National Academy of
Sciences of the United States of America 102, no. 30 (2005): 10706–11; and
S. L. Rauch, L. M. Shin, and E. A.
Phelps, “Neurocircuitry Models of Posttraumatic Stress Disorder and
Extinction: Human Neuroimaging Research—Past, Present, and Future,”
Biological Psychiatry 60, no. 4 (2006): 376–82.

21. A. Freud and D. T. Burlingham. War
and Children (New York University Press, 1943).

22. There are three different ways in which
people deal with overwhelming experiences: dissociation (spacing out, shutting
down), depersonalization (feeling like it’s not you it’s happening to),
and derealization (feeling like whatever is happening is not real).

23. My colleagues at the Justice Resource
Institute created a residential treatment program for adolescents, The van der Kolk
Center at Glenhaven Academy, that implements many of the trauma-informed treatments
discussed in this book, including yoga, sensory integration, neurofeedback and
theater. http://www.jri.org/vanderkolk/about. The overarching treatment model,
attachment, self-regulation, and competency (ARC), was developed by my colleagues
Margaret Blaustein and Kristine Kinneburgh. Margaret E. Blaustein, and Kristine M.
Kinniburgh, Treating Traumatic Stress in Children and Adolescents: How to Foster
Resilience Through Attachment, Self-Regulation, and Competency (New York:
Guilford Press, 2012).

24. C. K. Chandler, Animal Assisted
Therapy in Counseling (New York: Routledge, 2011). See also A. J.
Cleveland, “Therapy Dogs and the Dissociative Patient: Preliminary
Observations,” Dissociation 8, no. 4 (1995): 247–52; and A. Fine,
Handbook on Animal Assisted Therapy: Theoretical Foundations and Guidelines
for Practice (San Diego: Academic Press, 2010).

25. E. Warner, et al., “Can the Body
Change the Score? Application of Sensory Modulation Principles in the Treatment of
Traumatized Adolescents in Residential Settings,” Journal of Family
Violence 28, no. 7 (2013): 729–38. See also A. J. Ayres, Sensory
Integration and Learning Disorders (Los Angeles: Western Psychological
Services, 1972); H. Hodgdon, et al., “Development and Implementation of
Trauma-Informed Programming in Residential Schools Using the ARC Framework,”
Journal of Family Violence 27, no. 8 (2013); J. LeBel, et al.,
“Integrating Sensory and Trauma-Informed Interventions: A Massachusetts State
Initiative, Part 1,” Mental Health Special Interest Section Quarterly
33, no. 1 (2010): 1–4;

26. They appeared to have activated the
vestibule-cerebellar system in the brain, which seems to be involved in
self-regulation and can be damaged by early neglect.

27. Aaron R. Lyon and Karen S. Budd, “A
Community Mental Health Implementation of Parent–Child Interaction Therapy
(PCIT).” Journal of Child and Family Studies 19, no. 5 (2010):
654–68. See also Anthony J. Urquiza and Cheryl Bodiford McNeil, “Parent-Child
Interaction Therapy: An Intensive Dyadic Intervention for Physically Abusive
Families.” Child Maltreatment 1, no 2 (1996): 134–44; J. Borrego Jr.,
et al. “Research Publications.” Child and Family Behavior
Therapy 20: 27-54.

28. B. A. van der Kolk, et al., “Fluoxetine in Post
Traumatic Stress,” Journal of Clinical
Psychiatry (1994): 517–22.

29. P. Ogden, K. Minton, and C. Pain,
Trauma and the Body (New York, Norton, 2010); P. Ogden and J.
Fisher, Sensorimotor Psychotherapy: Interventions for Trauma and
Attachment (New York: Norton, 2014).

30. P. Levine, In an Unspoken Voice
(Berkeley: North Atlantic Books); P. Levine, Waking the Tiger (Berkeley:
North Atlantic Books).

31. For more on impact model mugging, see http://modelmugging.org/.

32. S. Freud, Remembering, Repeating, and
Working Through (Further Recommendations on the Technique of Psychoanalysis
II), standard ed. (London: Hogarth Press, 1914), p. 371

33. E. Santini, R. U. Muller, and G. J.
Quirk, “Consolidation of Extinction Learning Involves Transfer from
NMDA-Independent to NMDA-Dependent Memory,” Journal of Neuroscience
21 (2001): 9009–17.

34. E. B. Foa and M. J. Kozak,
“Emotional Processing of Fear: Exposure to Corrective Information,”
Psychological Bulletin 99, no. 1 (1986): 20–35.

35. C. R. Brewin, “Implications for
Psychological Intervention,” in Neuropsychology of PTSD: Biological,
Cognitive, and Clinical Perspectives, ed. J. J. Vasterling and C. R. Brewin
(New York: Guilford, 2005), 272.

36. T. M. Keane, “The Role of Exposure
Therapy in the Psychological Treatment of PTSD,” National Center for PTSD
Clinical Quarterly 5, no. 4 (1995): 1–6.

37. E. B. Foa and R. J. McNally,
“Mechanisms of Change in Exposure Therapy,” in Current Controversies
in the Anxiety Disorders, ed. R. M. Rapee (New York: Guilford, 1996),
329–43.

38. J. D. Ford and P. Kidd, “Early
Childhood Trauma and Disorders of Extreme Stress as Predictors of Treatment Outcome
with Chronic PTSD,” Journal of Traumatic Stress 18 (1998): 743–61.
See also A. McDonagh-Coyle, et al., “Randomized Trial of Cognitive-Behavioral
Therapy for Chronic Posttraumatic Stress Disorder in Adult Female Survivors of
Childhood Sexual Abuse,” Journal of Consulting and Clinical
Psychology 73, no. 3 (2005): 515–24; Institute of Medicine of the National
Academies, Treatment of Posttraumatic Stress Disorder: An Assessment of the
Evidence (Washington: National Academies Press, 2008); and R. Bradley, et
al., “A Multidimensional Meta-Analysis of Psychotherapy for PTSD,”
American Journal of Psychiatry 162, no. 2 (2005): 214–27.

39. J. Bisson, et al., “Psychological
Treatments for Chronic Posttraumatic Stress Disorder: Systematic Review and
Meta-Analysis,” British Journal of Psychiatry 190 (2007): 97–104. See
also L. H. Jaycox, E. B. Foa, and A. R. Morrall, “Influence of Emotional
Engagement and Habituation on Exposure Therapy for PTSD,” Journal of
Consulting and Clinical Psychology 66 (1998): 185–92.

40. “Dropouts: in prolonged exposure (n
= 53 [38%]); in present-centered therapy (n = 30 [21%]) (P = .002). The control
group also had a high rate of casualties: 2 nonsuicidal deaths, 9 psychiatric
hospitalizations, and 3 suicide attempts.” P. P. Schnurr, et al., “Cognitive Behavioral Therapy for
Posttraumatic Stress Disorder in Women,” JAMA 297, no. 8
(2007): 820–30.

41. R. Bradley, et al., “A
Multidimensional Meta-Analysis of Psychotherapy for PTSD,” American
Journal of Psychiatry 162, no. 2 (2005): 214–27.

42. J. H. Jaycox and E. B. Foa,
“Obstacles in Implementing Exposure Therapy for PTSD: Case Discussions and
Practical Solutions,” Clinical Psychology and Psychotherapy 3, no. 3
(1996): 176–84. See also E. B. Foa, D. Hearst-Ikeda, and K. J. Perry,
“Evaluation of a Brief Cognitive-Behavioral Program for the Prevention of
Chronic PTSD in Recent Assault Victims,” Journal of Consulting and
Clinical Psychology 63 (1995): 948–55.

43. Alexander McFarlane personal
communication.

44. R. K. Pitman, et al., “Psychiatric
Complications During Flooding Therapy for Posttraumatic Stress Disorder,”
Journal of Clinical Psychiatry 52, no. 1 (January 1991): 17–20.

45. Jean Decety, Kalina J. Michalska, and
Katherine D. Kinzler, “The Contribution of Emotion and Cognition to Moral
Sensitivity: A Neurodevelopmental Study,” Cerebral Cortex 22 no. 1 (2012):
209–20; Jean Decety, C. Daniel Batson, “Neuroscience Approaches to
Interpersonal Sensitivity,” 2, nos. 3-4 (2007).

46. K. H. Seal, et al., “VA Mental
Health Services Utilization in Iraq and Afghanistan Veterans in the First Year of
Receiving New Mental Health Diagnoses,” Journal of Traumatic Stress
23 (2010): 5–16.

47. L. Jerome,
“(+/-)-3,4-Methylenedioxymethamphetamine (MDMA, “Ecstasy”)
Investigator’s Brochure,” December 2007, available at www.maps.org/research/mdma/protocol/ib_mdma_new08.pdf[URL inactive] (accessed August 16,
2012).

48. John H. Krystal, et al. “Chronic 3,
4-methylenedioxymethamphetamine (MDMA) use: effects on mood and neuropsychological
function?.” The American Journal of Drug and Alcohol Abuse 18.3
(1992): 331-341.

49. Mithoefer, Michael C., et al., “The
safety and efficacy of±3, 4-methylenedioxymethamphetamine-assisted psychotherapy in
subjects with chronic, treatment-resistant posttraumatic stress disorder: the first
randomized controlled pilot study.” Journal of Psychopharmacology
25.4 (2011): 439-452; M. C. Mithoefer, et al., “Durability of Improvement in
Post-traumatic Stress Disorder Symptoms and Absence of Harmful Effects or Drug
Dependency after 3, 4-Methylenedioxymethamphetamine-Assisted Psychotherapy: A
Prospective Long-Term Follow-up Study,” Journal of Psychopharmacology
27, no. 1 (2013): 28–39.

50. J. D. Bremner, “Neurobiology of
Post-traumatic Stress Disorder,” in Posttraumatic
Stress Disorder: A Critical Review, ed. R. S. Rynoos (Lutherville, MD:
Sidran Press, 1994), 43–64.

51. http://cdn.nextgov.com/nextgov/interstitial.html?v=2.1.1&rf=http%3A%2F%2Fwww.nextgov.com%2Fhealth%2F2011%2F01%2Fmilitarys-drug-policy-threatens-troops-health-doctors-say%2F48321%2F.

52. J. R. T. Davidson, “Drug Therapy of
Post-traumatic Stress Disorder,” British Journal of Psychiatry 160
(1992): 309–314. See also R. Famularo, R. Kinscherff, and T. Fenton,
“Propranolol Treatment for Childhood Posttraumatic Stress Disorder Acute Type,” American Journal of
Disorders of Childhood 142 (1988): 1244–47; F. A. Fesler, “Valproate
in Combat-Related Posttraumatic Stress Disorder,” Journal of Clinical
Psychiatry 52 (1991): 361–64; B. H. Herman, et al., “Naltrexone
Decreases Self-Injurious Behavior,” Annals of Neurology 22 (1987):
530–34; and B. A. van der Kolk, et al., “Fluoxetine in Posttraumatic Stress
Disorder.”

53. B. Van der Kolk, et al., “A
Randomized Clinical Trial of EMDR, Fluoxetine and Pill Placebo in the Treatment of
PTSD: Treatment Effects and Long-Term Maintenance,” Journal of Clinical
Psychiatry 68 (2007): 37–46.

54. R. A. Bryant, et al., “Treating
Acute Stress Disorder: An Evaluation of Cognitive Behavior Therapy and Supportive
Counseling Techniques,” American Journal of Psychiatry 156, no. 11
(November 1999): 1780–86; N. P. Roberts et al., “Early Psychological
Interventions to Treat Acute Traumatic Stress Symptoms,” Cochran Database
of Systematic Reviews 3 (March 2010).

55. This includes the alpha_1
receptor antagonist prazosin, the alpha_2 receptor antagonist clonidine,
and the beta receptor antagonist propranolol. See M. J. Friedman and J. R. Davidson,
“Pharmacotherapy for PTSD,” in Handbook of PTSD: Science and
Practice, ed. M. J. Friedman, T. M. Keane, and P. A. Resick (New York:
Guilford Press, (2007), 376.

56. M. A. Raskind, et al., “A Parallel
Group Placebo Controlled Study of Prazosin for Trauma Nightmares and Sleep
Disturbance in Combat Veterans with Posttraumatic Stress Disorder,”
Biological Psychiatry 61, no. 8 (2007): 928–34. F. B. Taylor,
et al., “Prazosin Effects on Objective Sleep Measures and Clinical Symptoms in
Civilian Trauma Posttraumatic Stress Disorder: A Placebo-Controlled Study,”
Biological Psychiatry 63, no. 6 (2008): 629–32.

57. Lithium, lamotrigin, carbamazepine,
divalproex, gabapentin, and topiramate may help to control trauma-related aggression
and irritability. Valproate has been shown to be effective in several case reports
with PTSD, including with military veteran patients with chronic PTSD. Friedman and
Davidson, “Pharmacotherapy for PTSD”; F. A. Fesler, “Valproate in
Combat-Related Posttraumatic Stress Disorder,” Journal of Clinical
Psychiatry 52, no. 9 (1991): 361–64. The following study showed a 37.4
percent reduction in PTSD S. Akuchekian and S. Amanat, “The Comparison of
Topiramate and Placebo in the Treatment of Posttraumatic Stress Disorder: A
Randomized, Double-Blind Study,” Journal of Research in Medical
Sciences 9, no. 5 (2004): 240–44.

58. G. Bartzokis, et al., “Adjunctive
Risperidone in the Treatment of Chronic Combat-Related Posttraumatic Stress
Disorder,” Biological Psychiatry 57, no. 5 (2005): 474–79. See also
D. B. Reich, et al., “A Preliminary Study of Risperidone in the Treatment of
Posttraumatic Stress Disorder Related to Childhood Abuse in Women,”
Journal of Clinical Psychiatry 65, no. 12 (2004): 1601–1606.

59. The other methods include interventions
that usually help traumatized individuals sleep, like the antidepressant trazodone,
binaural beat apps, light/sound machines like Proteus (www.brainmachines.com), HRV monitors
like hearthmath (http://www.heartmath.com/)
, and iRest, an effective yoga-based
intervention. (http://www.irest.us/)

60. D. Wilson, “Child’s Ordeal
Shows Risks of Psychosis Drugs for Young,” New York Times, September
1, 2010, available at http://www.nytimes.com/2010/09/02/business/02kids.html?pagewanted=all&_r=0.

61. M. Olfson, et al., “National Trends
in the Office-Based Treatment of Children, Adolescents, and Adults with
Antipsychotics,” Archives of General Psychiatry 69, no. 12 (2012):
1247–56.

62. E. Harris, et al., “Perspectives on
Systems of Care: Concurrent Mental Health Therapy Among Medicaid-Enrolled Youths
Starting Antipsychotic Medications,” FOCUS 10, no. 3 (2012):
401–407.

63. B. A. Van der Kolk, “The Body Keeps
the Score: Memory and the Evolving Psychobiology of Posttraumatic Stress,”
Harvard Review of Psychiatry 1, no. 5 (1994): 253–65.

64. B. Brewin, “Mental Illness is the
Leading Cause of Hospitalization for Active-Duty Troops,” Nextgov.com, May 17, 2012, http://www.nextgov.com/health/2012/05/mental-illness-leading-cause-hospitalization-active-duty-troops/55797/.

65. Mental health drug expenditures,
Department of Veterans affairs. http://www.veterans.senate.gov/imo/media/doc/For%20the%20Record%20-%20CCHR%204.30.14.pdf.

CHAPTER 14: LANGUAGE: MIRACLE AND
TYRANNY

1. Dr. Spencer Eth to Bessel A. van der Kolk,
March 2002.

2. J. Breuer and S. Freud, “The
Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of
the Complete Psychological Works of Sigmund Freud (London: Hogarth Press,
1893). J. Breuer and S. Freud, Studies on Hysteria (New York: Basic Books,
2009).

3. T. E. Lawrence, Seven Pillars of
Wisdom (New York: Doubleday, 1935).

4. E. B. Foa, et al., “The
Posttraumatic Cognitions Inventory (PTCI): Development and Validation,”
Psychological Assessment 11, no. 3 (1999): 303–314.

5. K. Marlantes, What It Is Like to Go to
War (New York: Grove Press, 2011).

6. Ibid., 114.

7. Ibid., 129.

8. H. Keller, The World I Live In
(1908), ed. R. Shattuck (New York: NYRB Classics, 2004). See also R. Shattuck,
“A World of Words,” New York Review of Books, February 26,
2004.

9. H. Keller, The Story of My Life,
ed. R. Shattuck and D. Herrmann (New York: Norton, 2003).

10. W. M. Kelley, et al., “Finding the
Self? An Event-Related fMRI Study,” Journal of Cognitive Neuroscience
14, no. 5 (2002): 785–94. See also N. A. Farb, et al., “Attending to the
Present: Mindfulness Meditation Reveals Distinct Neural Modes of
Self-Reference,” Social Cognitive and Affective Neuroscience 2, no. 4
(2007): 313–22. P. M. Niedenthal,
“Embodying Emotion,” Science 316, no. 5827 (2007): 1002–1005;
and J. M. Allman, “The Anterior Cingulate Cortex,” Annals of the New
York Academy of Sciences 935, no. 1 (2001): 107–117.

11. J. Kagan, dialogue with the Dalai Lama,
Massachusetts Institute of Technology, 2006. http://www.mindandlife.org/about/history/.

12. A. Goldman and F. de Vignemont, “Is
Social Cognition Embodied?” Trends in Cognitive Sciences 13, no. 4
(2009): 154–59. See also A. D. Craig, “How Do You Feel—Now? The Anterior
Insula and Human Awareness,” Nature Reviews Neuroscience 10 (2009): 59–70; H.
D. Critchley, “Neural Mechanisms of Autonomic, Affective, and Cognitive
Integration,” Journal of Comparative Neurology 493, no. 1 (2005):
154–66; T. D. Wager, et al., “Prefrontal-Subcortical Pathways Mediating
Successful Emotion Regulation,” Neuron 59, no. 6 (2008): 1037–50; K.
N. Ochsner, et al., “Rethinking Feelings: An fMRI Study of the Cognitive
Regulation of Emotion,” Journal of Cognitive Neuroscience 14, no. 8
(2002): 1215–29; A. D’Argembeau, et al., “Self-Reflection Across Time:
Cortical Midline Structures Differentiate Between Present and Past Selves,”
Social Cognitive and Affective Neuroscience 3, no. 3 (2008): 244–52; Y.
Ma, et al., “Sociocultural Patterning of Neural Activity During
Self-Reflection,” Social Cognitive and Affective Neuroscience 9, no.
1 (2014): 73–80; R. N. Spreng, R. A. Mar, and A. S. Kim, “The Common Neural
Basis of Autobiographical Memory, Prospection, Navigation, Theory of Mind, and the
Default Mode: A Quantitative Meta-Analysis,” Journal of Cognitive
Neuroscience 21, no. 3 (2009): 489–510; H. D. Critchley, “The Human
Cortex Responds to an Interoceptive Challenge,” Proceedings of the
National Academy of Sciences of the United States of America 101, no. 17
(2004): 6333–34; and C. Lamm, C. D. Batson, and J. Decety, “The Neural
Substrate of Human Empathy: Effects of Perspective-Taking and Cognitive
Appraisal,” Journal of Cognitive Neuroscience 19, no. 1 (2007):
42–58.

13. J. W. Pennebaker, Opening Up: The
Healing Power of Expressing Emotions (New York: Guilford Press, 2012),
12.

14. Ibid., p. 19.

15. Ibid., p.35.

16. Ibid., p. 50.

17. J. W. Pennebaker, J. K. Kiecolt-Glaser,
and R. Glaser, “Disclosure of Traumas and Immune Function: Health Implications
for Psychotherapy,” Journal of Consulting and Clinical Psychology 56,
no. 2 (1988): 239–45.

18. D. A. Harris, “Dance/Movement
Therapy Approaches to Fostering Resilience and Recovery Among African Adolescent
Torture Survivors,” Torture 17, no. 2 (2007): 134–55; M. Bensimon, D.
Amir, and Y. Wolf, “Drumming Through Trauma: Music Therapy with Post-traumatic
Soldiers,” Arts in Psychotherapy 35, no. 1 (2008): 34–48; M. Weltman,
“Movement Therapy with Children Who Have Been Sexually Abused,”
American Journal of Dance Therapy 9, no. 1 (1986): 47–66; H. Englund,
“Death, Trauma and Ritual: Mozambican Refugees in Malawi,” Social
Science & Medicine 46, no. 9 (1998): 1165–74; H. Tefferi, Building on
Traditional Strengths: The Unaccompanied
Refugee Children from South Sudan (1996); D. Tolfree, Restoring Playfulness:
Different Approaches to Assisting Children Who Are Psychologically Affected by
War or Displacement (Stockholm: Rädda Barnen, 1996), 158–73; N. Boothby,
“Mobilizing Communities to Meet the Psychosocial Needs of Children in War and
Refugee Crises,” in Minefields in Their Hearts: The Mental
Health of Children in War and Communal Violence, ed. R. Apfel and B. Simon
(New Haven, Yale Universit Press, 1996), 149–64; S. Sandel, S. Chaiklin, and A.
Lohn, Foundations of Dance/Movement Therapy: The Life and Work of Marian
Chace (Columbia, MD: American Dance Therapy Association, 1993); K.
Callaghan, “Movement Psychotherapy with Adult Survivors of Political Torture
and Organized Violence,” Arts in Psychotherapy 20, no. 5 (1993):
411–21; A. E. L. Gray, “The Body Remembers: Dance Movement Therapy with an
Adult Survivor of Torture,” American Journal of Dance Therapy 23, no.
1 (2001): 29–43.

19. A. M. Krantz, and J. W. Pennebaker,
“Expressive Dance, Writing, Trauma, and Health: When Words Have a Body.”
Whole Person Healthcare 3 (2007): 201–29.

20. P. Fussell, The Great War and Modern
Memory (London: Oxford University Press, 1975).

21. Theses findings have been replicated in
the following studies: J. D. Bremner, “Does Stress Damage the Brain?”
Biological Psychiatry 45, no. 7 (1999): 797–805; I. Liberzon, et al.,
“Brain Activation in PTSD in Response to Trauma-Related Stimuli,”
Biological Psychiatry 45, no. 7 (1999): 817–26; L. M. Shin, et al.,
“Visual Imagery and Perception in Posttraumatic Stress Disorder: A Positron
Emission Tomographic Investigation,” Archives of General Psychiatry
54, no. 3 (1997): 233–41; L. M. Shin, et al., “Regional Cerebral Blood Flow
During Script-Driven Imagery in Childhood Sexual Abuse–Related PTSD: A PET
Investigation,” American Journal of Psychiatry 156, no. 4 (1999):
575–84.

22. I am not sure if this term originated
with me or with Peter Levine. I own a video where he credits me, but most of what I
have learned about pendulation I’ve learned from him.

23. A small body of evidence offers support
for claims that exposure/acupoints stimulation yields stronger outcomes and
exposures strategies that incorporate conventional relaxation techniques. (www.vetcases.com). D. Church, et al.,
“Single-Session Reduction of the Intensity of Traumatic Memories in Abused
Adolescents After EFT: A Randomized Controlled Pilot Study,”
Traumatology 18, no. 3 (2012): 73–79; and D. Feinstein and D. Church,
“Modulating Gene Expression Through Psychotherapy: The Contribution of
Noninvasive Somatic Interventions,” Review of General Psychology 14,
no. 4 (2010): 283–95.

24. T. Gil, et al., “Cognitive
Functioning in Post-traumatic Stress Disorder,” Journal of
Traumatic Stress 3, no. 1 (1990): 29–45; J. J. Vasterling, et al.,
“Attention, Learning, and Memory Performances and Intellectual Resources in
Vietnam Veterans: PTSD and No Disorder Comparisons,” Neuropsychology
16, no. 1 (2002): 5.

25. In a neuroimaging study the PTSD subjects
deactivated the speech area of their brain, Broca’s area, in response to
neutral words. In other words: the decreased Broca’s area functioning that we had found in PTSD
patients (see chapter 3) did not only occur in
response to traumatic memories; it also happened when they were asked to pay
attention to neutral words. This means that, as a group, traumatized patients have a
harder time to articulate what they feel and think about ordinary events. The PTSD
group also had decreased activation of the medial prefrontal cortex (mPFC), the
frontal lobe area that, as we have seen, conveys awareness of one’s self, and
dampens activation of the amygdala, the smoke detector. This made it harder for them
to suppress the brain’s fear response in response to a simple language task
and again, made it harder to pay attention and go on with their lives. See: Moores,
K. A., Clark, C. R., McFarlane, A. C., Brown, G. C., Puce, A., & Taylor, D. J.
(2008). Abnormal recruitment of working memory updating networks during maintenance
of trauma-neutral information in post-traumatic stress disorder. Psychiatry
Research: Neuroimaging, 163(2), 156–170.

26. J. Breuer and S. Freud, “The
Physical Mechanisms of Hysterical Phenomena,” in The Standard Edition of
the Complete Psychological Works of Sigmund Freud (London: Hogarth Press,
1893).

27. D. L. Schacter, Searching for
Memory (New York: Basic Books, 1996).

CHAPTER 15: LETTING GO OF THE PAST:
EMDR

1. F. Shapiro, EMDR: The Breakthrough Eye
Movement Therapy for Overcoming Anxiety, Stress, and Trauma (New York:
Basic Books, 2004).

2. B. A. van der Kolk, et al., “A
Randomized Clinical Trial of Eye Movement Desensitization and Reprocessing (EMDR),
Fluoxetine, and Pill Placebo in the Treatment of Posttraumatic Stress Disorder:
Treatment Effects and Long-Term Maintenance,” Journal of Clinical
Psychiatry 68, no. 1 (2007): 37–46.

3. J. G. Carlson, et al., “Eye Movement
Desensitization and Reprocessing (EDMR) Treatment for Combat-Related Posttraumatic
Stress Disorder,” Journal of Traumatic Stress 11, no. 1 (1998):
3–24.

4. J. D. Payne, et al., “Sleep
Increases False Recall of Semantically Related Words in the Deese-Roediger-McDermott
Memory Task,” Sleep 29 (2006): A373.

5. B. A. van der Kolk and C. P. Ducey,
“The Psychological Processing of Traumatic Experience: Rorschach Patterns in
PTSD,” Journal of Traumatic Stress 2, no. 3 (1989): 259–74.

6. M. Jouvet, The Paradox of Sleep: The
Story of Dreaming, trans. Laurence Garey (Cambridge, MA: MIT Press,
1999).

7. R. Greenwald, “Eye Movement
Desensitization and Reprocessing (EMDR): A New Kind of Dreamwork?”
Dreaming 5, no. 1 (1995): 51–55.

8. R. Cartwright, et al., “REM Sleep
Reduction, Mood Regulation and Remission in Untreated Depression,”
Psychiatry Research 121, no. 2 (2003): 159–67. See also R. Cartwright,
et al., “Role of REM Sleep and Dream Affect in Overnight Mood Regulation: A
Study of Normal Volunteers,” Psychiatry Research 81, no. 1 (1998):
1–8.

9. R. Greenberg, C. A. Pearlman, and D. Gampel, “War
Neuroses and the Adaptive Function of REM Sleep,” British Journal of
Medical Psychology 45, no. 1 1972): 27–33. Ramon Greenberg and Chester
Pearlman, as well as our lab, found that traumatized veterans wake themselves up as
soon as they enter a REM period. While many traumatized individuals use alcohol to
help them sleep, they thereby keep themselves from the full benefits of dreaming
(the integration and transformation of memory) and thereby may contribute to
preventing the resolution of their PTSD.

10. B. van der Kolk, et al.,
“Nightmares and Trauma: A Comparison of Nightmares After Combat with Lifelong
Nightmares in Veterans,” American Journal of Psychiatry 141, no. 2
(1984): 187–90.

11. N. Breslau, et al., “Sleep
Disturbance and Psychiatric Disorders: A Longitudinal Epidemiological Study of Young
Adults,” Biological Psychiatry 39, no. 6 (1996): 411–18.

12. R. Stickgold, et al.,
“Sleep-Induced Changes in Associative Memory,” Journal of Cognitive
Neuroscience 11, no. 2 (1999): 182–93. See also R. Stickgold,
“Of Sleep, Memories and Trauma,” Nature Neuroscience 10, no. 5
(2007): 540–42; and B. Rasch, et al., “Odor Cues During Slow-Wave Sleep Prompt
Declarative Memory Consolidation,” Science 315, no. 5817 (2007):
1426–29.

13. E. J. Wamsley, et al., “Dreaming of
a Learning Task Is Associated with Enhanced Sleep-Dependent Memory
Consolidation,” Current Biology 20, no. 9, (May 11, 2010):
850–55.

14. R. Stickgold, “Sleep-Dependent
Memory Consolidation,” Nature 437 (2005): 1272–78.

15. R. Stickgold, et al.,
“Sleep-Induced Changes in Associative Memory,” Journal of
Cognitive Neuroscience 11, no. 2 (1999): 182–93.

16. J. Williams, et al., “Bizarreness
in Dreams and Fantasies: Implications for the Activation-Synthesis
Hypothesis,” Consciousness and Cognition 1, no. 2 (1992): 172–85. See
also Stickgold, et al., “Sleep-Induced Changes in Associative
Memory.”

17. M. P. Walker, et al., “Cognitive
Flexibility Across the Sleep-Wake Cycle: REM-Sleep Enhancement of Anagram Problem
Solving,” Cognitive Brain Research 14 (2002): 317–24.

18. R. Stickgold, “EMDR: A Putative
Neurobiological Mechanism of Action,” Journal of Clinical Psychology
58 (2002): 61–75.

19. There are several studies on how eye
movements help to process and transform traumatic memories. M. Sack, et al.,
“Alterations in Autonomic Tone During Trauma Exposure Using Eye Movement
Desensitization and Reprocessing (EMDR)—Results of a Preliminary
Investigation,” Journal of Anxiety Disorders 22, no. 7 (2008):
1264–71; B. Letizia, F. Andrea, and C. Paolo, Neuroanatomical Changes After Eye
Movement Desensitization and Reprocessing (EMDR) Treatment in Posttraumatic Stress
Disorder, The Journal of Neuropsychiatry and Clinical Neurosciences,
19, no. 4 (2007): 475–76; P. Levin, S. Lazrove, and B. van der Kolk, (1999). What Psychological
Testing and Neuroimaging Tell Us About the Treatment of Posttraumatic Stress
Disorder by Eye Movement Desensitization and Reprocessing, Journal of Anxiety
Disorders, 13, nos. 1–2, 159–72; M. L. Harper, T. Rasolkhani Kalhorn, J. F.
Drozd, “On the Neural Basis of EMDR Therapy: Insights from Qeeg Studies,
Traumatology, 15, no. 2 (2009): 81–95; K. Lansing, D. G. Amen, C.
Hanks, L. Rudy, “High-Resolution Brain SPECT Imaging and Eye Movement
Desensitization and Reprocessing in Police Officers with PTSD,” The
Journal of Neuropsychiatry and Clinical Neurosciences 17, no. 4 (2005):
526–32; T. Ohtani, K. Matsuo, K. Kasai, T. Kato, and N. Kato, “Hemodynamic
Responses of Eye Movement Desensitization and Reprocessing in Posttraumatic Stress
Disorder. Neuroscience Research, 65, no. 4 (2009): 375–83; M. Pagani, G.
Högberg, D. Salmaso, D. Nardo, Ö. Sundin, C. Jonsson, and T. Hällström,
“Effects of EMDR Psychotherapy on 99mtc-HMPAO
Distribution in Occupation-Related Post-Traumatic Stress Disorder,”
Nuclear Medicine Communications 28 (2007): 757–65; H. P. Söndergaard
and U. Elofsson, “Psychophysiological Studies of EMDR,” Journal of
EMDR Practice and Research 2, no. 4 (2008): 282–88.

CHAPTER 16: LEARNING TO INHABIT YOUR
BODY: YOGA

1. Acupuncture and acupressure are widely
practiced among trauma-oriented clinicians and is beginning to be systematically
studied as a treatment for clinical PTSD. M. Hollifield, et al., “Acupuncture
for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial,”
Journal of Nervous and Mental Disease 195, no. 6 (2007):
504–513. Studies that use fMRI to measure the effects of acupuncture on the areas of
the brain associated with fear report acupuncture to produce rapid regulation of
these brain regions. K. K. Hui, et al., “The Integrated Response of the Human
Cerebro-Cerebellar and Limbic Systems to Acupuncture Stimulation at ST 36 as
Evidenced by fMRI,” NeuroImage 27 (2005): 479–96; J. Fang, et al.,
“The Salient Characteristics of the Central Effects of Acupuncture Needling:
Limbic-Paralimbic-Neocortical Network Modulation,” Human Brain
Mapping 30 (2009): 1196–206. D. Feinstein, “Rapid Treatment of PTSD:
Why Psychological Exposure with Acupoint Tapping May Be Effective,”
Psychotherapy: Theory, Research, Practice, Training 47, no. 3 (2010):
385–402; D. Church, et al., “Psychological Trauma Symptom Improvement in
Veterans Using EFT (Emotional Freedom Technique): A Randomized Controlled
Trial,” Journal of Nervous and Mental Disease 201 (2013): 153–60; D.
Church, G. Yount, and A. J. Brooks, “The Effect of Emotional Freedom
Techniques (EFT) on Stress Biochemistry: A Randomized Controlled Trial,”
Journal of Nervous and Mental Disease 200 (2012): 891–96; R. P. Dhond,
N. Kettner, and V. Napadow, “Neuroimaging Acupuncture Effects in the Human
Brain,” Journal of Alternative and Complementary Medicine 13 (2007):
603–616; K. K. Hui, et al., “Acupuncture Modulates the Limbic System and
Subcortical Gray Structures of the Human Brain: Evidence from fMRI Studies in Normal
Subjects,” Human Brain Mapping 9 (2000): 13–25.

2. M. Sack, J. W. Hopper, and F. Lamprecht, “Low
Respiratory Sinus Arrhythmia and Prolonged Psychophysiological Arousal in
Posttraumatic Stress Disorder: Heart Rate Dynamics and Individual Differences in
Arousal Regulation,” Biological Psychiatry 55, no. 3 (2004): 284–90.
See also H. Cohen, et al., “Analysis of Heart Rate Variability in
Posttraumatic Stress Disorder Patients in Response to a TraumaRelated
Reminder,” Biological Psychiatry 44, no. 10 (1998): 1054–59; H.
Cohen, et al., “Long-Lasting Behavioral Effects of Juvenile Trauma in an
Animal Model of PTSD Associated with a Failure of the Autonomic Nervous System to
Recover,” European Neuropsychopharmacology 17, no. 6 (2007): 464–77;
and H. Wahbeh and B. S. Oken, “Peak High-Frequency HRV and Peak Alpha
Frequency Higher in PTSD,” Applied Psychophysiology and Biofeedback
38, no. 1 (2013): 57–69.

3. J. W. Hopper, et al., “Preliminary
Evidence of Parasympathetic Influence on Basal Heart Rate in Posttraumatic Stress
Disorder,” Journal of Psychosomatic Research 60, no. 1 (2006):
83–90.

4. Arieh Shalev at Hadassah Medical School in
Jerusalem and Roger Pitman’s experiments at Harvard also pointed in this
direction: A. Y. Shalev, et al., “Auditory Startle Response in Trauma
Survivors with Posttraumatic Stress Disorder: A Prospective Study,”
American Journal of Psychiatry 157, no. 2 (2000): 255–61; R.
K. Pitman, et al., “Psychophysiologic Assessment of Posttraumatic Stress
Disorder Imagery in Vietnam Combat Veterans,” Archives of General
Psychiatry 44, no. 11 (1987): 970–75; A. Y. Shalev, et al.,
“A Prospective Study of Heart Rate Response Following Trauma and the
Subsequent Development of Posttraumatic Stress Disorder,” Archives of
General Psychiatry 55, no. 6 (1998): 553–59.

5. P. Lehrer, Y. Sasaki, and Y. Saito,
“Zazen and Cardiac Variability,” Psychosomatic Medicine 61, no.
6 (1999): 812–21. See also R. Sovik, “The Science of Breathing: The Yogic
View,” Progress in Brain Research 122 (1999): 491–505; P. Philippot,
G. Chapelle, and S. Blairy, “Respiratory Feedback in the Generation of
Emotion,” Cognition & Emotion 16, no. 5 (2002): 605–627; A.
Michalsen, et al., “Rapid Stress Reduction and Anxiolysis Among Distressed
Women as a Consequence of a Three-Month Intensive Yoga Program,” Medcal
Science Monitor 11, no. 12 (2005): 555–61; G. Kirkwood et al., “Yoga
for Anxiety: A Systematic Review of the Research Evidence,” British
Journal of Sports Medicine 39 (2005): 884–91; K. Pilkington, et al.,
“Yoga for Depression: The Research Evidence,” Journal of Affective
Disorders 89 (2005): 13–24; and P. Gerbarg and R. Brown, “Yoga: A
Breath of Relief for Hurricane Katrina Refugees,” Current Psychiatry
4 (2005): 55–67.

6. B. Cuthbert et al., “Strategies of
Arousal Control: Biofeedback, Meditation, and Motivation,” Journal of
Experimental Psychology 110 (1981): 518–46. See also S. B. S. Khalsa,
“Yoga as a Therapeutic Intervention: A Bibliometric Analysis of Published
Research Studies,” Indian Journal of Physiology and Pharmacology 48
(2004): 269–85; M. M. Delmonte, “Meditation as a Clinical Intervention
Strategy: A Brief Review,” International Journal of Psychosomatics 33
(1986): 9–12; I. Becker, “Uses of Yoga in Psychiatry and Medicine,” in
Complementary and Alternative
Medicine and Psychiatry, vol.
19, ed. P. R. Muskin PR (Washington: American Psychiatric Press, 2008); L. Bernardi,
et al., “Slow Breathing Reduces Chemoreflex Response to Hypoxia and
Hypercapnia, and Increases Baroreflex Sensitivity,” Journal of
Hypertension 19, no. 12 (2001): 2221–29; R. P. Brown and P. L. Gerbarg,
“Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and
Depression: Part I: Neurophysiologic Model,” Journal of Alternative and
Complementary Medicine 11 (2005): 189–201; R. P. Brown and P. L. Gerbarg,
“Sudarshan Kriya Yogic Breathing in the Treatment of Stress, Anxiety, and
Depression: Part II: Clinical Applications and Guidelines,” Journal of
Alternative and Complementary Medicine 11 (2005): 711–17; C. C. Streeter,
et al., “Yoga Asana Sessions Increase Brain GABA Levels: A Pilot Study,”
Journal of Alternative and Complementary Medicine 13 (2007): 419–26;
and C. C. Streeter, et al., “Effects of Yoga Versus Walking on Mood, Anxiety,
and Brain GABA Levels: A Randomized Controlled MRS Study,” Journal of
Alternative and Complementary Medicine 16 (2010): 1145–52.

7. There are dozens of scientific articles
showing the positive effect of yoga for various medical conditions. The following is
a small sample: S. B. Khalsa, “Yoga as a Therapeutic Intervention”; P.
Grossman, et al., “Mindfulness-Based Stress Reduction and Health Benefits: A
Meta-Analysis,” Journal of Psychosomatic Research 57 (2004): 35–43;
K. Sherman, et al., “Comparing Yoga, Exercise, and a Self-Care Book for
Chronic Low Back Pain: A Randomized, Controlled Trial,” Annals of Internal
Medicine 143 (2005): 849–56; K. A. Williams, et al., “Effect of
Iyengar Yoga Therapy for Chronic Low Back Pain,” Pain 115 (2005):
107–117; R. B. Saper, et al., “Yoga for Chronic Low Back Pain in a
Predominantly Minority Population: A Pilot Randomized Controlled Trial,”
Alternative Therapies in Health and Medicine 15 (2009): 18–27; J. W.
Carson, et al., “Yoga for Women with Metastatic Breast Cancer: Results from a
Pilot Study,” Journal of Pain and Symptom Management 33 (2007):
331–41.

8. B. A. van der Kolk, et al., “Yoga as
an Adjunctive Therapy for PTSD,” Journal of
Clinical Psychiatry 75, no. 6 (June 2014): 559–65.

9. A California company, HeartMath, has
developed nifty devices and computer games that are both fun and effective in
helping people to achieve better HRV. To date nobody has studied whether simple
devices such as those developed by HeartMath can reduce PTSD symptoms, but this very
likely the case. (see in www.heartmath.org.)

10. As of this writing there are twenty-four
apps available on iTunes that claim to be able to help increase HRV, such as emWave,
HeartMath, and GPS4Soul.

11. B. A. van der Kolk, “Clinical
Implications of Neuroscience Research in PTSD,” Annals of the New York
Academy of Sciences 1071, no. 1 (2006): 277–93.

12. S. Telles, et al., “Alterations of
Auditory Middle Latency Evoked Potentials During Yogic Consciously Regulated
Breathing and Attentive State of Mind,” International Journal of
Psychophysiology 14, no. 3 (1993): 189–98. See also P. L. Gerbarg, “Yoga and
Neuro-Psychoanalysis,” in Bodies in Treatment: The Unspoken
Dimension, ed. Frances Sommer Anderson (New York, Analytic Press, 2008),
127–50.

13. D. Emerson and E. Hopper, Overcoming
Trauma Through Yoga: Reclaiming Your
Body (Berkeley, North Atlantic Books, 2011).

14. A. Damasio, The Feeling of What
Happens: Body and Emotion in the Making of
Consciousness (New York, Hartcourt, 1999).

15. “Interoception” is the
scientific name for this basic self-sensing ability. Brain-imaging studies of
traumatized people have repeatedly shown problems in the areas of the brain related
to physical self-awareness, particularly an area called the insula. J. W. Hopper, et
al., “Neural Correlates of Reexperiencing, Avoidance, and Dissociation in
PTSD: Symptom Dimensions and Emotion dDsregulation in Responses to Script-Driven
Trauma Imagery,” Journal of Traumatic Stress 20, no. 5 (2007):
713–25. See also I. A. Strigo, et al., “Neural Correlates of Altered Pain
Response in Women with Posttraumatic Stress Disorder from Intimate Partner
Violence,” Biological Psychiatry 68, no. 5 (2010): 442–50; G. A.
Fonzo, et al., “Exaggerated and Disconnected Insular-Amygdalar Blood
Oxygenation Level-Dependent Response to Threat-Related Emotional Faces in Women with
Intimate-Partner Violence Posttraumatic Stress Disorder,” Biological
Psychiatry 68, no. 5 (2010): 433–41; P. A. Frewen, et al., “Social
Emotions and Emotional Valence During Imagery in Women with PTSD: Affective and
Neural Correlates,” Psychological Trauma: Theory, Research, Practice, and
Policy 2, no. 2 (2010): 145–57; K. Felmingham, et al., “Dissociative
Responses to Conscious and Non-conscious Fear Impact Underlying Brain Function in
Post-traumatic Stress Disorder,” Psychological Medicine 38, no. 12
(2008): 1771–80; A. N. Simmons, et al., “Functional Activation and Neural
Networks in Women with Posttraumatic Stress Disorder Related to Intimate Partner
Violence,” Biological Psychiatry 64, no. 8 (2008): 681–90; R. J. L.
Lindauer, et al., “Effects of Psychotherapy on Regional Cerebral Blood Flow
During Trauma Imagery in Patients with Post-traumatic Stress Disorder: A Randomized
Clinical Trial,” Psychological Medicine 38, no. 4 (2008): 543–54 and
A. Etkin and T. D. Wager, “Functional Neuroimaging of Anxiety: A Meta-Analysis
of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific
Phobia,” American Journal of Psychiatry 164, no. 10 (2007):
1476–88.

16. J. C. Nemiah and P. E. Sifneos,
“Psychosomatic Illness: A Problem in Communication,” Psychotherapy
and Psychosomatics 18, no. 1–6 (1970): 154–60. See also G. J. Taylor, R. M.
Bagby, and J. D. A. Parker, Disorders of Affect Regulation: Alexithymia in
Medical and Psychiatric Illness (Cambridge: Cambridge University Press,
1997).

17. A. R. Damásio, The Feeling of What
Happens: Body and Emotion and the Making of Consciousness (Random House,
2000), 28.

18. B. A. van der Kolk, “Clinical
Implications of Neuroscience Research in PTSD,” Annals of the New York
Academy of Sciences 1071, no. 1 (2006): 277–93. See also B. K. Hölzel, et
al., “How Does Mindfulness Meditation Work? Proposing Mechanisms of Action from a Conceptual and Neural
Perspective,” Perspectives on Psychological Science 6, no. 6 (2011):
537–59.

19. B. K. Hölzel, et al., “Mindfulness
Practice Leads to Increases in Regional Brain Gray Matter Density,”
Psychiatry Research: Neuroimaging 191, no. 1 (2011): 36–43. See also B.
K. Hölzel, et al., “Stress Reduction Correlates with Structural Changes in the
Amygdala,” Social Cognitive and Affective Neuroscience 5, no. 1
(2010): 11–17; and S. W. Lazar, et al., “Meditation Experience Is Associated
with Increased Cortical Thickness,” NeuroReport 16 (2005):
1893–97.

CHAPTER 17: PUTTING THE PIECES
TOGETHER: SELF-LEADERSHIP

1. R. A. Goulding and R. C. Schwartz, The
Mosaic Mind: Empowering the Tormented
Selves of Child Abuse Survivors (New York: Norton, 1995), 4.

2. J. G. Watkins and H. H. Watkins, Ego
States (New York: Norton, 1997). Jung calls personality parts archetypes
and complexes; cognitive psychology schemes and the DID literature refers to them as
alters. See also J. G. Watkins and H. H. Watkins, “Theory and Practice of Ego
State Therapy: A Short-Term Therapeutic Approach,” Short-Term Approaches
to Psychotherapy 3 (1979): 176–220; J. G. Watkins and H. H. Watkins,
“Ego States and Hidden Observers,” Journal of Altered States of
Consciousness 5, no. 1 (1979): 3–18; and C. G. Jung, Lectures:
Psychology and Religion (New Haven CT: Yale University Press, 1960).

3. W. James, The Principles of
Psychology (New York: Holt, 1890), 206.

4. C. Jung, Collected Works, vol. 9,
The Archetypes and the Collective Unconscious (Princeton, NJ: Princeton
University Press, 1955/1968), 330.

5. C. Jung, Collected Works, vol.
10, Civilization in Transition (Princeton, NJ: Princeton University Press,
1957/1964), 540.

6. Ibid., 133.

7. M. S. Gazzaniga, The Social Brain:
Discovering the Networks of the Mind (New York: Basic Books, 1985), 90.

8. Ibid., 356.

9. M, Minsky, The Society of Mind
(New York: Simon & Schuster, 1988), 51.

10. Goulding and Schwartz, Mosaic
Mind, p. 290.

11. O. van der Hart, E. R. Nijenhuis, and K.
Steele, The Haunted Self: Structural Dissociation and the Treatment of Chronic
Traumatization (New York: WW Norton, 2006); R. P. Kluft, Shelter from
the Storm (self-published, 2013).

12. R. Schwartz, Internal Family Systems
Therapy (New York: Guilford Press, 1995).

13. Ibid., p. 34.

14. Ibid., p. 19.

15. Goulding and Schwartz, Mosaic
Mind, 63.

16. J. G. Watkins, 1997, illustrates this as
an example of personifying depression: “We need to know what the imaginal
sense of the depression is and who, which character, suffers it.”

17. Richard Schwartz, personal
communication.

18. Goulding and Schwartz, Mosaic Mind, 33.

19. A. W. Evers, et al., “Tailored
Cognitive-Behavioral Therapy in Early Rheumatoid Arthritis for Patients at Risk: A
Randomized Controlled Trial,” Pain 100, no. 1–2 (2002): 141–53; E. K.
Pradhan, et al., “Effect of Mindfulness-Based Stress Reduction in Rheumatoid
Arthritis Patients,” Arthritis & Rheumatology 57, no. 7 (2007):
p. 1134–42; J. M. Smyth, et al., “Effects of Writing About Stressful
Experiences on Symptom Reduction in Patients with Asthma or Rheumatoid Arthritis: A
Randomized Trial,” JAMA 281, no. 14 (1999): 1304–9; L. Sharpe, et
al., “Long-Term Efficacy of a Cognitive Behavioural Treatment from a
Randomized Controlled Trial for Patients Recently Diagnosed with Rheumatoid
Arthritis,” Rheumatology (Oxford) 42, no. 3 (2003): 435–41; H. A.
Zangi, et al., “A Mindfulness-Based Group Intervention to Reduce Psychological
Distress and Fatigue in Patients with Inflammatory Rheumatic Joint Diseases: A
Randomised Controlled Trial,” Annals of the Rheumatic Diseases 71,
no. 6 (2012): 911–17.

CHAPTER 18: FILLING IN THE HOLES:
CREATING STRUCTURES

1. Pesso Boyden System Psychomotor. See http://pbsp.com/.

2. D. Goleman, Social Intelligence: The
New Science of Human Relationships (Random House Digital, 2006).

3. A. Pesso, “PBSP: Pesso Boyden System
Psychomotor,” in Getting in Touch: A Guide to Body-Centered Therapies,
ed. S. Caldwell (Wheaton, IL: Theosophical Publishing House, 1997); A.
Pesso, Movement in Psychotherapy: Psychomotor Techniques and Training (New
York: New York University Press, 1969); A. Pesso, Experience in Action: A
Psychomotor Psychology (New York: New York University Press, 1973); A.
Pesso and J. Crandell, eds., Moving Psychotherapy: Theory and Application of
Pesso System/Psychomotor (Cambridge, MA: Brookline Books, 1991); M. Scarf,
Secrets, Lies, and Betrayals (New York: Ballantine Books, 2005); M. van
Attekum, Aan Den Lijve (Netherlands: Pearson Assessment, 2009); and A.
Pesso, “The Externalized Realization of the Unconscious and the Corrective
Experience,” in Handbook of Body-Psychotherapy/Handbuch der
Körperpsychotherapie, ed. H. Weiss and G. Marlock (Stuttgart, Germany:
Schattauer, 2006).

4. Luiz Pessoa, and Ralph Adolphs,
“Emotion Processing and the Amygdala: from a ‘Low Road’ to
‘Many Roads’ of Evaluating Biological Significance.” Nature
Reviews
Neuroscience 11, no. 11 (2010): 773–83.

CHAPTER 19: REWIRING THE BRAIN:
NEUROFEEDBACK

1. H. H. Jasper, P. Solomon, and C. Bradley,
“Electroencephalographic Analyses of Behavior Problem Children,”
American Journal of Psychiatry 95 (1938): 641–58; P. Solomon, H. H.
Jasper, and C. Braley, “Studies in Behavior Problem Children,”
American Neurology and Psychiatry 38 (1937): 1350–51.

2. Martin Teicher at Harvard Medical School,
has done extensive research that documents temporal lobe abnormalities in adults who
were abused as children: M. H. Teicher et al., “The Neurobiological
Consequences of Early Stress and Childhood Maltreatment,” Neuroscience &
Biobehavioral Reviews 27, no. 1–2) (2003): 33–44; M. H. Teicher et al.,
“Early Childhood Abuse and Limbic System Ratings in Adult Psychiatric
Outpatients,” Journal of Neuropsychiatry & Clinical Neurosciences
5, no. 3 (1993): 301–6; M. H. Teicher, et al., “Sticks, Stones and Hurtful
Words: Combined Effects of Childhood Maltreatment Matter Most,” American
Journal of Psychiatry (2012).

3. Sebern F. Fisher, Neurofeedback in the
Treatment of Developmental Trauma: Calming the Fear-Driven Brain. (New
York: Norton, 2014).

4. J. N. Demos, Getting Started with
Neurofeedback (New York: WW Norton, 2005). See also R. J. Davidson,
“Affective Style and Affective Disorders: Prospectives from Affective
Neuroscience,” Cognition and Emotion 12, no. 3 (1998): 307–30; and R.
J. Davidson, et al., “Regional Brain Function, Emotion and Disorders of
Emotion,” Current Opinion in Neurobiology 9 (1999): 228–34.

5. J. Kamiya, “Conscious Control of
Brain Waves,” Psychology Today, April 1968, 56–60. See also D. P.
Nowlis, and J. Kamiya, “The Control of Electroencephalographic Alpha Rhythms
Through Auditory Feedback and the Associated Mental Activity,”
Psychophysiology 6, no. 4 (1970): 476–84 and D. Lantz and M. B.
Sterman, “Neuropsychological Assessment of Subjects with Uncontrolled
Epilepsy: Effects of EEG Feedback Training,” Epilepsia 29, no. 2
(1988): 163–71.

6. M. B. Sterman, L. R. Macdonald, and R. K.
Stone, “Biofeedback Training of the Sensorimotor Electroencephalogram Rhythm
in Man: Effects on Epilepsy,” Epilepsia 15, no. 3 (1974): 395–416. A
recent meta-analysis of eighty-seven studies showed that neurofeedback led to a
significant reduction in seizure frequency in approximately 80 percent of epileptics
who received the training. Gabriel Tan, et al., “Meta-Analysis of EEG
Biofeedback in Treating Epilepsy,” Clinical EEG and Neuroscience 40,
no. 3 (2009): 173–79.

7. This is part of the same circuit of
self-awareness that I described in chapter 5. Alvaro
Pascual-Leone has shown how, when one temporarily knocks out the area above the
medial prefrontal cortex with transcranial magnetic stimulation (TMS), people can
temporarily not identify whom they are looking at when they stare into the mirror.
J. Pascual-Leone, “Mental Attention, Consciousness, and the Progressive
Emergence of Wisdom,” Journal of Adult Development 7, no. 4
(2000): 241–54.

8. http://www.eegspectrum.com/intro-to-neurofeedback/.

9. S. Rauch, et al., “Symptom
Provocation Study Using Positron Emission Tomography and Script Driven
Imagery,” Archives of General Psychiatry 53 (1996): 380–87. Three
other studies using a new way of imaging the brain, magnetoencephalography (MEG),
showed that people with PTSD suffer from increased activation of the right temporal
cortex: C. Catani, et al., “Pattern of Cortical Activation During Processing
of Aversive Stimuli in Traumatized Survivors of War and Torture,” European
Archives of Psychiatry and Clinical Neuroscience 259, no. 6 (2009): 340–51;
B. E. Engdahl, et al., “Post-traumatic Stress Disorder: A Right Temporal Lobe
Syndrome?” Journal of Neural Engineering 7, no. 6 (2010): 066005; A.
P. Georgopoulos, et al., “The
Synchronous Neural Interactions Test as a Functional Neuromarker for Post-traumatic
Stress Disorder (PTSD): A Robust Classification Method Based on the
Bootstrap,” Journal of Neural Engineering 7. no. 1 (2010):
016011.

10. As measured on the Clinician Administered
PTSD Scale (CAPS).

11. As measured by John Briere’s
Inventory of Altered Self-Capacities (IASC).

12. Posterior and central alpha rhythms are
generated by thalamocortical networks; beta rhythms appear to be generated by local
cortical networks; and the frontal midline theta rhythm (the only healthy theta
rhythm in the human brain) is hypothetically generated by the septohippocampal
neuronal network. For a recent review see J. Kropotov, Quantitative EEG,
ERP’s And Neurotherapy (Amsterdam: Elsevier, 2009).

13. H. Benson, “The Relaxation
Response: Its Subjective and Objective Historical Precedents and Physiology,”
Trends in Neurosciences 6 (1983): 281–84.

14. Tobias Egner and John H. Gruzelier,
“Ecological Validity of Neurofeedback: Modulation of Slow Wave EEG Enhances
Musical Performance,” Neuroreport 14 no. 9 (2003): 1221–4; David J.
Vernon, “Can Neurofeedback Training Enhance Performance? An Evaluation of the
Evidence with Implications for Future Research,” Applied Psychophysiology
and Biofeedback 30, no. 4 (2005): 347–64.

15. “Vancouver Canucks Race to the
Stanley Cup—Is It All in Their Minds?” Bio-Medical.com, June 2, 2011, http://bio-medical.com/news/2011/06/vancouver-canucks-race-to-the-stanley-cup-is-it-all-in-their-minds/.

16. M. Beauregard, Brain Wars (New
York: Harper Collins, 2013), p. 33.

17. J. Gruzelier, T. Egner, and D. Vernon,
“Validating the Efficacy of Neurofeedback for Optimising Performance,”
Progress in Brain Research 159 (2006): 421–31. See also D.
Vernon and J. Gruzelier, “Electroencephalographic Biofeedback as a Mechanism
to Alter Mood, Creativity and Artistic Performance,” in Mind-Body and
Relaxation Research Focus, ed. B. N. De Luca (New York: Nova Science,
2008), 149–64.

18. See, e.g., M. Arns, et al.,
“Efficacy of Neurofeedback Treatment in ADHD: The Effects on Inattention,
Impulsivity and Hyperactivity: A Meta-Analysis,” Clinical EEG and
Neuroscience 40, no. 3 (2009): 180–89; T. Rossiter, “The
Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part I: Review
of Methodological Issues,” Applied Psychophysiology and Biofeedback
29, no. 2 (June 2004): 95–112; T. Rossiter, “The Effectiveness of
Neurofeedback and Stimulant Drugs in Treating AD/HD: Part II: Replication,”
Applied Psychophysiology and Biofeedback 29, no. 4 (2004): 233–43; and
L. M. Hirshberg, S. Chiu, and J. A. Frazier, “Emerging Brain-Based
Interventions for Children and Adolescents: Overview and Clinical
Perspective,” Child and Adolescent Psychiatric Clinics of North
America 14, no. 1 (2005): 1–19.

19. For more on qEEG, see http://thebrainlabs.com/qeeg.shtml.

20. N. N. Boutros, M. Torello, and T. H.
McGlashan, “Electrophysiological Aberrations in Borderline Personality
Disorder: State of the Evidence,” Journal of Neuropsychiatry and Clinical
Neurosciences 15 (2003): 145–54.

21. In chapter 17, we saw how
essential it is to cultivate a state of steady, calm self-observation, which IFS
calls a state of “being in self.” Dick Schwartz claims that with
persistence anybody can achieve such a state, and indeed, I have seen him help very
traumatized people do precisely that. I am not that skilled, and many of my most
severely traumatized patients become frantic or spaced out when we approach
upsetting subjects. Others feel so chronically out of control that it is difficult
to find any abiding sense of “self.” In most psychiatric settings people
with these problems are given medications to stabilize them. Sometimes that works,
but many patients lose their motivation and drive. In our randomized controlled
study of neurofeedback, chronically traumatized patients had an approximately 30
percent reduction in PTSD symptoms and a significant improvement in measures of
executive function and emotional control (van der Kolk et al., submitted 2014).

22. Traumatized kids with sensory-integration
deficits need programs specifically developed for their needs. At present, the
leaders of this effort are my Trauma Center colleague Elizabeth Warner and Adele
Diamond at the University of British Columbia.

23. R. J. Castillo, “Culture, Trance,
and the Mind-Brain,” Anthropology of Consciousness 6, no. 1 (March
1995): 17–34. See also B. Inglis, Trance: A Natural History of Altered States of
Mind (London: Paladin, 1990); N. F. Graffin, W. J. Ray, and R. Lundy,
“EEG Concomitants of Hypnosis and Hypnotic Susceptibility,” Journal
of Abnormal Psychology 104, no. 1 (1995): 123–31; D. L. Schacter,
“EEG Theta Waves and Psychological Phenomena: A Review and Analysis,”
Biological Psychology 5, no. 1 (1977): 47–82; and M. E. Sabourin, et
al., “EEG Correlates of Hypnotic Susceptibility and Hypnotic Trance: Spectral
Analysis and Coherence,” International Journal of Psychophysiology
10, no. 2 (1990): 125–42.

24. E. G. Peniston and P. J. Kulkosky,
“Alpha-Theta Brainwave Neuro-Feedback Therapy for Vietnam Veterans with
Combat-Related Post-traumatic Stress Disorder,” Medical Psychotherapy
4 (1991): 47–60.

25. T. M. Sokhadze, R. L. Cannon, and D. L.
Trudeau, “EEG Biofeedback as a Treatment for Substance Use Disorders: Review,
Rating of Efficacy and Recommendations for Further Research,” Journal of
Neurotherapy 12, no. 1 (2008): 5–43.

26. R. C. Kessler, “Posttraumatic
Stress Disorder: The Burden to the Individual and to Society,” Journal of
Clinical Psychiatry 61, suppl. 5 (2000): 4–14. See also R. Acierno, et al.,
“Risk Factors for Rape, Physical Assault, and Posttraumatic Stress Disorder in
Women: Examination of Differential Multivariate Relationships,” Journal of
Anxiety Disorders 13, no. 6 (1999): 541–63; and H. D. Chilcoat and N.
Breslau, “Investigations of Causal Pathways Between PTSD and Drug Use
Disorders,” Addictive Behaviors 23, no. 6 (1998): 827–40.

27. S. L. Fahrion et al., “Alterations
in EEG Amplitude, Personality Factors, and Brain Electrical Mapping After
Alpha-Theta Brainwave Training: A Controlled Case Study of an Alcoholic in
Recovery,” Alcoholism: Clinical and Experimental Research 16, no. 3
(June 1992): 547–52; R. J. Goldberg, J. C. Greenwood, and Z. Taintor, “Alpha
Conditioning as an Adjunct Treatment
for Drug Dependence: Part 1,” International Journal of Addiction 11,
no. 6 (1976): 1085–89; R. F. Kaplan, et al., “Power and Coherence Analysis of
the EEG in Hospitalized Alcoholics and Nonalcoholic Controls,” Journal of
Studies on Alcohol 46 (1985): 122–27; Y. Lamontagne et al., “Alpha
and EMG Feedback Training in the Prevention of Drug Abuse: A Controlled
Study,” Canadian Psychiatric Association Journal 22, no. 6 (October
1977): 301–10; Saxby and E. G. Peniston, “Alpha-Theta Brainwave Neurofeedback
Training: An Effective Treatment for Male and Female Alcoholics with Depressive
Symptoms,” Journal of Clinical Psychology 51, no. 5 (1995): 685–93;
W. C. Scott, et al., “Effects of an EEG Biofeedback Protocol on a Mixed
Substance Abusing Population,” American Journal Drug and Alcohol
Abuse 31, no. 3 (2005): 455–69; and D. L. Trudeau, “Applicability of
Brain Wave Biofeedback to Substance Use Disorder in Adolescents,”
Child
& Adolescent Psychiatric Clinics of North America 14, no. 1 (January
2005): 125–36.

28. E. G. Peniston, “EMG
Biofeedback-Assisted Desensitization Treatment for Vietnam Combat Veterans
Post-traumatic Stress Disorder,” Clinical Biofeedback and Health 9
(1986): 35–41.

29. Eugene G. Peniston, and Paul J. Kulkosky.
“Alpha-Theta Brainwave Neurofeedback for Vietnam Veterans with Combat-Related
Post-Traumatic Stress Disorder.” Medical Psychotherapy 4, no. 1
(1991): 47-60.

30. Similar results were reported by another
group seven years later: W. C. Scott, et al., “Effects of an EEG Biofeedback
Protocol on a Mixed Substance Abusing Population,” American Journal of
Drug and Alcohol Abuse 31, no. 3 (2005): 455–69.

31. D. L. Trudeau, T. M. Sokhadze, and R. L.
Cannon, “Neurofeedback in Alcohol and Drug Dependency,” in Introduction
to Quantitative EEG and Neurofeedback: Advanced Theory and
Applications, ed. T. Budzynski, et al. Amsterdam, Elsevier, (1999) pp.
241–68; F. D. Arani, R. Rostami, and M. Nostratabadi, “Effectiveness of
Neurofeedback Training as a Treatment for Opioid-Dependent Patients,”
Clinical EEG and Neuroscience 41, no. 3 (2010): 170–77; F.
Dehghani-Arani, R. Rostami, and H. Nadali, “Neurofeedback Training for Opiate
Addiction: Improvement of Mental Health and Craving,” Applied
Psychophysiology and Biofeedback, 38, no. 2 (2013): 133–41; J. Luigjes, et
al., “Neuromodulation as an Intervention for Addiction: Overview and Future
Prospects,” Tijdschrift voor psychiatrie 55, no. 11 (2012):
841–52.

32. S. Othmer, “Remediating PTSD with
Neurofeedback,” October 11, 2011, http://hannokirk.com/files/Remediating-PTSD_10-01-11.pdf.

33. F. H. Duffy, “The State of EEG
Biofeedback Therapy (EEG Operant Conditioning) in 2000: An Editor’s
Opinion,” an editorial in Clinical Electroencephalography 31, no. 1
(2000): v–viii.

34. Thomas R. Insel, “Faulty
Circuits,” Scientific American 302, no. 4 (2010): 44-51.

35. T. Insel, “Transforming
Diagnosis,” National Insitute of Mental Health, Director’s Blog, April
29, 2013, http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml.

36. Joshua W. Buckholtz and Andreas Meyer-Lindenberg,
“Psychopathology and the Human Connectome: Toward a Transdiagnostic Model of
Risk For Mental Illness,” Neuron 74, no. 4 (2012): 990–1004.

37. F. Collins, “The Symphony Inside
Your Brain,” NIH Director’s Blog, November 5, 2012, http://directorsblog.nih.gov/2012/11/05/the-symphony-inside-your-brain/.

CHAPTER 20: FINDING YOUR VOICE:
COMMUNAL RHYTHMS AND THEATER

1. F. Butterfield, “David Mamet Lends a
Hand to Homeless Vietnam Veterans,” New York Times, October 10, 1998.
For more on the new shelter, see http://www.nechv.org/historyatnechv.html.

2. P. Healy, “The Anguish of War for
Today’s Soldiers, Explored by Sophocles,” New York Times,
November 11, 2009. For more on Doerries’s project, see http://www.outsidethewirellc.com/projects/theater-of-war/overview.

3. Sara Krulwich, “The Theater of
War,” New York Times, November 11, 2009.

4. W. H. McNeill, Keeping Together in
Time: Dance and Drill in Human History (Cambridge, MA: Harvard University
Press, 1997).

5. Plutarch, Lives, vol. 1 (Digireads.com, 2009), 58.

6. M. Z. Seitz, “The Singing
Revolution,” New York Times, December 14, 2007.

7. For more on Urban Improv, see http://www.urbanimprov.org/.

8. The Trauma Center Web site, offers a
full-scale downloadable curriculum for a fourth-grade Urban Improv program that can
be run by teachers nationwide. http://www.traumacenter.org/initiatives/psychosocial.php.

9. For more on the Possibility Project, see
http://the-possibility-project.org/.

10. For more on Shakespeare in the Courts,
see http://www.shakespeare.org/education/for-youth/shakespeare-courts/.

11. C. Kisiel, et al., “Evaluation of a
Theater-Based Youth Violence Prevention Program for Elementary School
Children,” Journal of School Violence 5, no. 2 (2006):
19–36.

12. The Urban Improv and Trauma Center
leaders were Amie Alley, PhD, Margaret Blaustein, PhD, Toby Dewey, MA, Ron Jones,
Merle Perkins, Kevin Smith, Faith Soloway, Joseph Spinazzola, PhD.

13. H. Epstein and T. Packer, The
Shakespeare & Company Actor Training Experience (Lenox MA, Plunkett
Lake Press, 2007); H. Epstein, Tina Packer Builds a Theater (Lenox, MA:
Plunkett Lake Press, 2010).

Acknowledgments

This book is the fruit of thirty years of
trying to understand how people deal with, survive, and heal from traumatic
experiences. Thirty years of clinical work with traumatized men, women and children;
innumerable discussions with colleagues and students, and participation in the
evolving science about how mind, brain, and body deal with, and recover from,
overwhelming experiences.

Let me start with the people who helped
me organize, and eventually publish, this book. Toni Burbank, my editor, with whom I
communicated many times each week over a two-year period about the scope,
organization, and specific contents of the book. Toni truly understood what this
book is about, and that understanding has been critical in defining its form and
substance. My agent, Brettne Bloom, understood the importance of this work, found a
home for it with Viking, and provided critical support at critical moments. Rick
Kot, my editor at Viking, supplied invaluable feedback and editorial guidance.

My colleagues and students at the Trauma
Center have provided the feeding ground, laboratory, and support system for this
work. They also have been constant reminders of the sober reality of our work for
these three decades. I cannot name them all, but Joseph Spinazzola, Margaret
Blaustein, Roslin Moore, Richard Jacobs, Liz Warner, Wendy D’Andrea, Jim
Hopper, Fran Grossman, Alex Cook, Marla Zucker, Kevin Becker, David Emerson, Steve
Gross, Dana Moore, Robert Macy, Liz Rice-Smith, Patty Levin, Nina Murray, Mark
Gapen, Carrie Pekor, Debbie Korn, and Betta de Boer van der Kolk all have been
critical collaborators. And of course Andy Pond and Susan Wayne of the Justice
Resource Institute.

My most important companions and guides in
understanding and researching traumatic stress have been Alexander McFarlane, Onno
van der Hart, Ruth Lanius and Paul Frewen, Rachel Yehuda, Stephen Porges, Glenn
Saxe, Jaak Panksepp, Janet Osterman, Julian Ford, Brad Stolback, Frank Putnam, Bruce
Perry, Judith Herman, Robert Pynoos, Berthold Gersons, Ellert Nijenhuis, Annette
Streeck-Fisher, Marylene Cloitre, Dan Siegel, Eli Newberger, Vincent Felitti, Robert
Anda, and Martin Teicher; as well as my colleagues who taught me about attachment:
Edward Tronick, Karlen Lyons-Ruth, and Beatrice Beebe.

Peter Levine, Pat Ogden, and Al Pesso
read my paper on the importance of the body in traumatic stress back in 1994 and
then offered to teach me about the body. I am still learning from them, and that
learning has since then been expanded by yoga and meditation teachers Stephen Cope,
Jon Kabat-Zinn, and Jack Kornfield.

Sebern Fisher first taught me about
neurofeedback. Ed Hamlin and Larry Hirshberg later expanded that understanding.
Richard Schwartz taught me internal family systems (IFS) therapy and assisted in
helping to write the chapter on IFS. Kippy Dewey and Cissa Campion introduced me to
theater, Tina Packer tried to teach me how to do it, and Andrew Borthwick- Leslie
provided critical details.

Adam Cummings, Amy Sullivan, and Susan
Miller provided indispensible support, without which many projects in this book
could never have been accomplished.

Licia Sky created the environment that
allowed me to concentrate on writing this book; she provided invaluable feedback on
each one of the chapters; she donated her artistic gifts to many illustrations; and
she contributed to sections on body awareness and clinical case material. My trusty
secretary, Angela Lin, took care of multiple crises and kept the ship running at
full speed. Ed and Edith Schonberg often provided a shelter from the storm; Barry
and Lorrie Goldensohn served as literary critics and inspiration; and my children,
Hana and Nicholas, showed me that every new generation lives in a world that is
radically different from the previous one, and that each life is unique—a creative
act by its owner that defies explanation by genetics, environment, or culture
alone.

Finally, my patients, to whom I dedicate
this book—I wish I could mention you all by name—who taught me almost everything I
know—because you were my true textbook—and the affirmation of the life force, which
drives us human beings to create a meaningful life, regardless of the obstacles we
encounter.

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