Body Scores Pt 5.2 Path to Recovery Ch 17-20

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

and

It was early in my career, and I had been seeing Mary, a shy, lonely, 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 sub-personalities 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

different

It is one thing to process memories of trauma, but it is an entirely

matter to confront the inner void—the holes in th

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

e soul that result from not 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

part-time

T he summer after my first year of medical school, I worked as a

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

Hartmann’s

research assistant in Ernest

sleep laboratory at Boston State

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 nur

sing 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

to

M any scientists I know were inspired by their children’s health problems 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 long­standing 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.