The body keeps the score/Bessel A. van der Kolk.

 Praise for The Body Keeps the Score




“This book is a tour de force. Its deeply empathic, insightful, and compassionate

perspective promises to further humanize the treatment of trauma victims,

dramatically expand their repertoire of self-regulatory healing practices and

therapeutic options, and also stimulate greater creative thinking and research on

trauma and its effective treatment. The body does keep the score, and Van der

Kolk’s ability to demonstrate this through compelling descriptions of the work of

others, his own pioneering trajectory and experience as the field evolved and

him along with it, and above all, his discovery of ways to work skillfully with

people by bringing mindfulness to the body (as well as to their thoughts and

emotions) through yoga, movement, and theater are a wonderful and welcome

breath of fresh air and possibility in the therapy world.”

—Jon Kabat-Zinn, professor of medicine emeritus, UMass Medical School; author of

Full Catastrophe Living




“This exceptional book will be a classic of modern psychiatric thought. The

impact of overwhelming experience can only be truly understood when many

disparate domains of knowledge, such as neuroscience, developmental

psychopathology, and interpersonal neurobiology are integrated, as this work

uniquely does. There is no other volume in the field of traumatic stress that has

distilled these domains of science with such rich historical and clinical

perspectives, and arrived at such innovative treatment approaches. The clarity of

vision and breadth of wisdom of this unique but highly accessible work is

remarkable. This book is essential reading for anyone interested in

understanding and treating traumatic stress and the scope of its impact on

society.”

—Alexander McFarlane AO, MB BS (Hons) MD FRANZCP, director of the Centre

for Traumatic Stress Studies, The University of Adelaide, South Australia.




“This is an amazing accomplishment from the neuroscientist most responsible

for the contemporary revolution in mental health toward the recognition that so

many mental problems are the product of trauma. With the compelling writing of

a good novelist, van der Kolk revisits his fascinating journey of discovery that

has challenged established wisdom in psychiatry. Interspersed with that narrative

are clear and understandable descriptions of the neurobiology of trauma;

explanations of the ineffectiveness of traditional approaches to treating trauma;

and introductions to the approaches that take patients beneath their cognitive

minds to heal the parts of them that remained frozen in the past. All this is

illustrated vividly with dramatic case histories and substantiated with convincing

research. This is a watershed book that will be remembered as tipping the scales

within psychiatry and the culture at large toward the recognition of the toll

traumatic events and our attempts to deny their impact take on us all.”

—Richard Schwartz, originator, Internal Family Systems Therapy




“The Body Keeps the Score is clear, fascinating, hard to put down, and filled with

powerful case histories. Van der Kolk, the eminent impresario of trauma

treatment, who has spent a career bringing together diverse trauma scientists and

clinicians and their ideas, while making his own pivotal contributions, describes

what is arguably the most important series of breakthroughs in mental health in

the last thirty years. We’ve known that psychological trauma fragments the

mind. Here we see not only how psychological trauma also breaks connections

within the brain, but also between mind and body, and learn about the exciting

new approaches that allow people with the severest forms of trauma to put all the

parts back together again.”

—Norman Doidge, author of The Brain That Changes Itself




“In The Body Keeps the Score we share the author’s courageous journey into the

parallel dissociative worlds of trauma victims and the medical and psychological

disciplines that are meant to provide relief. In this compelling book we learn that

as our minds desperately try to leave trauma behind, our bodies keep us trapped

in the past with wordless emotions and feelings. These inner disconnections

cascade into ruptures in social relationships with disastrous effects on marriages,

families, and friendships. Van der Kolk offers hope by describing treatments and

strategies that have successfully helped his patients reconnect their thoughts with

their bodies. We leave this shared journey understanding that only through

fostering self-awareness and gaining an inner sense of safety will we, as a

species, fully experience the richness of life.

—Stephen W. Porges, PhD, professor of psychiatry, University of North Carolina at

Chapel Hill; author of The Polyvagal Theory: Neurophysiological Foundations of

Emotions, Attachment, Communication, and Self-Regulation




“Bessel van der Kolk is unequaled in his ability to synthesize the stunning

developments in the field of psychological trauma over the past few decades.

Thanks in part to his work, psychological trauma—ranging from chronic child

abuse and neglect, to war trauma and natural disasters—is now generally

recognized as a major cause of individual, social, and cultural breakdown. In this

masterfully lucid and engaging tour de force, Van der Kolk takes us—both

specialists and the general public— on his personal journey and shows what he

has learned from his research, from his colleagues and students, and, most

important, from his patients. The Body Keeps the Score is, simply put, brilliant.”

—Onno van der Hart, PhD, Utrecht University, The Netherlands; senior author, The

Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization




“The Body Keeps the Score articulates new and better therapies for toxic stress

based on a deep understanding of the effects of trauma on brain development and

attachment systems. This volume provides a moving summary of what is

currently known about the effects of trauma on individuals and societies, and

introduces the healing potential of both age-old and novel approaches to help

traumatized children and adults fully engage in the present.”

—Jessica Stern, policy consultant on terrorism; author of Denial: A Memoir of Terror




“A book about understanding the impact of trauma by one of the true pioneers in

the field. It is a rare book that integrates cutting edge neuroscience with wisdom

and understanding about the experience and meaning of trauma, for people who

have suffered from it. Like its author, this book is wise and compassionate,

occasionally quite provocative, and always interesting.”

—Glenn N. Saxe, MD, Arnold Simon Professor and chairman, Department of Child

and Adolescent Psychiatry; director, NYU Child Study Center, New York University

School of Medicine.




“A fascinating exploration of a wide range of therapeutic treatments shows

readers how to take charge of the healing process, gain a sense of safety, and find

their way out of the morass of suffering.”

—Francine Shapiro, PhD, originator of EMDR therapy; senior research fellow,

Emeritus Mental Research Institute; author of Getting Past Your Past




“As an attachment researcher I know that infants are psychobiological beings.

They are as much of the body as they are of the brain. Without language or

symbols infants use every one of their biological systems to make meaning of

their self in relation to the world of things and people. Van der Kolk shows that

those very same systems continue to operate at every age, and that traumatic

experiences, especially chronic toxic experience during early development,

produce psychic devastation. With this understanding he provides insight and

guidance for survivors, researchers, and clinicians alike. Bessel van der Kolk

may focus on the body and trauma, but what a mind he must have to have

written this book.”

—Ed Tronick, distinguished professor, University of Massachusetts, Boston; author of

Neurobehavior and Social Emotional Development of Infants and Young Children




“The Body Keeps the Score eloquently articulates how overwhelming

experiences affect the development of brain, mind, and body awareness, all of

which are closely intertwined. The resulting derailments have a profound impact

on the capacity for love and work. This rich integration of clinical case examples

with ground breaking scientific studies provides us with a new understanding of

trauma, which inevitably leads to the exploration of novel therapeutic

approaches that ‘rewire’ the brain, and help traumatized people to reengage in

the present. This book will provide traumatized individuals with a guide to

healing and permanently change how psychologists and psychiatrists think about

trauma and recovery.”

—Ruth A. Lanius, MD, PhD, Harris-Woodman chair in Psyche and Soma, professor

of psychiatry, and director PTSD research at the University of Western Ontario; author

of The Impact of Early Life Trauma on Health and Disease




“When it comes to understanding the impact of trauma and being able to

continue to grow despite overwhelming life experiences, Bessel van der Kolk

leads the way in his comprehensive knowledge, clinical courage, and creative

strategies to help us heal. The Body Keeps the Score is a cutting-edge offering

for the general reader to comprehend the complex effects of trauma, and a guide

to a wide array of scientifically informed approaches to not only reduce

suffering, but to move beyond mere survival— and to thrive.”

—Daniel J. Siegel, MD, clinical professor, UCLA School of Medicine, author of

Brainstorm: The Power and Purpose of the Teenage Brain; Mindsight: The New

Science of Personal Transformation; and The Developing Mind: How Relationships

and the Brain Interact to Shape Who We Are




“In this magnificent book, Bessel van der Kolk takes the reader on a captivating

journey that is chock-full of riveting stories of patients and their struggles

interpreted through history, research, and neuroscience made accessible in the

words of a gifted storyteller. We are privy to the author’s own courageous efforts

to understand and treat trauma over the past forty years, the results of which

have broken new ground and challenged the status quo of psychiatry and

psychotherapy. The Body Keeps the Score leaves us with both a profound

appreciation for and a felt sense of the debilitating effects of trauma, along with

hope for the future through fascinating descriptions of novel approaches to

treatment. This outstanding volume is absolutely essential reading not only for

therapists but for all who seek to understand, prevent, or treat the immense

suffering caused by trauma.”

—Pat Ogden PhD, founder/educational director of the Sensorimotor Psychotherapy

Institute; author of Sensorimotor Psychotherapy: Interventions for Trauma and

Attachment




“This is masterpiece of powerful understanding and brave heartedness, one of

the most intelligent and helpful works on trauma I have ever read. Dr. Van der

Kolk offer a brilliant synthesis of clinical cases, neuroscience, powerful tools

and caring humanity, offering a whole new level of healing for the traumas

carried by so many.”

—Jack Kornfield, author of A Path with Heart

 VIKING

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Includes bibliographical references and index.

eBook ISBN 978-1-10160830-2

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Neither the publisher nor the author is engaged in rendering professional advice or services to the individual

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Version_1

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

 CONTENTS










Praise for The Body Keeps the Score

Title Page

Copyright

Dedication

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







ACKNOWLEDGMENTS

APPENDIX: CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA

DISORDER

RESOURCES

FURTHER READING

NOTES

INDEX

 PROLOGUE




FACING TRAUMA













O ne 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













T he 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













I n 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 perspective21 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













I n 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.

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.













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.







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 way

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 Sperry1













O n 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.













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 lifesaving addition: a trampoline at the bottom of the collapsing building.







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.

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.













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.







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.







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.”













AP PHOTO/PAUL HAWTHORNE

 ILLINOISPHOTO.COM

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.







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.

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.













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.







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.

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.













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.







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

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 ear-splitting 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 that 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 acupressure19 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













T oward 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 CODE7

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.













COURTESY OF NED KALIN, MD

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 shutdown, 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 halfhearted 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













S herry 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 selfhood and agency validates the kinds of somatic

therapies that my friends Peter Levine13 and Pat Ogden14 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 revictimization23 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

Geneva25 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













T he 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 Edinburgh-based 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 breakins 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 irrelevant41, 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













M arilyn 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













H ow 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 us10 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 know at 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 questions14 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













T here 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 childcare 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 childcare 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 trauma16 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 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 well-paying 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













I n 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













PAINTING BY ANDRE BROUILLET

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.







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 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













S cientific 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. Consciousness-raising 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 existed23 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













N obody 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.













DRAWING BY LICIA SKY

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.




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 regulation18

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 psychotherapy29 and somatic

experiencing30 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 mind-altering 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 benzodiazepines65—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)













I n 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 first-person “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

selfhood: “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 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 the

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













D avid, 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 his 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 sleep9—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













T he 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 anxiety5

and that yoga can positively affect such wide-ranging medical problems as high

blood pressure, elevated stress hormone secretion,6 asthma, and low-back 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













I t 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 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













I t 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 standin 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













T he 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

brainwave 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.













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.







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 brainwave 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 nontraumatic information

that has profound implications for understanding day-to-day information

processing. These brainwave 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.

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 brainwave 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 brainwave

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.







BRAINWAVE 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 (T3, T4, T5).

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 brainwave 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 brainwave

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 PTSD28—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













M any 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 Boston7 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













W e 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 check-ins: 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 mad

e

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.

 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.

 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/;

http://aces tudy.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. 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.

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.

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: Lifelong 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.nationaltraumaconsortium.org.

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. Gazzola, “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

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 Communication 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 PostTraumatic

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 Psychoanalysis: 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.,

“Polyvictimization 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. Lyons-Ruth, 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 1b_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.




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 Posttraumatic 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 Stress-Induced 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 Down-and 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 Posttraumatic 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, “Posttraumatic 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 Psychoanalysis 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 Posttraumatic 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

(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 Posttraumatic 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 Posttraumatic 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 Posttraumatic 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 alpha1 receptor antagonist prazosin, the alpha2 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 Posttraumatic 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 Posttraumatic 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

posttraumatic 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 PostTraumatic 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 Trauma-Related 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

Dysregulation 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 Posttraumatic 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 Posttraumatic 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.,

“Posttraumatic 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 Posttraumatic 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 NeuroFeedback Therapy for Vietnam

Veterans with Combat-Related Posttraumatic 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 Posttraumatic 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 PostTraumatic 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).

 INDEX










The page numbers in this index refer to the printed version of this book. To find the corresponding locations

in the text of this digital version, please use the “search” function on your e-reader. Note that not all terms

may be searchable.




Page numbers in italics refer to illustrations.




abandonment, 140, 141, 150, 179, 301, 304, 327, 340, 350

Abilify, 37, 101, 226

ACE (Adverse Childhood Experiences) study, 85, 144–48, 156, 347, 350–51

acetylcholine, 266

acupressure, 264–65, 410n–11n

acupuncture, 231, 410n–11n

addiction, see substance abuse addictive behaviors, 288–89

see also specific behaviors

ADHD (attention deficit hyperactivity disorder), 107, 136, 150, 310, 322

adolescent behavior problems, child-caregiver relationship as predictor of, 160–61

adrenaline, 46, 61, 77, 176, 225

Aeschylus, 332

Afghanistan War:

deaths in, 348

veterans of, 222–23, 229, 332

agency, sense of, 95–98, 331, 355

as lacking in childhood trauma survivors, 113

Ainsworth, Mary, 115

Ajax (Sophocles), 332

alcoholism, 146

alexithymia, 98–99, 247, 272–73, 291, 319

All Quiet on the Western Front (Remarque), 171, 186

alpha-theta training, 321, 326

alpha waves, 314–15, 321, 326, 417n

American Academy of Pediatrics, 348

American College of Neuropsychopharmacology (ACNP), 29, 33

American Counseling Association, 165, 393n

American Journal of Psychiatry, 27, 140, 164

American Psychiatric Association (APA):

developmental trauma disorder diagnosis rejected by, 149, 158–59, 166

PTSD recognized by, 19

 see also Diagnostic and Statistical Manual of Mental Disorders (DSM) American Psychological

Association, 165, 393n

amnesia, 179, 183

dissociative, 190

see also repressed memory amygdala, 33, 35, 42, 68–69, 301

balance between MPFC and, 62–64

fight/flight response and, 60–61, 61, 247, 265, 408n

mindfulness and, 209–10

Anda, Robert, 144, 148

androstenedione, 163

anesthesia awareness, 196–99

Angell, Marcia, 374n–75n

Angelou, Maya, 356

animals, in trauma therapy, 80, 150–51, 213

anorexia nervosa, 98–99

anterior cingulate, 91, 91, 254, 376n, 387n

Anthony (trauma survivor), 150

anticonvulsant drugs, 225

antidepressants, 35, 37, 136, 146, 225

see also specific drugs

antipsychotic drugs, 27–29, 101, 136, 224, 225–27

children and, 37–38, 226

PTSD and, 226–27

see also specific drugs

anxiety, 150

ARC (attachment, self-regulation, competency) model, 401n

Archimedes, 92

arousal, 56, 107, 153, 165

flashbacks and, 42–43, 196–97

in infants, 84, 113, 121, 161

memory and, 175–76

neurofeedback and, 326

PTSD and, 157, 326

regulation of, 77–79, 113, 160, 161, 205–8

sexual, 94, 108

SNS and, 77

soothing and, 113

yoga and, 270

see also threat, hypersensitivity to art, trauma recovery and, 242–43

asanas, 270, 272

Assault, The (film), 375

athletics, 349, 355

Ativan, 225

attachment, 109–11, 113, 128–29, 210, 213, 318, 401n

anxious (ambivalent), 116, 117

avoidant, 116, 117

as basic instinct, 115

ongoing need for, 114–15

resilience and, 161

in rhesus monkeys, 153–54

 secure, 115–16, 117, 154–55

attachment, disorganized, 117, 166, 381n

long-term effects of, 119–21

psychiatric and physiological problems from, 118

socioeconomic stress and, 117–18

trauma and, 118–19

traumatized parents as contributors to, 118

attachment disorder, 282

attention deficit disorder (ADD), 151

attention deficit hyperactivity disorder (ADHD), 107, 136, 150

attractors, 32

attunement, emotional, 111–14, 117, 118, 122, 161, 213, 215, 354

lack of, dissociation and, 121–22

in relationships, 210

Auden, W. H., 125

Auerhahn, Nanette C., 372n

Auschwitz concentration camp, 195

autobiographical self, 236

autoimmune disease, 291–92

Automatisme psychologique, L’ (Janet), 178

autonomic nervous system (ANS), 60, 63–64, 77, 80, 225, 266–67




balance (proprioceptive) system, 247

Baltimore, Md., home-visitation program in, 167

basal ganglia, 254

Bastiaans, Jan, 223

Beebe, Beatrice, 109, 118

Beecher, Henry K., 32–33

befriending one’s body, 96, 100–101, 206–19, 206, 273, 274–75, 354

benzodiazepines, 225, 227

Berger, Hans, 310

beta waves, 314, 322, 417n

binge eating, 120

Bion, Wilfred, 109

bipolar disorder, 136, 151, 226

Blaustein, Margaret, 351, 401n

Bleuler, Eugen, 24–25

blood pressure, 46, 61, 66

body:

befriending of, 96, 100–101, 206–19, 206, 273, 274–75, 354

islands of safety in, 245, 275

self-awareness of, 87–102, 206, 206, 208–9, 236, 237–38, 247, 382n

body-brain connections, 74–86, 381n

body functions, brain stem regulation of, 56, 94–95, 266

body therapies, 3, 26, 72, 86, 89, 207–8, 215–17, 228–29, 245

see also specific therapies

borderline personality disorder (BPD), childhood trauma and, 138–41

Bowlby, John, 109–11, 114, 115, 121, 140–41, 232

brain:

 bodily needs and, 55

cognitive, see rational brain default state network (DSN) in, 90

electrophysiology of, 310–12, 328–29

left vs. right sides of, 44–45, 298

midline (“Mohawk”) structures of, 90–91, 91, 376n

old, see emotional brain sensory information organized by, 55, 60

survival as basic job of, 55, 94

trauma and changes to, 2–3, 21, 59, 347

triune model of, 59, 64

warning systems in, 55

see also specific regions

brain scans, 21

of PTSD patients, 102, 347, 408n

of trauma survivors, 39–47, 42, 66, 68–70, 68, 71–72, 72, 82, 99–100, 319

brain stem (reptilian brain), 55–56, 59, 60, 63, 176

basic body functions regulated by, 56, 94–95, 266

freeze response generated by, 83

self-awareness and, 93–94

see also emotional brain brain waves, 321

alpha, 315, 321, 326, 417n

beta, 314, 322, 417n

combat and, 324

delta, 320

dreaming and, 321

theta, 321, 326, 417n

of trauma survivors, 311–12, 311, 320

breathing:

ANS regulation through, 64

in fight/flight response, 61

HRV and, 267

therapeutic, 72, 131, 207, 208, 245, 268–69

in yoga (pranayama), 86, 270

Breuer, Josef, 181–82, 194, 231, 246

British General Staff, shell-shock diagnosis rejected by, 185

British Psychological Society, 165

Broca’s area, 43, 44, 45, 408n

Brodmann’s area 19, 44

Buchenwald concentration camp, 43

bulimia, 34, 98–99, 286, 287




calming and relaxation techniques, 131, 203–4

see also breathing; mindfulness; yoga cancer, 267

Cannon, Katie, 184

caregivers:

attunement of infants and, 111–13, 117, 118

children’s loyalty to, 133, 386n

children’s relationships with, as predictor of adolescent behavior, 160–61

infants’ bonds with, 109–11, 113, 128–29

insecure attachments with, 115–16

 as source of children’s distress, 116–17

traumatized, and disorganized attachment in children, 118

catatonia, 23

Catholic Church, pedophile scandals in, 171–75, 183, 190, 191

CBT, see cognitive behavioral therapy (CBT) CD45 cells, 127

Celexa, 35, 254

Centers for Disease Control and Prevention (CDC), 1, 144

Chang, C.-C., 22

Charcot, Jean-Martin, 177–78, 178, 182, 184

Chemtob, Claude, 119

childhood trauma survivors, 123–35, 351

agency, sense of, as lacking in, 113

arousal in, 161

attachment coping styles in, 114–20

attention and concentration problems in, 158, 166, 245–46, 328

borderline personality disorder and, 138–41

disorganized attachment in, 118–19, 166

dysregulation in, 158, 161, 166

high-risk behavior in, 120, 134, 147

home-visitation program for, 167

hypersensitivity to threat in, 158, 161, 310, 328

increased risk of rape and domestic abuse in, 85, 146–47

inhibition of curiosity in, 141, 350

internal world maps of, 127–30

loyalty to caregivers of, 133

misdiagnosis of, 136–48, 150, 151, 157, 226, 282

numbing in, 279

rage in, 304

relationship difficulties of, 158

safety, sense of, as lacking in, 141, 213, 301, 317

school problems of, 146, 158, 161

schools as resources for, 351–56

self-harming in, 141, 158

self-hatred in, 158, 279

sense of competence lacking in, 166, 350

social engagement and, 161

social support for, 167–68, 350

substance abuse by, 146, 151

suicidal behavior in, 141, 146

temporal lobe abnormalities in, 416n

trust as difficult for, 141, 158, 340

see also developmental trauma disorder (DTS) childhood trauma survivors, of emotional abuse and

neglect: abandonment of, 141, 304, 327, 340

depersonalization in, 72

numbing in, 87–89

prevalence of, 20–21

psychotherapy of, 296–97

Sandy as, 97

self-harming in, 87, 88

self-respect lacking in, 304

 sense of safety lacking in, 296–97

submissiveness in, 97, 218

substance abuse by, 327

suicidal behavior in, 88, 290

trust as difficult for, 150

childhood trauma survivors, of sexual abuse and family violence: dissociation in, 132–33, 162, 172, 265,

316, 329

flashbacks of, 20, 131, 135, 172, 173

“hallucinations” in, 25

helplessness of, 131, 133–34, 211, 265, 289–90

hypersensitivity to threat in, 17, 143

of incest, see incest survivors incoherent sense of self in, 166

intimacy as difficult for, 143

isolation of, 131

legal cases involving, 174–75, 183, 190

Lisa as, 316–18, 325, 329

loyalty to caregivers of, 386n

Maggie as, 250–51

Maria as, 300–304

Marilyn as, 123–35, 289

Mary as, 130, 277–78

nightmares of, 20, 134–35

numbing in, 124, 265–66

obesity in, 144, 147, 266

prevalence of, 1, 11, 20–21

public acknowledgment of, 189

rage in, 285

repressed memories in, 190

seizures in, 172, 174

self-blame in, 131

self-deceit in, 2, 23–24

self-harming in, 20, 25, 141, 172, 264, 316, 317

self-hatred in, 134, 143

shame in, 13–14, 67, 132, 174

substance abuse by, 327

suicidal behavior in, 141, 147, 150–51, 286, 287, 316

TAT test and, 106–7

trust as difficult for, 134

children:

abuse of, as most costly public health issue, 148, 149–50

antipsychotic drugs prescribed to, 37–38, 226

attachment in, see attachment caregivers’ relationships with, as predictor of adolescent behavior, 160–61

internal world maps of, 109, 127, 129

loyalty to caregivers of, 133

see also infants

Children’s Clinic (MMHC), 105–9, 111, 121

Child Sexual Abuse Accommodation Syndrome, The (Summit), 131, 136

China, traditional medicine in, 207

chlorpromazine (Thorazine), 22–23

chronic fatigue syndrome, 330

clonidine, 225

Clozaril, 28

cognitive behavioral therapy (CBT), 182, 230–31, 246, 292

in treatment of PTSD, 194, 220–21

Coleman, Kevin, 336, 342, 344

collapse, see freeze response (immobilization) combat:

brain waves and, 324

see also PTSD (posttraumatic stress disorder), of combat veterans community, mental health and, 38,

213–14, 244, 331–34, 355

Community Mental Health Act (1963), 373n

competence, sense of, 166, 341

Comprehensive Textbook of Psychiatry (Freedman and Kaplan), 20, 188–89

conduct disorder, 282, 392n

conflict:

as central to theater, 335

trauma survivors’ fear of, 335

consciousness, see self

Cope, Stephen, 123, 230, 263, 272

cortical networks, local, 417n

cortisol, 30, 61, 154, 162, 223

Countway Library of Medicine, 11, 24

creativity, see imagination Cummings, Adam, 155

cummings, e. e., 122

Cymbalta, 35, 37




Dalai Lama, 79

Damasio, Antonio, 93, 94–95, 382n

dance:

in trauma recovery, 242–43, 355

see also rhythmic movement Darwin, Charles, 74–76, 75, 77

Daubert hearings, 174–75

Decety, Jean, 222

default state network (DSN), 90

Defense Department, U.S., 156, 224, 226–27, 332

Pharmacoeconomic Center of, 224

defense mechanisms, suspension of, in intimate relationships, 84–85

Delbo, Charlotte, 195

delta waves, 320

Dementia Praecox (Bleuler), 24–25

denial, 46, 291

Denial: A Memoir (Stern), 7

depersonalization, 71–73, 71, 99–100, 132–33, 286, 386n, 401n

depression, 136, 150, 162, 225

chemistry of, 26, 29

derealization, 401n

desensitization therapies, 46–47, 73, 220, 222–23

developmental psychopathology, 2

developmental trauma disorder (DTS; proposed), 166–68

APA’s rejection of, 149, 158–59, 166

 criteria for, 158, 359–62

see also childhood trauma survivors Dewey, Kippy, 337

diagnosis, definition of, 137–38

diagnosis, psychiatric, childhood trauma as misunderstood in, 136–48

Diagnostic and Statistical Manual of Mental Disorders (DSM), 29, 137

arbitrariness of, 323

childhood trauma survivors ignored by, 143

DSM-III, 29, 137, 142, 156, 190

DSM-IV, 143

DSM-5, 159, 164–66, 329, 393n

reliability issues in, 164–65

social causation ignored in, 165

dialectical behavior therapy (DBT), 262, 270

Diamond, Adele, 418n

disruptive mood dysregulation disorder, 157, 393n

dissociation, 66–68, 95, 179, 180–81, 194, 211, 247, 281, 294, 317–18, 401n

maternal misattunement and, 121–22, 286

neurofeedback and, 318

in sexual abuse survivors, 132–33, 162, 172, 265, 316, 329

dissociative amnesia, 190

dissociative identity disorder (DID), 277–78

Doerries, Bryan, 332

domestic violence, 1, 11, 23–24

deaths from, 348

increased incidence of, in survivors of childhood abuse, 85, 146–47

repressed memory and, 190

victims’ loyalty to abusers in, 133

victims’ submissiveness in, 218

dopamine, 29, 226

dorsal vagal complex (DVC), 82, 82, 83

dorsolateral prefrontal cortex (DLPFC), 68–69, 376n

dreaming, 260–61, 308, 309–10, 321

drumming, 86, 208

Duffy, Frank, 328

Dunkirk evacuation, repressed memory and, 189–90

dysfunctional thinking, 246




ecstasy (MDMA), 223–24

education system:

cutting of social engagement programs in, 349

inattention to emotional brain in, 86

as resources for childhood trauma recovery, 351–56

EEGs (electroencephalograms), 309–11, 320, 321

Effexor, 225

Ekman, Paul, 74

Eli Lilly, 34–35

El Sistema, 355

EMDR, see eye movement desensitization and reprocessing (EMDR) Emerson, David, 269

emotional brain, 54, 57, 62, 63, 176, 226, 265

 balance between rational brain and, 64–65, 129–30, 205, 310

befriending of, 206–19, 206, 273, 274–75

education system’s inattention to, 86

inner world map encoded in, 129

medial prefrontal cortex and, 206, 206, 236, 353

physical manifestations of trauma in, 204–5

Emotional Freedom Technique (EFT), 264–65

emotional intelligence, 354

emotions:

articulation of, 232–34

calming effect of physical activity on, 88

fear of, in trauma survivors, 335

physical expression of, 74–76, 75, 78

regulation of, see self-regulation in therapeutic theater, 335, 344–45

vagus nerve and, 76, 78, 80–82, 81

writing and, 238–42

empathy, 58–60, 111–12, 161

endocrine system, 56

endorphins, 32

epigenetics, 152

epilepsy, 310, 315

equine therapy, 150–51, 213

Erichsen, John Eric, 189

Erickson, Milton, 254

Esalen Institute, 300

Estonia, “Singing Revolution” in, 334

Eth, Spencer, 231

executive function, 62, 323

exiles (in IFS therapy), 281–82, 289–90, 291–95

exposure therapy, 194

EMDR vs., 255–56

PTSD and, 256

Expression of the Emotions in Man and Animals, The (Darwin), 74–76

eye contact, direct vs. averted, 102

eye movement desensitization and reprocessing (EMDR), 47, 220, 225, 228, 231, 246, 248–62, 290, 308,

321

author’s training in, 251–53

clinical study of, 254–55

exposure therapy vs., 255–56

medication vs., 254, 261

origin of, 251

PTSD and, 248–49, 253–54, 260

sleep disorders and, 259–61

eyewitness testimony, unreliability of, 192




Fairbairn, Ronald, 109

false memories, 189, 190, 191–92

Father-Daughter Incest (Herman), 138

“Faulty Circuits” (Insel), 328

Feeling of What Happens, The (Damasio), 93

Feldenkrais, Moshe, 92

Felitti, Vincent, 143–47, 156

feminist movement, 189

fight/flight response, 30, 42, 45–47, 54, 57, 60–61, 64, 77, 78, 80, 82, 85, 96, 97, 209, 217, 218, 247, 265,

329, 408n

firefighters, in IFS therapy, 282, 288–89, 291–92

Fisher, Sebern, 312–14, 316–18, 325

Fish-Murray, Nina, 105–7

Fisler, Rita, 40

flashbacks, 8, 13, 16, 20, 40, 42, 44, 45, 66–67, 68, 68, 70, 72, 101, 135, 172, 173, 176, 193–94, 196–98,

219, 227

fluoxetine, see Prozac (fluoxetine) Foa, Edna, 233

focus:

in trauma recovery, 203, 347–48, 355

trauma 

survivors’ difficulties with, 158, 166, 245–46, 311–12, 328

Fortunoff Video Archive, 195

Fosha, Diana, 105

foster-care youth, Possibility Project theater program for, 340–42

free writing, 238–39

freeze response (immobilization), 54, 54, 82–83, 82, 85, 95, 217, 218, 265

of Ute Lawrence, 65–66, 68, 71–72, 80, 82, 99–100, 219–20

see also numbing

Freud, Sigmund, 15, 27, 177, 181–82, 183, 184, 194, 219, 220, 231, 246–47

Frewen, Paul, 99

Friedman, Matthew, 159

frontal cortex, 314

frontal lobes, 57–58, 62, 176

ADHD and, 310, 320

empathy and, 58–60

imagination and, 58

P
TSD and, 320
ee also medial prefrontal cortex (MPFC) frontal midline theta rhythm, 417n

functional magnetic resonance imaging (fMRI), 39, 66

Fussell, Paul, 243–44

Galen, 77

Gazzaniga, Michael, 280–81

gene expression:

attachment and, 154–55

stress and, 152, 347

genetics:

mental illness and, 151–52

of rhesus monkeys, 153–54

Germany, treatment of shell-shock victims in, 185, 186–87

Glenhaven Academy, Van der Kolk Center at, 213, 401n

Gottman, John, 113

Grant Study of Adult Development, 175

Gray, Jeffrey, 33

Great Depression, 186

Great War in Modern Memory, The (Fussell), 243–44

Great Work of Your Life, The (Cope), 230

Greenberg, Mark, 31, 32, 33

Greenberg, Ramon, 409n

Greer, Germaine, 187

Griffin, Paul, 335, 340–42

Gross, Steve, 85

group therapy, limits of, 18

Gruzelier, John, 322

gun control, 348

Guntrip, Harry, 109

gut feelings, 96–97




Haig, Douglas, 185

Haley, Sarah, 13

Hamlin, Ed, 323

handwriting, switching in, 241–42

Harris, Bill, 155

Hartmann, Ernest, 309–10

Harvard Medical School, 40

Countway Library of Medicine at, 11, 24

Laboratory of Human Development at, 112

see also Massachusetts Mental Health Center Hawthorne, Nathaniel, 309

Head Start, 350

heart disease, 267

HeartMath, 413n

heart rate, 46, 61, 66, 72, 116

heart rate variability (HRV), 77, 266–69, 268, 271, 355, 413n

Heckman, James, 167, 347

Hedges, Chris, 31

helplessness, of trauma survivors, 131, 133–34, 211, 265, 289–90, 341

Herman, Judith, 138–41, 189, 296

hippocampus, 60, 69, 176

Hobson, Allan, 26, 259–60, 261

Holocaust, 43

Holocaust survivors, 99, 195, 223, 372n

children of, 118–19, 293–95

Holocaust Testimonies: The Ruins of Memory (Langer), 195, 372n

Hölzel, Britta, 209–10, 275

homeostasis, 56

Hopper, Jim, 266

Hosseini, Khaled, 7

human connectome, 329

humans, as social animals, 110, 166, 349

Hurt Locker, The (film), 312

Huston, John, 187, 220

hypnagogic (trance) states, 117, 187, 238, 302, 305, 326

hypnosis, 187, 220

hypothalamus, 56, 60

hysteria, 177–78, 178

Freud and Breuer on, 181–82, 194

hysterical blindness, 126




imagination:

dreams and, 261

frontal lobes as seat of, 58

loss of, 17, 350

pathological, 25

psychomotor therapy and, 305

recovery of, 205

imitation, 112

immobilization, see freeze response (immobilization) immune system, 56

stress and, 240

of trauma survivors, 126–27, 291

impulsivity, 120, 164

incest survivors:

cognitive defects in, 162

depression in, 162

dissociation in, 132–33, 162

distorted perception of safety in, 164

father-daughter, 20, 188–89, 250, 265

high-risk behavior in, 164

hypersensitivity to threat in, 163

immune systems of, 126–27

longitudinal study of, 161–64

misguided views of, 20, 188–89

numbing in, 162–63

obesity in, 144, 162

self-harming in, 162

self-hatred in, 163

troubled sexual development in, 162, 163

trust as difficult for, 163

India, traditional medicine in, 207

inescapable shock, 29–31

infants, 83–84

arousal in, 84, 113, 121, 161

attunement of caregivers and, 111–13, 117, 118

caregivers’ bonds with, 109–11, 113, 128–29

internal locus of control in, 113

sense of self in, 113

sensory experiences of, 93–94

VVC development in, 83–84

inferior medial prefrontal cortex, 376n

Insel, Thomas, 328

Institute of the Pennsylvania Hospital, 251

insula, 91, 91, 247, 274, 274, 382

integration, of traumatic memories, 181, 219–20, 222, 228, 237, 279, 308

interdependence, 340–41

intermittent explosive disorder, 151

internal family systems (IFS) therapy, 223–24, 262, 281–95, 418n

exiles in, 281–82, 289–90, 291–95

firefighters in, 282, 288–89, 291–92

managers in, 282, 286–88, 291–92, 293

mindfulness in, 283

rheumatoid arthritis and, 291–92

Self in, 224, 283–85, 288, 289, 305

unburdening in, 295

interoception, 95–96, 413n

yoga and, 272–74

see also sensory self-awareness interpersonal neurobiology, 2, 58–60

intimacy:

suspension of defense mechanisms in, 84–85

trauma survivors’ difficulty with, 99, 143

Iraq War:

deaths in, 348

veterans of, 220, 221, 222–23, 229, 312, 332

irritability, 10

isolation, of childhood sexual abuse survivors, 131




James, William, 89–90, 93, 184, 277, 280, 296, 309

Janet, Pierre, 54, 177, 178–79, 181, 182, 184, 194, 218, 220, 312, 396n

Jouvet, Michel, 259–60

Jung, Carl, 27, 280, 296

Justice Resource Institute, 339, 401n




Kabat-Zinn, Jon, 209

Kagan, Jerome, 79, 237–38

Kaiser Permanente, 144

Kamiya, Joe, 315

Kandel, Eric, 26

Kardiner, Abram, 11, 187, 189, 371n

Katrina, Hurricane, 54

Keats, John, 248

Keegan, John, 185

Keeping Together in Time (McNeill), 333

Keller, Helen, 234–35

Kennedy, John F., 373n

Kinneburgh, Kristine, 401n

Kite Runner, The (Hosseini), 7

Klonopin, 225

Kluft, Richard, 251, 281

Koch, Robert, 164

Kradin, Richard, 126

Krantz, Anne, 243

Krystal, Henry, 99

Krystal, John, 30

Kulkosky, Paul, 326, 327




Lancet, 189

Langer, Lawrence, 195, 372n

language:

failure of, in trauma survivors, 43–44, 243–45, 352–53

limitations of, 235–37, 243–45

mental health and, 38

self-discovery and, 234–35

in trauma recovery, 230–47, 275–76

Lanius, Ruth, 66, 90, 92, 99, 102

Laub, Dori, 372n

Lawrence, T. E., 232

Lazar, Sara, 209–10, 275

learning disabilities, neurofeedback and, 325

LeDoux, Joseph, 60, 206

legal cases:

admissibility of evidence in, 174–75

involving pedophile priests, 183, 190, 191

Lejune, Camp, 270

Letters to a Young Poet (Rilke), 87

Let There Be Light (film), 187, 220

Levine, Peter, 26, 96, 217–18, 245, 408n

Lifton, Robert J., 19

limbic system, 42, 42, 56–57, 59, 60, 64

development of, 56–57

therapy for, 205–6

in trauma survivors, 59, 95, 176, 265

see also emotional brain lithium, 27–28, 136, 225

loss, as basic human experience, 26–27

love, as basic human experience, 26–27

LSD, 223

L-tryptophan, 34

lupus erythematosus, 126

Lyons-Ruth, Karlen, 119–22




MacArthur, Douglas, 186

Macbeth (Shakespeare), 43, 230

McFarlane, Alexander, 89, 245–46, 311–12, 324–25

McGaugh, James, 176

MacLean, Paul, 64

McNeill, William H., 333

Maier, Steven, 29–30

Main, Mary, 115–17, 381n

Mamet, David, 331

managers, in IFS therapy, 282, 286–88, 291–92, 293

Mandela, Nelson, 356

map of the world, internal:

in childhood trauma survivors, 127–30

 of children, 109, 127, 129

March of the Penguins (film), 96

Marlantes, Karl, 233–34

martial arts, 86, 208, 355

Massachusetts Department of Mental Health, 253

Massachusetts General Hospital, 192, 251

Neuroimaging Laboratory of, 40

Massachusetts Mental Health Center, 19–20, 22, 26, 28, 36, 142, 259–60

see also Children’s Clinic (MMHC); Trauma Clinic massage therapy, 89, 92

Matthew, Elizabeth, 253–54

Maurice, Prince of Orange, 333–34

MDMA (ecstasy), 223–24

meaning-making, as human trait, 16–17

medial prefrontal cortex (MPFC), 62, 63, 69, 91, 92, 96, 274, 274

accessing emotional brain through, 206, 206, 236, 353

balance between amygdala and, 62–64

sensory self-awareness and, 90–91, 206, 354, 376n, 408n, 417n

Medicaid, 37

medicine, non-Western, 76, 86, 207–8

meditation, 208

mindfulness, 63, 321, 400n

in yoga, 270

Meltzoff, Andrew, 112

memory:

level of arousal and, 175–76

as narrative, 176, 179, 194, 219

rewriting of, 175, 191, 236, 255–56, 398n

see also repressed memory; traumatic memory mental health, safety as fundamental to, 351, 352

mental hospitals, population of, 28

mental illness:

disorder model of, 27

genetics and, 151–52

pharmacological revolution and, 36–38

as self-protective adaptations, 278–79

social engagement and, 78–79

methylation, 152

militarism, 186

mindfulness, 62, 63, 96, 131, 207, 208–10, 224, 225, 269, 270, 283, 292, 321

meditation for, 63, 321, 400n

Mindfulness-Based Stress Reduction (MBSR), 209

Minnesota Longitudinal Study of Risk and Adaptation, 160–61

Minsky, Marvin, 281

mirror neurons, 58–59, 78, 102, 111–12

misdiagnosis, of childhood trauma survivors, 136–48, 150, 151, 157, 226

model mugging program, 218–19, 308

monomethylhydrazine (MMH), 315

mood dysregulation disorder, 226

mood stabilizing drugs, 225

Moore, Dana, 269

MPFC, see medial prefrontal cortex (MPFC) multiple personality disorder, 277–78

Murray, Henry, 105–6

Murrow, Ed, 43

muscular bonding, 333–34

music, in trauma recovery, 242–43, 349, 355

Myers, Charles Samuel, 185, 187, 189

Myers, Frederic, 189




naltrexone, 327

Nathan Cummings Foundation, 155

National Aeronautics and Space Administration (NASA), 315

National Association of State Mental Health Program Directors, 159

National Child Traumatic Stress Network (NCTSN), 155–56, 157, 351, 356

National Institutes of Health, 28, 138, 207, 251, 254, 315, 329

DSM-5 diagnostic criteria rejected by, 165–66, 329

nature vs. nurture debate, 153–55, 160

Nazis, shell-shock victims as viewed by, 186–87

neocortex, see rational brain nervous system, 76–77

autonomic (ANS), 60, 63–64, 77, 80, 225, 266–67

parasympathetic (PNS), 77, 83–84, 264, 266–67

sympathetic (SNS), 77, 82, 82, 209, 266–67

neuroception, 80

neurofeedback, 207, 312–29, 313, 418n

ADHD and, 322

alpha-theta training in, 321, 326

author’s experience of, 313–14

dissociation and, 318

epilepsy and, 315

history of, 315

learning disabilities and, 325

performance enhancement and, 322

PTSD and, 326–28

self-regulation in, 313

substance abuse and, 327–28

Trauma Center program for, 318–20

neuroimaging, see brain scans neuroplasticity, 3, 56, 167

neuroscience, 2, 29, 39, 275, 347

neurotransmitters, 28–29

see also specific neurotransmitters

Newberger, Carolyn and Eli, 355

New England Journal of Medicine, 374n–75n

New York Times, 334, 375n

nightmares, 8, 9, 14, 15, 20, 44, 134–35, 327

Nijenhuis, Ellert, 281

1984 (Orwell), 109

non-Western medicine, 76, 86, 207–8

norepinephrine, 29

North American Association for the Study of Obesity, 144

numbing, 14–15, 67, 71–73, 84, 87–89, 92, 99, 119, 124, 162–63, 198, 205, 247, 265–66, 273, 279, 304–5,

306

 see also freeze response (immobilization) obesity, 144, 147, 162, 266

Ogden, Pat, 26, 96, 217–18

Olds, David, 167

On the Origin of Species (Darwin), 74

oppositional defiant disorder (ODD), 150, 151, 157, 282, 392n

orbital prefrontal cortex, 91

Oresteia (Aeschylus), 332

Orr, Scott, 33

Orwell, George, 109

out-of-body experiences, 100, 132–33, 286, 386n

oxytocin, 223




Packer, Tina, 330, 335, 345–46

“Pain in Men Wounded in Battle” (Beecher), 32–33

painkillers, 146, 349

panic attacks, 97, 172

Panksepp, Jaak, 334, 387n, 398n

paralysis, episodic, 228–29

paranoid schizophrenia, 15

parasympathetic nervous system (PNS), 77, 83–84, 264, 266–67

parent-child interactive therapy (PCIT), 215

parietal lobes, 91

Pascual-Leone, Alvaro, 417n

Pasteur, Louis, 164

Patton, George, 186

Pavlov, Ivan, 39

Paxil, 35, 225, 254

PBSP psychomotor therapy, see psychomotor therapy Pearlman, Chester, 409n

pendulation, 217–18, 245, 286, 333, 408n

Peniston, Eugene, 326, 327

Pennebaker, James, 239–41, 243

performance enhancement, neurofeedback and, 322

periaqueductal gray, 102

Perry, Bruce, 56

Perry, Chris, 138, 141, 296

Pesso, Albert, 297–99

pharmaceutical industry, power of, 374n–75n

pharmacological revolution, 27–29, 36–38, 310

profit motive in, 38

phobias, 256

physical actions, completion of, in trauma survivors, 96

physical activity:

calming effect of, 88

in trauma therapy, 207–8

physiology:

self-regulation of, 38

see also body; brain Piaget, Jean, 105

Pilates, 199

Pitman, Roger, 30, 33, 222

placebo effect, 35

plane crashes, survivors of, 80

Plutarch, 334

pneumogastric nerve, see vagus nerve Pollak, Seth, 114

polyvagal theory, 77–78, 86

Porges, Stephen, 77–78, 80, 83, 84–85, 86

positron emission tomography (PET), 39

Possibility Project, 335, 340–42

posterior cingulate, 90–91, 91

Posttraumatic Cognitions Inventory, 233

pranayama, 86, 270

prefrontal cortex, 59, 68–69, 102

executive function in, 62

see also medial prefrontal cortex (MPFC) prefrontal lobes, 254

Prince, Morton, 184

Principles of Psychology, The (James), 277

prisons:

population of, 348

spending on, 168

prolactin, 223

propranolol, 225

proprioceptive (balance) system, 247

protagonists, in psychomotor therapy, 297, 300–302

proto-self, 94

Prozac (fluoxetine), 34–35, 37, 223, 262

PTSD and, 35–36, 225, 226, 254, 261

psychiatry:

drug-based approach of, 315, 349

socioeconomic factors ignored in, 348

psychoanalysis, 22, 184, 230–31

see also talk therapy (talking cure) psychodynamic psychotherapy, 199

Psychology Today, 315

psychomotor therapy, 296–308

author’s experience in, 298–99

feeling safe in, 300, 301

protagonists in, 297, 300–302

structures in, 298–308

witnesses in, 297, 300, 301, 306

psychopharmacology, 20, 206

psychotherapy, of child neglect survivors, 296–97

psychotropic drugs, 27–29, 37–38, 101, 136, 315, 349–50

PTSD and, 254, 261, 405n

in trauma recovery, 223–27

see also specific drugs

PTSD (posttraumatic stress disorder):

acupuncture and acupressure in treatment of, 410n–11n

amygdala-MPFC imbalance in, 62–64

attention and concentration problems in, 311–12

brain scans of, 102, 347, 408n

brain-wave patterns in, 311, 312

 CBT and, 194, 220–21

children of parents with, 118–19

diagnosis of, 136–37, 142, 150, 156–57, 188, 319

dissociation in, 66–68

EMDR in treatment of, 248–49, 253–54

exposure therapy and, 256

flashbacks in, 72, 327

in Holocaust survivors, 118–19

HRV in, 267, 268

hypersensitivity to threat in, 102, 327, 408n

language failure in, 244–45

MDMA in treatment of, 223–24

memory and, 175, 190

numbing in, 72–73, 99

psychotropic drugs and, 254, 261, 405n

reliving in, 66–68, 180–81, 325

and security of attachment to caregiver, 119

sensory self-awareness in, 89–92

social engagement and, 102

substance abuse and, 327

yoga therapy for, 207, 228–29, 268–69

PTSD (posttraumatic stress disorder), of accident and disaster survivors, 41–43, 142–43, 348

EMDR and, 260

flashbacks in, 66–67, 68, 68, 196–98

hypersensivity to threat in, 45–47, 68

irritability and rage in, 68, 248–49

Lelog as, 177–78

numbing in, 198

PTSD (posttraumatic stress disorder), of combat veterans, 1–2, 106, 348, 371n

antipsychotic drugs and, 226–27

attention and concentration problems of, 312

CBT and, 194, 220–21

diagnosis of, 19–21

downside of medications for, 36–37

flashbacks in, 8, 13, 16, 227

hypersensitivity to threat in, 11, 327

hypnosis and, 187, 220

in-or-out construct in, 18

irritability and rage in, 10, 14

neurofeedback and, 326–28

nightmares in, 8, 9, 14, 15, 134–35

numbing in, 14–15

pain and, 33

prevalence of, 20

Prozac and, 35–36, 226

serotonin levels in, 33–34, 36

shame in, 13

shell-shock as, 11, 184–85

sleep disorders in, 409n

stress hormone levels in, 30

 suicide and, 17, 332

theater as therapy for, 331–32, 343–44

traumatic event as sole source of meaning in, 18

VA and, 19, 187–88, 222–23

yoga therapy for, 270

PTSD scores, 254, 319, 324

Puk, Gerald, 252–53

purpose, sense of, 14, 92, 233

Putnam, Frank, 30, 161–64, 251




qigong, 86, 208, 245, 264

quantitative EEG (qEEG), 323




rage, 83

displacement of, 133–34, 140

in PTSD, 10, 14, 68, 248–49

in trauma survivors, 46, 95, 99, 285, 304

“railway spine,” 177

rape, 1–2, 17, 88, 213–14

increased incidence of, in survivors of childhood abuse, 85, 146–47

prevalence of, 20–21

rational brain, 55, 57–58

balance between emotional brain and, 64–65, 129–30, 205, 310

feelings and, 205

Rauch, Scott, 40, 42

reactive attachment disorder, 150, 151

reciprocity, 79–80

reckless behavior, 120

reenacting, 31–33, 179, 180, 181, 182

relationships:

emotional brain and, 122

mental health and, 38, 55

in trauma recovery, 210–13

see also intimacy; social engagement reliving, 66–68, 180–81

Relman, Arnold, 374n–75n

Remarque, Erich Maria, 171, 186

Rembrandt van Rijn, 215

Remembering, Repeating and Working Through (Freud), 219

REM sleep, 260–61, 309–10, 409n

repressed memory, 183, 184–99

of childhood sexual abuse survivors, 190, 397n

false memories and, 189, 190, 191–92

reliability of, 191

see also traumatic memory Research Domain Criteria (RDoC), 165–66

resilience, 105, 109, 161, 278–79, 314, 316, 351, 355, 356

Respiridol, 215

rhesus monkeys:

peer-raised, 154

personality types in, 153

rheumatoid arthritis (RA), IFS in treatment of, 291–92

rhythmic movement, in trauma therapy, 85, 207, 208, 214, 242–43, 333–34, 349

right temporal lobe, 319, 324

Rilke, Rainer Maria, 87

Risperdal, 37, 226, 227

Ritalin, 107, 136

ritual, trauma recovery and, 331–32

Rivers, W. H. R., 189

road rage, 83

role-playing, in psychomotor therapy, 298–300

Rorschach test, 15–17, 35

Roy, Alec, 154

Rozelle, Deborah, 214

Rumi, 277

Rwanda genocide, 244




safety:

a fundamental to mental health, 351, 352

as lacking in childhood trauma survivors, 141, 213, 296, 301, 351

in trauma recovery, 204, 212, 270, 275, 300, 301, 349, 353

trauma survivors’ distorted perception of, 79–80, 85, 96–97, 164, 270

Salpêtrière, La, 177–78, 178, 194

Saul, Noam, 51–53, 52, 58, 261

Saxe, Glenn, 119

Scentific American, 149

Schacter, Dan, 93

Schilder, Paul, 100

schizophrenia, 15, 22–23, 27, 29

genetics and, 151–52

schools, see education system Schwartz, Richard, 281, 282, 283, 289, 290, 291, 418n

Science, 94–95

selective serotonin reuptake inhibitors (SSRIs), 35, 36

see also Prozac (fluoxetine) Self:

disorganized attachment and, 120

in IFS therapy, 224, 283–85, 288, 289, 305

in infants, 113

multiple aspects of, 280–95; see also internal family systems (IFS) therapy reestablishing ownership of,

203–4, 318

in trauma survivors, 166, 233, 247

self-awareness:

autobiographical self in, 236

sensory, 87–102, 206, 206, 208–9, 236, 237–38, 247, 273, 354, 376n, 382n, 408n, 418n

self-blame, in childhood sexual abuse survivors, 131, 132

self-compassion, 292

self-confidence, 205, 350

self-deceit, as source of suffering, 11, 26–27

self-discovery, language and, 234–35

self-harming, 20, 25, 87, 138, 141, 158, 162, 172, 264, 266, 288–89, 316, 317

self-hatred, 134, 143, 158, 163, 279

self-leadership, 203, 280–95

self-nurture, 113

self-recognition, absence of, 105

self-regulation, 113, 158, 161, 207, 224, 300, 347–48, 354, 401

neurofeedback and, 313

yoga and, 271–72, 274, 275

Seligman, Martin, 29–30

Semrad, Elvin, 11, 26, 237

sensation seeking, 266, 272

sensorimotor therapy, 96, 214–15, 217–18

sensory self-awareness, 87–102, 206, 206, 208–9, 236, 237–38, 247, 273, 347, 354, 376n, 382n, 408n, 418n

September 11, 2001, terrorist attacks, 51–53, 52

children as witnesses to, 119

therapies for trauma from, 230–31

Seroquel, 37, 101, 215, 226, 227

serotonin, 33, 153, 154, 262

serotonin reuptake inhibitors (SSRIs), 215, 225

Servan-Schreiber, David, 304

Seven Pillars of Wisdom (Lawrence), 232

sexual promiscuity, 120, 285, 286

Shadick, Nancy, 291

Shakespeare, William, 43, 230, 343–46, 355

Shakespeare & Company, 335, 343–46

Shakespeare in the Courts, 335, 336, 342–44

Shalev, Arieh, 30

shame, 13–14, 102, 132, 138, 174, 211, 300

Shanley, Paul, 171–74, 183, 191

Shapiro, Francine, 251

Shatan, Chaim, 19

shavasana, 271

shell-shock, 11, 184–85

Shell Shock in France (Myers), 187

singing and chanting, in trauma recovery, 86, 214

“Singing Revolution,” 334

Sketches of War, 331

Sky, Licia, 216–17

sleep disorders, 46, 95

EMDR and, 259–61

in PTSD, 409n

REM sleep and, 260–61, 409n

see also nightmares

SMART (sensory motor arousal regulation treatment), 215

smoking, surgeon general’s report on, 148

Social Brain, The (Gazzaniga), 280–81

social engagement:

as basic human trait, 110, 166

PTSD and, 102

as response to threat, 80–81, 82, 88

in rhesus monkeys, 153–54

in trauma recovery, 204

 trauma survivors and, 3, 62, 78–80, 84, 86, 161, 349

social support, for childhood trauma survivors, 167–68, 350

socioeconomic stress, disorganized attachment and, 117–18

Solomon, Richard, 32

Solomon, Roger, 260

somatic experiencing, 217–18

Somme, Battle of the (1916), 185

soothing, arousal and, 113

Sophocles, 332

South Africa, 213–14, 333, 349

Southborough Report, shell-shock diagnosis rejected by, 185

Southwick, Steve, 30

Sowell, Nancy, 291

speech centers (brain), 42, 43

Sperry, Roger, 51

Spinazzola, Joseph, 156, 339, 351

Spitzer, Robert, 142

Sroufe, Alan, 160–61, 166

Steel, Kathy, 281

Sterman, Barry, 315

Stern, Jessica, 7

Stickgold, Robert, 260, 261

stimuli:

adjustment to, 32

hypersensitivity to, see threat, hypersensitivity to Story of My Life, The (Keller), 234

Strange Situation, 115

stress:

gene expression and, 152

immune function and, 240

see also trauma

stress hormones, 30, 42, 46, 60, 61, 66–67, 158, 162, 217, 233

structural dissociation model, 281

structures, in psychomotor therapy, 298–308

subcortical brain structures, 95

submissiveness, 97, 218

subpersonalities, 280–95

substance abuse, 70, 120, 146, 151, 225, 266

neurofeedback and, 327–28

withdrawal and, 32, 327

suicidal behavior and thoughts, 24, 28, 88, 120, 138, 141, 146, 147, 150, 151, 154, 256, 287, 316, 332

suicide by cop, 182

Summit, Roland, 131, 136

Suomi, Stephen, 153–54, 160

superior temporal cortex, 386n

sympathetic nervous system (SNS), 77, 82, 82, 209, 266–67

Szyf, Moshe, 152




tai chi, 207–8

talk therapy (talking cure), 22, 27, 36, 72, 181–82, 230–37, 253

 experience vs. telling in, 235–36

TAQ, see Traumatic Antecedents Questionaire (TAQ) Tavistock Clinic, 109

Teicher, Martin, 140, 149, 416n

temporal lobe abnormalities, 416n

temporal parietal junction, 100

tension, in trauma survivors, 100–101, 265–66

terrorism:

PTSD from, 348

see also September 11, 2001, terrorist attacks testosterone, 163

thalamocortical networks, 417n

thalamus, 60, 70–71, 176, 324

theater, in trauma recovery, 214, 330–32, 334–46, 355

conflict and, 335

emotions and, 335, 344–45

feeling safe in, 336–37

Theater of War, 332

Thematic Apperception Test (TAT), 106–7

therapists, in trauma recovery, 212–13, 244

theta waves, 321, 326, 417n

Thorazine (chlorpromazine), 22–23

thoughts, physical sensations and, 209

threat:

confusion of safety and, 85, 97, 119, 164

hypersensitivity to, 2, 11, 17, 33, 45–47, 68, 84, 95, 102, 143, 158, 161, 163, 196–97, 225, 265, 310, 327,

328, 408n

social engagement as response to, 80–81, 82, 88

whole-body response to, 53–55, 53, 60–62, 61

see also fight/flight response; freeze response (immobilization) time, sense of, 273

Tourette, Gilles de la, 177

trance (hypnagogic) states, 117, 187, 238, 302, 305, 326

transcranial magnetic stimulation (TMS), 417n

trauma:

articulation of, 232–34

brain changes from, 2–3, 21, 59, 347

growing awareness of, 347

as most urgent public health issue, 148, 149–50, 356

narratives of, 7, 43, 46, 70, 130, 135, 175, 176, 194, 219, 220, 231, 250, 252–53, 261–62; see also

traumatic memory physiological changes from, 2–3, 21, 53, 53, 72

prevalence of, 1

reactivation of, 2

risk of, socioeconomic status and, 348

trauma, healing from, 203–29

animal therapy in, 80, 150–51, 213

ARC model in, 401n

art and, 242–43

body therapies for, 3, 26, 72, 86, 89, 207–8, 215–17, 228–29, 245; see also specific therapies

calming and relaxation techniques in, 131, 203–4; see also breathing; mindfulness; yoga CBT in, 182,

194, 220–21

community in, 213–14, 244, 331–34, 355

desensitization therapies in, 46–47, 73, 220, 222–23

 EMDR therapy in, see eye movement desensitization and reprocessing (EMDR) emotional self-

regulation in, 203–4, 206–8, 212, 353, 401n

feeling safe in, 204, 212, 270, 275, 300, 301, 349, 353

focus in, 203, 347–48, 355

giving up self-deceit in, 204

IFS therapy in, see internal family systems (IFS) therapy integrating traumatic memories in, 181, 219–20,

222, 228, 237, 279

language and, 230–47, 275–76

limbic system therapy in, 205–6

living in present as goal of, 204

mindfulness in, 207, 208–10, 224, 225, 269, 270

music in, 242–43, 349, 355

need to revisit trauma in, 204–5, 211

neurofeedback in, see neurofeedback professional therapists for, 212–13, 244

psychomotor therapy in, 296–308

reestablishing ownership of one’s self as goal of, 204–5

relationships in, 204, 210–13

rhythmic movement and, 85, 207, 208, 214, 242–43, 333–34, 349

schools as resources for, 351–56

search for meaning in, 233–34

self-awareness in, 208, 235–38, 273, 347

self-leadership in, 203, 280–95

sensorimotor therapy in, 96, 214–15

singing and chanting in, 86, 214

talk therapy in, 230–37, 253

theater in, see theater, in trauma recovery writing and, 238–42

yoga in, 63, 86, 207, 225, 228–29, 231, 263–76

Trauma and Recovery (Herman), 189

Trauma Center, 3–4, 72, 85, 86, 121, 122, 163–64, 166, 214–15, 228, 266, 269, 271, 340, 351

neurofeedback laboratory at, 318–20, 324

Trauma Drama program of, 335, 336–37, 339, 355

Urban Improv study of, 338–39

Trauma Clinic, 35, 251, 253

trauma survivors:

alexithymia in, 98–99, 247, 272–73, 291, 319

blaming in, 45

brain scans of, 39–47, 42, 66, 68–70, 68, 71–72, 72, 82, 99–100, 319

brain-wave patterns in, 311–12, 311, 324

continued stress mobilization in, 53–55, 53

denial in, 46, 291

depersonalization in, 71–73, 71, 99–100, 132–33, 286, 291, 386n, 401n

derealization in, 401n

dissociation in, 66–68, 95, 172, 179, 180–81, 194, 211, 247, 281, 294, 316, 317–18

distorted perception of safety in, 79–80, 85, 96–97, 119, 164, 270

fear of emotions in, 335

fear of experimentation in, 305

flashbacks in, 40, 42, 45, 70, 176, 193–94, 219

freeze response (immobilization) in, 54, 54, 80, 82–83, 82, 85, 95, 217, 218

handwriting of, 241–42

helplessness of, 217, 341

 hypersensitivity to threat in, 2, 61–62, 84

immune systems of, 126–27, 291

inner void in, 296–308

intimacy as difficult for, 99

irritability and rage in, 46, 95, 99

language failure in, 43–44, 243–45, 352–53

limbic system in, 59, 95, 265

living in present as difficult for, 67, 70, 73, 312

loss of imagination in, 17, 96

loss of purpose in, 92, 233

medication and, 3

memory and attention problems in, 46

nightmares in, 44

numbing in, 67, 84, 119, 205, 247, 272, 304–5, 306

panic attacks in, 97

polarization of self-system in, 281

reciprocity and, 79–80

reenacting in, 31–33, 179, 180, 181, 182

self-harming in, 266, 288–89

self-protective strategies of, 278–79

sensation seeking in, 266, 272

sense of self in, 166, 233, 247

sense of time in, 273

sensory overload in, 70–71

sensory self-awareness in, 89, 96, 247, 418n

shame in, 102, 138, 211, 300

sleep disorders in, 46, 95

social engagement and, 3, 62, 78–80, 84, 86, 161, 349

somatic symptoms in, 97–98

stress hormone levels in, 30

substance abuse by, 70, 120, 146, 151, 225, 266

tension and defensiveness in, 100–101, 265–66

trust as difficult for, 18, 134, 141, 150, 158, 163, 253

see also childhood trauma survivors; PTSD (posttraumatic stress disorder) Traumatic Antecedents

Questionaire (TAQ), 138–40, 141

traumatic memory, 171–83, 246–47, 278

as disorganized, 193

hysteria as, see hysteria integration of, 181, 219–20, 222, 228, 237, 255–56, 261–62, 279, 308

narrative memory vs., 176, 179, 194, 219, 231–32, 236

normal memory vs., 175–76, 180, 181, 189, 192–94, 219, 372n

“railway spine” as, 177

see also repressed memory Traumatic Neuroses of War, The (Kardiner), 11, 187

Trevarthen, Colwyn, 111

Trickett, Penelope, 161–63

triggered responses, 66–68

Tronick, Ed, 84, 112

trust, difficulty of, 18, 134, 141, 150, 158, 163, 253

Truth and Reconciliation Commission, 213–14, 333, 349

Tutu, Desmond, 333

Ubuntu, 349

United States Association for Body Psychotherapy, 297

Urban Improv, 334–35

Trauma Center study of, 337–39




vagus nerve, 76, 78, 80–82, 81, 207, 245

Valium, 225

valproate, 136, 225, 405n

van der Hart, Onno, 281, 396n

Van der Kolk Center, 213, 401n

vasopressin, 223

ventral vagal complex (VVC), 81–82,

82, 83–84

development of, 84

Versailles, Treaty of (1919), 186

Veterans Administration (VA):

Boston Clinic of, 7, 10, 11, 12, 187–88, 227, 331

PTSD and, 19, 222–23, 226–27, 244–45

Veterans Affairs Department, U.S, 156, 224, 255

Vietnam veterans, 7–8, 12, 15, 17–18, 33, 156, 182, 187–88, 190, 222–23, 227, 233–34

visual cortex, 42, 44

voice, responses to, 85–86




Walter Reed National Military Medical Center, 322

War Is a Force That Gives Us Meaning (Hedges), 31

Warner, Liz, 214, 418

Warren, Robert Penn, 22

Werner, Emily, 392n

“What Is an Emotion?” (James), 89–90

What It Is Like to Go to War (Marlantes), 233

“When the Patient Reports Atrocities” (Haley), 13

Wiesel, Elie, 356

Williams, Dar, 203

Williams, Linda Meyer, 190–91

Wilson, Scott, 126

Winfrey, Oprah, 356

Winnicott, Donald, 109, 113–14

witnesses, in psychomotor therapy, 297, 300, 301, 306

Woodman, Marion, 230

World Enough and Time (Warren), 22

World I Live In, The (Keller), 235

World War I, 243–44

shell-shock in, 11, 184–86, 189

World War II, 9, 210

combat trauma in, 187–88

veterans of, 18, 53, 187, 188

writing, in trauma recovery, 238–42




Xanax, 225

Yale University, Fortunoff Video Archive at, 195

Yehuda, Rachel, 30, 118

yoga, 63, 86, 231, 263–76, 354

asanas (postures) in, 270, 272

clinical studies of, 273–75, 274

HRV and, 268–69, 271

interoception and, 272–74

meditation in, 270

pranayama (breathing) in,

86, 270

PTSD and, 207, 228–29, 268–69, 270

self-regulation and, 271–72, 274, 275

Yoga and the Quest for the True Self (Cope), 263, 272




Zaichkowsky, Len, 322

Zoloft, 35, 225, 254

Zyprexa, 37, 101