The Body Keeps The Score (Bessel van red Kolk) Summary

Contents
    

PART ONE: THE REDISCOVERY OF TRAUMA

1. LESSONS FROM VIETNAM VETERANS
2. REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN
3. LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION

PART TWO: THIS IS YOUR BRAIN ON TRAUMA

4. RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL
5. BODY-BRAIN CONNECTIONS
6. LOSING YOUR BODY, LOSING YOUR SELF

PART THREE: THE MINDS OF CHILDREN

7. GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT
8. TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT9. WHAT’S LOVE GOT TO DO WITH IT?
10. DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

PART FOUR: THE IMPRINT OF TRAUMA

11. UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY
12. THE UNBEARABLE HEAVINESS OF REMEMBERING

PART FIVE: PATHS TO RECOVERY

13. HEALING FROM TRAUMA: OWNING YOUR SELF
14. LANGUAGE: MIRACLE AND TYRANNY
15. LETTING GO OF THE PAST: EMDR
16. LEARNING TO INHABIT YOUR BODY: YOGA
17. PUTTING THE PIECES TOGETHER: SELF-LEADERSHIP
18. FILLING IN THE HOLES: CREATING STRUCTURES
19. REWIRING THE BRAIN: NEUROFEEDBACK
20. FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER

PART ONE: THE REDISCOVERY OF TRAUMA

CH 1: LESSONS FROM VIETNAM VETERANS

What does trauma does to you?
 
1. TRAUMA AND THE LOSS OF SELF

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

Many of the men had friendships similar to Tom’s with Alex. Tom met Alex, an Italian guy from Malden, Massachusetts, on his first day in country, and they instantly became close friends. They drove their jeep together, listened to the same music, and read each other’s letters from home. They got drunk together and chased the same Vietnamese bar girls.
After about three months in country Tom led his squad on a foot patrol through a rice paddy just before sunset. Suddenly a hail of gunfire spurted from the green wall of the surrounding jungle, hitting the men around him one by one. Tom told me how he had looked on in helpless horror as all the members of his platoon were killed or wounded in a matter of seconds. He would never get one image out of his mind: the back of Alex’s head as he lay facedown in the rice paddy, his feet in the air. Tom wept as he recalled,
“He was the only real friend I ever had.” Afterward, at night, Tom continued to hear the screams of his men and to see their bodies falling into the water. Any sounds, smells, or images that reminded him of the ambush (like the popping of firecrackers on the Fourth of July) made him feel just as paralyzed, terrified, and enraged as he had the day the helicopter evacuated him from the rice paddy.

Maybe even worse for Tom than the recurrent flashbacks of the ambush was the memory of what happened afterward. I could easily imagine how Tom’s rage about his friend’s death had led to the calamity that followed. It took him months of dealing with his paralyzing shame before he could tell me about it. Since time immemorial veterans, like Achilles in Homer’s Iliad, have responded to the death of their comrades with unspeakable acts of revenge. The day after the ambush Tom went into a frenzy to a neighboring village, killing children, shooting an innocent farmer, and raping a Vietnamese woman. After that it became truly impossible for him to go home again in any meaningful way. How can you face your sweetheart and tell her that you brutally raped a woman just like her, or watch your son take his first step when you are reminded of the child you murdered? Tom experienced the death of Alex as if part of himself had been forever destroyed—the part that was good and honorable and trustworthy.
Trauma, whether it is the result of something done to you or something you yourself have done, almost always makes it difficult to engage in intimate relationships. After you have experienced something so unspeakable, how do you learn to trust yourself or anyone else again? Or, conversely, how can you surrender to an intimate relationship after you have been brutally violated? Tom kept showing up faithfully for his appointments, as I had become for him a lifeline—the father he’d never had, an Alex who had survived the ambush. It takes enormous trust and courage to allow yourself to remember.
One of the hardest things for traumatized people is to confront their shame about the way they behaved during a traumatic episode, whether it is objectively warranted (as in the commission of atrocities) or not (as in the case of a child who tries to placate her abuser). One of the first people to write about this phenomenon was Sarah Haley, who occupied an office next to mine at the VA Clinic. In an article entitled “When the Patient Reports Atrocities,”4 which became a major impetus for the ultimate creation of the PTSD diagnosis, she discussed the well-nigh intolerable difficulty of talking about (and listening to) the horrendous acts that are often committed by soldiers in the course of their war experiences. It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances. They despise themselves for how terrified, dependent, excited, or enraged they felt.
In later years I encountered a similar phenomenon in victims of child abuse: Most of them suffer from agonizing shame about the actions they took to survive and maintain a connection with the person who abused them. This was particularly true if the abuser was someone close to the child, someone the child depended on, as is so often the case. The result can be confusion about whether one was a victim or a willing participant, which in turn leads to bewilderment about the difference between love and terror; pain and pleasure. We will return to this dilemma throughout this book.

2. NUMBING

Maybe the worst of Tom’s symptoms was that he felt emotionally numb. He desperately wanted to love his family, but he just couldn’t evoke any deep feelings for them. He felt emotionally distant from everybody, as though his heart were frozen and he were living behind a glass wall. That numbness extended to himself, as well. He could not really feel anything except for his momentary rages and his shame. He described how he hardly recognized himself when he looked in the mirror to shave. When he heard himself arguing a case in court, he would observe himself from a distance and wonder how this guy, who happened to look and talk like him, was able to make such cogent arguments. When he won a case he pretended to be gratified, and when he lost it was as though he had seen it coming and was resigned to the defeat even before it happened. Despite the fact that he was a very effective lawyer, he always felt as though he were floating in space, lacking any sense of purpose or direction.
The only thing that occasionally relieved this feeling of aimlessness was intense involvement in a particular case. During the course of our treatment Tom had to defend a mobster on a murder charge. For the duration of that trial he was totally absorbed in devising a strategy for winning the case, and there were many occasions on which he stayed up all night to immerse himself in something that actually excited him. It was like being in combat, he said—he felt fully alive, and nothing else mattered. The moment Tom won that case, however, he lost his energy and sense of purpose. The nightmares returned, as did his rage attacks—so intensely that he had to move into a motel to ensure that he would not harm his wife or children. But being alone, too, was terrifying, because the demons of the war returned in full force. Tom tried to stay busy, working, drinking, and drugging—doing anything to avoid confronting his demons.
He kept thumbing through Soldier of Fortune, fantasizing about enlisting as a mercenary in one of the many regional wars then raging in Africa. That spring he took out his Harley and roared up the Kancamagus Highway in New Hampshire. The vibrations, speed, and danger of that ride helped him pull himself back together, to the point that he was able to leave his motel room and return to his family.

3. THE REORGANIZATION OF PERCEPTION
...And The Rorschach Test 

Another study I conducted at the VA started out as research about nightmares but ended up exploring how trauma changes people’s perceptions and imagination. Bill, a former medic who had seen heavy action in Vietnam a decade earlier, was the first person enrolled in my nightmare study. After his discharge he had enrolled in a theological seminary and had been assigned to his first parish in a Congregational church in a Boston suburb. He was doing fine until he and his wife had their first child. Soon after the baby’s birth, his wife, a nurse, had gone back to work while he remained at home, working on his weekly sermon and other parish duties and taking care of their newborn. On the very first day he was left alone with the baby, it began to cry, and he found himself suddenly flooded with unbearable images of dying children in Vietnam.
Bill had to call his wife to take over child care and came to the VA in a panic. He described how he kept hearing the sounds of babies crying and seeing images of burned and bloody children’s faces. My medical colleagues thought that he must surely be psychotic, because the textbooks of the time said that auditory and visual hallucinations were symptoms of paranoid schizophrenia. The same texts that provided this diagnosis also supplied a cause: Bill’s psychosis was probably triggered by his feeling displaced in his wife’s affections by their new baby.
As I arrived at the intake office that day, I saw Bill surrounded by worried doctors who were preparing to inject him with a powerful antipsychotic drug and ship him off to a locked ward. They described his symptoms and asked my opinion. Having worked in a previous job on a ward specializing in the treatment of schizophrenics, I was intrigued.
Something about the diagnosis didn’t sound right. I asked Bill if I could talk with him, and after hearing his story, I unwittingly paraphrased something Sigmund Freud had said about trauma in 1895: “I think this man is suffering from memories.” I told Bill that I would try to help him and, after offering him some medications to control his panic, asked if he would be willing to come back a few days later to participate in my nightmare study.5
He agreed.
As part of that study we gave our participants a Rorschach test.6 Unlike tests that require answers to straightforward questions, responses to the Rorschach are almost impossible to fake. The Rorschach provides us with a unique way to observe how people construct a mental image from what is basically a meaningless stimulus: a blot of ink. Because humans are meaning-making creatures, we have a tendency to create some sort of image or story out of those inkblots, just as we do when we lie in a meadow on a beautiful summer day and see images in the clouds floating high above. What people make out of these blots can tell us a lot about how their minds work.
On seeing the second card of the Rorschach test, Bill exclaimed in horror, “This is that child that I saw being blown up in Vietnam. In the middle, you see the charred flesh, the wounds, and the blood is spurting out all over.” Panting and with sweat beading on his forehead, he was in a panic similar to the one that had initially brought him to the VA clinic. Although I had heard veterans describing their flashbacks, this was the first time I actually witnessed one. In that very moment in my office, Bill was obviously seeing the same images, smelling the same smells, and feeling the same physical sensations he had felt during the original event. Ten years after helplessly holding a dying baby in his arms, Bill was reliving the trauma in response to an inkblot.
Experiencing Bill’s flashback firsthand in my office helped me realize the agony that regularly visited the veterans I was trying to treat and helped me appreciate again how critical it was to find a solution. The traumatic event itself, however horrendous, had a beginning, a middle, and an end, but I now saw that flashbacks could be even worse. You never know when you will be assaulted by them again and you have no way of telling when they will stop. It took me years to learn how to effectively treat flashbacks, and in this process Bill turned out to be one of my most important mentors.
When we gave the Rorschach test to twenty-one additional veterans, the response was consistent: Sixteen of them, on seeing the second card, reacted as if they were experiencing a wartime trauma. The second Rorschach card is the first card that contains color and often elicits socalled color shock in response. The veterans interpreted this card with descriptions like “These are the bowels of my friend Jim after a mortar shell ripped him open” and “This is the neck of my friend Danny after his head was blown off by a shell while we were eating lunch.” None of them mentioned dancing monks, fluttering butterflies, men on motorcycles, or any of the other ordinary, sometimes whimsical images that most people see.
While the majority of the veterans were greatly upset by what they saw, the reactions of the remaining five were even more alarming: They simply went blank. “This is nothing,” one observed, “just a bunch of ink.” They were right, of course, but the normal human response to ambiguous stimuli is to use our imagination to read something into them.
We learned from these Rorschach tests that traumatized people have a tendency to superimpose their trauma on everything around them and have trouble deciphering whatever is going on around them. There appeared to be little in between. We also learned that trauma affects the imagination.
The five men who saw nothing in the blots had lost the capacity to let their minds play. But so, too, had the other sixteen men, for in viewing scenes from the past in those blots they were not displaying the mental flexibility that is the hallmark of imagination. They simply kept replaying an old reel.
Imagination is absolutely critical to the quality of our lives. Our imagination enables us to leave our routine everyday existence by fantasizing about travel, food, sex, falling in love, or having the last word— all the things that make life interesting. Imagination gives us the opportunity to envision new possibilities—it is an essential launchpad for making our hopes come true. It fires our creativity, relieves our boredom, alleviates our pain, enhances our pleasure, and enriches our most intimate relationships. When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility. Without imagination there is no hope, no chance to envision a better future, no place to go, no goal to reach.
The Rorschach tests also taught us that traumatized people look at the world in a fundamentally different way from other people. For most of us a man coming down the street is just someone taking a walk. A rape victim, however, may see a person who is about to molest her and go into a panic.
A stern schoolteacher may be an intimidating presence to an average kid, but for a child whose stepfather beats him up, she may represent a torturer and precipitate a rage attack or a terrified cowering in the corner.

A NEW UNDERSTANDING

In the three decades since I met Tom, we have learned an enormous amount not only about the impact and manifestations of trauma but also about ways to help traumatized people find their way back. Since the early 1990s brainimaging tools have started to show us what actually happens inside the brains of traumatized people. This has proven essential to understanding the damage inflicted by trauma and has guided us to formulate entirely new avenues of repair.
We have also begun to understand how overwhelming experiences affect our innermost sensations and our relationship to our physical reality —the core of who we are. We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body. This imprint has ongoing consequences for how the human organism manages to survive in the present.

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

Ch 2 - Revolutions in understanding mind and brain

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

TRAUMA BEFORE DAWN

A few years later after 1950, as a young doctor, I was confronted with an especially stark example of the medical model in action. I was then moonlighting at a Catholic hospital, doing physical examinations on women who’d been admitted to receive electroshock treatment for depression.
Being my curious immigrant self, I’d look up from their charts to ask them about their lives. Many of them spilled out stories about painful marriages, difficult children, and guilt over abortions. As they spoke, they visibly brightened and often thanked me effusively for listening to them. Some of them wondered if they really still needed electroshock after having gotten so much off their chests. I always felt sad at the end of these meetings, knowing that the treatments that would be administered the following morning would erase all memory of our conversation. I did not last long in that job.
On my days off from the ward at MMHC, I often went to the Countway Library of Medicine to learn more about the patients I was supposed to help. One Saturday afternoon I came across a treatise that is still revered today: Eugen Bleuler’s 1911 textbook Dementia Praecox. Bleuler’s observations were fascinating: Among schizophrenic body hallucinations, the sexual ones are by far the most frequent and the most important. All the raptures and joys of normal and abnormal sexual satisfaction are experienced by these patients, but even more frequently every obscene and disgusting practice which the most extravagant fantasy can conjure up. Male patients have their semen drawn off; painful erections are stimulated. The women patients are raped and injured in the most devilish ways. . . . In spite of the symbolic meaning of many such hallucinations, the majority of them correspond to real sensations.2
This made me wonder: Our patients had hallucinations—the doctors routinely asked about them and noted them as signs of how disturbed the patients were. But if the stories I’d heard in the wee hours were true, could it be that these “hallucinations” were in fact the fragmented memories of real experiences? Were hallucinations just the concoctions of sick brains? Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes.

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

MAKING SENSE OF SUFFERING

After my year on the research ward I resumed medical school and then, as a newly minted MD, returned to MMHC to be trained as a psychiatrist, a program to which I was thrilled to be accepted. Many famous psychiatrists had trained there, including Eric Kandel, who later won the Nobel Prize in Physiology and Medicine. Allan Hobson discovered the brain cells responsible for the generation of dreams in a lab in the hospital basement while I trained there, and the first studies on the chemical underpinnings of depression were also conducted at MMHC. But for many of us residents, the greatest draw was the patients. We spent six hours each day with them and then met as a group with senior psychiatrists to share our observations, pose our questions, and compete to make the wittiest remarks.
Our great teacher, Elvin Semrad, actively discouraged us from reading psychiatry textbooks during our first year. (This intellectual starvation diet may account for the fact that most of us later became voracious readers and prolific writers.) Semrad did not want our perceptions of reality to become obscured by the pseudocertainties of psychiatric diagnoses. I remember asking him once: “What would you call this patient—schizophrenic or schizoaffective?” He paused and stroked his chin, apparently in deep thought. “I think I’d call him Michael McIntyre,” he replied.
Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people “acknowledge, experience, and bear” the reality of life—with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves,” he’d say, urging us to be honest with ourselves about every facet of our experience.
He often said that people can never get better without knowing what they know and feeling what they feel.

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

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


A major textbook of psychiatry went so far as to state: “The cause of mental illness is now considered an aberration of the brain, a chemical imbalance.”

B. J. Deacon, and J. J. Lickel, “On the Brain Disease Model of Mental Disorders,” Behavior Therapist 32, no. 6 (2009).

Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals in the United States, from over 500,000 in 1955 to fewer than 100,000 in 1996.7 For people today who did not know the world before the advent of these treatments, the change is almost unimaginable. As a first-year medical student I visited Kankakee State Hospital in Illinois and saw a burly ward attendant hose down dozens of filthy, naked, incoherent patients in an unfurnished dayroom supplied with gutters for the runoff water. This memory now seems more like a nightmare than like something I witnessed with my own eyes. My first job after finishing my residency in 1974 was as the second-to-last director of a once venerable institution, the Boston State Hospital, which had formerly housed thousands of patients and been spread over hundreds of acres with dozens of buildings, including greenhouses, gardens, and workshops—most of them by then in ruins. During my time there patients were gradually dispersed into “the community,” the blanket term for the anonymous shelters and nursing homes where most of them ended up. (Ironically, the hospital was started as an “asylum,” a word meaning “sanctuary” that gradually took on a sinister connotation. It actually did offer a sheltered community where everybody knew the patients’ names and idiosyncrasies.) In 1979, shortly after I went to work at the VA, the Boston State Hospital’s gates were permanently locked, and it became a ghost town.
During my time at Boston State I continued to work in the MMHC psychopharmacology lab, which was now focusing on another direction for research. In the 1960s scientists at the National Institutes of Health had begun to develop techniques for isolating and measuring hormones and neurotransmitters in blood and the brain. Neurotransmitters are chemical messengers that carry information from neuron to neuron, enabling us to engage effectively with the world.

Now that scientists were finding evidence that:

# Abnormal levels of norepinephrine were associated with depression, and # Abnormal levels of dopamine with schizophrenia.

Low levels of norepinephrine may lead to conditions such as attention deficit hyperactivity disorder (ADHD), depression, and hypotension (very low blood pressure).

Having too much adrenaline or norepinephrine can cause: high blood pressure, anxiety, excessive sweating.

Low levels of dopamine have been linked to Parkinson's disease, restless legs syndrome and depression.

High dopamine in the brain results in suspicions and hallucinations.

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

INESCAPABLE SHOCK

Preoccupied with so many lingering questions about traumatic stress, I became intrigued with the idea that the nascent field of neuroscience could provide some answers and started to attend the meetings of the American College of Neuropsychopharmacology (ACNP). In 1984 the ACNP offered many fascinating lectures about drug development, but it was not until a few hours before my scheduled flight back to Boston that I heard a presentation by Steven Maier of the University of Colorado, who had collaborated with Martin Seligman of the University of Pennsylvania. His topic was learned helplessness in animals. Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.”9 Being a dog lover, I realized that I could never have done such research myself, but I was curious about how this cruelty would affect the animals.
After administering several courses of electric shock, the researchers opened the doors of the cages and then shocked the dogs again. A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open—they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom.
Like Maier and Seligman’s dogs, many traumatized people simply give up.
Rather than risk experimenting with new options they stay stuck in the fear they know.
I was riveted by Maier’s account. What they had done to these poor dogs was exactly what had happened to my traumatized human patients.
They, too, had been exposed to somebody (or something) who had inflicted terrible harm on them—harm they had no way of escaping. I made a rapid mental review of the patients I had treated. Almost all had in some way been trapped or immobilized, unable to take action to stave off the inevitable. Their fight/flight response had been thwarted, and the result was either extreme agitation or collapse.
Maier and Seligman also found that traumatized dogs secreted much larger amounts of stress hormones than was normal. This supported what we were beginning to learn about the biological underpinnings of traumatic stress. A group of young researchers, among them Steve Southwick and John Krystal at Yale, Arieh Shalev at Hadassah Medical School in Jerusalem, Frank Putnam at the National Institute of Mental Health (NIMH), and Roger Pitman, later at Harvard, were all finding that traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount Sinai in New York confronted us with her seemingly paradoxical findings that the levels of the stress hormone cortisol are low in PTSD. Her discoveries only started to make sense when her research clarified that cortisol puts an end to the stress response by sending an all-safe signal, and that, in PTSD, the body’s stress hormones do, in fact, not return to baseline after the threat has passed.
Ideally our stress hormone system should provide a lightning-fast response to threat, but then quickly return us to equilibrium. In PTSD patients, however, the stress hormone system fails at this balancing act.
Fight/flight/freeze signals continue after the danger is over, and, as in the case of the dogs, do not return to normal. Instead, the continued secretion of stress hormones is expressed as agitation and panic and, in the long term, wreaks havoc with their health.
I missed my plane that day because I had to talk with Steve Maier. His workshop offered clues not only about the underlying problems of my patients but also potential keys to their resolution. For example, he and Seligman had found that the only way to teach the traumatized dogs to get off the electric grids when the doors were open was to repeatedly drag them out of their cages so they could physically experience how they could get away. I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control? What if they could be taught to physically move to escape a potentially threatening situation that was similar to the trauma in which they had been trapped and immobilized? As I will discuss in the treatment part 5 of this book, that was one of the conclusions I eventually reached.
Further animal studies involving mice, rats, cats, monkeys, and elephants brought more intriguing data.10 For example, when researchers played a loud, intrusive sound, mice that had been raised in a warm nest with plenty of food scurried home immediately. But another group, raised in a noisy nest with scarce food supplies, also ran for home, even after spending time in more pleasant surroundings.11
Scared animals return home, regardless of whether home is safe or frightening. I thought about my patients with abusive families who kept going back to be hurt again. Are traumatized people condemned to seek refuge in what is familiar? If so, why, and is it possible to help them become attached to places and activities that are safe and pleasurable?

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

One of the things that struck my colleague Mark Greenberg and me when we ran therapy groups for Vietnam combat veterans was how, despite their feelings of horror and grief, many of them seemed to come to life when they talked about their helicopter crashes and their dying comrades.
(Former New York Times correspondent Chris Hedges, who covered a number of brutal conflicts, entitled his book War Is a Force That Gives Us Meaning.13) Many traumatized people seem to seek out experiences that would repel most of us,14 and patients often complain about a vague sense

of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity.
My patient Julia was brutally raped at gunpoint in a hotel room at age sixteen. Shortly thereafter she got involved with a violent pimp who prostituted her. He regularly beat her up. She was repeatedly jailed for prostitution, but she always went back to her pimp. Finally her grandparents intervened and paid for an intense rehab program. After she successfully completed inpatient treatment, she started working as a receptionist and taking courses at a local college. In her sociology class she wrote a term paper about the liberating possibilities of prostitution, for which she read the memoirs of several famous prostitutes. She gradually dropped all her other courses. A brief relationship with a classmate quickly went sour—he bored her to tears, she said, and she was repelled by his boxer shorts. She then picked up an addict on the subway who first beat her up and then started to stalk her. She finally became motivated to return to treatment when she was once again severely beaten.
Freud had a term for such traumatic reenactments: “the compulsion to repeat.” He and many of his followers believed that reenactments were an unconscious attempt to get control over a painful situation and that they eventually could lead to mastery and resolution. There is no evidence for that theory—repetition leads only to further pain and self-hatred. In fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation.
Mark Greenberg and I decided to learn more about attractors—the things that draw us, motivate us, and make us feel alive. Normally attractors are meant to make us feel better. So, why are so many people attracted to dangerous or painful situations? We eventually found a study that explained how activities that cause fear or pain can later become thrilling experiences.15 In the 1970s Richard Solomon of the University of Pennsylvania had shown that the body learns to adjust to all sorts of stimuli.
We may get hooked on recreational drugs because they right away make us feel so good, but activities like sauna bathing, marathon running, or parachute jumping, which initially cause discomfort and even terror, can ultimately become very enjoyable. This gradual adjustment signals that a new chemical balance has been established within the body, so that marathon runners, say, get a sense of well-being and exhilaration from pushing their bodies to the limit.
At this point, just as with drug addiction, we start to crave the activity and experience withdrawal when it’s not available. In the long run people become more preoccupied with the pain of withdrawal than the activity itself. This theory could explain why some people hire someone to beat them, or burn themselves with cigarettes. or why they are only attracted to people who hurt them. Fear and aversion, in some perverse way, can be transformed into pleasure.
Solomon hypothesized that endorphins—the morphinelike chemicals that the brain secretes in response to stress—play a role in the paradoxical addictions he described. I thought of his theory again when my library habit led me to a paper titled “Pain in Men Wounded in Battle,” published in 1946. Having observed that 75 percent of severely wounded soldiers on the Italian front did not request morphine, a surgeon by the name of Henry K.
Beecher speculated that “strong emotions can block pain.”16
Were Beecher’s observations relevant to people with PTSD? Mark Greenberg, Roger Pitman, Scott Orr, and I decided to ask eight Vietnam combat veterans if they would be willing to take a standard pain test while they watched scenes from a number of movies. The first clip we showed was from Oliver Stone’s graphically violent Platoon (1986), and while it ran we measured how long the veterans could keep their right hands in a bucket of ice water. We then repeated this process with a peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their hands in the painfully cold water 30 percent longer during Platoon. We then calculated that the amount of analgesia produced by watching fifteen minutes of a combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain.
We concluded that Beecher’s speculation that “strong emotions can block pain” was the result of the release of morphinelike substances manufactured in the brain. This suggested that for many traumatized people, reexposure to stress might provide a similar relief from anxiety.17 It was an interesting experiment, but it did not fully explain why Julia kept going back to her violent pimp.

SOOTHING THE BRAIN

The 1985 ACNP meeting was, if possible, even more thought provoking than the previous year’s session. Kings College professor Jeffrey Gray gave a talk about the amygdala, a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat. Gray’s data showed that the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.18
That struck me as an important finding: My patients were always blowing up in response to small provocations and felt devastated by the slightest rejection. I became fascinated by the possible role of serotonin in PTSD. Other researchers had shown that dominant male monkeys had much higher levels of brain serotonin than lower-ranking animals but that their serotonin levels dropped when they were prevented from maintaining eye contact with the monkeys they had once lorded over. In contrast, lowranking monkeys who were given serotonin supplements emerged from the pack to assume leadership.19 The social environment interacts with brain chemistry. Manipulating a monkey into a lower position in the dominance hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the rank of former subordinates.
The implications for traumatized people were obvious. Like Gray’s low-serotonin animals, they were hyperreactive, and their ability to cope socially was often compromised. If we could find ways to increase brain serotonin levels, perhaps we could address both problems simultaneously.
At that same 1985 meeting I learned that drug companies were developing two new products to do precisely that, but since neither was yet available, I experimented briefly with the health-food-store supplement L-tryptophan, which is a chemical precursor of serotonin in the body. (The results were disappointing.) One of the drugs under investigation never made it to the market. The other was fluoxetine, which, under the brand name Prozac, became one of the most successful psychoactive drugs ever created.
On Monday, February 8, 1988, Prozac was released by the drug company Eli Lilly. The first patient I saw that day was a young woman with a horrendous history of childhood abuse who was now struggling with bulimia—she basically spent much of her life bingeing and purging. I gave her a prescription for this brand-new drug, and when she returned on Thursday she said, “I’ve had a very different last few days: I ate when I was hungry, and the rest of the time I did my schoolwork.” This was one of the most dramatic statements I had ever heard in my office.
On Friday I saw another patient to whom I’d given Prozac the previous Monday. She was a chronically depressed mother of two school-aged children, preoccupied with her failures as a mother and wife and overwhelmed by demands from the parents who had badly mistreated her as a child. After four days on Prozac she asked me if she could skip her appointment the following Monday, which was Presidents’ Day. “After all,” she explained, “I’ve never taken my kids skiing—my husband always does —and they are off that day. It would really be nice for them to have some good memories of us having fun together.”
This was a patient who had always struggled merely to get through the day. After her appointment I called someone I knew at Eli Lilly and said,
“You have a drug that helps people to be in the present, instead of being locked in the past.” Lilly later gave me a small grant to study the effects of Prozac on PTSD in sixty-four people—twenty-two women and forty-two men—the first study of the effects of this new class of drugs on PTSD. Our Trauma Clinic team enrolled thirty-three nonveterans and my collaborators, former colleagues at the VA, enrolled thirty-one combat veterans. For eight weeks half of each group received Prozac and the other half a placebo. The study was blinded: Neither we nor the patients knew which substance they were taking, so that our preconceptions could not skew our assessments.
Everyone in the study—even those who had received the placebo— improved, at least to some degree. Most treatment studies of PTSD find a significant placebo effect. People who screw up their courage to participate in a study for which they aren’t paid, in which they’re repeatedly poked with needles, and in which they have only a fifty-fifty chance of getting an active drug are intrinsically motivated to solve their problem. Maybe their reward is only the attention paid to them, the opportunity to respond to questions about how they feel and think. But maybe the mother’s kisses that soothe her child’s scrapes are “just” a placebo as well.
Prozac worked significantly better than the placebo for the patients from the Trauma Clinic. They slept more soundly; they had more control over their emotions and were less preoccupied with the past than those who received a sugar pill.20 Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged.
These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modest improvements, most have not benefited at all. I have never been able to explain this, and I cannot accept the most common explanation: that receiving a pension or disability benefits prevents people from getting better. After all, the amygdala knows nothing of pensions—it just detects threats.
Nonetheless, medications such as Prozac and related drugs like Zoloft,
Celexa, Cymbalta, and Paxil, have made a substantial contribution to the treatment of trauma-related disorders. In our Prozac study we used the Rorschach test to measure how traumatized people perceive their surroundings. These data gave us an important clue to how this class of drugs (formally known as selective serotonin reuptake inhibitors, or SSRIs) might work. Before taking Prozac these patients’ emotions controlled their reactions. I think of a Dutch patient, for example (not in the Prozac study) who came to see me for treatment for a childhood rape and who was convinced that I would rape her as soon as she heard my Dutch accent.
Prozac made a radical difference: It gave PTSD patients a sense of perspective21 and helped them to gain considerable control over their impulses. Jeffrey Gray must have been right: When their serotonin levels rose, many of my patients became less reactive.

THE TRIUMPH OF PHARMACOLOGY
 The new generation of antipsychotics, such as Abilify, Risperdal,
Zyprexa, and Seroquel, are the top-selling drugs in the United States. In 2012 the public spent $1,526,228,000 on Abilify, more than on any other medication. Number three was Cymbalta, an antidepressant that sold well over a billion dollars’ worth of pills,25 even though it has never been shown to be superior to older antidepressants like Prozac, for which much cheaper generics are available. Medicaid, the government health program for the poor, spends more on antipsychotics than on any other class of drugs.26 In 2008, the most recent year for which complete data are available, it funded $3.6 billion for antipsychotic medications, up from $1.65 billion in 1999.
The number of people under the age of twenty receiving Medicaid-funded prescriptions for antipsychotic drugs tripled between 1999 and 2008. On November 4, 2013, Johnson & Johnson agreed to pay more than $2.2 billion in criminal and civil fines to settle accusations that it had improperly promoted the antipsychotic drug Risperdal to older adults, children, and people with developmental disabilities.27 But nobody is holding the doctors who prescribed them accountable.
Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines. These medications often are used to make abused and neglected children more tractable. In 2008 19,045 children age five and under were prescribed antipsychotics through Medicaid.28 One study, based on Medicaid data in thirteen states, found that 12.4 percent of children in foster care received antipsychotics, compared with 1.4 percent of Medicaid-eligible children in general.29 These medications make children more manageable and less aggressive, but they also interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society. Children who take them are also at risk of becoming morbidly obese and developing diabetes. Meanwhile, drug overdoses involving a combination of psychiatric and pain medications continue to rise.30
Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31
Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered.

ADAPTATION OR DISEASE?

The brain-disease model overlooks four fundamental truths:

(1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring wellbeing;

(2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning;

(3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and

(4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

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

Ch 3 - Looking into the brain - the neuroscience revolution

Harvard Medical School was and is at the forefront of the neuroscience revolution, and in 1994 a young psychiatrist, Scott Rauch, was appointed as the first director of the Massachusetts General Hospital Neuroimaging Laboratory. After considering the most relevant questions that this new technology could answer and reading some articles I had written, Scott asked me whether I thought we could study what happens in the brains of people who have flashbacks.
I had just finished a study on how trauma is remembered (to be discussed in chapter 12), in which participants repeatedly told me how upsetting it was to be suddenly hijacked by images, feelings, and sounds from the past. When several said they wished they knew what trick their brains were playing on them during these flashbacks, I asked eight of them if they would be willing to return to the clinic and lie still inside a scanner (an entirely new experience that I described in detail) while we re-created a scene from the painful events that haunted them. To my surprise, all eight agreed, many of them expressing their hope that what we learned from their suffering could help other people.
My research assistant, Rita Fisler, who was working with us prior to entering Harvard Medical School, sat down with every participant and carefully constructed a script that re-created their trauma moment to moment. We deliberately tried to collect just isolated fragments of their experience—particular images, sounds, and feelings—rather than the entire story, because that is how trauma is experienced. Rita also asked the participants to describe a scene where they felt safe and in control. One person described her morning routine; another, sitting on the porch of a farmhouse in Vermont overlooking the hills. We would use this script for a second scan, to provide a baseline measurement.
After the participants checked the scripts for accuracy (reading silently, which is less overwhelming than hearing or speaking), Rita made a voice recording that would be played back to them while they were in the scanner.
A typical script: You are six years old and getting ready for bed. You hear your mother and father yelling at each other. You are frightened and your stomach is in a knot. You and your younger brother and sister are huddled at the top of the stairs. You look over the banister and see your father holding your mother’s arms while she struggles to free herself. Your mother is crying, spitting and hissing like an animal. Your face is flushed and you feel hot all over. When your mother frees herself, she runs to the dining room and breaks a very expensive Chinese vase. You yell at your parents to stop, but they ignore you. Your mom runs upstairs and you hear her breaking the TV. Your little brother and sister try to get her to hide in the closet.
Your heart pounds and you are trembling.
At this first session we explained the purpose of the radioactive oxygen the participants would be breathing: As any part of the brain became more or less metabolically active, its rate of oxygen consumption would immediately change, which would be picked up by the scanner. We would monitor their blood pressure and heart rate throughout the procedure, so that these physiological signs could be compared with brain activity.
Several days later the participants came to the imaging lab. Marsha, a forty-year-old schoolteacher from a suburb outside of Boston, was the first volunteer to be scanned. Her script took her back to the day, thirteen years earlier, when she picked up her five-year-old daughter, Melissa, from day camp. As they drove off, Marsha heard a persistent beeping, indicating that Melissa’s seatbelt was not properly fastened. When Marsha reached over to adjust the belt, she ran a red light. Another car smashed into hers from the right, instantly killing her daughter. In the ambulance on the way to the emergency room, the seven-month-old fetus Marsha was carrying also died.
Overnight Marsha had changed from a cheerful woman who was the life of the party into a haunted and depressed person filled with self-blame.
She moved from classroom teaching into school administration, because working directly with children had become intolerable—as for many parents who have lost children, their happy laughter had become a powerful trigger. Even hiding behind her paperwork she could barely make it through the day. In a futile attempt to keep her feelings at bay, she coped by working day and night.
I was standing outside the scanner as Marsha underwent the procedure and could follow her physiological reactions on a monitor. The moment we turned on the tape recorder, her heart started to race, and her blood pressure jumped. Simply hearing the script similar activated the same physiological responses that had occurred during the accident thirteen years earlier. After the recorded script concluded and Marsha’s heart rate and blood pressure returned to normal, we played her second script: getting out of bed and brushing her teeth. This time her heart rate and blood pressure did not change.
As she emerged from the scanner, Marsha looked defeated, drawn out, and frozen. Her breathing was shallow, her eyes were opened wide, and her shoulders were hunched—the very image of vulnerability and defenselessness. We tried to comfort her, but I wondered if whatever we discovered would be worth the price of her distress.



Picturing the brain on trauma. Bright spots in (A) the limbic brain, and (B) the visual cortex, show heightened activation. In drawing (C) the brain’s speech center shows markedly decreased activation.
After all eight participants completed the procedure, Scott Rauch went to work with his mathematicians and statisticians to create composite images that compared the arousal created by a flashback with the brain in neutral. After a few weeks he sent me the results, which you see above. I taped the scans up on the refrigerator in my kitchen, and for the next few months I stared at them every evening. It occurred to me that this was how early astronomers must have felt when they peered through a telescope at a new constellation.
There were some puzzling dots and colors on the scan, but the biggest area of brain activation—a large red spot in the right lower center of the brain, which is the limbic area, or emotional brain—came as no surprise. It was already well known that intense emotions activate the limbic system, in particular an area within it called the amygdala. We depend on the amygdala to warn us of impending danger and to activate the body’s stress response. Our study clearly showed that when traumatized people are presented with images, sounds, or thoughts related to their particular experience, the amygdala reacts with alarm—even, as in Marsha’s case, thirteen years after the event. Activation of this fear center triggers the cascade of stress hormones and nerve impulses that drive up blood pressure, heart rate, and oxygen intake—preparing the body for fight or flight.1 The monitors attached to Marsha’s arms recorded this physiological state of frantic arousal, even though she never totally lost track of the fact that she was resting quietly in the scanner.

SPEECHLESS HORROR

Our most surprising finding was a white spot in the left frontal lobe of the cortex, in a region called Broca’s area. In this case the change in color meant that there was a significant decrease in that part of the brain. Broca’s area is one of the speech centers of the brain, which is often affected in stroke patients when the blood supply to that region is cut off. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. In other words, we had visual proof that the effects of trauma are not necessarily different from—and can overlap with—the effects of physical lesions like strokes.
All trauma is preverbal. Shakespeare captures this state of speechless terror in Macbeth, after the murdered king’s body is discovered: “Oh horror! horror! horror! Tongue nor heart cannot conceive nor name thee! Confusion now hath made his masterpiece!” Under extreme conditions people may scream obscenities, call for their mothers, howl in terror, or simply shut down. Victims of assaults and accidents sit mute and frozen in emergency rooms; traumatized children “lose their tongues” and refuse to speak. Photographs of combat soldiers show hollow-eyed men staring mutely into a void.
Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies reexperience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate. Trauma by nature drives us to the edge of comprehension, cutting us off from language based on common experience or an imaginable past.
This doesn’t mean that people can’t talk about a tragedy that has befallen them. Sooner or later most survivors, like the veterans in chapter 1, come up with what many of them call their “cover story” that offers some explanation for their symptoms and behavior for public consumption. These stories, however, rarely capture the inner truth of the experience. It is enormously difficult to organize one’s traumatic experiences into a coherent account—a narrative with a beginning, a middle, and an end. Even a seasoned reporter like the famed CBS correspondent Ed Murrow struggled to convey the atrocities he saw when the Nazi concentration camp Buchenwald was liberated in 1945: “I pray you believe what I have said. I reported what I saw and heard, but only part of it. For most of it I have no words.”
When words fail, haunting images capture the experience and return as nightmares and flashbacks. In contrast to the deactivation of Broca’s area, another region, Brodmann’s area 19, lit up in our participants. This is a region in the visual cortex that registers images when they first enter the brain. We were surprised to see brain activation in this area so long after the original experience of the trauma. Under ordinary conditions raw images registered in area 19 are rapidly diffused to other brain areas that interpret the meaning of what has been seen. Once again, we were witnessing a brain region rekindled as if the trauma were actually occurring.

SHIFTING TO ONE SIDE OF THE BRAIN

The scans also revealed that during flashbacks, our subjects’ brains lit up only on the right side. Today there’s a huge body of scientific and popular literature about the difference between the right and left brains. Back in the early nineties I had heard that some people had begun to divide the world between left-brainers (rational, logical people) and right-brainers (the intuitive, artistic ones), but I hadn’t paid much attention to this idea.
However, our scans clearly showed that images of past trauma activate the right hemisphere of the brain and deactivate the left.
We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical. While the left half of the brain does all the talking, the right half of the brain carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing, or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants.
We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experiences to others.
The left and right sides of the brain also process the imprints of the past in dramatically different ways.2 The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, smell, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past. What it recalls feels like intuitive truth—the way things are. Even as we enumerate a loved one’s virtues to a friend, our feelings may be more deeply stirred by how her face recalls the aunt we loved at age four.3
Under ordinary circumstances the two sides of the brain work together more or less smoothly, even in people who might be said to favor one side over the other. However, having one side or the other shut down, even temporarily, or having one side cut off entirely (as sometimes happened in early brain surgery) is disabling.
Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words. (Broca’s area, which blacks out during flashbacks, is on the left side.) Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future. People who are very upset sometimes say they are “losing their minds.” In technical terms they are experiencing the loss of executive functioning.
When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present. But because their left brain is not working very well, they may not be aware that they are reexperiencing and reenacting the past—they are just furious, terrified, enraged, ashamed, or frozen. After the emotional storm passes, they may look for something or somebody to blame for it. They behaved the way they did way because you were ten minutes late, or because you burned the potatoes, or because you “never listen to me.” Of course, most of us have done this from time to time, but when we cool down, we hopefully can admit our mistake. Trauma interferes with this kind of awareness, and, over time, our research demonstrated why.

STUCK IN FIGHT OR FLIGHT

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

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

We now know that there is another possible response to threat, which our scans aren’t yet capable of measuring. Some people simply go into denial: Their bodies register the threat, but their conscious minds go on as if nothing has happened. However, even though the mind may learn to ignore the messages from the emotional brain, the alarm signals don’t stop. The emotional brain keeps working, and stress hormones keep sending signals to the muscles to tense for action or immobilize in collapse. The physical effects on the organs go on unabated until they demand notice when they are expressed as illness. Medications, drugs, and alcohol can also temporarily dull or obliterate unbearable sensations and feelings. But the body continues to keep the score.
We can interpret what happened to Marsha in the scanner from several different perspectives, each of which has implications for treatment. We can focus on the neurochemical and physiological disruptions that were so evident and make a case that she is suffering from a biochemical imbalance that is reactivated whenever she is reminded of her daughter’s death. We might then search for a drug or a combination of drugs that would damp down the reaction or, in the best case, restore her chemical equilibrium.
Based on the results of our scans, some of my colleagues at MGH began investigating drugs that might make people less responsive to the effects of elevated adrenaline.
We can also make a strong case that Marsha is hypersensitized to her memories of the past and that the best treatment would be some form of desensitization.4 After repeatedly rehearsing the details of the trauma with a therapist, her biological responses might become muted, so that she could realize and remember that “that was then and this is now,” rather than reliving the experience over and over.
For a hundred years or more, every textbook of psychology and psychotherapy has advised that some method of talking about distressing feelings can resolve them. However, as we’ve seen, the experience of trauma itself gets in the way of being able to do that. No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality. I am continually impressed by how difficult it is for people who have gone through the unspeakable to convey the essence of their experience. It is so much easier for them to talk about what has been done to them—to tell a story of victimization and revenge—than to notice, feel, and put into words the reality of their internal experience.
Our scans had revealed how their dread persisted and could be triggered by multiple aspects of daily experience. They had not integrated their experience into the ongoing stream of their life. They continued to be “there” and did not know how to be “here”—fully alive in the present.
Three years after being a participant in our study Marsha came to see me as a patient. I successfully treated her with EMDR, the subject of chapter 15.

PART TWO:THIS IS YOUR BRAIN ON TRAUMA

CH 4: RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL

On September 11, 2001, five-year-old Noam Saul witnessed the first passenger plane slam into the World Trade Center from the windows of his first-grade classroom at PS 234, less than 1,500 feet away. He and his classmates ran with their teacher down the stairs to the lobby, where most of them were reunited with parents who had dropped them off at school just moments earlier. Noam, his older brother, and their dad were three of the tens of thousands of people who ran for their lives through the rubble, ash, and smoke of lower Manhattan that morning.
Ten days later I visited his family, who are friends of mine, and that evening his parents and I went for a walk in the eerie darkness through the still-smoking pit where Tower One once stood, making our way among the rescue crews who were working around the clock under the blazing klieg lights. When we returned home, Noam was still awake, and he showed me a picture that he had drawn at 9:00 a.m. on September 12. The drawing depicted what he had seen the day before: an airplane slamming into the tower, a ball of fire, firefighters, and people jumping from the tower’s windows. But at the bottom of the picture he had drawn something else: a black circle at the foot of the buildings. I had no idea what it was, so I asked him. “A trampoline,” he replied. What was a trampoline doing there? Noam explained, “So that the next time when people have to jump they will be safe.” I was stunned: This five-year-old boy, a witness to unspeakable mayhem and disaster just twenty-four hours before he made that drawing, had used his imagination to process what he had seen and begin to go on with his life.
Noam was fortunate. His entire family was unharmed, he had grown up surrounded by love, and he was able to grasp that the tragedy they had witnessed had come to an end. During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.



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


But Noam’s experience allows us to see in outline two critical aspects of the adaptive response to threat that is basic to human survival. At the time the disaster occurred, he was able to take an active role by running away from it, thus becoming an agent in his own rescue. And once he had reached the safety of home, the alarm bells in his brain and body quieted.
This freed his mind to make some sense of what had happened and even to imagine a creative alternative to what he had seen—a lifesaving trampoline.
In contrast to Noam, traumatized people become stuck, stopped in their growth because they can’t integrate new experiences into their lives. I was very moved when the veterans of Patton’s army gave me a World War II army-issue watch for Christmas, but it was a sad memento of the year their lives had effectively stopped: 1944. Being traumatized means continuing to organize your life as if the trauma were still going on—unchanged and immutable—as every new encounter or event is contaminated by the past.


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


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

ORGANIZED TO SURVIVE

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



Effective action versus immobilization. 

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

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

THE BRAIN FROM BOTTOM TO TOP

The most important job of the brain is to ensure our survival, even under the most miserable conditions. Everything else is secondary. In order to do that, brains need to: (1) generate internal signals that register what our bodies need, such as food, rest, protection, sex, and shelter;

(2) create a map of the world to point us where to go to satisfy those needs;

(3) generate the necessary energy and actions to get us there;

(4) warn us of dangers and opportunities along the way; and

(5) adjust our actions based on the requirements of the moment.

And since we human beings are mammals, creatures that can only survive and thrive in groups, all of these imperatives require coordination and collaboration. Psychological problems occur when our internal signals don’t work, when our maps don’t lead us where we need to go, when we are too paralyzed to move, when our actions do not correspond to our needs, or when our relationships break down. Every brain structure that I discuss has a role to play in these essential functions, and as we will see, trauma can interfere with every one of them.

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

Brain Stem - The Reptilian Brain
 The brain is built from the bottom up. It develops level by level within every child in the womb, just as it did in the course of evolution. The most primitive part, the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain. It is located in the brain stem, just above the place where our spinal cord enters the skull. The reptilian brain is responsible for all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating.

The brain stem and the hypothalamus (which sits directly above it) together control the energy levels of the body. They coordinate the functioning of the heart and lungs and also the endocrine and immune systems, ensuring that these basic lifesustaining systems are maintained within the relatively stable internal balance known as homeostasis.

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

Limbic System - The Mammalian Brain

Right above the reptilian brain is the limbic system. It’s also known as the mammalian brain, because all animals that live in groups and nurture their young possess one. Development of this part of the brain truly takes off after a baby is born. It is the seat of the emotions, the monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is or is not important for survival purposes. It is also a central command post for coping with the challenges of living within our complex social networks.
The limbic system is shaped in response to experience, in partnership with the infant’s own genetic makeup and inborn temperament. (As all parents of more than one child quickly notice, babies differ from birth in the intensity and nature of their reactions to similar events.) Whatever happens to a baby contributes to the emotional and perceptual map of the world that its developing brain creates. As my colleague Bruce Perry explains it, the brain is formed in a “use-dependent manner.”5 This is another way of describing neuroplasticity, the relatively recent discovery that neurons that “fire together, wire together.” When a circuit fires repeatedly, it can become a default setting—the response most likely to occur. If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment.
As infants and toddlers we learn about the world by moving, grabbing, and crawling and by discovering what happens when we cry, smile, or protest. We are constantly experimenting with our surroundings—how do our interactions change the way our bodies feel? Attend any two-year-old’s birthday party and notice how little Kimberly will engage you, play with you, flirt with you, without any need for language. These early explorations shape the limbic structures devoted to emotions and memory, but these structures can also be significantly modified by later experiences: for the better by a close friendship or a beautiful first love, for example, or for the worse by a violent assault, relentless bullying, or neglect.

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

Neocortex - Our rational brain

The emotional brain’s cellular organization and biochemistry are simpler than those of the neocortex, our rational brain, and it assesses incoming information in a more global way. As a result, it jumps to conclusions based on rough similarities, in contrast with the rational brain, which is organized to sort through a complex set of options. (The textbook example is leaping back in terror when you see a snake—only to realize that it’s just a coiled rope.) The emotional brain initiates preprogrammed escape plans, like the fight-or-flight responses. These muscular and physiological reactions are automatic, set in motion without any thought or planning on our part, leaving our conscious, rational capacities to catch up later, often well after the threat is over.
Finally we reach the top layer of the brain, the neocortex. We share this outer layer with other mammals, but it is much thicker in us humans. In the second year of life the frontal lobes, which make up the bulk of our neocortex, begin to develop at a rapid pace. The ancient philosophers called seven years “the age of reason.” For us first grade is the prelude of things to come, a life organized around frontal-lobe capacities: sitting still; keeping sphincters in check; being able to use words rather than acting out; understanding abstract and symbolic ideas; planning for tomorrow; and being in tune with teachers and classmates.

The frontal lobes are responsible for the qualities that make us unique within the animal kingdom. They enable us to use language and abstract thought. They give us our ability to absorb and integrate vast amounts of information and attach meaning to it. Despite our excitement about the linguistic feats of chimpanzees and rhesus monkeys, only human beings command the words and symbols necessary to create the communal, spiritual, and historical contexts that shape our lives.
The frontal lobes allow us to plan and reflect, to imagine and play out future scenarios. They help us to predict what will happen if we take one action (like applying for a new job) or neglect another (not paying the rent).
They make choice possible and underlie our astonishing creativity.
Generations of frontal lobes, working in close collaboration, have created culture, which got us from dug-out canoes, horse-drawn carriages, and letters to jet planes, hybrid cars, and e-mail. They also gave us Noam’s lifesaving trampoline.

MIRRORING EACH OTHER: INTERPERSONAL NEUROBIOLOGY

Crucial for understanding trauma, the frontal lobes are also the seat of empathy—our ability to “feel into” someone else. One of the truly sensational discoveries of modern neuroscience took place in 1994, when in a lucky accident a group of Italian scientists identified specialized cells in the cortex that came to be known as mirror neurons.8 The researchers had attached electrodes to individual neurons in a monkey’s premotor area, then set up a computer to monitor precisely which neurons fired when the monkey picked up a peanut or grasped a banana. At one point an experimenter was putting food pellets into a box when he looked up at the computer. The monkey’s brain cells were firing at the exact location where the motor command neurons were located. But the monkey wasn’t eating or moving. He was watching the researcher, and his brain was vicariously mirroring the researcher’s actions.
Numerous other experiments followed around the world, and it soon became clear that mirror neurons explained many previously unexplainable aspects of the mind, such as empathy, imitation, synchrony, and even the development of language. One writer compared mirror neurons to “neural WiFi”9—we pick up not only another person’s movement but her emotional state and intentions as well. When people are in sync with each other, they tend to stand or sit similar ways, and their voices take on the same rhythms.
But our mirror neurons also make us vulnerable to others’ negativity, so that we respond to their anger with fury or are dragged down by their depression. I’ll have more to say about mirror neurons later in this book, because trauma almost invariably involves not being seen, not being mirrored, and not being taken into account. Treatment needs to reactivate the capacity to safely mirror, and be mirrored, by others, but also to resist being hijacked by others’ negative emotions.



The Triune (Three-part) Brain. The brain develops from the bottom up.
The reptilian brain develops in the womb and organizes basic life sustaining functions. It is highly responsive to threat throughout our entire life span.

The limbic system is organized mainly during the first six years of life but continues to evolve in a use-dependent manner. Trauma can have a major impact of its functioning throughout life.

The prefrontal cortex develops last, and also is affected by trauma exposure, including being unable to filter out irrelevant information.
Throughout life it is vulnerable to go off-line in response to threat.

As anybody who has worked with brain-damaged people or taken care of demented parents has learned the hard way, well-functioning frontal lobes are crucial for harmonious relationships with our fellow humans.
Realizing that other people can think and feel differently from us is a huge developmental step for two- and three-year-olds. They learn to understand others’ motives, so they can adapt and stay safe in groups that have different perceptions, expectations, and values. Without flexible, active frontal lobes people become creatures of habit, and their relationships become superficial and routine. Invention and innovation, discovery and wonder—all are lacking.
Our frontal lobes can also (sometimes, but not always) stop us from doing things that will embarrass us or hurt others. We don’t have to eat every time we’re hungry, kiss anybody who rouses our desires, or blow up every time we’re angry. But it is exactly on that edge between impulse and acceptable behavior where most of our troubles begin. The more intense the visceral, sensory input from the emotional brain, the less capacity the rational brain has to put a damper on it.

IDENTIFYING DANGER: THE COOK AND THE SMOKE DETECTOR

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

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



The emotional brain has first dibs on interpreting incoming information. 

Sensory Information about the environment and body state received by the eyes, ears, touch, kinesthetic sense, etc., converges on the thalamus, where it is processed, and then passed on to the amygdala to interpret its emotional significance. This occurs with lightning speed. If a threat is detected the amygdala sends messages to the hypothalamus to secrete stress hormones to defend against that threat. The neuroscientist Joseph LeDoux calls this the low road.

The second neural pathway, the high road, runs from the thalamus, via the hippocampus and anterior cingulate, to the prefrontal cortex, the rational brain, for a conscious and much more refined interpretation. This takes several microseconds longer. If the interpretation of threat by the amygdala is too intense, and/or the filtering system from the higher areas of the brain are too weak, as often happens in PTSD, people lose control over automatic emergency responses, like prolonged startle or aggressive outbursts. 

The amygdala’s danger signals trigger the release of powerful stress hormones, including cortisol and adrenaline, which increase heart rate, blood pressure, and rate of breathing, preparing us to fight back or run away. Once the danger is past, the body returns to its normal state fairly quickly. But when recovery is blocked, the body is triggered to defend itself, which makes people feel agitated and aroused.
While the smoke detector is usually pretty good at picking up danger clues, trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe. You can get along with other people only if you can accurately gauge whether their intentions are benign or dangerous.
Even a slight misreading can lead to painful misunderstandings in relationships at home and at work. Functioning effectively in a complex work environment or a household filled with rambunctious kids requires the ability to quickly assess how people are feeling and continuously adjusting your behavior accordingly. Faulty alarm systems lead to blowups or shutdowns in response to innocuous comments or facial expressions.

CONTROLLING THE STRESS RESPONSE: THE WATCHTOWER

If the amygdala is the smoke detector in the brain, think of the frontal lobes —and specifically the medial prefrontal cortex (MPFC),12 located directly above our eyes—as the watchtower, offering a view of the scene from on high. Is that smoke you smell the sign that your house is on fire and you need to get out, fast—or is it coming from the steak you put over too high a flame? The amygdala doesn’t make such judgments; it just gets you ready to fight back or escape, even before the frontal lobes get a chance to weigh in with their assessment. As long as you are not too upset, your frontal lobes can restore your balance by helping you realize that you are responding to a false alarm and abort the stress response.
Ordinarily the executive capacities of the prefrontal cortex enable people to observe what is going on, predict what will happen if they take a certain action, and make a conscious choice. Being able to hover calmly and objectively over our thoughts, feelings, and emotions (an ability I’ll call mindfulness throughout this book) and then take our time to respond allows the executive brain to inhibit, organize, and modulate the hardwired automatic reactions preprogrammed into the emotional brain. This capacity is crucial for preserving our relationships with our fellow human beings. As long as our frontal lobes are working properly, we’re unlikely to lose our temper every time a waiter is late with our order or an insurance company agent puts us on hold. (Our watchtower also tells us that other people’s anger and threats are a function of their emotional state.) When that system breaks down, we become like conditioned animals: The moment we detect danger we automatically go into fight-or-flight mode.



Top down or bottom up. 

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

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

Effectively dealing with stress depends upon achieving a balance between the smoke detector and the watchtower. If you want to manage your emotions better, your brain gives you two options: You can learn to regulate them from the top down or from the bottom up.
Knowing the difference between top down and bottom up regulation is central for understanding and treating traumatic stress. Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations. Mindfulness meditation and yoga can help with this.
Bottom-up regulation involves recalibrating the autonomic nervous system,
(which, as we have seen, originates in the brain stem). We can access the ANS through breath, movement, or touch. Breathing is one of the few body functions under both conscious and autonomic control. In part 5 of this book we’ll explore specific techniques for increasing both top-down and bottom-up regulation.

THE RIDER AND THE HORSE

For now I want to emphasize that emotion is not opposed to reason; our emotions assign value to experiences and thus are the foundation of reason.
Our self-experience is the product of the balance between our rational and our emotional brains. When these two systems are in balance, we “feel like ourselves.” However, when our survival is at stake, these systems can function relatively independently.
If, say, you are driving along, chatting with a friend, and a truck suddenly looms in the corner of your eye, you instantly stop talking, slam on the brakes, and turn your steering wheel to get out of harm’s way. If your instinctive actions have saved you from a collision, you may resume where you left off. Whether you are able to do so depends largely on how quickly your visceral reactions subside to the threat.
The neuroscientist Paul MacLean, who developed the three-part description of the brain that I’ve used here, compared the relationship between the rational brain and the emotional brain to that between a more or less competent rider and his unruly horse. As long as the weather is calm and the path is smooth, the rider can feel in excellent control. But unexpected sounds or threats from other animals can make the horse bolt, forcing the rider to hold on for dear life. Likewise, when people feel that their survival is at stake or they are seized by rages, longings, fear, or sexual desires, they stop listening to the voice of reason, and it makes little sense to argue with them. Whenever the limbic system decides that something is a question of life or death, the pathways between the frontal lobes and the limbic system become extremely tenuous.
Psychologists usually try to help people use insight and understanding to manage their behavior. However, neuroscience research shows that very few psychological problems are the result of defects in understanding; most originate in pressures from deeper regions in the brain that drive our perception and attention. When the alarm bell of the emotional brain keeps signaling that you are in danger, no amount of insight will silence it. I am reminded of the comedy in which a seven-time recidivist in an angermanagement program extols the virtue of the techniques he’s learned: “They are great and work terrific—as long as you are not really angry.”
When our emotional and rational brains are in conflict (as when we’re enraged with someone we love, frightened by someone we depend on, or lust after someone who is off limits), a tug-of-war ensues. This war is largely played out in the theater of visceral experience—your gut, your heart, your lungs—and will lead to both physical discomfort and psychological misery. Chapter 6 will discuss how the brain and viscera interact in safety and danger, which is key to understanding the many physical manifestations of trauma.
I’d like to end this chapter by examining two more brain scans that illustrate some of the core features of traumatic stress: timeless reliving; reexperiencing images, sounds, and emotions; and dissociation.

STAN AND UTE’S BRAINS ON TRAUMA

On a fine September morning in 1999, Stan and Ute Lawrence, a professional couple in their forties, set out from their home in London,
Ontario, to attend a business meeting in Detroit. Halfway through the journey they ran into a wall of dense fog that reduced visibility to zero in a split second. Stan immediately slammed on the brakes, coming to a standstill sideways on the highway, just missing a huge truck. An eighteenwheeler went flying over the trunk of their car; vans and cars slammed into them and into each other. People who got out of their cars were hit as they ran for their lives. The ear-splitting crashes went on and on—with each jolt from behind they felt this would be the one that killed them. Stan and Ute were trapped in car number thirteen of an eighty-seven-car pileup, the worst road disaster in Canadian history.15
Then came the eerie silence. Stan struggled to open the doors and windows, but the eighteen-wheeler that had crushed their trunk was wedged against the car. Suddenly, someone was pounding on their roof. A girl was screaming, “Get me out of here—I’m on fire!” Helplessly, they saw her die as the car she’d been in was consumed by flames. The next thing they knew, a truck driver was standing on the hood of their car with a fire extinguisher. He smashed the windshield to free them, and Stan climbed through the opening. Turning around to help his wife, he saw Ute sitting frozen in her seat. Stan and the truck driver lifted her out and an ambulance took them to an emergency room. Aside from a few cuts, they were found to be physically unscathed.
At home that night, neither Stan nor Ute wanted to go to sleep. They felt that if they let go, they would die. They were irritable, jumpy, and on edge. That night, and for many to come, they drank copious quantities of wine to numb their fear. They could not stop the images that were haunting them or the questions that went on and on: What if they’d left earlier? What if they hadn’t stopped for gas? After three months of this, they sought help from Dr. Ruth Lanius, a psychiatrist at the University of Western Ontario.
Dr. Lanius, who had been my student at the Trauma Center a few years earlier, told Stan and Ute she wanted to visualize their brains with an fMRI scan before beginning treatment. The fMRI measures neural activity by tracking changes in blood flow in the brain, and unlike the PET scan, it does not require exposure to radiation. Dr. Lanius used the same kind of script-driven imagery we had used at Harvard, capturing the images, sounds, smells, and other sensations Stan and Ute had experienced while they were trapped in the car.
Stan went first and immediately went into a flashback, just as Marsha had in our Harvard study. He came out of the scanner sweating, with his heart racing and his blood pressure sky high. “This was just the way I felt during the accident,” he reported. “I was sure I was going to die, and there was nothing I could do to save myself.” Instead of remembering the accident as something that had happened three months earlier, Stan was reliving it.

DISSOCIATION AND RELIVING

Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts, and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. As long as the trauma is not resolved, the stress hormones that the body secretes to protect itself keep circulating, and the defensive movements and emotional responses keep getting replayed. Unlike Stan, however, many people may not be aware of the connection between their “crazy” feelings and reactions and the traumatic events that are being replayed. They have no idea why they respond to some minor irritation as if they were about to be annihilated.
Flashbacks and reliving are in some ways worse that the trauma itself.
A traumatic event has a beginning and an end—at some point it is over. But for people with PTSD a flashback can occur at any time, whether they are awake or asleep. There is no way of knowing when it’s going to occur again or how long it will last. People who suffer from flashbacks often organize their lives around trying to protect against them. They may compulsively go to the gym to pump iron (but finding that they are never strong enough), numb themselves with drugs, or try to cultivate an illusory sense of control in highly dangerous situations (like motorcycle racing, bungee jumping, or working as an ambulance driver). Constantly fighting unseen dangers is exhausting and leaves them fatigued, depressed, and weary.
If elements of the trauma are replayed again and again, the accompanying stress hormones engrave those memories ever more deeply in the mind. Ordinary, day-to-day events become less and less compelling.
Not being able to deeply take in what is going on around them makes it impossible to feel fully alive. It becomes harder to feel the joys and aggravations of ordinary life, harder to concentrate on the tasks at hand. Not being fully alive in the present keeps them more firmly imprisoned in the past.
Triggered responses manifest in various ways. Veterans may react to the slightest cue—like hitting a bump in the road or a seeing a kid playing in the street—as if they were in a war zone. They startle easily and become enraged or numb. Victims of childhood sexual abuse may anesthetize their sexuality and then feel intensely ashamed if they become excited by sensations or images that recall their molestation, even when those sensations are the natural pleasures associated with particular body parts. If trauma survivors are forced to discuss their experiences, one person’s blood pressure may increase while another responds with the beginnings of a migraine headache. Still others may shut down emotionally and not feel any obvious changes. However, in the lab we have no problem detecting their racing hearts and the stress hormones churning through their bodies.
These reactions are irrational and largely outside people’s control.
Intense and barely controllable urges and emotions make people feel crazy —and makes them feel they don’t belong to the human race. Feeling numb during birthday parties for your kids or in response to the death of loved ones makes people feel like monsters. As a result, shame becomes the dominant emotion and hiding the truth the central preoccupation.
They are rarely in touch with the origins of their alienation. That is where therapy comes in—is the beginning of bringing the emotions that were generated by trauma being able to feel, the capacity to observe oneself online. However, the bottom line is that the threat-perception system of the brain has changed, and people’s physical reactions are dictated by the imprint of the past.
The trauma that started “out there” is now played out on the battlefield of their own bodies, usually without a conscious connection between what happened back then and what is going on right now inside. The challenge is not so much learning to accept the terrible things that have happened but learning how to gain mastery over one’s internal sensations and emotions.
Sensing, naming, and identifying what is going on inside is the first step to recovery.

THE SMOKE DETECTOR GOES ON OVERDRIVE

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



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

THE TIMEKEEPER COLLAPSES

Both Stan and Ute had become hypersensitive and irritable after the accident, suggesting that their prefrontal cortex was struggling to maintain control in the face of stress. Stan’s flashback precipitated a more extreme reaction.
The two white areas in the front of the brain (on top in the picture) are the right and left dorsolateral prefrontal cortex. When those areas are deactivated, people lose their sense of time and become trapped in the moment, without a sense of past, present, or future.16
Two brain systems are relevant for the mental processing of trauma: those dealing with emotional intensity and context. Emotional intensity is defined by the smoke alarm, the amygdala, and its counterweight, the watchtower, the medial prefrontal cortex. The context and meaning of an experience are determined by the system that includes the dorsolateral prefrontal cortex (DLPFC) and the hippocampus. The DLPFC is located to the side in the front brain, while the MPFC is in the center. The structures along the midline of the brain are devoted to your inner experience of yourself, those on the side are more concerned with your relationship with your surroundings.
The DLPFC tells us how our present experience relates to the past and how it may affect the future—you can think of it as the timekeeper of the brain. Knowing that whatever is happening is finite and will sooner or later come to an end makes most experiences tolerable. The opposite is also true —situations become intolerable if they feel interminable. Most of us know from sad personal experience that terrible grief is typically accompanied by the sense that this wretched state will last forever, and that we will never get over our loss. Trauma is the ultimate experience of “this will last forever.”
Stan’s scan reveals why people can recover from trauma only when the brain structures that were knocked out during the original experience— which is why the event registered in the brain as trauma in the first place— are fully online. Visiting the past in therapy should be done while people are, biologically speaking, firmly rooted in the present and feeling as calm, safe, and grounded as possible. (“Grounded” means that you can feel your butt in your chair, see the light coming through the window, feel the tension in your calves, and hear the wind stirring the tree outside.) Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past. For that to happen, the brain’s watchtower, cook, and timekeeper need to be online. Therapy won’t work as long as people keep being pulled back into the past.

THE THALAMUS SHUTS DOWN

Look again at the scan of Stan’s flashback, and you can see two more white holes in the lower half of the brain. These are his right and left thalamus— blanked out during the flashback as they were during the original trauma.
As I’ve said, the thalamus functions as a “cook”—a relay station that collects sensations from the ears, eyes, and skin and integrates them into the soup that is our autobiographical memory. Breakdown of the thalamus explains why trauma is primarily remembered not as a story, a narrative with a beginning middle and end, but as isolated sensory imprints: images, sounds, and physical sensations that are accompanied by intense emotions, usually terror and helplessness.17
In normal circumstances the thalamus also acts as a filter or gatekeeper.
This makes it a central component of attention, concentration, and new learning—all of which are compromised by trauma. As you sit here reading, you may hear music in the background or traffic rumbling by or feel a faint gnawing in your stomach telling you it’s time for a snack. If you are able to stay focused on this page, your thalamus is helping you distinguish between sensory information that is relevant and information that you can safely ignore. In chapter 19, on neurofeedback, I’ll discuss some of the tests we use to measure how well this gating system works, as well as ways to strengthen it.
People with PTSD have their floodgates wide open. Lacking a filter, they are on constant sensory overload. In order to cope, they try to shut themselves down and develop tunnel vision and hyperfocus. If they can’t shut down naturally, they may enlist drugs or alcohol to block out the world. The tragedy is that the price of closing down includes filtering out sources of pleasure and joy, as well.

DEPERSONALIZATION: SPLIT OFF FROM THE SELF

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



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

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

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

After seeing Ute’s scan, I started to take a very different approach toward blanked-out patients. With nearly every part of their brains tuned out, they obviously cannot think, feel deeply, remember, or make sense out of what is going on. Conventional talk therapy, in those circumstances, is virtually useless.
In Ute’s case it was possible to guess why she responded so differently from Stan. She was utilizing a survival strategy her brain had learned in childhood to cope with her mother’s harsh treatment. Ute’s father died when she was nine years old, and her mother subsequently was often nasty and demeaning to her. At some point Ute discovered that she could blank out her mind when her mother yelled at her. Thirty-five years later, when she was trapped in her demolished car, Ute’s brain automatically went into the same survival mode—she made herself disappear.

The challenge for people like Ute is to become alert and engaged, a difficult but unavoidable task if they want to recapture their lives. (Ute herself did recover—she wrote a book about her experiences and started a successful journal called Mental Fitness.) This is where a bottom-up approach to therapy becomes essential. The aim is actually to change the patient’s physiology, his or her relationship to bodily sensations. At the Trauma Center we work with such basic measures as heart rate and breathing patterns. We help patients evoke and notice bodily sensations by tapping acupressure19 points. Rhythmic interactions with other people are also effective—tossing a beach ball back and forth, bouncing on a Pilates ball, drumming, or dancing to music.

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

LEARNING TO LIVE IN THE PRESENT
 

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

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

CH 5: BODY-BRAIN CONNECTIONS

Darwin in his 1872 publication 'Expression of the Emotions in Man and Animals' starts his discussion by noting the physical organization common to all mammals, including human beings—the lungs, kidneys, brains, digestive organs, and sexual organs that sustain and continue life.
Although many scientists today would accuse him of anthropomorphism,
Darwin stands with animal lovers when he proclaims: “Man and the higher animals... [also] have instincts in common. All have the same senses, intuition, sensation, passions, affections, and emotions, even the more complex ones such as jealousy, suspicion, emulation, gratitude, and magnanimity." He observes that we humans share some of the physical signs of animal emotion. Feeling the hair on the back of your neck stand up when you’re frightened or baring your teeth when you’re enraged can only be understood as vestiges of a long evolutionary process.

 
 

 

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

For Darwin mammalian emotions are fundamentally rooted in biology: They are the indispensable source of motivation to initiate action. Emotions (from the Latin emovere—to move out) give shape and direction to whatever we do, and their primary expression is through the muscles of the face and body. These facial and physical movements communicate our mental state and intention to others:

# Angry expressions and threatening postures caution them to back off.

# Sadness attracts care and attention.

# Fear signals helplessness or alerts us to danger.

We instinctively read the dynamic between two people simply from their tension or relaxation, their postures and tone of voice, their changing facial expressions. Watch a movie in a language you don’t know, and you can still guess the quality of the relationship between the characters. We often can read other mammals (monkeys, dogs, horses) in the same way.
Darwin goes on to observe that the fundamental purpose of emotions is to initiate movement that will restore the organism to safety and physical equilibrium. Here is his comment on the origin of what today we would call PTSD:

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

In other words: If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love. For us humans, it means that as long as the mind is defending itself against invisible assaults, our closest bonds are threatened, along with our ability to imagine, plan, play, learn, and pay attention to other people’s needs.
Darwin also wrote about body-brain connections that we are still exploring today. Intense emotions involve not only the mind but also the gut and the heart: “Heart, guts, and brain communicate intimately via the ‘pneumogastric’ nerve, the critical nerve involved in the expression and management of emotions in both humans and animals. When the mind is strongly excited, it instantly affects the state of the viscera; so that under excitement there will be much mutual action and reaction between these, the two most important organs of the body.”

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

A WINDOW INTO THE NERVOUS SYSTEM

All of the little signs we instinctively register during a conversation—the muscle shifts and tensions in the other person’s face, eye movements and pupil dilation, pitch and speed of the voice—as well as the fluctuations in our own inner landscape—salivation, swallowing, breathing, and heart rate —are linked by a single regulatory system.5 All are a product of the synchrony between the two branches of the autonomic nervous system (ANS): the sympathetic, which acts as the body’s accelerator, and the parasympathetic, which serves as its brake.6 These are the “reciprocals”
Darwin spoke of, and working together they play an important role in managing the body’s energy flow, one preparing for its expenditure, the other for its conservation.
The sympathetic nervous system (SNS) is responsible for arousal, including the fight-or-flight response (Darwin’s “escape or avoidance behavior”). Almost two thousand years ago the Roman physician Galen gave it the name “sympathetic” because he observed that it functioned with the emotions (sym pathos). The SNS moves blood to the muscles for quick action, partly by triggering the adrenal glands to squirt out adrenaline, which speeds up the heart rate and increases blood pressure.
The second branch of the ANS is the parasympathetic (“against emotions”) nervous system (PNS), which promotes self-preservative functions like digestion and wound healing. It triggers the release of acetylcholine to put a brake on arousal, slowing the heart down, relaxing muscles, and returning breathing to normal. As Darwin pointed out,
“feeding, shelter, and mating activities” depend on the PNS.

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


THE NEURAL LOVE CODE

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

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

Human beings are astoundingly attuned to subtle emotional shifts in the people (and animals) around them. Slight changes in the tension of the brow, wrinkles around the eyes, curvature of the lips, and angle of the neck quickly signal to us how comfortable, suspicious, relaxed, or frightened someone is.9 Our mirror neurons register their inner experience, and our own bodies make internal adjustments to whatever we notice. Just so, the muscles of our own faces give others clues about how calm or excited we feel, whether our heart is racing or quiet, and whether we’re ready to pounce on them or run away. When the message we receive from another person is “You’re safe with me,” we relax. If we’re lucky in our relationships, we also feel nourished, supported, and restored as we look into the face and eyes of the other.
Our culture teaches us to focus on personal uniqueness, but at a deeper level we barely exist as individual organisms. Our brains are built to help us function as members of a tribe. We are part of that tribe even when we are by ourselves, whether listening to music (that other people created), watching a basketball game on television (our own muscles tensing as the players run and jump), or preparing a spreadsheet for a sales meeting (anticipating the boss’s reactions). Most of our energy is devoted to connecting with others.
If we look beyond the list of specific symptoms that entail formal psychiatric diagnoses, we find that almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal (as in the case of habitually becoming enraged, shut down, overexcited, or disorganized). Usually it’s a combination of both. The standard medical focus on trying to discover the right drug to treat a particular “disorder” tends to distract us from grappling with how our problems interfere with our functioning as members of our tribe.

SAFETY AND RECIPROCITY

A few years ago I heard Jerome Kagan, a distinguished emeritus professor of child psychology at Harvard, say to the Dalai Lama that for every act of cruelty in this world there are hundreds of small acts of kindness and connection. His conclusion: “To be benevolent rather than malevolent is probably a true feature of our species.” Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives. Numerous studies of disaster response around the globe have shown that social support is the most powerful protection against becoming overwhelmed by stress and trauma.
Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart.
For our physiology to calm down, heal, and grow we need a visceral feeling of safety. No doctor can write a prescription for friendship and love: These are complex and hard-earned capacities. You don’t need a history of trauma to feel self-conscious and even panicked at a party with strangers—but trauma can turn the whole world into a gathering of aliens.
Many traumatized people find themselves chronically out of sync with the people around them. Some find comfort in groups where they can replay their combat experiences, rape, or torture with others who have similar backgrounds or experiences. Focusing on a shared history of trauma and victimization alleviates their searing sense of isolation, but usually at the price of having to deny their individual differences: Members can belong only if they conform to the common code.
Isolating oneself into a narrowly defined victim group promotes a view of others as irrelevant at best and dangerous at worst, which eventually only leads to further alienation. Gangs, extremist political parties, and religious cults may provide solace, but they rarely foster the mental flexibility needed to be fully open to what life has to offer and as such cannot liberate their members from their traumas. Well-functioning people are able to accept individual differences and acknowledge the humanity of others.

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

THREE LEVELS OF SAFETY

After trauma the world is experienced with a different nervous system that has an altered perception of risk and safety. Porges coined the word “neuroception” to describe the capacity to evaluate relative danger and safety in one’s environment. When we try to help people with faulty neuroception, the great challenge is finding ways to reset their physiology, so that their survival mechanisms stop working against them. This means helping them to respond appropriately to danger but, even more, to recover the capacity to experience safety, relaxation, and true reciprocity.
I have extensively interviewed and treated six people who survived plane crashes. Two reported having lost consciousness during the incident; even though they were not physically injured, they collapsed mentally. Two went into a panic and stayed frantic until well after we had started treatment. Two remained calm and resourceful and helped evacuate fellow passengers from the burning wreckage. I’ve found a similar range of responses in survivors of rape, car crashes, and torture. In the previous chapter we saw the radically different reactions of Stan and Ute as they relived the highway disaster they’d experienced side by side. What accounts for this spectrum of responses: focused, collapsed, or frantic? Porges’s theory provides an explanation: The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time. Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse.

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



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




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


Any threat to our safety or social connections triggers changes in the areas innervated by the VVC. When something distressing happens, we automatically signal our upset in our facial expressions and tone of voice, changes meant to beckon others to come to our assistance.11 However, if no one responds to our call for help, the threat increases, and the older limbic brain jumps in. The sympathetic nervous system takes over, mobilizing muscles, heart, and lungs for fight or flight.12 Our voice becomes faster and more strident and our heart starts pumping faster. If a dog is in the room, she will stir and growl, because she can smell the activation of our sweat glands.
Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart “drop”), we can’t breathe, and our gut stops working or empties (literally “scaring the shit out of” us). This is the point at which we disengage, collapse, and freeze.

FIGHT OR FLIGHT VERSUS COLLAPSE


As we saw in Stan’s and Ute’s brain scans, trauma is expressed not only as fight or flight but also as shutting down and failing to engage in the present.
A different level of brain activity is involved for each response: the mammalian fight-or-flight system, which is protective and keeps us from shutting down, and the reptilian brain, which produces the collapse response. You can see the difference between these two systems at any big pet store. Kittens, puppies, mice and gerbils constantly play around, and when they’re tired they huddle together, skin to skin, in a pile. In contrast, the snakes and lizards lie motionless in the corners of their cages, unresponsive to the environment.13 This sort of immobilization, generated by the reptilian brain, characterizes many chronically traumatized people, as opposed to the mammalian panic and rage that make more recent trauma survivors so frightened and frightening.
Almost everyone knows what that quintessential fight/flight response, road rage, feels like: A sudden threat precipitates an intense impulse to move and attack. Danger turns off our social-engagement system, decreases our responsiveness to the human voice, and increases our sensitivity to threatening sounds. Yet for many people panic and rage are preferable to the opposite: shutting down and becoming dead to the world. Activating flight/flight at least makes them feel energized. That is why so many abused and traumatized people feel fully alive in the face of actual danger, while they go numb in situations that are more complex but objectively safe, like birthday parties or family dinners.
When fighting or running does not take care of the threat, we activate the last resort—the reptilian brain, the ultimate emergency system. This system is most likely to engage when we are physically immobilized, as when we are pinned down by an attacker or when a child has no escape from a terrifying caregiver. Collapse and disengagement are controlled by the DVC, an evolutionarily ancient part of the parasympathetic nervous system that is associated with digestive symptoms like diarrhea and nausea.
It also slows down the heart and induces shallow breathing. Once this system takes over, other people, and we ourselves, cease to matter.
Awareness is shut down, and we may no longer even register physical pain.

HOW WE BECOME HUMAN

In Porges’s grand theory the VVC evolved in mammals to support an increasingly complex social life. All mammals, including human beings, band together to mate, nurture their young, defend against common enemies, and coordinate hunting and food acquisition. The more efficiently the VVC synchronizes the activity of the sympathetic and parasympathetic nervous systems, the better the physiology of each individual will be attuned to that of other members of the tribe.
Thinking about the VVC in this way illuminates how parents naturally help their kids to regulate themselves. Newborn babies are not very social; they sleep most of the time and wake up when they’re hungry or wet. After having been fed they may spend a little time looking around, fussing, or staring, but they will soon be asleep again, following their own internal rhythms. Early in life they are pretty much at the mercy of the alternating tides of their sympathetic and parasympathetic nervous systems, and their reptilian brain runs most of the show.
But day by day, as we coo and smile and cluck at them, we stimulate the growth of synchronicity in the developing VVC. These interactions help to bring our babies’ emotional arousal systems into sync with their surroundings. The VVC controls sucking, swallowing, facial expression, and the sounds produced by the larynx. When these functions are stimulated in an infant, they are accompanied by a sense of pleasure and safety, which helps create the foundation for all future social behavior.14 As my friend Ed Tronick taught me a long time ago, the brain is a cultural organ— experience shapes the brain.
Being in tune with other members of our species via the VVC is enormously rewarding. What begins as the attuned play of mother and child continues with the rhythmicity of a good basketball game, the synchrony of tango dancing, and the harmony of choral singing or playing a piece of jazz or chamber music—all of which foster a deep sense of pleasure and connection.
We can speak of trauma when that system fails: when you beg for your life, but the assailant ignores your pleas; when you are a terrified child lying in bed, hearing your mother scream as her boyfriend beats her up; when you see your buddy trapped under a piece of metal that you’re not strong enough to lift; when you want to push away the priest who is abusing you, but you’re afraid you’ll be punished. Immobilization is at the root of most traumas. When that occurs the DVC is likely to take over: Your heart slows down, your breathing becomes shallow, and, zombielike, you lose touch with yourself and your surroundings. You dissociate, faint and collapse.

DEFEND OR RELAX?

Steve Porges helped me realize that the natural state of mammals is to be somewhat on guard. However, in order to feel emotionally close to another human being, our defensive system must temporarily shut down. In order to play, mate, and nurture our young, the brain needs to turn off its natural vigilance.
Many traumatized individuals are too hypervigilant to enjoy the ordinary pleasures that life has to offer, while others are too numb to absorb new experiences—or to be alert to signs of real danger. When the smoke detectors of the brain malfunction, people no longer run when they should be trying to escape or fight back when they should be defending themselves. The landmark ACE (Adverse Childhood Experiences) study, which I’ll discuss in more detail in chapter 9, showed that women who had an early history of abuse and neglect were seven times more likely to be raped in adulthood. Women who, as children, had witnessed their mothers being assaulted by their partners had a vastly increased chance to fall victim to domestic violence.15
Many people feel safe as long as they can limit their social contact to superficial conversations, but actual physical contact can trigger intense reactions. However, as Porges points out, achieving any sort of deep intimacy—a close embrace, sleeping with a mate, and sex—requires allowing oneself to experience immobilization without fear.16 It is especially challenging for traumatized people to discern when they are actually safe and to be able to activate their defenses when they are in danger. This requires having experiences that can restore the sense of physical safety, a topic to which we’ll return many times in the chapters that follow.

NEW APPROACHES TO TREATMENT

If we understand that traumatized children and adults get stuck in fight/flight or in chronic shut-down, how do we help them to deactivate these defensive maneuvers that once ensured their survival? Some gifted people who work with trauma survivors know how to do this intuitively. Steve Gross used to run the play program at the Trauma Center. Steve often walked around the clinic with a brightly colored beach ball, and when he saw angry or frozen kids in the waiting room, he would flash them a big smile. The kids rarely responded. Then, a little later, he would return and “accidentally” drop his ball close to where a kid was sitting. As Steve leaned over to pick it up, he’d nudge it gently toward the kid, who’d usually give a halfhearted push in return. Gradually Steve got a back-and-forth going, and before long you’d see smiles on both faces.
From simple, rhythmically attuned movements, Steve had created a small, safe place where the social-engagement system could begin to reemerge. In the same way, severely traumatized people may get more out of simply helping to arrange chairs before a meeting or joining others in tapping out a musical rhythm on the chair seats than they would from sitting in those same chairs and discussing the failures in their life.
One thing is certain: Yelling at someone who is already out of control can only lead to further dysregulation. Just as your dog cowers if you shout and wags his tail when you speak in a high singsong, we humans respond to harsh voices with fear, anger, or shutdown and to playful tones by opening up and relaxing. We simply cannot help but respond to these indicators of safety or danger.
Sadly, our educational system, as well as many of the methods that profess to treat trauma, tend to bypass this emotional-engagement system and focus instead on recruiting the cognitive capacities of the mind. Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain before trying to promote new ways of thinking. The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement. When children are oppositional, defensive, numbed out, or enraged, it’s also important to recognize that such “bad behavior” may repeat action patterns that were established to survive serious threats, even if they are intensely upsetting or off-putting.
Porges’s work has had a profound effect on how my Trauma Center colleagues and I organize the treatment of abused children and traumatized adults. It’s true that we would probably have developed a therapeutic yoga program for women at some point, given that yoga had proved so successful in helping them calm down and get in touch with their dissociated bodies.
We would also have been likely to experiment with a theater program in the Boston inner-city schools, with a karate program for rape survivors called impact model mugging, and with play techniques and body modalities like sensory stimulation that have now been used with survivors around the world. (All of these and more will be explored in part 5.) But the polyvagal theory helped us understand and explain why all these disparate, unconventional techniques worked so well. It enabled us to become more conscious of combining top-down approaches (to activate social engagement) with bottom-up methods (to calm the physical tensions in the body). We were more open to the value of other age-old, nonpharmacological approaches to health that have long been practiced outside Western medicine, ranging from breath exercises (pranayama) and chanting to martial arts like qigong to drumming and group singing and dancing. All rely on interpersonal rhythms, visceral awareness, and vocal and facial communication, which help shift people out of fight/flight states, reorganize their perception of danger, and increase their capacity to manage relationships.
If the memory of trauma is encoded in the viscera, in heartbreaking and gut-wrenching emotions, in autoimmune disorders and skeletal/muscular problems, and if mind / brain / visceral communication is the royal road to emotion regulation, this demands a radical shift in our therapeutic assumptions.
    
CH 6: LOSING YOUR BODY, LOSING YOUR SELF 




Be patient toward all that is unsolved in your heart and try to love the questions themselves.... Live the questions now. Perhaps you will gradually, without noticing it, live along some distant day into the answer.
—Rainer Maria Rilke, Letters to a Young Poet

Sherry walked into my office with her shoulders slumped, her chin nearly touching her chest. Even before we spoke a word, her body was telling me that she was afraid to face the world. I also noticed that her long sleeves only partially covered the scabs on her forearms. After sitting down, she told me in a high-pitched monotone that she couldn’t stop herself from picking at the skin on her arms and chest until she bled.
As far back as Sherry could remember, her mother had run a foster home, and their house was often packed with as many as fifteen strange, disruptive, frightened, and frightening kids who disappeared as suddenly as they arrived. Sherry had grown up taking care of these transient children, feeling that there was no room for her and her needs. “I know I wasn’t wanted,” she told me. “I’m not sure when I first realized that, but I’ve thought about things that my mother said to me, and the signs were always there. She’d tell me, ‘You know, I don’t think you belong in this family. I think they gave us the wrong baby.’ And she’d say it with a smile on her face. But, of course, people often pretend to joke when they say something serious.”
Over the years our research team has repeatedly found that chronic emotional abuse and neglect can be just as devastating as physical abuse and sexual molestation. Sherry turned out to be a living example of these findings: Not being seen, not being known, and having nowhere to turn to feel safe is devastating at any age, but it is particularly destructive for young children, who are still trying to find their place in the world.
Sherry had graduated from college, but she now worked in a joyless clerical job, lived alone with her cats, and had no close friends. When I asked her about men, she told me that her only “relationship” had been with a man who’d kidnapped her while she was on a college vacation in Florida.
He’d held her captive and raped her repeatedly for five consecutive days.
She remembered having been curled up, terrified and frozen for most of that time, until she realized she could try to get away. She escaped by simply walking out while he was in the bathroom. When she called her mother collect for help, her mother refused to take the call. Sherry finally managed to get home with assistance from a domestic violence shelter.
Sherry told me that she’d started to pick at her skin because it gave her some relief from feeling numb. The physical sensations made her feel more alive but also deeply ashamed—she knew she was addicted to these actions but could not stop them. She’d consulted many mental health professionals before me and had been questioned repeatedly about her “suicidal behavior.” She’d also been subjected to involuntary hospitalization by a psychiatrist who refused to treat her unless she could promise that she would never pick at herself again. However, in my experience, patients who cut themselves or pick at their skin like Sherry, are seldom suicidal but are trying to make themselves feel better in the only way they know.
This is a difficult concept for many people to understand. As I discussed in the previous chapter, the most common response to distress is to seek out people we like and trust to help us and give us the courage to go on. We may also calm down by engaging in a physical activity like biking or going to the gym. We start learning these ways of regulating our feelings from the first moment someone feeds us when we’re hungry, covers us when we’re cold, or rocks us when we’re hurt or scared.
But if no one has ever looked at you with loving eyes or broken out in a smile when she sees you; if no one has rushed to help you (but instead said,
“Stop crying, or I’ll give you something to cry about”), then you need to discover other ways of taking care of yourself. You are likely to experiment with anything—drugs, alcohol, binge eating, or cutting—that offers some kind of relief.
While Sherry dutifully came to every appointment and answered my questions with great sincerity, I did not feel we were making the sort of vital connection that is necessary for therapy to work. Struck by how frozen and uptight she was, I suggested that she see Liz, a massage therapist I had worked with previously. During their first meeting Liz positioned Sherry on the massage table, then moved to the end of the table and gently held Sherry’s feet. Lying there with her eyes closed, Sherry suddenly yelled in a panic: “Where are you?” Somehow Sherry had lost track of Liz, even though Liz was right there, with her hands on Sherry’s feet.
Sherry was one of the first patients who taught me about the extreme disconnection from the body that so many people with histories of trauma and neglect experience. I discovered that my professional training, with its focus on understanding and insight, had largely ignored the relevance of the living, breathing body, the foundation of our selves. Sherry knew that picking her skin was a destructive thing to do and that it was related to her mother’s neglect, but understanding the source of the impulse made no difference in helping her control it.

LOSING YOUR BODY

Once I was alerted to this, I was amazed to discover how many of my patients told me they could not feel whole areas of their bodies. Sometimes I’d ask them to close their eyes and tell me what I had put into their outstretched hands. Whether it was a car key, a quarter, or a can opener, they often could not even guess what they were holding—their sensory perceptions simply weren’t working.
I talked this over with my friend Alexander McFarlane in Australia, who had observed the same phenomenon. In his laboratory in Adelaide he had studied the question: How do we know without looking at it that we’re holding a car key? Recognizing an object in the palm of your hand requires sensing its shape, weight, temperature, texture, and position. Each of those distinct sensory experiences is transmitted to a different part of the brain, which then needs to integrate them into a single perception. McFarlane found that people with PTSD often have trouble putting the picture together.

When our senses become muffled, we no longer feel fully alive. In an article called “What Is an Emotion?” (1884), William James, the father of American psychology, reported a striking case of “sensory insensibility” in a woman he interviewed: “I have... no human sensations,” she told him.

“[I am] surrounded by all that can render life happy and agreeable, still to me the faculty of enjoyment and of feeling is wanting.... Each of my senses, each part of my proper self, is as it were separated from me and can no longer afford me any feeling; this impossibility seems to depend upon a void which I feel in the front of my head, and to be due to the diminution of the sensibility over the whole surface of my body, for it seems to me that I never actually reach the objects which I touch. All this would be a small matter enough, but for its frightful result, which is that of the impossibility of any other kind of feeling and of any sort of enjoyment, although I experience a need and desire of them that render my life an incomprehensible torture.”

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

HOW DO WE KNOW WE’RE ALIVE?

Most early neuroimaging studies of traumatized people were like those we’ve seen in chapter 3; they focused on how subjects reacted to specific reminders of the trauma. Then, in 2004, my colleague Ruth Lanius, who scanned Stan and Ute Lawrence’s brains, posed a new question: What happens in the brains of trauma survivors when they are not thinking about the past? Her studies on the idling brain, the “default state network” (DSN), opened up a whole new chapter in understanding how trauma affects selfawareness, specifically sensory self-awareness.
Dr. Lanius recruited a group of sixteen “normal” Canadians to lie in a brain scanner while thinking about nothing in particular. This is not easy for anyone to do—as long as we are awake, our brains are churning—but she asked them to focus their attention on their breathing and try to empty their minds as much as possible. She then repeated the same experiment with eighteen people who had histories of severe, chronic childhood abuse.
What is your brain doing when you have nothing in particular on your mind? It turns out that you pay attention to yourself: The default state activates the brain areas that work together to create your sense of “self.”

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

 

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

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

There could be only one explanation for such results: In response to the trauma itself, and in coping with the dread that persisted long afterward, these patients had learned to shut down the brain areas that transmit the visceral feelings and emotions that accompany and define terror. Yet in everyday life, those same brain areas are responsible for registering the entire range of emotions and sensations that form the foundation of our selfawareness, our sense of who we are. What we witnessed here was a tragic adaptation: In an effort to shut off terrifying sensations, they also deadened their capacity to feel fully alive.
The disappearance of medial prefrontal activation could explain why so many traumatized people lose their sense of purpose and direction. I used to be surprised by how often my patients asked me for advice about the most ordinary things, and then by how rarely they followed it. Now I understood that their relationship with their own inner reality was impaired. How could they make decisions, or put any plan into action, if they couldn’t define what they wanted or, to be more precise, what the sensations in their bodies, the basis of all emotions, were trying to tell them? The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror.
Brain scans show that this is not the result of mere inattention: The structures in charge of self-recognition may be knocked out along with the structures related to self-experience.
When Ruth Lanius showed me her study, a phrase from my classical high school education came back to me. The mathematician Archimedes, teaching about the lever, is supposed to have said: “Give me a place to stand and I will move the world.” Or, as the great twentieth-century body therapist Moshe Feldenkrais put it: “You can't do what you want till you know what you’re doing.” The implications are clear: to feel present you have to know where you are and be aware of what is going on with you. If the self-sensing system breaks down we need to find ways to reactivate it.

THE SELF-SENSING SYSTEM

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

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

He goes on to describe how this “screen” can work in our favor by enabling us to attend to pressing problems in the outside world. Yet it has a cost: "It tends to prevent us from sensing the possible origin and nature of what we call self." Building on the century-old work of William James, Damasio argues that the core of our self-awareness rests on the physical sensations that convey the inner states of the body: [P]rimordial feelings provide a direct experience of one’s own living body, wordless, unadorned, and connected to nothing but sheer existence. These primordial feelings reflect the current state of the body along varied dimensions,... along the scale that ranges from pleasure to pain, and they originate at the level of the brain stem rather than the cerebral cortex. All feelings of emotion are complex musical variations on primordial feelings.

Our sensory world takes shape even before we are born. In the womb we feel amniotic fluid against our skin, we hear the faint sounds of rushing blood and a digestive tract at work, we pitch and roll with our mother’s movements. After birth, physical sensation defines our relationship to ourselves and to our surroundings. We start off being our wetness, hunger, satiation, and sleepiness. A cacophony of incomprehensible sounds and images presses in on our pristine nervous system. Even after we acquire consciousness and language, our bodily sensing system provides crucial feedback on our moment-to-moment condition. Its constant hum communicates changes in our viscera and in the muscles of our face, torso, and extremities that signal pain and comfort, as well as urges such as hunger and sexual arousal. What is taking place around us also affects our physical sensations. Seeing someone we recognize, hearing particular sounds—a piece of music, a siren—or sensing a shift in temperature all change our focus of attention and, without our being aware of it, prime our subsequent thoughts and actions.
As we have seen, the job of the brain is to constantly monitor and evaluate what is going on within and around us. These evaluations are transmitted by chemical messages in the bloodstream and electrical messages in our nerves, causing subtle or dramatic changes throughout the body and brain. These shifts usually occur entirely without conscious input or awareness: The subcortical regions of the brain are astoundingly efficient in regulating our breathing, heartbeat, digestion, hormone secretion, and immune system. However, these systems can become overwhelmed if we are challenged by an ongoing threat, or even the perception of threat. This accounts for the wide array of physical problems researchers have documented in traumatized people.
Yet our conscious self also plays a vital role in maintaining our inner equilibrium: We need to register and act on our physical sensations to keep our bodies safe. Realizing we’re cold compels us to put on a sweater; feeling hungry or spacey tells us our blood sugar is low and spurs us to get a snack; the pressure of a full bladder sends us to the bathroom. Damasio points out that all of the brain structures that register background feelings are located near areas that control basic housekeeping functions, such as breathing, appetite, elimination, and sleep/wake cycles: “This is because the consequences of having emotion and attention are entirely related to the fundamental business of managing life within the organism. It is not possible to manage life and maintain homeostatic balance without data on the current state of the organism’s body.”9 Damasio calls these housekeeping areas of the brain the “proto-self,” because they create the “wordless knowledge” that underlies our conscious sense of self.

THE SELF UNDER THREAT

In 2000 Damasio and his colleagues published an article in the world’s foremost scientific publication, Science, which reported that reliving a strong negative emotion causes significant changes in the brain areas that receive nerve signals from the muscles, gut, and skin—areas that are crucial for regulating basic bodily functions. The team’s brain scans showed that recalling an emotional event from the past causes us to actually reexperience the visceral sensations felt during the original event. Each type of emotion produced a characteristic pattern, distinct from the others. For example, a particular part of the brain stem was “active in sadness and anger, but not in happiness or fear.”10 All of these brain regions are below the limbic system, to which emotions are traditionally assigned, yet we acknowledge their involvement every time we use one of the common expressions that link strong emotions with the body: “You make me sick”;
“It made my skin crawl”; “I was all choked up”; “My heart sank”; “He makes me bristle.”
The elementary self system in the brain stem and limbic system is massively activated when people are faced with the threat of annihilation, which results in an overwhelming sense of fear and terror accompanied by intense physiological arousal. To people who are reliving a trauma, nothing makes sense; they are trapped in a life-or-death situation, a state of paralyzing fear or blind rage. Mind and body are constantly aroused, as if they are in imminent danger. They startle in response to the slightest noises and are frustrated by small irritations. Their sleep is chronically disturbed, and food often loses its sensual pleasures. This in turn can trigger desperate attempts to shut those feelings down by freezing and dissociation.

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

AGENCY: OWNING YOUR LIFE

“Agency” is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances. The veterans who put their fists through drywall at the VA were trying to assert their agency—to make something happen. But they ended up feeling even more out of control, and many of these onceconfident men were trapped in a cycle between frantic activity and immobility.
Agency starts with what scientists call interoception, our awareness of our subtle sensory, body-based feelings: the greater that awareness, the greater our potential to control our lives. Knowing what we feel is the first step to knowing why we feel that way. If we are aware of the constant changes in our inner and outer environment, we can mobilize to manage them. But we can’t do this unless our watchtower, the MPFC, learns to observe what is going on inside us. This is why mindfulness practice, which strengthens the MPFC, is a cornerstone of recovery from trauma.12
After I saw the wonderful movie March of the Penguins, I found myself thinking about some of my patients. The penguins are stoic and endearing, and it’s tragic to learn how, from time immemorial, they have trudged seventy miles inland from the sea, endured indescribable hardships to reach their breeding grounds, lost numerous viable eggs to exposure, and then, almost starving, dragged themselves back to the ocean. If penguins had our frontal lobes, they would have used their little flippers to build igloos, devised a better division of labor, and reorganized their food supplies. Many of my patients have survived trauma through tremendous courage and persistence, only to get into the same kinds of trouble over and over again. Trauma has shut down their inner compass and robbed them of the imagination they need to create something better.
The neuroscience of selfhood and agency validates the kinds of somatic therapies that my friends Peter Levine13 and Pat Ogden14 have developed.
I’ll discuss these and other sensorimotor approaches in more detail in part V, but in essence their aim is threefold:

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

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

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

Our gut feelings signal what is safe, life sustaining, or threatening, even if we cannot quite explain why we feel a particular way. Our sensory interiority continuously sends us subtle messages about the needs of our organism. Gut feelings also help us to evaluate what is going on around us.
They warn us that the guy who is approaching feels creepy, but they also convey that a room with western exposure surrounded by daylilies makes us feel serene. If you have a comfortable connection with your inner sensations—if you can trust them to give you accurate information—you will feel in charge of your body, your feelings, and your self.
However, traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside.
They learn to hide from their selves.

The more people try to push away and ignore internal warning signs, the more likely they are to take over and leave them bewildered, confused, and ashamed. People who cannot comfortably notice what is going on inside become vulnerable to respond to any sensory shift either by shutting down or by going into a panic—they develop a fear of fear itself.
We now know that panic symptoms are maintained largely because the individual develops a fear of the bodily sensations associated with panic attacks. The attack may be triggered by something he or she knows is irrational, but fear of the sensations keeps them escalating into a full-body emergency. “Scared stiff” and “frozen in fear” (collapsing and going numb) describe precisely what terror and trauma feel like. They are its visceral foundation. The experience of fear derives from primitive responses to threat where escape is thwarted in some way. People’s lives will be held hostage to fear until that visceral experience changes.
The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation—from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others.

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

Suppressing our inner cries for help does not stop our stress hormones from mobilizing the body. Even though Sandy had learned to ignore her relationship problems and block out her physical distress signals, they showed up in symptoms that demanded her attention. Her therapy focused on identifying the link between her physical sensations and her emotions, and I also encouraged her to enroll in a kickboxing program. She had no emergency room visits during the three years she was my patient.
Somatic symptoms for which no clear physical basis can be found are ubiquitous in traumatized children and adults. They can include chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma.16 Traumatized children have fifty times the rate of asthma as their nontraumatized peers. Studies have shown that many children and adults with fatal asthma attacks were not aware of having breathing problems before the attacks.

ALEXITHYMIA: NO WORDS FOR FEELINGS

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

Psychiatrists call this phenomenon alexithymia—Greek for not having words for feelings. Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean. They may look furious but deny that they are angry; they may appear terrified but say that they are fine. Not being able to discern what is going on inside their bodies causes them to be out of touch with their needs, and they have trouble taking care of themselves, whether it involves eating the right amount at the right time or getting the sleep they need.
Like my aunt, alexithymics substitute the language of action for that of emotion. When asked, “How would you feel if you saw a truck coming at you at eighty miles per hour?” most people would say, “I’d be terrified” or “I’d be frozen with fear.” An alexithymic might reply, “How would I feel? I don’t know. . . . I’d get out of the way.”18 They tend to register emotions as physical problems rather than as signals that something deserves their attention. Instead of feeling angry or sad, they experience muscle pain, bowel irregularities, or other symptoms for which no cause can be found.
About three quarters of patients with anorexia nervosa, and more than half of all patients with bulimia, are bewildered by their emotional feelings and have great difficulty describing them. When researchers showed pictures of angry or distressed faces to people with alexithymia, they could not figure out what those people were feeling.

One of the first people who taught me about alexithymia was the psychiatrist Henry Krystal, who worked with more than a thousand Holocaust survivors in his effort to understand massive psychic trauma.

Krystal, himself a concentration camp survivor, found that many of his patients were professionally successful, but their intimate relationships were bleak and distant. Suppressing their feelings had made it possible to attend to the business of the world, but at a price. They learned to shut down their once overwhelming emotions, and, as a result, they no longer recognized what they were feeling. Few of them had any interest in therapy.
Paul Frewen at the University of Western Ontario did a series of brain scans of people with PTSD who suffered from alexithymia. One of the participants told him: “I don’t know what I feel, it’s like my head and body aren’t connected. I’m living in a tunnel, a fog, no matter what happens it’s the same reaction—numbness, nothing. Having a bubble bath and being burned or raped is the same feeling. My brain doesn’t feel.” Frewen and his colleague Ruth Lanius found that the more people were out of touch with their feelings, the less activity they had in the self-sensing areas of the brain.
Because traumatized people often have trouble sensing what is going on in their bodies, they lack a nuanced response to frustration. They either react to stress by becoming “spaced out” or with excessive anger. Whatever their response, they often can’t tell what is upsetting them. This failure to be in touch with their bodies contributes to their well-documented lack of selfprotection and high rates of revictimization23 and also to their remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning.
People with alexithymia can get better only by learning to recognize the relationship between their physical sensations and their emotions, much as colorblind people can only enter the world of color by learning to distinguish and appreciate shades of gray. Like my aunt and Henry Krystal’s patients, they usually are reluctant to do that: Most seem to have made an unconscious decision that it is better to keep visiting doctors and treating ailments that don’t heal than to do the painful work of facing the demons of the past.

DEPERSONALIZATION

One step further down on the ladder to self-oblivion is depersonalization— losing your sense of yourself. Ute’s brain scan in chapter 4 is, in its very blankness, a vivid illustration of depersonalization. Depersonalization is common during traumatic experiences. I was once mugged late at night in a park close to my home and, floating above the scene, saw myself lying in the snow with a small head wound, surrounded by three knife-wielding teenagers. I dissociated the pain of their stab wounds on my hands and did not feel the slightest fear as I calmly negotiated for the return of my emptied wallet.
I did not develop PTSD, partly, I think, because I was intensely curious about having an experience I had studied so closely in others, and partly because I had the delusion that I would be able make a drawing of my muggers to show to the police. Of course, they were never caught, but my fantasy of revenge must have given me a satisfying sense of agency.
Traumatized people are not so fortunate and feel separated from their bodies. One particularly good description of depersonalization comes from the German psychoanalyst Paul Schilder, writing in Berlin in 1928:24 “To the depersonalized individual the world appears strange, peculiar, foreign, dream-like. Objects appear at times strangely diminished in size, at times flat. Sounds appear to come from a distance. . . . The emotions likewise undergo marked alteration. Patients complain that they are capable of experiencing neither pain nor pleasure. . . . They have become strangers to themselves.”
I was fascinated to learn that a group of neuroscientists at the University of Geneva25 had induced similar out-of-body experiences by delivering mild electric current to a specific spot in the brain, the temporal parietal junction. In one patient this produced a sensation that she was hanging from the ceiling, looking down at her body; in another it induced an eerie feeling that someone was standing behind her. This research confirms what our patients tell us: that the self can be detached from the body and live a phantom existence on its own. Similarly, Lanius and Frewen, as well as a group of researchers at the University of Groningen in the Netherlands, did brain scans on people who dissociated their terror and found that the fear centers of the brain simply shut down as they recalled the event.

BEFRIENDING THE BODY

Trauma victims cannot recover until they become familiar with and befriend the sensations in their bodies. Being frightened means that you live in a body that is always on guard. Angry people live in angry bodies. The bodies of child-abuse victims are tense and defensive until they find a way to relax and feel safe. In order to change, people need to become aware of their sensations and the way that their bodies interact with the world around them. Physical self-awareness is the first step in releasing the tyranny of the past.
How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies—not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them.
Noticing sensations for the first time can be quite distressing, and it may precipitate flashbacks in which people curl up or assume defensive postures. These are somatic reenactments of the undigested trauma and most likely represent the postures they assumed when the trauma occurred.
Images and physical sensations may deluge patients at this point, and the therapist must be familiar with ways to stem torrents of sensation and emotion to prevent them from becoming retraumatized by accessing the past. (Schoolteachers, nurses, and police officers are often very skilled at soothing terror reactions because many of them are confronted almost daily with out-of-control or painfully disorganized people.) All too often, however, drugs such as Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills to deal with such distressing physical reactions. Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies.
The most natural way for human beings to calm themselves when they are upset is by clinging to another person. This means that patients who have been physically or sexually violated face a dilemma: They desperately crave touch while simultaneously being terrified of body contact. The mind needs to be reeducated to feel physical sensations, and the body needs to be helped to tolerate and enjoy the comforts of touch. Individuals who lack emotional awareness are able, with practice, to connect their physical sensations to psychological events. Then they can slowly reconnect with themselves.

CONNECTING WITH YOURSELF, CONNECTING WITH OTHERS

 

I’ll end this chapter with one final study that demonstrates the cost of losing your body. After Ruth Lanius and her group scanned the idling brain, they focused on another question from everyday life: What happens in chronically traumatized people when they make face-to-face contact? Many patients who come to my office are unable to make eye contact. I immediately know how distressed they are by their difficulty meeting my gaze. It always turns out that they feel disgusting and that they can’t stand having me see how despicable they are. It never occurred to me that these intense feelings of shame would be reflected in abnormal brain activation.
Ruth Lanius once again showed that mind and brain are indistinguishable— what happens in one is registered in the other.
Ruth bought an expensive device that presents a video character to a person lying in a scanner. (In this case, the cartoon resembled a kindly Richard Gere.) The figure can approach either head on (looking directly at the person) or at a forty-five-degree angle with an averted gaze. This made it possible to compare the effects of direct eye contact on brain activation with those of an averted gaze.

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

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

Ch 7: Getting on the same wavelength: Attachment and Attunement



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

The Children’s Clinic at the Massachusetts Mental Health Center was filled with disturbed and disturbing kids. They were wild creatures who could not sit still and who hit and bit other children, and sometimes even the staff. They would run up to you and cling to you one moment and run away, terrified, the next. Some masturbated compulsively; others lashed out at objects, pets, and themselves. They were at once starving for affection and angry and defiant. The girls in particular could be painfully compliant.
Whether oppositional or clingy, none of them seemed able to explore or play in ways typical for children their age. Some of them had hardly developed a sense of self—they couldn’t even recognize themselves in a mirror.
At the time, I knew very little about children, apart from what my two preschoolers were teaching me. But I was fortunate in my colleague Nina Fish-Murray, who had studied with Jean Piaget in Geneva, in addition to raising five children of her own. Piaget based his theories of child development on meticulous, direct observation of children themselves, starting with his own infants, and Nina brought this spirit to the incipient Trauma Center at MMHC.
Nina was married to the former chairman of the Harvard psychology department, Henry Murray, one of the pioneers of personality theory, and she actively encouraged any junior faculty members who shared her interests. She was fascinated by my stories about combat veterans because they reminded her of the troubled kids she worked with in the Boston public schools. Nina’s privileged position and personal charm gave us access to the Children’s Clinic, which was run by child psychiatrists who had little interest in trauma.
Henry Murray had, among other things, become famous for designing the widely used Thematic Apperception Test. The TAT is a so-called projective test, which uses a set of cards to discover how people’s inner reality shapes their view of the world. Unlike the Rorschach cards we used with the veterans, the TAT cards depict realistic but ambiguous and somewhat troubling scenes: a man and a woman gloomily staring away from each other, a boy looking at a broken violin. Subjects are asked to tell stories about what is going on in the photo, what has happened previously, and what happens next. In most cases their interpretations quickly reveal the themes that preoccupy them.
Nina and I decided to create a set of test cards specifically for children, based on pictures we cut out of magazines in the clinic waiting room. Our first study compared twelve six- to eleven-year-olds at the children’s clinic with a group of children from a nearby school who matched them as closely as possible in age, race, intelligence, and family constellation.1 What differentiated our patients was the abuse they had suffered within their families. They included a boy who was severely bruised from repeated beatings by his mother; a girl whose father had molested her at the age of four; two boys who had been repeatedly tied to a chair and whipped; and a girl who, at the age of five, had seen her mother (a prostitute) raped, dismembered, burned, and put into the trunk of a car. The mother’s pimp was suspected of sexually abusing the girl.
The children in our control group also lived in poverty in a depressed area of Boston where they regularly witnessed shocking violence. While the study was being conducted, one boy at their school threw gasoline at a classmate and set him on fire. Another boy was caught in crossfire while walking to school with his father and a friend. He was wounded in the groin, and his friend was killed. Given their exposure to such a high baseline level of violence, would their responses to the cards differ from those of the hospitalized children? One of our cards depicted a family scene: two smiling kids watching dad repair a car. Every child who looked at it commented on the danger to the man lying underneath the vehicle. While the control children told stories with benign endings—the car would get fixed, and maybe dad and the kids would drive to McDonald’s—the traumatized kids came up with gruesome tales. One girl said that the little girl in the picture was about to smash in her father’s skull with a hammer. A nine-year-old boy who had been severely physically abused told an elaborate story about how the boy in the picture kicked away the jack, so that the car mangled his father’s body and his blood spurted all over the garage.



As they told us these stories, our patients got very excited and disorganized. We had to take considerable time out at the water cooler and going for walks before we could show them the next card. It was little wonder that almost all of them had been diagnosed with ADHD, and most were on Ritalin—though the drug certainly didn’t seem to dampen their arousal in this situation.
The abused kids gave similar responses to a seemingly innocuous picture of a pregnant woman silhouetted against a window. When we showed it to the seven-year-old girl who’d been sexually abused at age four, she talked about penises and vaginas and repeatedly asked Nina questions like “How many people have you humped?” Like several of the other sexually abused girls in the study, she became so agitated that we had to stop. A seven-year-old girl from the control group picked up the wistful mood of the picture: Her story was about a widowed lady sadly looking out the window, missing her husband. But in the end, the lady found a loving man to be a good father to her baby.



In card after card we saw that, despite their alertness to trouble, the children who had not been abused still trusted in an essentially benign universe; they could imagine ways out of bad situations. They seemed to feel protected and safe within their own families. They also felt loved by at least one of their parents, which seemed to make a substantial difference in their eagerness to engage in schoolwork and to learn.
The responses of the clinic children were alarming. The most innocent images stirred up intense feelings of danger, aggression, sexual arousal, and terror. We had not selected these photos because they had some hidden meaning that sensitive people could uncover; they were ordinary images of everyday life. We could only conclude that for abused children, the whole world is filled with triggers. As long as they can imagine only disastrous outcomes to relatively benign situations, anybody walking into a room, any stranger, any image, on a screen or on a billboard might be perceived as a harbinger of catastrophe. In this light the bizarre behavior of the kids at the children’s clinic made perfect sense.2
To my amazement, staff discussions on the unit rarely mentioned the horrific real-life experiences of the children and the impact of those traumas on their feelings, thinking, and self-regulation. Instead, their medical records were filled with diagnostic labels: “conduct disorder” or “oppositional defiant disorder” for the angry and rebellious kids; or “bipolar disorder.” ADHD was a “comorbid” diagnosis for almost all. Was the underlying trauma being obscured by this blizzard of diagnoses? Now we faced two big challenges. One was to learn whether the different worldview of normal children could account for their resilience and, on a deeper level, how each child actually creates her map of the world. The other, equally crucial, question was: Is it possible to help the minds and brains of brutalized children to redraw their inner maps and incorporate a sense of trust and confidence in the future?

MEN WITHOUT MOTHERS

The scientific study of the vital relationship between infants and their mothers was started by upper-class Englishmen who were torn from their families as young boys to be sent off to boarding schools, where they were raised in regimented same-sex settings. The first time I visited the famed Tavistock Clinic in London I noticed a collection of black-and-white photographs of these great twentieth-century psychiatrists hanging on the wall going up the main staircase: John Bowlby, Wilfred Bion, Harry Guntrip, Ronald Fairbairn, and Donald Winnicott. Each of them, in his own way, had explored how our early experiences become prototypes for all our later connections with others, and how our most intimate sense of self is created in our minute-to-minute exchanges with our caregivers.
Scientists study what puzzles them most, so that they often become experts in subjects that others take for granted. (Or, as the attachment researcher Beatrice Beebe once told me, “most research is me-search.”) These men who studied the role of mothers in children’s lives had themselves been sent off to school at a vulnerable age, sometime between six and ten, long before they should have faced the world alone. Bowlby himself told me that just such boarding-school experiences probably inspired George Orwell’s novel 1984, which brilliantly expresses how human beings may be induced to sacrifice everything they hold dear and true—including their sense of self—for the sake of being loved and approved of by someone in a position of authority.
Since Bowlby was close friends with the Murrays, I had a chance to talk with him about his work whenever he visited Harvard. He was born into an aristocratic family (his father was surgeon to the King’s household), and he trained in psychology, medicine, and psychoanalysis at the temples of the British establishment. After attending Cambridge University, he worked with delinquent boys in London’s East End, a notoriously rough and crime-ridden neighborhood that was largely destroyed during the Blitz.
During and after his service in World War II, he observed the effects of wartime evacuations and group nurseries that separated young children from their families. He also studied the effect of hospitalization, showing that even brief separations (parents back then were not allowed to visit overnight) compounded the children’s suffering. By the late 1940s Bowlby had become persona non grata in the British psychoanalytic community, as a result of his radical claim that children’s disturbed behavior was a response to actual life experiences—to neglect, brutality, and separation— rather than the product of infantile sexual fantasies. Undaunted, he devoted the rest of his life to developing what came to be called attachment theory.3

A SECURE BASE

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

As we grow up, we gradually learn to take care of ourselves, both physically and emotionally, but we get our first lessons in self-care from the way that we are cared for. Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage—a kind of buffer against the worst that fate can hand them.
John Bowlby realized that children are captivated by faces and voices and are exquisitely sensitive to facial expression, posture, tone of voice, physiological changes, tempo of movement and incipient action. He saw this inborn capacity as a product of evolution, essential to the survival of these helpless creatures. Children are also programmed to choose one particular adult (or at most a few) with whom their natural communication system develops. This creates a primary attachment bond. The more responsive the adult is to the child, the deeper the attachment and the more likely the child will develop healthy ways of responding to the people around him.
Bowlby would often visit Regent’s Park in London, where he would make systematic observations of the interactions between children and their mothers. While the mothers sat quietly on park benches, knitting or reading the paper, the kids would wander off to explore, occasionally looking over their shoulders to ascertain that Mum was still watching. But when a neighbor stopped by and absorbed his mother’s interest with the latest gossip, the kids would run back and stay close, making sure he still had her attention. When infants and young children notice that their mothers are not fully engaged with them, they become nervous. When their mothers disappear from sight, they may cry and become inconsolable, but as soon as their mothers return, they quiet down and resume their play.
Bowlby saw attachment as the secure base from which a child moves out into the world. Over the subsequent five decades research has firmly established that having a safe haven promotes self-reliance and instills a sense of sympathy and helpfulness to others in distress. From the intimate give-and-take of the attachment bond children learn that other people have feelings and thoughts that are both similar to and different from theirs. In other words, they get “in sync” with their environment and with the people around them and develop the self-awareness, empathy, impulse control, and self-motivation that make it possible to become contributing members of the larger social culture. These qualities were painfully missing in the kids at our Children’s Clinic.

THE DANCE OF ATTUNEMENT

Children become attached to whoever functions as their primary caregiver.
But the nature of that attachment—whether it is secure or insecure—makes a huge difference over the course of a child’s life. Secure attachment develops when caregiving includes emotional attunement. Attunement starts at the most subtle physical levels of interaction between babies and their caretakers, and it gives babies the feeling of being met and understood.
As Edinburgh-based attachment researcher Colwyn Trevarthen says: “The brain coordinates rhythmic body movements and guides them to act in sympathy with other people’s brains. Infants hear and learn musicality from their mother’s talk, even before birth.”4
In chapter 4 I described the discovery of mirror neurons, the brain-tobrain links that give us our capacity for empathy. Mirror neurons start functioning as soon as babies are born. When researcher Andrew Meltzoff at the University of Oregon pursed his lips or stuck out his tongue at sixhour- old babies, they promptly mirrored his actions.5 (Newborns can focus their eyes only on objects within eight to twelve inches—just enough see the person who is holding them). Imitation is our most fundamental social skill. It assures that we automatically pick up and reflect the behavior of our parents, teachers, and peers.
Most parents relate to their babies so spontaneously that they are barely aware of how attunement unfolds. But an invitation from a friend, the attachment researcher Ed Tronick, gave me the chance to observe that process more closely. Through a one-way mirror at Harvard’s Laboratory of Human Development, I watched a mother playing with her two-month-old son, who was propped in an infant seat facing her.
They were cooing to each other and having a wonderful time—until the mother leaned in to nuzzle him and the baby, in his excitement, yanked on her hair. The mother was caught unawares and yelped with pain, pushing away his hand while her face contorted with anger. The baby let go immediately, and they pulled back physically from each other. For both of them the source of delight had become a source of distress. Obviously frightened, the baby brought his hands up to his face to block out the sight of his angry mother. The mother, in turn, realizing that her baby was upset, refocused on him, making soothing sounds in an attempt to smooth things over. The infant still had his eyes covered, but his craving for connection soon reemerged. He started peeking out to see if the coast was clear, while his mother reached toward him with a concerned expression. As she started to tickle his belly, he dropped his arms and broke into a happy giggle, and harmony was reestablished. Infant and mother were attuned again. This entire sequence of delight, rupture, repair, and new delight took slightly less than twelve seconds.
Tronick and other researchers have now shown that when infants and caregivers are in sync on an emotional level, they’re also in sync physically.6 Babies can’t regulate their own emotional states, much less the changes in heart rate, hormone levels, and nervous-system activity that accompany emotions. When a child is in sync with his caregiver, his sense of joy and connection is reflected in his steady heartbeat and breathing and a low level of stress hormones. His body is calm; so are his emotions. The moment this music is disrupted—as it often is in the course of a normal day —all these physiological factors change as well. You can tell equilibrium has been restored when the physiology calms down.
We soothe newborns, but parents soon start teaching their children to tolerate higher levels of arousal, a job that is often assigned to fathers. (I once heard the psychologist John Gottman say, “Mothers stroke, and fathers poke.”) Learning how to manage arousal is a key life skill, and parents must do it for babies before babies can do it for themselves. If that gnawing sensation in his belly makes a baby cry, the breast or bottle arrives. If he’s scared, someone holds and rocks him until he calms down. If his bowels erupt, someone comes to make him clean and dry. Associating intense sensations with safety, comfort, and mastery is the foundation of selfregulation, self-soothing, and self-nurture, a theme to which I return throughout this book.
A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life.7 Securely attached children learn what makes them feel good; they discover what makes them (and others) feel bad, and they acquire a sense of agency: that their actions can change how they feel and how others respond. Securely attached kids learn the difference between situations they can control and situations where they need help. They learn that they can play an active role when faced with difficult situations. In contrast, children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver. Nothing they can do or say stops the beating or brings attention and help. In effect they’re being conditioned to give up when they face challenges later in life.

BECOMING REAL

Bowlby’s contemporary, the pediatrician and psychoanalyst Donald Winnicott, is the father of modern studies of attunement. His minute observations of mothers and children started with the way mothers hold their babies. He proposed that these physical interactions lay the groundwork for a baby’s sense of self—and, with that, a lifelong sense of identity. The way a mother holds her child underlies “the ability to feel the body as the place where the psyche lives.”8 This visceral and kinesthetic sensation of how our bodies are met lays the foundation for what we experience as “real.”
Winnicott thought that the vast majority of mothers did just fine in their attunement to their infants—it does not require extraordinary talent to be what he called a “good enough mother.”10 But things can go seriously wrong when mothers are unable to tune in to their baby’s physical reality. If a mother cannot meet her baby’s impulses and needs, “the baby learns to become the mother’s idea of what the baby is.” Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose, and direction.
In the years since Bowlby’s and Winnicott’s ideas were introduced, attachment research around the world has shown that the vast majority of children are securely attached. When they grow up, their history of reliable, responsive caregiving will help to keep fear and anxiety at bay. Barring exposure to some overwhelming life event—trauma—that breaks down the self-regulatory system, they will maintain a fundamental state of emotional security throughout their lives. Secure attachment also forms a template for children’s relationships. They pick up what others are feeling and early on learn to tell a game from reality, and they develop a good nose for phony situations or dangerous people. Securely attached children usually become pleasant playmates and have lots of self-affirming experiences with their peers. Having learned to be in tune with other people, they tend to notice subtle changes in voices and faces and to adjust their behavior accordingly.
They learn to live within a shared understanding of the world and are likely to become valued members of the community.
This upward spiral can, however, be reversed by abuse or neglect.
Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync. Dr. Seth Pollak of the University of Wisconsin showed a series of faces to a group of normal eight-year-olds and compared their responses with those of a group of abused children the same age. Looking at this spectrum of angry to sad expressions, the abused kids were hyperalert to the slightest features of anger.



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

The need for attachment never lessens. Most human beings simply cannot tolerate being disengaged from others for any length of time. People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.
A few years ago, on Christmas Eve, I was called to examine a fourteenyear- old boy at the Suffolk County Jail. Jack had been arrested for breaking into the house of neighbors who were away on vacation. The burglar alarm was howling when the police found him in the living room.
The first question I asked Jack was who he expected would visit him in jail on Christmas. “Nobody,” he told me. “Nobody ever pays attention to me.” It turned out that he had been caught during break-ins numerous times before. He knew the police, and they knew him. With delight in his voice, he told me that when the cops saw him standing in the middle of the living room, they yelled, “Oh my God, it’s Jack again, that little motherfucker.”
Somebody recognized him; somebody knew his name. A little while later Jack confessed, “You know, that is what makes it worthwhile.” Kids will go to almost any length to feel seen and connected.

LIVING WITH THE PARENTS YOU HAVE

Children have a biological instinct to attach—they have no choice. Whether their parents or caregivers are loving and caring or distant, insensitive, rejecting, or abusive, children will develop a coping style based on their attempt to get at least some of their needs met.
We now have reliable ways to assess and identify these coping styles, thanks largely to the work of two American scientists, Mary Ainsworth and Mary Main, and their colleagues, who conducted thousands of hours of observation of mother-infant pairs over many years. Based on these studies,
Ainsworth created a research tool called the Strange Situation, which looks at how an infant reacts to temporary separation from the mother. Just as Bowlby had observed, securely attached infants are distressed when their mother leaves them, but they show delight when she returns, and after a brief check-in for reassurance, they settle down and resume their play.
But with infants who are insecurely attached, the picture is more complex. Children whose primary caregiver is unresponsive or rejecting learn to deal with their anxiety in two distinct ways. The researchers noticed that some seemed chronically upset and demanding with their mothers, while others were more passive and withdrawn. In both groups contact with the mothers failed to settle them down—they did not return to play contentedly, as happens in secure attachment.
In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.”12 Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies.
In another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.”13 They seem to have concluded that unless they make a spectacle, nobody is going to pay attention to them. They become enormously upset when they do not know where their mother is but derive little comfort from her return. And even though they don’t seem to enjoy her company, they stay passively or angrily focused on her, even in situations when other children would rather play.

Attachment researchers think that the three “organized” attachment strategies (secure, avoidant, and anxious) work because they elicit the best care a particular caregiver is capable of providing. Infants who encounter a consistent pattern of care—even if it’s marked by emotional distance or insensitivity—can adapt to maintain the relationship. That does not mean that there are no problems: Attachment patterns often persist into adulthood.

Anxious toddlers tend to grow into anxious adults, while avoidant toddlers are likely to become adults who are out of touch with their own feelings and those of others. (As in, “There’s nothing wrong with a good spanking. I got hit and it made me the success I am today.”) In school avoidant children are likely to bully other kids, while the anxious children are often their victims. However, development is not linear, and many life experiences can intervene to change these outcomes.
But there is another group that is less stably adapted, a group that makes up the bulk of the children we treat and a substantial proportion of the adults who are seen in psychiatric clinics. Some twenty years ago, Mary Main and her colleagues at Berkeley began to identify a group of children (about 15 percent of those they studied) who seemed to be unable to figure out how to engage with their caregivers. The critical issue turned out to be that the caregivers themselves were a source of distress or terror to the children.

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

BECOMING DISORGANIZED WITHIN

Conscientious parents often become alarmed when they discover attachment research, worrying that their occasional impatience or their ordinary lapses in attunement may permanently damage their kids. In real life there are bound to be misunderstandings, inept responses, and failures of communication. Because mothers and fathers miss cues or are simply preoccupied with other matters, infants are frequently left to their own devices to discover how they can calm themselves down. Within limits this is not a problem. Kids need to learn to handle frustrations and disappointments. With “good enough” caregivers, children learn that broken connections can be repaired. The critical issue is whether they can incorporate a feeling of being viscerally safe with their parents or other caregivers.
In a study of attachment patterns in over two thousand infants in “normal” middle-class environments, 62 percent were found to be secure,
15 percent avoidant, 9 percent anxious (also known as ambivalent), and 15 percent disorganized.21 Interestingly, this large study showed that the child’s gender and basic temperament have little effect on attachment style; for example, children with “difficult” temperaments are not more likely to develop a disorganized style. Kids from lower socioeconomic groups are more likely to be disorganized, with parents often severely stressed by economic and family instability.
Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems.23 They also show more physiological stress, as expressed in heart rate, heart rate variability,24 stress hormone responses, and lowered immune factors. Does this kind of biological dysregulation automatically reset to normal as a child matures or is moved to a safe environment? So far as we know, it does not.

Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection. While all parents need all the help they can get to help raise secure children, traumatized parents, in particular, need help to be attuned to their children’s needs.
Caregivers often don’t realize that they are out of tune. I vividly remember a videotape Beatrice Beebe showed me.28 It featured a young mother playing with her three-month-old infant. Everything was going well until the baby pulled back and turned his head away, signaling that he needed a break. But the mother did not pick up on his cue, and she intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, looking crestfallen. She obviously felt terrible, but she had simply missed the relevant cues. It’s easy to imagine how this kind of misattunement, repeated over and over again, can gradually lead to a chronic disconnection. (Anyone who’s raised a colicky or hyperactive baby knows how quickly stress rises when nothing seems to make a difference.) Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.

In practice it often is difficult to distinguish the problems that result from disorganized attachment from those that result from trauma: They are often intertwined. My colleague Rachel Yehuda studied rates of PTSD in adult New Yorkers who had been assaulted or raped.29 Those whose mothers were Holocaust survivors with PTSD had a significantly higher rate of developing serious psychological problems after these traumatic experiences. The most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it difficult for them to regain their equilibrium after being violated. Yehuda found a similar vulnerability in the children of pregnant women who were in the World Trade Center that fatal day in 2001.
Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are. My former student Glenn Saxe, now chairman of the Department of Child and Adolescent Psychiatry at NYU, showed that when children were hospitalized for treatment of severe burns, the development of PTSD could be predicted by how safe they felt with their mothers.31 The security of their attachment to their mothers predicted the amount of morphine that was required to control their pain—the more secure the attachment, the less painkiller was needed.
Another colleague, Claude Chemtob, who directs the Family Trauma Research Program at NYU Langone Medical Center, studied 112 New York City children who had directly witnessed the terrorist attacks on 9/11.

Children whose mothers were diagnosed with PTSD or depression during follow-up were six times more likely to have significant emotional problems and eleven times more likely to be hyperaggressive in response to their experience. Children whose fathers had PTSD showed behavioral problems as well, but Chemtob discovered that this effect was indirect and was transmitted via the mother. (Living with an irascible, withdrawn, or terrified spouse is likely to impose a major psychological burden on the partner, including depression.) If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly.
You probably deserve it, and anyway, there is nothing you can do about it.
When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences.

THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT

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

Disorganized attachment showed up in two different ways: One group of mothers seemed to be too preoccupied with their own issues to attend to their infants. They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs. Another group of mothers seemed helpless and fearful. They often came across as sweet or fragile, but they didn’t know how to be the adult in the relationship and seemed to want their children to comfort them. They failed to greet their children after having been away and did not pick them up when the children were distressed. The mothers didn’t seem to be doing these things deliberately—they simply didn’t know how to be attuned to their kids and respond to their cues and thus failed to comfort and reassure them. The hostile/intrusive mothers were more likely to have childhood histories of physical abuse and/or of witnessing domestic violence, while the withdrawn/dependent mothers were more likely to have histories of sexual abuse or parental loss (but not physical abuse).35
I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse.
About eighteen years later, when these kids were around twenty years old, Lyons-Ruth did a follow-up study to see how they were coping. Infants with seriously disrupted emotional communication patterns with their mothers at eighteen months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving, and binge eating), inappropriate and intense anger, and recurrent suicidal behavior.
Karlen and her colleagues had expected that hostile/intrusive behavior on the part of the mothers would be the most powerful predictor of mental instability in their adult children, but they discovered otherwise. Emotional withdrawal had the most profound and long-lasting impact. Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults.

DISSOCIATION: KNOWING AND NOT KNOWING

Lyons-Ruth was particularly interested in the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down. She found a “striking and unexpected” relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood. Lyons-Ruth concludes that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and to see.”36
Infants who live in secure relationships learn to communicate not only their frustrations and distress but also their emerging selves—their interests, preferences, and goals. Receiving a sympathetic response cushions infants (and adults) against extreme levels of frightened arousal. But if your caregivers ignore your needs, or resent your very existence, you learn to anticipate rejection and withdrawal. You cope as well as you can by blocking out your mother’s hostility or neglect and act as if it doesn’t matter, but your body is likely to remain in a state of high alert, prepared to ward off blows, deprivation, or abandonment. Dissociation means simultaneously knowing and not knowing.37
Bowlby wrote: “What cannot be communicated to the [m]other cannot be communicated to the self.”38 If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.39 Maybe the most devastating long-term effect of this shutdown is not feeling real inside, a condition we saw in the kids in the Children’s Clinic and that we see in the children and adults who come to the Trauma Center. When you don’t feel real nothing matters, which makes it impossible to protect yourself from danger. Or you may resort to extremes in an effort to feel something— even cutting yourself with a razor blade or getting into fistfights with strangers.
Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults.40 Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. The critical underlying issue was that these patients didn’t know how to feel safe. Lack of safety within the early caregiving relationship led to an impaired sense of inner reality, excessive clinging, and self-damaging behavior: Poverty, single parenthood, or maternal psychiatric symptoms did not predict these symptoms.
This does not imply that child abuse is irrelevant41, but that the quality of early caregiving is critically important in preventing mental health problems, independent of other traumas. For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation.

RESTORING SYNCHRONY
 

Early attachment patterns create the inner maps that chart our relationships throughout life, not only in terms of what we expect from others, but also in terms of how much comfort and pleasure we can experience in their presence. I doubt that the poet e. e. cummings could have written his joyous lines: 
“I like my body when it is with your body.... muscles better and nerves more” if his earliest experiences had been frozen faces and hostile glances. Our relationship maps are implicit, etched into the emotional brain and not reversible simply by understanding how they were created.

You may realize that your fear of intimacy has something to do with your mother’s postpartum depression or with the fact that she herself was molested as a child, but that alone is unlikely to open you to happy, trusting engagement with others.

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

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

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

Marilyn was a tall, athletic-looking woman in her midthirties who worked as an operating-room nurse in a nearby town. She told me that a few months earlier she’d started to play tennis at her sports club with a Boston fireman named Michael. She usually steered clear of men, she said, but she had gradually become comfortable enough with Michael to accept his invitations to go out for pizza after their matches. They’d talk about tennis, movies, their nephews and nieces—nothing too personal.
Michael clearly enjoyed her company, but she told herself he didn’t really know her.
One Saturday evening in August, after tennis and pizza, she invited him to stay over at her apartment. She described feeling “uptight and unreal” as soon as they were alone together. She remembered asking him to go slow but had very little sense of what had happened after that. After a few glasses of wine and a rerun of Law & Order, they apparently fell asleep together on top of her bed. At around two in the morning, Michael turned over in his sleep. When Marilyn felt his body touch hers, she exploded—pounding him with her fists, scratching and biting, screaming, “You bastard, you bastard!”
Michael, startled awake, grabbed his belongings and fled. After he left,
Marilyn sat on her bed for hours, stunned by what had happened. She felt deeply humiliated and hated herself for what she had done, and now she’d come to me for help in dealing with her terror of men and her inexplicable rage attacks.
My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem.
Therapy often starts with some inexplicable behavior: attacking a boyfriend in the middle of the night, feeling terrified when somebody looks you in the eye, finding yourself covered with blood after cutting yourself with a piece of glass, or deliberately vomiting up every meal. It takes time and patience to allow the reality behind such symptoms to reveal itself.

A TORN MAP OF THE WORLD

How do people learn what is safe and what is not safe, what is inside and what is outside, what should be resisted and what can safely be taken in? The best way we can understand the impact of child abuse and neglect is to listen to what people like Marilyn can teach us. One of the things that became clear as I came to know her better was that she had her own unique view of how the world functions.
As children, we start off at the center of our own universe, where we interpret everything that happens from an egocentric vantage point. If our parents or grandparents keep telling us we’re the cutest, most delicious thing in the world, we don’t question their judgment—we must be exactly that. And deep down, no matter what else we learn about ourselves, we will carry that sense with us: that we are basically adorable. As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated.
Marilyn’s past shaped her view of every relationship. She was convinced that men didn’t give a damn about other people’s feelings and that they got away with whatever they wanted. Women couldn’t be trusted either. They were too weak to stand up for themselves, and they’d sell their bodies to get men to take care of them. If you were in trouble, they wouldn’t lift a finger to help you. This worldview manifested itself in the way Marilyn approached her colleagues at work: She was suspicious of the motives of anyone who was kind to her and called them on the slightest deviation from the nursing regulations. As for herself: She was a bad seed, a fundamentally toxic person who made bad things happen to those around her.
When I first encountered patients like Marilyn, I used to challenge their thinking and try to help them see the world in a more positive, flexible way.
One day a woman named Kathy set me straight. A group member had arrived late to a session because her car had broken down, and Kathy immediately blamed herself: “I saw how rickety your car was last week; I knew I should have offered you a ride.” Her self-criticism escalated to the point that, only a few minutes later, she was taking responsibility for her sexual abuse: “I brought it on myself: I was seven years old and I loved my daddy. I wanted him to love me, and I did what he wanted me to do. It was my own fault.” When I intervened to reassure her, saying, “Come on, you were just a little girl—it was your father’s responsibility to maintain the boundaries,” Kathy turned toward me. “You know, Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor—I was trained to take care of the needs of grown-up, insecure men. But after two years I trust you enough to tell you that those comments make me feel terrible. Yes, it’s true; I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.”
I genuinely thanked her for her feedback, and I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world.
As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don’t only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time.
This doesn’t mean, however, that our maps can’t be modified by experience. A deep love relationship, particularly during adolescence, when the brain once again goes through a period of exponential change, truly can transform us. So can the birth of a child, as our babies often teach us how to love. Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. In contrast, previously uncontaminated childhood maps can become so distorted by an adult rape or assault that all roads are rerouted into terror or despair. These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs. Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system, the subject of the treatment section of this book.
Nonetheless, learning to recognize irrational thoughts and behavior can be a useful first step. People like Marilyn often discover that their assumptions are not the same as those of their friends. If they are lucky, their friends and colleagues will tell them in words, rather than in actions, that their distrust and self-hatred makes collaboration difficult. But that rarely happens, and Marilyn’s experience was typical: After she assaulted Michael, he had absolutely no interest in working things out, and she lost both his friendship and her favorite tennis partner. It is at this point that smart and courageous people like Marilyn, who maintain their curiosity and determination in the face of repeated defeats, start looking for help.
Generally the rational brain can override the emotional brain, as long as our fears don’t hijack us. (For example, your fear at being flagged down by the police can turn instantly to gratitude when the cop warns you that there’s an accident ahead.) But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains.
That means learning to observe and tolerate the heartbreaking and gut- wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.

HATING YOUR HOME

Children have no choice who their parents are, nor can they understand that parents may simply be too depressed, enraged, or spaced out to be there for them or that their parents’ behavior may have little to do with them.
Children have no choice but to organize themselves to survive within the families they have. Unlike adults, they have no other authorities to turn to for help—their parents are the authorities. They cannot rent an apartment or move in with someone else: Their very survival hinges on their caregivers.
Children sense—even if it they are not explicitly threatened—that if they talked about their beatings or molestation to teachers they would be punished. Instead, they focus their energy on not thinking about what has happened and not feeling the residues of terror and panic in their bodies.
Because they cannot tolerate knowing what they have experienced, they also cannot understand that their anger, terror, or collapse has anything to do with that experience. They don’t talk; they act and deal with their feelings by being enraged, shut down, compliant, or defiant.
Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror. I have never met a child below the age of ten who was tortured at home (and who had broken bones and burned skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry them, or had sexual relations with them; victims of domestic violence often cover up for their abusers. Judges often tell me how humiliated they feel when they try to protect victims of domestic violence by issuing restraining orders, only to find out that many of them secretly allow their partners to return.
It took Marilyn a long time before she was ready to talk about her abuse: She was not ready to violate her loyalty to her family—deep inside she felt that she still needed them to protect her against her fears. The price of this loyalty is unbearable feelings of loneliness, despair, and the inevitable rage of helplessness. Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions. One of my patients told me, “It is like hating your home, your kitchen and pots and pans, your bed, your chairs, your table, your rugs.”
Nothing feels safe—least of all your own body.
Learning to trust is a major challenge. One of my other patients, a schoolteacher whose grandfather raped her repeatedly before she was six, sent me the following e-mail: “I started mulling the danger of opening up with you in traffic on the way home after our therapy appointment, and then, as I merged into Route 124, I realized that I had broken the rule of not getting attached, to you and to my students.”
During our next meeting she told me she had also been raped by her lab instructor in college. I asked her whether she had sought help and made a complaint against him. “I couldn’t make myself cross the road to the clinic,” she replied. “I was desperate for help, but as I stood there, I felt very deeply that I would only be hurt even more. And that might well have been true. Of course, I had to hide what had happened from my parents— and from everyone else.”
After I told her that I was concerned about what was going on with her, she wrote me another e-mail: “I’m trying to remind myself that I didn’t do anything to deserve such treatment. I don’t think I have ever had anyone look at me like that and say they were worried about me, and I am holding on to it like a treasure: the idea that I am worth being worried about by someone I respect and who does understand how deeply I am struggling now.”
In order to know who we are—to have an identity—we must know (or at least feel that we know) what is and what was “real.” We must observe what we see around us and label it correctly; we must also be able trust our memories and be able to tell them apart from our imagination. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called “soul murder.” Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust.

CHAPTER 9: WHAT’S LOVE GOT TO DO WITH IT?

How do we organize our thinking with regard to individuals like Marilyn, Mary, and Kathy, and what can we do to help them? The way we define their problems, our diagnosis, will determine how we approach their care. Such patients typically receive five or six different unrelated diagnoses in the course of their psychiatric treatment. If their doctors focus on their mood swings, they will be identified as bipolar and prescribed lithium or valproate. If the professionals are most impressed with their despair, they will be told they are suffering from major depression and given antidepressants. If the doctors focus on their restlessness and lack of attention, they may be categorized as ADHD and treated with Ritalin or other stimulants. And if the clinic staff happens to take a trauma history, and the patient actually volunteers the relevant information, he or she might receive the diagnosis of PTSD. None of these diagnoses will be completelyoff the mark, and none of them will begin to meaningfully describe who these patients are and what they suffer from.
Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.
The first serious attempt to create a systematic manual of psychiatric diagnoses occurred in 1980, with the release of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the official list of all mental diseases recognized by the American Psychiatric Association (APA). The preamble to the DSM-III warned explicitly that its categories were insufficiently precise to be used in forensic settings or for insurance purposes. Nonetheless it gradually became an instrument of enormous power: Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories. DSM labels quickly found their way into the larger culture as well. Millions of people know that Tony Soprano suffered from panic attacks and depression and that Carrie Mathison of Homeland struggles with bipolar disorder. The manual has become a virtual industry that has earned the American Psychiatric Association well over $100 million. The question is: Has it provided comparable benefits for the patients it is meant to serve? A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects.
Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo.
None of these diagnoses takes into account the unusual talents that many of our patients develop or the creative energies they have mustered tosurvive. All too often diagnoses are mere tallies of symptoms, leaving patients such as Marilyn, Kathy, and Mary likely to be viewed as out-of- control women who need to be straightened out.
The dictionary defines diagnosis as: “A. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data.

B. The opinion derived from such an evaluation.” In this chapter, and the next, I will discuss the chasm between official diagnoses and what our patients actually suffer from and discuss how my colleagues and I have tried to change the way patients with chronic trauma histories are diagnosed.

THE POWER OF DIAGNOSIS

Our study also confirmed that there was a traumatized population quite distinct from the combat soldiers and accident victims for whom the PTSD diagnosis had been created. People like Marilyn and Kathy, as well as the patients Judy and I had studied, and the kids in the outpatient clinic at MMHC that I described in chapter 7, do not necessarily remember their traumas (one of the criteria for the PTSD diagnosis) or at least are not preoccupied with specific memories of their abuse, but they continue to behave as if they were still in danger. They go from one extreme to the other; they have trouble staying on task, and they continually lash out against themselves and others. To some degree their problems do overlap with those of combat soldiers, but they are also very different in that their childhood trauma has prevented them from developing some of the mental capacities that adult soldiers possessed before their traumas occurred.
After we realized this, a group of us10 went to see Robert Spitzer, who, after having guided the development of the DSM-III, was in the process of revising the manual. He listened carefully to what we told him. He told us it was likely that clinicians who spend their days treating a particular patient population are likely to develop considerable expertise in understanding what ails them. He suggested that we do a study, a so-called field trial, to compare the problems of different groups of traumatized individuals.11
Spitzer put me in charge of the project. First we developed a rating scale that incorporated all the different trauma symptoms that had been reported in the scientific literature, then we interviewed 525 adult patients at five sites around the country to see if particular populations suffered from different constellations of problems. Our populations fell into three groups: those with histories of childhood physical or sexual abuse by caregivers; recent victims of domestic violence; and people who had recently been through a natural disaster.
There were clear differences among these groups, particularly those on the extreme ends of the spectrum: victims of child abuse and adults who had survived natural disasters. The adults who had been abused as children often had trouble concentrating, complained of always being on edge, and were filled with self-loathing. They had enormous trouble negotiating intimate relationships, often veering from indiscriminate, high-risk, andunsatisfying sexual involvements to total sexual shutdown. They also had large gaps in their memories, often engaged in self-destructive behaviors, and had a host of medical problems. These symptoms were relatively rare in the survivors of natural disasters.
Each major diagnosis in the DSM had a workgroup responsible for suggesting revisions for the new edition. I presented the results of the field trial to our DSM-IV PTSD work group, and we voted nineteen to two to create a new trauma diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short.12,13 We then eagerly anticipated the publication of the DSM-IV in May 1994. But much to our surprise the diagnosis that our work group had overwhelmingly approved did not appear in the final product. None of us had been consulted.
This was a tragic exclusion. It meant that large numbers of patients could not be accurately diagnosed and that clinicians and researchers would be unable to scientifically develop appropriate treatments for them. You cannot develop a treatment for a condition that does not exist. Not having a diagnosis now confronts therapists with a serious dilemma: How do we treat people who are coping with the fall-out of abuse, betrayal and abandonment when we are forced to diagnose them with depression, panic disorder, bipolar illness, or borderline personality, which do not really address what they are coping with? The consequences of caretaker abuse and neglect are vastly more common and complex than the impact of hurricanes or motor vehicle accidents. Yet the decision makers who determined the shape of our diagnostic system decided not to recognize this evidence. To this day, after twenty years and four subsequent revisions, the DSM and the entire system based on it fail victims of child abuse and neglect—just as they ignored the plight of veterans before PTSD was introduced back in 1980.

THE HIDDEN EPIDEMIC

How do you turn a newborn baby with all its promise and infinite capacities into a thirty-year-old homeless drunk? As with so many great discoveries,internist Vincent Felitti came across the answer to this question accidentally.
In 1985 Felitti was chief of Kaiser Permanente’s Department of Preventive Medicine in San Diego, which at the time was the largest medical screening program in the world. He was also running an obesity clinic that used a technique called “supplemented absolute fasting” to bring about dramatic weight loss without surgery. One day a twenty-eight-year- old nurse’s aide showed up in his office. Felitti accepted her claim that obesity was her principal problem and enrolled her in the program. Over the next fifty-one weeks her weight dropped from 408 pounds to 132 pounds.
However, when Felitti next saw her a few months later, she had regained more weight than he thought was biologically possible in such a short time. What had happened? It turned out that her newly svelte body had attracted a male coworker, who started to flirt with her and then suggested sex. She went home and began to eat. She stuffed herself during the day and ate while sleepwalking at night. When Felitti probed this extreme reaction, she revealed a lengthy incest history with her grandfather.
This was only the second case of incest Felitti had encountered in his twenty-three-year medical practice, and yet about ten days later he heard a similar story. As he and his team started to inquire more closely, they were shocked to discover that most of their morbidly obese patients had been sexually abused as children. They also uncovered a host of other family problems.
In 1990 Felitti went to Atlanta to present data from the team’s first 286 patient interviews at a meeting of the North American Association for the Study of Obesity. He was stunned by the harsh response of some experts: Why did he believe such patients? Didn’t he realize they would fabricate any explanation for their failed lives? However, an epidemiologist from the Centers for Disease Control and Prevention (CDC) encouraged Felitti to start a much larger study, drawing on a general population, and invited him to meet with a small group of researchers at the CDC. The result was the monumental investigation of Adverse Childhood Experiences (now know at the ACE study), a collaboration between the CDC and Kaiser Permanente, with Robert Anda, MD, and Vincent Felitti, MD, as co–principal investigators.More than fifty thousand Kaiser patients came through the Department of Preventive Medicine annually for a comprehensive evaluation, filling out an extensive medical questionnaire in the process. Felitti and Anda spent more than a year developing ten new questions14 covering carefully defined categories of adverse childhood experiences, including physical and sexual abuse, physical and emotional neglect, and family dysfunction, such as having had parents who were divorced, mentally ill, addicted, or in prison.
They then asked 25,000 consecutive patients if they would be willing to provide information about childhood events; 17,421 said yes. Their responses were then compared with the detailed medical records that Kaiser kept on all patients.
The ACE study revealed that traumatic life experiences during childhood and adolescence are far more common than expected. The study respondents were mostly white, middle class, middle aged, well educated, and financially secure enough to have good medical insurance, and yet only one-third of the respondents reported no adverse childhood experiences.

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

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

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

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

Each yes answer was scored as one point, leading to a possible ACE score ranging from zero to ten. For example, a person who experienced frequent verbal abuse, who had an alcoholic mother, and whose parents divorced would have an ACE score of three. Of the two-thirds of respondents who reported an adverse experience, 87 percent scored two or more. One in six of all respondents had an ACE score of four or higher.
In short, Felitti and his team had found that adverse experiences are interrelated, even though they’re usually studied separately. People typically don’t grow up in a household where one brother is in prison but everything else is fine. They don’t live in families where their mother is regularly beaten but life is otherwise hunky-dory. Incidents of abuse are never stand-alone events. And for each additional adverse experience reported, the toll in later damage increases.
Felitti and his team found that the effects of childhood trauma first become evident in school. More than half of those with ACE scores of four or higher reported having learning or behavioral problems, compared with 3 percent of those with a score of zero. As the children matured, they didn’t “outgrow” the effects of their early experiences. As Felitti notes,
“Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives. For example, high ACE scores turned out to correlate with higher workplace absenteeism, financial problems, and lower lifetime income.
When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically.
For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared with an overall rate of 12 percent in those with an ACE score of zero. The likelihood of being on antidepressant medication or prescription painkillers also rose proportionally. As Felitti has pointed out, we may be treating today experiences that happened fifty years ago—at ever-increasing cost.
Antidepressant drugs and painkillers constitute a significant portion of ourrapidly rising national health-care expenditures.16 (Ironically, research has shown that depressed patients without prior histories of abuse or neglect tend to respond much better to antidepressants than patients with those backgrounds.17) Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. The more isolated and unprotected a person feels, the more death will feel like the only escape. When the media report an environmental link to a 30 percent increase in the risk of some cancer, it is headline news, yet these far more dramatic figures are overlooked.
As part of their initial medical evaluation, study participants were asked, “Have you ever considered yourself to be an alcoholic?” People with an ACE score of four were seven times more likely to be alcoholic than adults with a score of zero. Injection drug use increased exponentially: For those with an ACE score of six or more, the likelihood of IV drug use was 4,600 percent greater than in those with a score of zero.
Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent. Why are abused or neglected girls so much more likely to be raped later in life? The answers to this question have implications far beyond rape. For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold.18 More than 12 percent of study participants had seen their mothers being battered.
The list of high-risk behaviors predicted by the ACE score included smoking, obesity, unintended pregnancies, multiple sexual partners, and sexually transmitted diseases. Finally, the toll of major health problems was striking: Those with an ACE score of six or above had a 15 percent or greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four timesas likely to have emphysema. The ongoing stress on the body keeps taking its toll.

CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM

The first time I heard Robert Anda present the results of the ACE study, he could not hold back his tears. In his career at the CDC he had previously worked in several major risk areas, including tobacco research and cardiovascular health. But when the ACE study data started to appear on his computer screen, he realized that they had stumbled upon the gravest and most costly public health issue in the United States: child abuse. He had calculated that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters.20 It would also have a dramatic effect on workplace performance and vastly decrease the need for incarceration.
When the surgeon general’s report on smoking and health was published in 1964, it unleashed a decades-long legal and medical campaign that has changed daily life and long-term health prospects for millions. The number of American smokers fell from 42 percent of adults in 1965 to 19 percent in 2010, and it is estimated that nearly 800,000 deaths from lung cancer were prevented between 1975 and 2000.21
The ACE study, however, has had no such effect. Follow-up studies and papers are still appearing around the world, but the day-to-day reality of children like Marilyn and the children in outpatient clinics and residential treatment centers around the country remains virtually the same. Only now they receive high doses of psychotropic agents, which makes them more tractable but which also impairs their ability to feel pleasure and curiosity, to grow and develop emotionally and intellectually, and to become contributing members of society.

CHAPTER 10: DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC

There are hundreds of thousands of children like the ones I am about to describe, and they absorb enormous resources, often withoutappreciable benefit. They end up filling our jails, our welfare rolls, and our medical clinics. Most of the public knows them only as statistics. Tens of thousands of schoolteachers, probation officers, welfare workers, judges, and mental health professionals spend their days trying to help them, and the taxpayer pays the bills.
Anthony was only two and a half when he was referred to our Trauma Center by a child-care center because its employees could not manage his constant biting and pushing, his refusal to take naps, and his intractable crying, head banging, and rocking. He did not feel safe with any staff member and fluctuated between despondent collapse and angry defiance.
When we met with him and his mother, he anxiously clung to her, hiding his face, while she kept saying, “Don’t be such a baby.” He startled when a door banged somewhere down the corridor and then burrowed deeper into his mom’s lap. When she pushed him away, he sat in a corner and started to bang his head. “He just does that to bug me,” his mother remarked. When we asked about her own background, she told us that she’d been abandoned by her parents and raised by a series of relatives who hit her, ignored her, and started to sexually abuse her at age thirteen. She’d become pregnant by a drunken boyfriend who left her when she told him she was carrying his child. Anthony was just like his father, she said—a good-for-nothing. She had had numerous violent rows with subsequent boyfriends, but she was sure that this had happened too late at night for Anthony to notice.
If Anthony were admitted to a hospital, he would likely be diagnosed with a host of different psychiatric disorders: depression, oppositional defiant disorder, anxiety, reactive attachment disorder, ADHD, and PTSD.
None of these diagnoses, however, would clarify what was wrong with Anthony: that he was scared to death and fighting for his life, and he did not trust that his mother could help him.
Then there’s Maria, a fifteen-year-old Latina, one of the more than half a million kids in the United States who grow up in foster care and residential treatment programs. Maria is obese and aggressive. She has a history of sexual, physical, and emotional abuse and has lived in more than twenty out-of-home placements since age eight. The pile of medical charts that arrived with her described her as mute, vengeful, impulsive, reckless,and self-harming, with extreme mood swings and an explosive temper. She describes herself as “garbage, worthless, rejected.”
After multiple suicide attempts Maria was placed in one of our residential treatment centers. Initially she was mute and withdrawn and became violent when people got too close to her. After other approaches failed to work, she was placed in an equine therapy program where she groomed her horse daily and learned simple dressage. Two years later I spoke with Maria at her high school graduation. She had been accepted by a four-year college. When I asked her what had helped her most, she answered, “The horse I took care of.” She told me that she first started to feel safe with her horse; he was there every day, patiently waiting for her, seemingly glad upon her approach. She started to feel a visceral connection with another creature and began to talk to him like a friend. Gradually she started talking with the other kids in the program and, eventually, with her counselor.
Virginia is a thirteen-year-old adopted white girl. She was taken away from her biological mother because of the mother’s drug abuse; after her first adoptive mother fell ill and died, she moved from foster home to foster home before being adopted again. Virginia was seductive with any male who crossed her path, and she reported sexual and physical abuse by various babysitters and temporary caregivers. She came to our residential treatment program after thirteen crisis hospitalizations for suicide attempts.
The staff described her as isolated, controlling, explosive, sexualized, intrusive, vindictive, and narcissistic. She described herself as disgusting and said she wished she were dead. The diagnoses in her chart were bipolar disorder, intermittent explosive disorder, reactive attachment disorder, attention deficit disorder (ADD) hyperactive subtype, oppositional defiant disorder (ODD), and substance use disorder. But who, really, is Virginia? How can we help her have a life?1
We can hope to solve the problems of these children only if we correctly define what is going on with them and do more than developing new drugs to control them or trying to find “the” gene that is responsible for their “disease.” The challenge is to find ways to help them lead productive lives and, in so doing, save hundreds of millions of dollars of taxpayers’ money. That process starts with facing the facts.

MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE VERSUS NURTURE

One of the clearest ways of understanding how the quality of parenting and environment affects the expression of genes comes from the work of Stephen Suomi, chief of the National Institutes of Health’s Laboratory of Comparative Ethology.9 For more than forty years Suomi has been studying the transmission of personality through generations of rhesus monkeys, which share 95 percent of human genes, a number exceeded only by chimpanzees and bonobos. Like humans, rhesus monkeys live in large social groups with complex alliances and status relationships, and only members who can synchronize their behavior with the demands of the troop survive and flourish.
Rhesus monkeys are also like humans in their attachment patterns.
Their infants depend on intimate physical contact with their mothers, and just as Bowlby observed in humans, they develop by exploring their reactions to their environment, running back to their mothers whenever they feel scared or lost. Once they become more independent, play with their peers is the primary way they learn to get along in life.
Suomi identified two personality types that consistently ran into trouble: uptight, anxious monkeys, who become fearful, withdrawn, and depressed even in situations where other monkeys will play and explore; and highly aggressive monkeys, who make so much trouble that they are often shunned, beaten up, or killed. Both types are biologically different from their peers. Abnormalities in arousal levels, stress hormones, and metabolism of brain chemicals like serotonin can be detected within the first few weeks of life, and neither their biology nor their behavior tends to change as they mature. Suomi discovered a wide range of genetically driven behaviors. For example, the uptight monkeys (classified as such on the basis of both their behavior and their high cortisol levels at six months) will consume more alcohol in experimental situations than the others when they reach the age of four. The genetically aggressive monkeys also overindulge —but they binge drink to the point of passing out, while the uptight monkeys seem to drink to calm down.
And yet the social environment also contributes significantly to behavior and biology. The uptight, anxious females don’t play well with others and thus often lack social support when they give birth and are at high risk for neglecting or abusing their firstborns. But when these females belong to a stable social group they often become diligent mothers who carefully watch out for their young. Under some conditions being an anxious mom can provide much needed protection. The aggressive mothers, on the other hand, did not provide any social advantages: very punitive with their offspring, there is lots of hitting, kicking, and biting. If the infants survive, their mothers usually keep them from making friends with their peers.
In real life it is impossible to tell whether people’s aggressive or uptight behavior is the result of parents’ genes or of having been raised by an abusive mother—or both. But in a monkey lab you can take newborns with vulnerable genes away from their biological mothers and have them raised by supportive mothers or in playgroups with peers.
Young monkeys who are taken away from their mothers at birth and brought up solely with their peers become intensely attached to them. They desperately cling to one another and don’t peel away enough to engage in healthy exploration and play. What little play there is lacks the complexity and imagination typical of normal monkeys. These monkeys grow up to be uptight: scared in new situations and lacking in curiosity. Regardless of their genetic predisposition, peer-raised monkeys overreact to minor stresses:

# Their cortisol increases much more in response to loud noises than does that of monkeys who were raised by their mothers. 

# Their serotonin metabolism is even more abnormal than that of the monkeys who are genetically predisposed to aggression but who were raised by their own mothers. 

This leads to the conclusion that, at least in monkeys, early experience has at least as much impact on biology as heredity does.
Monkeys and humans share the same two variants of the serotonin gene (known as the short and long serotonin transporter alleles). In humans the short allele has been associated with impulsivity, aggression, sensation seeking, suicide attempts, and severe depression. Suomi showed that, at least in monkeys, the environment shapes how these genes affect behavior.
Monkeys with the short allele that were raised by an adequate mother behaved normally and had no deficit in their serotonin metabolism. Those who were raised with their peers became aggressive risk takers.10 Similarly,
New Zealand researcher Alec Roy found that humans with the short allele had higher rates of depression than those with the long version but that this was true only if they also had a childhood history of abuse or neglect. The conclusion is clear: Children who are fortunate enough to have an attuned and attentive parent are not going to develop this genetically related problem.11
Suomi’s work supports everything we’ve learned from our colleagues who study human attachment and from our own clinical research: Safe and protective early relationships are critical to protect children from long-term problems. In addition, even parents with their own genetic vulnerabilities can pass on that protection to the next generation provided that they are given the right support.

THE POWER OF DIAGNOSIS

In the 1970s there was no way to classify the wide-ranging symptoms of hundreds of thousands of returning Vietnam veterans. As we saw in the opening chapters of this book, this forced clinicians to improvise the treatment of their patients and prevented them from being able to systematically study what approaches actually worked. The adoption of the PTSD diagnosis by the DSM III in 1980 led to extensive scientific studies and to the development of effective treatments, which turned out to be relevant not only to combat veterans but also to victims of a range of traumatic events, including rape, assault, and motor vehicle accidents.14 An example of the far-ranging power of having a specific diagnosis is the fact that between 2007 and 2010 the Department of Defense spent more than $2.7 billion for the treatment of and research on PTSD in combat veterans, while in fiscal year 2009 alone the Department of Veterans Affairs spent $24.5 million on in-house PTSD research.
The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability). This description suggests a clear story line: A person is suddenly and unexpectedly devastated by an atrocious event and is never the same again. The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system.
How relevant was this definition to the children we were seeing? After a single traumatic incident—a dog bite, an accident, or witnessing a school shooting—children can indeed develop basic PTSD symptoms similar to those of adults, even if they live in safe and supportive homes. As a result of having the PTSD diagnosis, we now can treat those problems quite effectively.
In the case of the troubled children with histories of abuse and neglect who show up in clinics, schools, hospitals, and police stations, the traumatic roots of their behaviors are less obvious, particularly because they rarely talk about having been hit, abandoned, or molested, even when asked.
Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.15
Because they often are shut down, suspicious, or aggressive they now receive pseudoscientific diagnoses such as “oppositional defiant disorder,” meaning “This kid hates my guts and won’t do anything I tell him to do,” or “disruptive mood dysregulation disorder,” meaning he has temper tantrums.
Having as many problems as they do, these kids accumulate numerous diagnoses over time. Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage.
As the NCTSN treated more and more kids, it became increasingly obvious that we needed a diagnosis that captured the reality of their experience. We began with a database of nearly twenty thousand kids who were being treated in various sites within the network and collected all the research articles we could find on abused and neglected kids. These were winnowed down to 130 particularly relevant studies that reported on more than one hundred thousand children and adolescents worldwide. A core work group of twelve clinician/researchers specializing in childhood trauma16 then convened twice a year for four years to draft a proposal for an appropriate diagnosis, which we decided to call Developmental Trauma Disorder.17
As we organized our findings, we discovered a consistent profile: (1) a pervasive pattern of dysregulation, (2) problems with attention and concentration, and (3) difficulties getting along with themselves and others.
These children’s moods and feelings rapidly shifted from one extreme to another—from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling.
Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine- motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted.
Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they can not help but define themselves as defective and worthless. They come by their self- loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and overreacting to slight frustrations makes it difficult for them to make friends.
We published the first articles about our findings, developed a validated rating scale,18 and collected data on about 350 kids and their parents or foster parents to establish that this one diagnosis, Developmental Trauma Disorder, captured the full range of what was wrong with these children. It would enable us to give them a single diagnosis, as opposed to multiple labels, and would firmly locate the origin of their problems in a combination of trauma and compromised attachment.
In February 2009 we submitted our proposed new diagnosis of Developmental Trauma Disorder to the American Psychiatric Association, stating the following in a cover letter: Children who develop in the context of ongoing danger, maltreatment and disrupted caregiving systems are being ill served by the current diagnostic systems that lead to an emphasis on behavioral control with no recognition of interpersonal trauma.
Studies on the sequelae of childhood trauma in the context of caregiver abuse or neglect consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas. In absence of a sensitive trauma- specific diagnosis, such children are currently diagnosed with an average of 3–8 co-morbid disorders. The continued practice of applying multiple distinct co-morbid diagnoses to traumatized children has grave consequences: it defies parsimony, obscures etiological clarity, and runs the danger of relegating treatment and intervention to a small aspect of the child’s psychopathology rather than promoting a comprehensive treatment approach.
Shortly after submitting our proposal, I gave a talk on Developmental Trauma Disorder in Washington DC to a meeting of the mental health commissioners from across the country. They offered to support our initiative by writing a letter to the APA. The letter began by pointing out that the National Association of State Mental Health Program Directors served 6.1 million people annually, with a budget of $29.5 billion, and concluded: “We urge the APA to add developmental trauma to its list of priority areas to clarify and better characterize its course and clinical sequelae and to emphasize the strong need to address developmental trauma in the assessment of patients.”
I felt confident that this letter would ensure that the APA would take our proposal seriously, but several months after our submission, Matthew Friedman, executive director of the National Center for PTSD and chair of the relevant DSM subcommittee, informed us that DTD was unlikely to be included in the DSM-5. The consensus, he wrote, was that no new diagnosis was required to fill a “missing diagnostic niche.” One million children who are abused and neglected every year in the United States a “diagnostic niche”? The letter went on: “The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. This statement is commonly made but cannot be backed up by prospective studies.” In fact, we had included several prospective studies in our proposal. Let’s look at just two of them here.

THE LONG-TERM EFFECTS OF INCEST

In 1986 Frank Putnam and Penelope Trickett, his colleague at the National Institute of Mental Health, initiated the first longitudinal study of the impact of sexual abuse on female development.25 Until the results of this study came out, our knowledge about the effects of incest was based entirely on reports from children who had recently disclosed their abuse and on accounts from adults reconstructing years or even decades later how incest had affected them. No study had ever followed girls as they matured to examine how sexual abuse might influence their school performance, peer relationships, and self-concept, as well as their later dating life. Putnam and Trickett also looked at changes over time in their subjects’ stress hormones, reproductive hormones, immune function, and other physiological measures. In addition they explored potential protective factors, such as intelligence and support from family and peers.
The researchers painstakingly recruited eighty-four girls referred by the District of Columbia Department of Social Services who had a confirmed history of sexual abuse by a family member. These were matched with a comparison group of eighty-two girls of the same age, race, socioeconomic status, and family constellation who had not been abused. The average starting age was eleven. Over the next twenty years these two groups were thoroughly assessed six times, once a year for the first three years and again at ages eighteen, nineteen, and twenty-five. Their mothers participated in the early assessments, and their own children took part in the last. A remarkable 96 percent of the girls, now grown women, have stayed in the study from its inception.
The results were unambiguous: Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation. They dropped out of high school at a higher rate than the control group and had more major illnesses and health-care utilization. They also showed abnormalities in their stress hormone responses, had an earlier onset of puberty, and accumulated a host of different, seemingly unrelated, psychiatric diagnoses.
The follow-up research revealed many details of how abuse affects development. For example, each time they were assessed, the girls in both groups were asked to talk about the worst thing that had happened to them during the previous year. As they told their stories, the researchers observed how upset they became, while measuring their physiology. During the first assessment all the girls reacted by becoming distressed. Three years later, in response to the same question, the nonabused girls once again displayed signs of distress, but the abused girls shut down and became numb. Their biology matched their observable reactions: During the first assessment all of the girls showed an increase in the stress hormone cortisol; three years later cortisol went down in the abused girls as they reported on the most stressful event of the past year. Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action.
Putnam’s study also captured the pervasive long-term effects of incest on friendships and partnering. Before the onset of puberty nonabused girls usually have several girlfriends, as well as one boy who functions as a sort of spy who informs them about what these strange creatures, boys, are all about. After they enter adolescence, their contacts with boys gradually increase. In contrast, before puberty the abused girls rarely have close friends, girls or boys, but adolescence brings many chaotic and often traumatizing contacts with boys.
Lacking friends in elementary school makes a crucial difference. Today we’re aware how cruel third-, fourth-, and fifth-grade girls can be. It’s a complex and rocky time when friends can suddenly turn on one another and alliances dissolve in exclusions and betrayals. But there is an upside: By the time girls get to middle school, most have begun to master a whole set of social skills, including being able to identify what they feel, negotiating relationships with others, pretending to like people they don’t, and so on.
And most of them have built a fairly steady support network of girls who become their stress-debriefing team. As they slowly enter the world of sex and dating, these relationships give them room for reflection, gossip, and discussion of what it all means.
The sexually abused girls have an entirely different developmental pathway. They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress.
Other kids usually don’t want anything to do with them—they simply are too weird.
But that’s only the beginning of the trouble. The abused, isolated girls with incest histories mature sexually a year and a half earlier than the nonabused girls. Sexual abuse speeds up their biological clocks and the secretion of sex hormones. Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group.
Results of Putnam and Trickett’s study continue to be published, but it has already created an invaluable road map for clinicians dealing with sexually abused girls. At the Trauma Center, for example, one of our clinicians reported on a Monday morning that a patient named Ayesha had been raped—again—over the weekend. She had run away from her group home at five o’clock on Saturday, gone to a place in Boston where druggies hang out, smoked some dope and done some other drugs, and then left with a bunch of boys in a car. At five o’clock Sunday morning they had gang- raped her. Like so many of the adolescents we see, Ayesha can’t articulate what she wants or needs and can’t think through how she might protect herself. Instead, she lives in a world of actions. Trying to explain her behavior in terms of victim/perpetrator isn’t helpful, nor are labels like “depression,” “oppositional defiant disorder,” “intermittent explosive disorder,” “bipolar disorder,” or any of the other options our diagnostic manuals offer us. Putnam’s work has helped us understand how Ayesha experiences the world—why she cannot tell us what is going on with her, why she is so impulsive and lacking in self-protection, and why she views us as frightening and intrusive rather than as people who can help her.

WHAT DIFFERENCE WOULD DTD (Developmental Trauma Disorder) MAKE?

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

Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment. Recognizing the profound effects of trauma and deprivation on child development need not lead to blaming parents. We can assume that parents do the best they can, but all parents need help to nurture their kids. Nearly every industrialized nation, with the exception of the United States, recognizes this and provides some form of guaranteed support to families. James Heckman, winner of the 2000 Nobel Prize in Economics, has shown that quality early-childhood programs that involve parents and promote basic skills in disadvantaged children more than pay for themselves in improved outcomes.36
In the early 1970s psychologist David Olds was working in a Baltimore day-care center where many of the preschoolers came from homes wracked by poverty, domestic violence, and drug abuse. Aware that only addressing the children’s problems at school was not sufficient to improve their home conditions, he started a home-visitation program in which skilled nurses helped mothers to provide a safe and stimulating environment for their children and, in the process, to imagine a better future for themselves.
Twenty years later, the children of the home-visitation mothers were not only healthier but also less likely to report having been abused or neglected than a similar group whose mothers had not been visited. They also were more likely to have finished school, to have stayed out of jail, and to be working in well-paying jobs. Economists have calculated that every dollar invested in high-quality home visitation, day care, and preschool programs results in seven dollars of savings on welfare payments, health-care costs, substance-abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.37
When I go to Europe to teach, I often am contacted by officials at the ministries of health in the Scandinavian countries, the United Kingdom,
Germany, or the Netherlands and asked to spend an afternoon with them sharing the latest research on the treatment of traumatized children, adolescents, and their families. The same is true for many of my colleagues.
These countries have already made a commitment to universal health care, ensuring a guaranteed minimum wage, paid parental leave for both parents after a child is born, and high-quality childcare for all working mothers.

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

PART FOUR: THE IMPRINT OF TRAUMA

CHAPTER 11: UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY

In the spring of 2002 I was asked to examine a young man who claimed to have been sexually abused while he was growing up by Paul Shanley, a Catholic priest who had served in his parish in Newton, Massachusetts.
Now twenty-five years old, he had apparently forgotten the abuse until he heard that the priest was currently under investigation for molesting young boys. The question posed to me was: Even though he had seemingly “repressed” the abuse for well over a decade after it ended, were his memories credible, and was I prepared to testify to that fact before a judge? I will share what this man, whom I’ll call Julian, told me, drawing on my original case notes. (Even though his real name is in the public record,
I’m using a pseudonym because I hope that he has regained some privacy and peace with the passage of time.1)His experiences illustrate the complexities of traumatic memory. The controversies over the case against Father Shanley are also typical of the passions that have swirled around this issue since psychiatrists first described the unusual nature of traumatic memories in the final decades of the nineteenth century.

FLOODED BY SENSATIONS AND IMAGES

On February 11, 2001, Julian was serving as a military policeman at an air force base. During his daily phone conversation with his girlfriend, Rachel, she mentioned a lead article she’d read that morning in the Boston Globe. A priest named Shanley was under suspicion for molesting children. Hadn’t Julian once told her about a Father Shanley who had been his parish priest back in Newton? “Did he ever do anything to you?” she asked. Julian initially recalled Father Shanley as a kind man who’d been very supportive after his parents got divorced. But as the conversation went on, he started to go into a panic. He suddenly saw Shanley silhouetted in a doorframe, his hands stretched out at forty-five degrees, staring at Julian as he urinated.
Overwhelmed by emotion, he told Rachel, “I’ve got to go.” He called his flight chief, who came over accompanied by the first sergeant. After he met with the two of them, they took him to the base chaplain. Julian recalls telling him: “Do you know what is going on in Boston? It happened to me, too.” The moment he heard himself say those words, he knew for certain that Shanley had molested him—even though he did not remember the details. Julian felt extremely embarrassed about being so emotional; he had always been a strong kid who kept things to himself.
That night he sat on the corner of his bed, hunched over, thinking he was losing his mind and terrified that he would be locked up. Over the subsequent week images kept flooding into his mind, and he was afraid of breaking down completely. He thought about taking a knife and plunging it into his leg just to stop the mental pictures. Then the panic attacks started to be accompanied by seizures, which he called “epileptic fits.” He scratched his body until he bled. He constantly felt hot, sweaty, and agitated. Between panic attacks he “felt like a zombie”; he was observing himself from a distance, as if what he was experiencing were actually happening to somebody else.
In April he received an administrative discharge, just ten days short of being eligible to receive full benefits.
When Julian entered my office almost a year later, I saw a handsome, muscular guy who looked depressed and defeated. He told me immediately that he felt terrible about having left the air force. He had wanted to make it his career, and he’d always received excellent evaluations. He loved the challenges and the teamwork, and he missed the structure of the military lifestyle.
Julian was born in a Boston suburb, the second-oldest of five children.
His father left the family when Julian was about six because he could not tolerate living with Julian’s emotionally labile mother. Julian and his father get along quite well, but he sometimes reproaches his father for having worked too hard to support his family and for abandoning him to the care of his unbalanced mother. Neither his parents nor any of his siblings has ever received psychiatric care or been involved with drugs.
Julian was a popular athlete in high school. Although he had many friends, he felt pretty bad about himself and covered up for being a poor student by drinking and partying. He feels ashamed that he took advantage of his popularity and good looks by having sex with many girls. He mentioned wanting to call several of them to apologize for how badly he’d treated them.
He remembered always hating his body. In high school he took steroids to pump himself up and smoked marijuana almost every day. He did not go to college, and after graduating from high school he was virtually homeless for almost a year because he could no longer stand living with his mother.
He enlisted to try to get his life back on track.
Julian met Father Shanley at age six when he was taking a CCD
(catechism) class at the parish church. He remembered Father Shanley taking him out of the class for confession. Father Shanley rarely wore a cassock, and Julian remembered the priest’s dark blue corduroy pants. They would go to a big room with one chair facing another and a bench to kneel on. The chairs were covered with red and there was a red velvet cushion on the bench. They played cards, a game of war that turned into strip poker.
Then he remembered standing in front of a mirror in that room. Father Shanley made him bend over. He remembered Father Shanley putting a finger into his anus. He does not think Shanley ever penetrated him with his penis, but he believes that the priest fingered him on numerous occasions.
Other than that, his memories were quite incoherent and fragmentary.
He had flashes of images of Shanley’s face and of isolated incidents: Shanley standing in the door of the bathroom; the priest going down on his knees and moving “it” around with his tongue. He could not say how old he was when that happened. He remembered the priest telling him how to perform oral sex, but he did not remember actually doing it. He remembered passing out pamphlets in church and then Father Shanley sitting next to him in a pew, fondling him with one hand and holding Julian’s hand on himself with the other. He remembered that, as he grew older, Father Shanley would pass close to him and caress his penis. Paul did not like it but did not know what to do to stop it. After all, he told me,
“Father Shanley was the closest thing to God in my neighborhood.”
In addition to these memory fragments, traces of his sexual abuse were clearly being activated and replayed. Sometimes when he was having sex with his girlfriend, the priest’s image popped into his head, and, as he said, he would “lose it.” A week before I interviewed him, his girlfriend had pushed a finger into his mouth and playfully said: “You give good head.”
Julian jumped up and screamed, “If you ever say that again I’ll fucking kill you.” Then, terrified, they both started to cry. This was followed by one of Julian’s “epileptic fits,” in which he curled up in a fetal position, shaking and whimpering like a baby. While telling me this Julian looked very small and very frightened.
Julian alternated between feeling sorry for the old man that Father Shanley had become and simply wanting to “take him into a room somewhere and kill him.” He also spoke repeatedly of how ashamed he felt, how hard it was to admit that he could not protect himself: “Nobody fucks with me, and now I have to tell you this.” His self-image was of a big, tough Julian.
How do we make sense of a story like Julian’s: years of apparent forgetting, followed by fragmented, disturbing images, dramatic physical symptoms, and sudden reenactments? As a therapist treating people with a legacy of trauma, my primary concern is not to determine exactly what happened to them but to help them tolerate the sensations, emotions, and reactions they experience without being constantly hijacked by them. When the subject of blame arises, the central issue that needs to be addressed is usually self-blame—accepting that the trauma was not their fault, that it was not caused by some defect in themselves, and that no one could ever have deserved what happened to them.
Once a legal case is involved, however, determination of culpability becomes primary, and with it the admissibility of evidence. I had previously examined twelve people who had been sadistically abused as children in a Catholic orphanage in Burlington, Vermont. They had come forward (with many other claimants) more than four decades later, and although none had had any contact with the others until the first claim was filed, their abuse memories were astonishingly similar: They all named the same names and the particular abuses that each nun or priest had committed—in the same rooms, with the same furniture, and as part of the same daily routines. Most of them subsequently accepted an out-of-court settlement from the Vermont diocese.
Before a case goes to trial, the judge holds a so-called Daubert hearing to set the standards for expert testimony to be presented to the jury. In a 1996 case I had convinced a federal circuit court judge in Boston that it was common for traumatized people to lose all memories of the event in question, only to regain access to them in bits and pieces at a much later date. The same standards would apply in Julian’s case. While my report to his lawyer remains confidential, it was based on decades of clinical experience and research on traumatic memory, including the work of some of the great pioneers of modern psychiatry.

NORMAL VERSUS TRAUMATIC MEMORY

We all know how fickle memory is; our stories change and are constantly revised and updated. When my brothers, sisters, and I talk about events in our childhood, we always end up feeling that we grew up in different families—so many of our memories simply do not match. Such autobiographical memories are not precise reflections of reality; they are stories we tell to convey our personal take on our experience.
The extraordinary capacity of the human mind to rewrite memory is illustrated in the Grant Study of Adult Development, which has systematically followed the psychological and physical health of more than two hundred Harvard men from their sophomore years of 1939–44 to the present.2 Of course, the designers of the study could not have anticipated that most of the participants would go off to fight in World War II, but we can now track the evolution of their wartime memories. The men were interviewed in detail about their war experiences in 1945/1946 and again in 1989/1990. Four and a half decades later, the majority gave very different accounts from the narratives recorded in their immediate postwar interviews: With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended.
Whether we remember a particular event at all, and how accurate our memories of it are, largely depends on how personally meaningful it was and how emotional we felt about it at the time. The key factor is our level of arousal. We all have memories associated with particular people, songs, smells, and places that stay with us for a long time. Most of us still have precise memories of where we were and what we saw on Tuesday,
September 11, 2001, but only a fraction of us recall anything in particular about September 10.
Most day-to-day experience passes immediately into oblivion. On ordinary days we don’t have much to report when we come home in the evening. The mind works according to schemes or maps, and incidents that fall outside the established pattern are most likely to capture our attention.
If we get a raise or a friend tells us some exciting news, we will retain the details of the moment, at least for a while. We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds. Even if the content of the remark fades, our dislike for the person who made it usually persists.
When something terrifying happens, like seeing a child or a friend get hurt in an accident, we will retain an intense and largely accurate memory of the event for a long time. As James McGaugh and colleagues have

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

THE ORIGINS OF THE “TALKING CURE”

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

Breuer and Freud believed that traumatic memories were lost to ordinary consciousness either because “circumstances made a reaction impossible,” or because they started during “severely paralyzing affects, such as fright.” In 1896 Freud boldly claimed that “the ultimate cause of hysteria is always the seduction of the child by an adult.”22 Then, faced with his own evidence of an epidemic of abuse in the best families of Vienna—one, he noted, that would implicate his own father—he quickly began to retreat. Psychoanalysis shifted to an emphasis on unconscious wishes and fantasies, though Freud occasionally kept acknowledging the reality of sexual abuse.23 After the horrors of World War I confronted him with the reality of combat neuroses, Freud reaffirmed that lack of verbal memory is central in trauma and that, if a person does not remember, he is likely to act out: “[H]e reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.”24
The lasting legacy of Breuer and Freud’s 1893 paper is what we now call the “talking cure”: “[W]e found, to our great surprise, at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affect into words (all italics in original). Recollection without affect almost invariably produces no result.”
They explain that unless there is an “energetic reaction” to the traumatic event, the affect “remains attached to the memory” and cannot be discharged. The reaction can be discharged by an action—“from tears to acts of revenge.” “But language serves as a substitute for action; by its help, an affect can be ‘abreacted’ almost as effectively.” “It will now be understood,” they conclude, “how it is that the psychotherapeutic procedure which we have described in these pages has a curative effect. It brings to an end the operative force . . . which was not abreacted in the first instance [i.e., at the time of the trauma], by allowing its strangulated affect to find a way out through speech; and it subjects it to associative correction by introducing it into normal consciousness.”Even though psychoanalysis is today in eclipse, the “talking cure” has lived on, and psychologists have generally assumed that telling the trauma story in great detail will help people to leave it behind. That is also a basic premise of cognitive behavioral therapy (CBT), which today is taught in graduate psychology courses around the world.
Although the diagnostic labels have changed, we continue to see patients similar to those described by Charcot, Janet, and Freud. In 1986 my colleagues and I wrote up the case of a woman who had been a cigarette girl at Boston’s Cocoanut Grove nightclub when it burned down in 1942.25
During the 1970s and 1980s she annually reenacted her escape on Newbury Street, a few blocks from the original location, which resulted in her being hospitalized with diagnoses like schizophrenia and bipolar disorder. In 1989
I reported on a Vietnam veteran who yearly staged an “armed robbery” on the exact anniversary of a buddy’s death.26 He would put a finger in his pants pocket, claim that it was a pistol, and tell a shopkeeper to empty his cash register—giving him plenty of time to alert the police. This unconscious attempt to commit “suicide by cop” came to an end after a judge referred the veteran to me for treatment. Once we had dealt with his guilt about his friend’s death, there were no further reenactments.
Such incidents raise a critical question: How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remember? How can patients themselves identify the source of their behavior? If their history is not known, they are likely to be labeled as crazy or punished as criminals rather than helped to integrate the past.

CHAPTER 12: THE UNBEARABLE HEAVINESS OF REMEMBERING

Scientific interest in trauma has fluctuated wildly during the past 150 years. Charcot’s death in 1893 and Freud’s shift in emphasis to inner conflicts, defenses, and instincts at the root of mental suffering were just part of mainstream medicine’s overall loss of interest in the subject.
Psychoanalysis rapidly gained in popularity. In 1911 the Boston psychiatrist Morton Prince, who had studied with William James and Pierre Janet, complained that those interested in the effects of trauma were like “clams swamped by the rising tide in Boston Harbor.”
This neglect lasted for only a few years, though, because the outbreak of World War in 1914 once again confronted medicine and psychology with hundreds of thousands of men with bizarre psychological symptoms, unexplained medical conditions, and memory loss. The new technology of motion pictures made it possible to film these soldiers, and today on YouTube we can observe their bizarre physical postures, strange verbal utterances, terrified facial expressions, and tics—the physical, embodied expression of trauma: “a memory that is inscribed simultaneously in the mind, as interior images and words, and on the body.”1Early in the war the British created the diagnosis of “shell shock,” which entitled combat veterans to treatment and a disability pension. The alternative, similar, diagnosis was “neurasthenia,” for which they received neither treatment nor a pension. It was up to the orientation of the treating physician which diagnosis a soldier received.2
More than a million British soldiers served on the Western Front at any one time. In the first few hours of July 1, 1916 alone, in the Battle of the Somme, the British army suffered 57,470 casualties, including 19,240 dead, the bloodiest day in its history. The historian John Keegan says of their commander, Field Marshal Douglas Haig, whose statue today dominates Whitehall in London, once the center of the British Empire: “In his public manner and private diaries no concern for human suffering was or is discernible.” At the Somme “he had sent the flower of British youth to death or mutilation.”3
As the war wore on, shell shock increasingly compromised the efficiency of the fighting forces. Caught between taking the suffering of their soldiers seriously and pursuing victory over the Germans, the British General Staff issued General Routine Order Number 2384 in June of 1917, which stated, “In no circumstances whatever will the expression ‘shell shock’ be used verbally or be recorded in any regimental or other casualty report, or any hospital or other medical document.” All soldiers with psychiatric problems were to be given a single diagnosis of “NYDN” (Not Yet Diagnosed, Nervous).4 In November 1917 the General Staff denied Charles Samuel Myers, who ran four field hospitals for wounded soldiers, permission to submit a paper on shell shock to the British Medical Journal.
The Germans were even more punitive and treated shell shock as a character defect, which they managed with a variety of painful treatments, including electroshock.
In 1922 the British government issued the Southborough Report, whose goal was to prevent the diagnosis of shell shock in any future wars and to undermine any more claims for compensation. It suggested the elimination of shell shock from all official nomenclature and insisted that these cases should no more be classified “as a battle casualty than sickness or disease is so regarded.”5 The official view was that well-trained troops, properly led, would not suffer from shell shock and that the servicemen who hadsuccumbed to the disorder were undisciplined and unwilling soldiers. While the political storm about the legitimacy of shell shock continued to rage for several more years, reports on how to best treat these cases disappeared from the scientific literature.6
In the United States the fate of veterans was also fraught with problems. In 1918, when they returned home from the battlefields of France and Flanders, they had been welcomed as national heroes, just as the soldiers returning from Iraq and Afghanistan are today. In 1924 Congress voted to award them a bonus of $1.25 for each day they had served overseas, but disbursement was postponed until 1945.
By 1932 the nation was in the middle of the Great Depression, and in May of that year about fifteen thousand unemployed and penniless veterans camped on the Mall in Washington DC to petition for immediate payment of their bonuses. The Senate defeated the bill to move up disbursement by a vote of sixty-two to eighteen. A month later President Hoover ordered the army to clear out the veterans’ encampment. Army chief of staff General Douglas MacArthur commanded the troops, supported by six tanks. Major Dwight D. Eisenhower was the liaison with the Washington police, and Major George Patton was in charge of the cavalry. Soldiers with fixed bayonets charged, hurling tear gas into the crowd of veterans. The next morning the Mall was deserted and the camp was in flames.7 The veterans never received their pensions.
While politics and medicine turned their backs on the returning soldiers, the horrors of the war were memorialized in literature and art. In All Quiet on the Western Front,8 a novel about the war experiences of frontline soldiers by the German writer Erich Maria Remarque, the book’s protagonist, Paul Bäumer, spoke for an entire generation: “I am aware that I, without realizing it, have lost my feelings—I don’t belong here anymore,
I live in an alien world. I prefer to be left alone, not disturbed by anybody.
They talk too much—I can’t relate to them—they are only busy with superficial things.”9 Published in 1929, the novel instantly became an international best seller, with translations in twenty-five languages. The 1930 Hollywood film version won the Academy Award for Best Picture.
But when Hitler came to power a few years later, All Quiet on the Western Front was one of the first “degenerate” books the Nazis burned inthe public square in front of Humboldt University in Berlin.10 Apparently awareness of the devastating effects of war on soldiers’ minds would have constituted a threat to the Nazis’ plunge into another round of insanity.
Denial of the consequences of trauma can wreak havoc with the social fabric of society. The refusal to face the damage caused by the war and the intolerance of “weakness” played an important role in the rise of fascism and militarism around the world in the 1930s. The extortionate war reparations of the Treaty of Versailles further humiliated an already disgraced Germany. German society, in turn, dealt ruthlessly with its own traumatized war veterans, who were treated as inferior creatures. This cascade of humiliations of the powerless set the stage for the ultimate debasement of human rights under the Nazi regime: the moral justification for the strong to vanquish the inferior—the rationale for the ensuing war.

NORMAL VERSUS TRAUMATIC MEMORY

In 1994 I and my colleagues at Massachusetts General Hospital decided to undertake a systematic study comparing how people recall benign experiences and horrific ones. We placed advertisements in local newspapers, in laundromats, and on student union bulletin boards that said:

“Has something terrible happened to you that you cannot get out of your mind? Call 727-5500; we will pay you $10.00 for participating in this study.” In response to our first ad seventy-six volunteers showed up.26
After we introduced ourselves, we started off by asking each participant: “Can you tell us about an event in your life that you think you will always remember but that is not traumatic?” One participant lit up and said, “The day that my daughter was born”; others mentioned their wedding day, playing on a winning sports team, or being valedictorian at their high school graduation. Then we asked them to focus on specific sensory details of those events, such as: “Are you ever somewhere and suddenly have a vivid image of what your husband looked like on your wedding day?” The answers were always negative. “How about what your husband’s body felt like on your wedding night?” (We got some odd looks on that one.) We continued: “Do you ever have a vivid, precise recollection of the speech you gave as a valedictorian?” “Do you ever have intense sensations recalling the birth of your first child?” The replies were all in the negative.
Then we asked them about the traumas that had brought them into the study—many of them rapes. “Do you ever suddenly remember how your rapist smelled?” we asked, and, “Do you ever experience the same physical sensations you had when you were raped?” Such questions precipitated powerful emotional responses: “That is why I cannot go to parties anymore, because the smell of alcohol on somebody’s breath makes me feel like I am being raped all over again” or “I can no longer make love to my husband, because when he touches me in a particular way I feel like I am being raped again.”

There were two major differences between how people talked about memories of positive versus traumatic experiences: 
(1) how the memories were organized, and 
(2) their physical reactions to them. 

Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events.
In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events orother vital details (the first person who arrived to help, whether an ambulance or a police car took them to the hospital).
We also asked the participants how they recalled their trauma at three points in time: right after it happened; when they were most troubled by their symptoms; and during the week before the study. All of our traumatized participants said that they had not been able to tell anybody precisely what had happened immediately following the event. (This will not surprise anyone who has worked in an emergency room or ambulance service: People brought in after a car accident in which a child or a friend has been killed sit in stunned silence, dumbfounded by terror.) Almost all had repeated flashbacks: They felt overwhelmed by images, sounds, sensations, and emotions. As time went on, even more sensory details and feelings were activated, but most participants also started to be able to make some sense out of them. They began to “know” what had happened and to be able to tell the story to other people, a story that we call “the memory of the trauma.”
Gradually the images and flashbacks decreased in frequency, but the greatest improvement was in the participants’ ability to piece together the details and sequence of the event. By the time of our study, 85 percent of them were able to tell a coherent story, with a beginning, a middle, and an end. Only a few were missing significant details. We noted that the five who said they had been abused as children had the most fragmented narratives—their memories still arrived as images, physical sensations, and intense emotions.
In essence, our study confirmed the dual memory system that Janet and his colleagues at the Salpêtrière had described more than a hundred years earlier: Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography.
Perhaps the most important finding in our study was that remembering the trauma with all its associated affects, does not, as Breuer and Freud claimed back in 1893, necessarily resolve it. Our research did not support the idea that language can substitute for action. Most of our study participants could tell a coherent story and also experience the pain associated with those stories, but they kept being haunted by unbearableimages and physical sensations. Research in contemporary exposure treatment, a staple of cognitive behavioral therapy, has similarly disappointing results: The majority of patients treated with that method continue to have serious PTSD symptoms three months after the end of treatment. As we will see, finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries.

LISTENING TO SURVIVORS

Nobody wants to remember trauma. In that regard society is no different from the victims themselves. We all want to live in a world that is safe, manageable, and predictable, and victims remind us that this is not always the case. In order to understand trauma, we have to overcome our natural reluctance to confront that reality and cultivate the courage to listen to the testimonies of survivors.
In his book Holocaust Testimonies: The Ruins of Memory (1991), Lawrence Langer writes about his work in the Fortunoff Video Archive at Yale University: “Listening to accounts of Holocaust experience, we unearth a mosaic of evidence that constantly vanishes into bottomless layers of incompletion.28 We wrestle with the beginnings of a permanently unfinished tale, full of incomplete intervals, faced by the spectacle of a faltering witness often reduced to a distressed silence by the overwhelming solicitations of deep memory.” As one of his witnesses says: “If you were not there, it’s difficult to describe and say how it was. How men function under such stress is one thing, and then how you communicate and express that to somebody who never knew that such a degree of brutality exists seems like a fantasy.”

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

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

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

PART FIVE: PATHS TO RECOVERY

CHAPTER 13: HEALING FROM TRAUMA: OWNING YOUR SELF

Nobody can “treat” a war, or abuse, rape, molestation, or any other
horrendous event, for that matter; what has happened cannot be
undone. But what can be dealt with are the imprints of the trauma on body,
mind, and soul: the crushing sensations in your chest that you may label as
anxiety or depression; the fear of losing control; always being on alert for
danger or rejection; the self-loathing; the nightmares and flashbacks; the
fog that keeps you from staying on task and from engaging fully in what
you are doing; being unable to fully open your heart to another human
being.
Trauma robs you of the feeling that you are in charge of yourself, of
what I will call self-leadership in the chapters to come.1 The challenge of
recovery is to reestablish ownership of your body and your mind—of your
self. This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed. For
most people this involves: 

(1) finding a way to become calm and focused,

(2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, 

(3) finding a way to be fully alive in the present and engaged with the people around you, 

(4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.

These goals are not steps to be achieved, one by one, in some fixed
sequence. They overlap, and some may be more difficult than others,
depending on individual circumstances. In each of the chapters that follow,
I’ll talk about specific methods or approaches to accomplish them. I have
tried to make these chapters useful both to trauma survivors and to the
therapists who are treating them. People under temporary stress may also
find them useful. I’ve used every one of these methods extensively to treat
my patients, and I have also experienced them myself. Some people get
better using just one of these methods, but most are helped by different
approaches at different stages of their recovery.
I have done scientific studies of many of the treatments I describe here
and have published the research findings in peer-reviewed scientific
journals. My aim in this chapter is to provide an overview of underlying
principles, a preview of what’s to come, and some brief comments on
methods I don’t cover in depth later on.

A NEW FOCUS FOR RECOVERY

When we talk about trauma, we often start with a story or a question: “What
happened during the war?” “Were you ever molested?” “Let me tell you
about that accident or that rape,” or “Was anybody in your family a problem
drinker?” However, trauma is much more than a story about something that
happened long ago. The emotions and physical sensations that were
imprinted during the trauma are experienced not as memories but as
disruptive physical reactions in the present.
In order to regain control over your self, you need to revisit the trauma:
Sooner or later you need to confront what has happened to you, but only
after you feel safe and will not be retraumatized by it. The first order ofbusiness is to find ways to cope with feeling overwhelmed by the sensations
and emotions associated with the past.
As the previous parts of this book have shown, the engines of
posttraumatic reactions are located in the emotional brain. In contrast with
the rational brain, which expresses itself in thoughts, the emotional brain
manifests itself in physical reactions: gut-wrenching sensations, heart
pounding, breathing becoming fast and shallow, feelings of heartbreak,
speaking with an uptight and reedy voice, and the characteristic body
movements that signify collapse, rigidity, rage, or defensiveness.
Why can’t we just be reasonable? And can understanding help? The
rational, executive brain is good at helping us understand where feelings
come from (as in: “I get scared when I get close to a guy because my father
molested me” or “I have trouble expressing my love toward my son because
I feel guilty about having killed a child in Iraq”). However, the rational
brain cannot abolish emotions, sensations, or thoughts (such as living with a
low-level sense of threat or feeling that you are fundamentally a terrible
person, even though you rationally know that you are not to blame for
having been raped). Understanding why you feel a certain way does not
change how you feel. But it can keep you from surrendering to intense
reactions (for example, assaulting a boss who reminds you of a perpetrator,
breaking up with a lover at your first disagreement, or jumping into the
arms of a stranger). However, the more frazzled we are, the more our
rational brains take a backseat to our emotions.

LIMBIC SYSTEM THERAPY

The fundamental issue in resolving traumatic stress is to restore the proper
balance between the rational and emotional brains, so that you can feel in
charge of how you respond and how you conduct your life. When we’re
triggered into states of hyper- or hypoarousal, we are pushed outside our
“window of tolerance”—the range of optimal functioning.4 We become
reactive and disorganized; our filters stop working—sounds and lights
bother us, unwanted images from the past intrude on our minds, and we
panic or fly into rages. If we’re shut down, we feel numb in body and mind; our thinking becomes sluggish and we have trouble getting out of our
chairs.
As long as people are either hyperaroused or shut down, they cannot
learn from experience. Even if they manage to stay in control, they become
so uptight (Alcoholics Anonymous calls this “white-knuckle sobriety”) that
they are inflexible, stubborn, and depressed. Recovery from trauma
involves the restoration of executive functioning and, with it, self-
confidence and the capacity for playfulness and creativity.
If we want to change posttraumatic reactions, we have to access the
emotional brain and do “limbic system therapy”: repairing faulty alarm
systems and restoring the emotional brain to its ordinary job of being a
quiet background presence that takes care of the housekeeping of the body,
ensuring that you eat, sleep, connect with intimate partners, protect your
children, and defend against danger.



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

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

BEFRIENDING THE EMOTIONAL BRAIN

1. DEALING WITH HYPERAROUSAL

Over the past few decades mainstream psychiatry has focused on using
drugs to change the way we feel, and this has become the accepted way to
deal with hyper- and hypoarousal. I will discuss drugs later in this chapter,
but first I need to stress the fact that we have a host of inbuilt skills to keep
us on an even keel. In chapter 5 we saw how emotions are registered in the
body. Some 80 percent of the fibers of the vagus nerve (which connects the
brain with many internal organs) are afferent; that is, they run from the
body into the brain.6 This means that we can directly train our arousal
system by the way we breathe, chant, and move, a principle that has been
utilized since time immemorial in places like China and India, and in every
religious practice that I know of, but that is suspiciously eyed as
“alternative” in mainstream culture.
In research supported by the National Institutes of Health, my
colleagues and I have shown that ten weeks of yoga practice markedly
reduced the PTSD symptoms of patients who had failed to respond to any
medication or to any other treatment.7 (I will discuss yoga in chapter 16.)
Neurofeedback, the topic of chapter 19, also can be particularly effective
for children and adults who are so hyperaroused or shut down that they
have trouble focusing and prioritizing.8

Learning how to breathe calmly and remaining in a state of relative
physical relaxation, even while accessing painful and horrifying memories,
is an essential tool for recovery.9 When you deliberately take a few slow,
deep breaths, you will notice the effects of the parasympathetic brake on
your arousal (as explained in chapter 5). The more you stay focused on your
breathing, the more you will benefit, particularly if you pay attention until
the very end of the out breath and then wait a moment before you inhale
again. As you continue to breathe and notice the air moving in and out of
your lungs you may think about the role that oxygen plays in nourishing
your body and bathing your tissues with the energy you need to feel alive
and engaged. Chapter 16 documents the full-body effects of this simple
practice.
Since emotional regulation is the critical issue in managing the effects
of trauma and neglect, it would make an enormous difference if teachers,
army sergeants, foster parents, and mental health professionals were
thoroughly schooled in emotional-regulation techniques. Right now this still
is mainly the domain of preschool and kindergarten teachers, who deal with
immature brains and impulsive behavior on a daily basis and who are often
very adept at managing them.10
Mainstream Western psychiatric and psychological healing traditions
have paid scant attention to self-management. In contrast to the Western
reliance on drugs and verbal therapies, other traditions from around the
world rely on mindfulness, movement, rhythms, and action. Yoga in India,
tai chi and qigong in China, and rhythmical drumming throughout Africa
are just a few examples. The cultures of Japan and the Korean peninsula
have spawned martial arts, which focus on the cultivation of purposeful
movement and being centered in the present, abilities that are damaged in
traumatized individuals. Aikido, judo, tae kwon do, kendo, and jujitsu, as
well as capoeira from Brazil, are examples. These techniques all involve
physical movement, breathing, and meditation. Aside from yoga, few of
these popular non-Western healing traditions have been systematically
studied for the treatment of PTSD.

2. NO MIND WITHOUT MINDFULNESS

At the core of recovery is self-awareness. The most important phrases in
trauma therapy are “Notice that” and “What happens next?” Traumatized
people live with seemingly unbearable sensations: They feel heartbroken
and suffer from intolerable sensations in the pit of their stomach or tightness
in their chest. Yet avoiding feeling these sensations in our bodies increases
our vulnerability to being overwhelmed by them.
Body awareness puts us in touch with our inner world, the landscape of
our organism. Simply noticing our annoyance, nervousness, or anxiety
immediately helps us shift our perspective and opens up new options other
than our automatic, habitual reactions. Mindfulness puts us in touch with
the transitory nature of our feelings and perceptions. When we pay focused
attention to our bodily sensations, we can recognize the ebb and flow of our
emotions and, with that, increase our control over them.
Traumatized people are often afraid of feeling. It is not so much the
perpetrators (who, hopefully, are no longer around to hurt them) but their
own physical sensations that now are the enemy. Apprehension about being
hijacked by uncomfortable sensations keeps the body frozen and the mind
shut. Even though the trauma is a thing of the past, the emotional brain
keeps generating sensations that make the sufferer feel scared and helpless.
It’s not surprising that so many trauma survivors are compulsive eaters and
drinkers, fear making love, and avoid many social activities: Their sensory
world is largely off limits.
In order to change you need to open yourself to your inner experience.
The first step is to allow your mind to focus on your sensations and notice
how, in contrast to the timeless, ever-present experience of trauma, physical
sensations are transient and respond to slight shifts in body position,
changes in breathing, and shifts in thinking. Once you pay attention to your
physical sensations, the next step is to label them, as in “When I feel
anxious, I feel a crushing sensation in my chest.” I may then say to a
patient: “Focus on that sensation and see how it changes when you take a
deep breath out, or when you tap your chest just below your collarbone, or
when you allow yourself to cry.” Practicing mindfulness calms down the
sympathetic nervous system, so that you are less likely to be thrown into
fight-or-flight.11 Learning to observe and tolerate your physical reactions is
a prerequisite for safely revisiting the past. If you cannot tolerate what youare feeling right now, opening up the past will only compound the misery
and retraumatize you further.
We can tolerate a great deal discomfort as long as we stay conscious of
the fact that the body’s commotions constantly shift. One moment your
chest tightens, but after you take a deep breath and exhale, that feeling
softens and you may observe something else, perhaps a tension in your
shoulder. Now you can start exploring what happens when you take a
deeper breath and notice how your rib cage expands.13 Once you feel
calmer and more curious, you can go back to that sensation in your
shoulder. You should not be surprised if a memory spontaneously arises in
which that shoulder was somehow involved.
A further step is to observe the interplay between your thoughts and
your physical sensations. How are particular thoughts registered in your
body? (Do thoughts like “My father loves me” or “my girlfriend dumped
me” produce different sensations?) Becoming aware of how your body
organizes particular emotions or memories opens up the possibility of
releasing sensations and impulses you once blocked in order to survive.14 In
chapter 20, on the benefits of theater, I’ll describe in more detail how this
works.
Jon Kabat-Zinn, one of the pioneers in mind-body medicine, founded
the Mindfulness-Based Stress Reduction (MBSR) program at the University
of Massachusetts Medical Center in 1979, and his method has been
thoroughly studied for more than three decades. As he describes
mindfulness, “One way to think of this process of transformation is to think
of mindfulness as a lens, taking the scattered and reactive energies of your
mind and focusing them into a coherent source of energy for living, for
problem solving, for healing.”15
Mindfulness has been shown to have a positive effect on numerous
psychiatric, psychosomatic, and stress-related symptoms, including
depression and chronic pain.16 It has broad effects on physical health,
including improvements in immune response, blood pressure, and cortisol
levels.17 It has also been shown to activate the brain regions involved in
emotional regulation18 and to lead to changes in the regions related to body
awareness and fear.19 Research by my Harvard colleagues Britta Hölzel and
Sara Lazar has shown that practicing mindfulness even decreases theactivity of the brain’s smoke detector, the amygdala, and thus decreases
reactivity to potential triggers.

3. RELATIONSHIPS

Study after study shows that having a good support network constitutes the
single most powerful protection against becoming traumatized. Safety and
terror are incompatible. When we are terrified, nothing calms us down like
the reassuring voice or the firm embrace of someone we trust. Frightened
adults respond to the same comforts as terrified children: gentle holding and
rocking and the assurance that somebody bigger and stronger is taking care
of things, so you can safely go to sleep. In order to recover, mind, body, and
brain need to be convinced that it is safe to let go. That happens only when
you feel safe at a visceral level and allow yourself to connect that sense of
safety with memories of past helplessness.
After an acute trauma, like an assault, accident, or natural disaster,
survivors require the presence of familiar people, faces, and voices;
physical contact; food; shelter and a safe place; and time to sleep. It is
critical to communicate with loved ones close and far and to reunite as soon
as possible with family and friends in a place that feels safe. Our attachment
bonds are our greatest protection against threat. For example, children who
are separated from their parents after a traumatic event are likely to suffer
serious negative long-term effects. Studies conducted during World War II
in England showed that children who lived in London during the Blitz and
were sent away to the countryside for protection against German bombing
raids fared much worse than children who remained with their parents and
endured nights in bomb shelters and frightening images of destroyed
buildings and dead people.21
Traumatized human beings recover in the context of relationships: with
families, loved ones, AA meetings, veterans’ organizations, religious
communities, or professional therapists. The role of those relationships is to
provide physical and emotional safety, including safety from feeling
shamed, admonished, or judged, and to bolster the courage to tolerate, face,
and process the reality of what has happened.
As we have seen, much the wiring of our brain circuits is devoted to
being in tune with others. Recovery from trauma involves (re)connectingwith our fellow human beings. This is why trauma that has occurred within
relationships is generally more difficult to treat than trauma resulting from
traffic accidents or natural disasters. In our society the most common
traumas in women and children occur at the hands of their parents or
intimate partners. Child abuse, molestation, and domestic violence all are
inflicted by people who are supposed to love you. That knocks out the most
important protection against being traumatized: being sheltered by the
people you love.
If the people whom you naturally turn to for care and protection terrify
or reject you, you learn to shut down and to ignore what you feel.22 As we
saw in part 3, when your caregivers turn on you, you have to find
alternative ways to deal with feeling scared, angry, or frustrated. Managing
your terror all by yourself gives rise to another set of problems:
dissociation, despair, addictions, a chronic sense of panic, and relationships
that are marked by alienation, disconnection, and explosions. Patients with
these histories rarely make the connection between what happened to them
long ago and how they currently feel and behave. Everything just seems
unmanageable.
Relief does not come until they are able to acknowledge what has
happened and recognize the invisible demons they’re struggling with.
Recall, for example, the men I described in chapter 11 who had been abused
by pedophile priests. They visited the gym regularly, took anabolic steroids,
and were strong as oxen. However, in our interviews they often acted like
scared kids; the hurt boys deep inside still felt helpless.
While human contact and attunement are the wellspring of
physiological self-regulation, the promise of closeness often evokes fear of
getting hurt, betrayed, and abandoned. Shame plays an important role in
this: “You will find out how rotten and disgusting I am and dump me as
soon as you really get to know me.” Unresolved trauma can take a terrible
toll on relationships. If your heart is still broken because you were assaulted
by someone you loved, you are likely to be preoccupied with not getting
hurt again and fear opening up to someone new. In fact, you may
unwittingly try to hurt them before they have a chance to hurt you.
This poses a real challenge for recovery. Once you recognize that
posttraumatic reactions started off as efforts to save your life, you maygather the courage to face your inner music (or cacophony), but you will
need help to do so. You have to find someone you can trust enough to
accompany you, someone who can safely hold your feelings and help you
listen to the painful messages from your emotional brain. You need a guide
who is not afraid of your terror and who can contain your darkest rage,
someone who can safeguard the wholeness of you while you explore the
fragmented experiences that you had to keep secret from yourself for so
long. Most traumatized individuals need an anchor and a great deal of
coaching to do this work.

Choosing a Professional Therapist

The training of competent trauma therapists involves learning about the
impact of trauma, abuse, and neglect and mastering a variety of techniques
that can help to: 

(1) stabilize and calm patients down, 

(2) help to lay traumatic memories and reenactments to rest, and 

(3) reconnect patients with their fellow men and women. 

Ideally the therapist will also have been
on the receiving end of whatever therapy he or she practices.
While it’s inappropriate and unethical for therapists to tell you the
details of their personal struggles, it is perfectly reasonable to ask what
particular forms of therapy they have been trained in, where they learned
their skills, and whether they’ve personally benefited from the therapy they
propose for you.
There is no one “treatment of choice” for trauma, and any therapist
who believes that his or her particular method is the only answer to your
problems is suspect of being an ideologue rather than somebody who is
interested in making sure that you get well. No therapist can possibly be
familiar with every effective treatment, and he or she must be open to your
exploring options other than the ones he or she offers. He or she also must
be open to learning from you. Gender, race, and personal background are
relevant only if they interfere with helping the patient feel safe and
understood.
Do you feel basically comfortable with this therapist? Does he or she
seem to feel comfortable in his or her own skin and with you as a fellow
human being? Feeling safe is a necessary condition for you to confront your
fears and anxieties. Someone who is stern, judgmental, agitated, or harsh is likely to leave you feeling scared, abandoned, and humiliated, and that
won’t help you resolve your traumatic stress. There may be times as old
feelings from the past are stirred up, when you become suspicious that the
therapist resembles someone who once hurt or abused you. Hopefully, this
is something you can work through together, because in my experience
patients get better only if they develop deep positive feelings for their
therapists. I also don’t think that you can grow and change unless you feel
that you have some impact on the person who is treating you.
The critical question is this: Do you feel that your therapist is curious to
find out who you are and what you, not some generic “PTSD patient,”
need? Are you just a list of symptoms on some diagnostic questionnaire, or
does your therapist take the time to find out why you do what you do and
think what you think? Therapy is a collaborative process—a mutual
exploration of your self.
Patients who have been brutalized by their caregivers as children often
do not feel safe with anyone. I often ask my patients if they can think of any
person they felt safe with while they were growing up. Many of them hold
tight to the memory of that one teacher, neighbor, shopkeeper, coach, or
minister who showed that he or she cared, and that memory is often the
seed of learning to reengage. We are a hopeful species. Working with
trauma is as much about remembering how we survived as it is about what
is broken.
I also ask my patients to imagine what they were like as newborns—
whether they were lovable and filled with spunk. All of them believe they
were and have some image of what they must have been like before they
were hurt.
Some people don’t remember anybody they felt safe with. For them,
engaging with horses or dogs may be much safer than dealing with human
beings. This principle is currently being applied in many therapeutic
settings to great effect, including in jails, residential treatment programs,
and veterans’ rehabilitation. Jennifer, a member of the first graduating class
of the Van der Kolk Center,23 who had come to the program as an out-of-
control, mute fourteen-year-old, said during her graduation ceremony that
having been entrusted with the responsibility of caring for a horse was the
critical first step for her. Her growing bond with her horse helped her feelsafe enough to begin to relate to the staff of the center and then to focus on
her classes, take her SATs, and be accepted to college.

4. COMMUNAL RHYTHMS AND SYNCHRONY

From the moment of our birth, our relationships are embodied in responsive
faces, gestures, and touch. As we saw in chapter 7, these are the foundations
of attachment. Trauma results in a breakdown of attuned physical
synchrony: When you enter the waiting room of a PTSD clinic, you can
immediately tell the patients from the staff by their frozen faces and
collapsed (but simultaneously agitated) bodies. Unfortunately, many
therapists ignore those physical communications and focus only on the
words with which their patients communicate.
The healing power of community as expressed in music and rhythms
was brought home for me in the spring of 1997, when I was following the
work of the Truth and Reconciliation Commission in South Africa. In some
places we visited, terrible violence continued. One day I attended a group
for rape survivors in the courtyard of a clinic in a township outside
Johannesburg. We could hear the sound of bullets being fired at a distance
while smoke billowed over the walls of the compound and the smell of
teargas hung in the air. Later we heard that forty people had been killed.
Yet, while the surroundings were foreign and terrifying, I recognized
this group all too well: The women sat slumped over—sad and frozen—like
so many rape therapy groups I had seen in Boston. I felt a familiar sense of
helplessness, and, surrounded by collapsed people, I felt myself mentally
collapse as well. Then one of the women started to hum, while gently
swaying back and forth. Slowly a rhythm emerged; bit by bit other women
joined in. Soon the whole group was singing, moving, and getting up to
dance. It was an astounding transformation: people coming back to life,
faces becoming attuned, vitality returning to bodies. I made a vow to apply
what I was seeing there and to study how rhythm, chanting, and movement
can help to heal trauma.
We will see more of this in chapter 20, on theater, where I show how
groups of young people—among them juvenile offenders and at-risk foster
kids—gradually learn to work together and to depend on one another,
whether as partners in Shakespearean swordplay or as the writers andperformers of full-length musicals. Different patients have told me how
much choral singing, aikido, tango dancing, and kickboxing have helped
them, and I am delighted to pass their recommendations on to other people I
treat.
I learned another powerful lesson about rhythm and healing when
clinicians at the Trauma Center were asked to treat a five-year-old mute
girl, Ying Mee, who had been adopted from an orphanage in China. After
months of failed attempts to make contact with her, my colleagues Deborah
Rozelle and Liz Warner realized that her rhythmical engagement system
didn’t work—she could not resonate with the voices and faces of the people
around her. That led them to sensorimotor therapy.25
The sensory integration clinic in Watertown, Massachusetts, is a
wondrous indoor playground filled with swings, tubs full of multicolored
rubber balls so deep that you can make yourself disappear, balance beams,
crawl spaces fashioned from plastic tubing, and ladders that lead to
platforms from which you can dive onto foam-filled mats. The staff bathed
Ying Mee in the tub with plastic balls; that helped her feel sensations on her
skin. They helped her sway on swings and crawl under weighted blankets.
After six weeks something shifted—and she started to talk.26
Ying Mee’s dramatic improvement inspired us to start a sensory
integration clinic at the Trauma Center, which we now also use in our
residential treatment programs. We have not yet explored how well sensory
integration works for traumatized adults, but I regularly incorporate sensory
integration experiences and dance in my seminars.
Learning to become attuned provides parents (and their kids) with the
visceral experience of reciprocity. Parent-child interaction therapy (PCIT) is
an interactive therapy that fosters this, as is SMART (sensory motor arousal
regulation treatment), developed by my colleagues at the Trauma Center.27
When we play together, we feel physically attuned and experience a
sense of connection and joy. Improvisation exercises (such as those found at
http://learnimprov.com/) also are a marvelous way to help people connect in
joy and exploration. The moment you see a group of grim-faced people
break out in a giggle, you know that the spell of misery has broken.

5. GETTING IN TOUCH

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



Rembrandt van Rijn: Christ Healing the Sick. Gestures of comfort are universally
recognizable and reflect the healing power of attuned touch.
Touch, the most elementary tool that we have to calm down, is
proscribed from most therapeutic practices. Yet you can’t fully recover if
you don’t feel safe in your skin. Therefore, I encourage all my patients to
engage in some sort of bodywork, be it therapeutic massage, Feldenkrais, or
craniosacral therapy.I asked my favorite bodywork practitioner, Licia Sky, about her
practice with traumatized individuals. Here is some of what she told me: “I
never begin a bodywork session without establishing a personal connection.
I’m not taking a history; I’m not finding out how traumatized a person is or
what happened to them. I check in where they are in their body right now. I
ask them if there is anything they want me to pay attention to. All the while,
I’m assessing their posture; whether they look me in the eye; how tense or
relaxed they seem; are they connecting with me or not.
“The first decision I make is if they will feel safer face up or face
down. If I don’t know them, I usually start face up. I am very careful about
draping; very careful to let them feel safe with whatever clothing they want
to leave on. These are important boundaries to set up right at the beginning.
“Then, with my first touch, I make firm, safe contact. Nothing forced or
sharp. Nothing too fast. The touch is slow, easy for the client to follow,
gently rhythmic. It can be as strong as a handshake. The first place I might
touch is their hand and forearm, because that’s the safest place to touch
anybody, the place where they can touch you back.
“You have to meet their point of resistance—the place that has the most
tension—and meet it with an equal amount of energy. That releases the
frozen tension. You can’t hesitate; hesitation communicates a lack of trust
in yourself. Slow movement, careful attuning to the client is different from
hesitation. You have to meet them with tremendous confidence and
empathy, let the pressure of your touch meet the tension they are holding in
their bodies.”
What does bodywork do for people? Licia’s reply: “Just like you can
thirst for water, you can thirst for touch. It is a comfort to be met
confidently, deeply, firmly, gently, responsively. Mindful touch and
movement grounds people and allows them to discover tensions that they
may have held for so long that they are no longer even aware of them.
When you are touched, you wake up to the part of your body that is being
touched.
“The body is physically restricted when emotions are bound up inside.
People’s shoulders tighten; their facial muscles tense. They spend enormous
energy on holding back their tears—or any sound or movement that might
betray their inner state. When the physical tension is released, the feelings
can be released. Movement helps breathing to become deeper, and as thetensions are released, expressive sounds can be discharged. The body
becomes freer—breathing freer, being in flow. Touch makes it possible to
live in a body that can move in response to being moved.
“People who are terrified need to get a sense of where their bodies are
in space and of their boundaries. Firm and reassuring touch lets them know
where those boundaries are: what’s outside them, where their bodies end.
They discover that they don’t constantly have to wonder who and where
they are. They discover that their body is solid and that they don’t have to
be constantly on guard. Touch lets them know that they are safe.”

6. TAKING ACTION

The body responds to extreme experiences by secreting stress hormones.
These are often blamed for subsequent illness and disease. However, stress
hormones are meant to give us the strength and endurance to respond to
extraordinary conditions. People who actively do something to deal with a
disaster—rescuing loved ones or strangers, transporting people to a
hospital, being part of a medical team, pitching tents or cooking meals—
utilize their stress hormones for their proper purpose and therefore are at
much lower risk of becoming traumatized. (Nonetheless, everyone has his
or her breaking point, and even the best-prepared person may become
overwhelmed by the magnitude of the challenge.)
Helplessness and immobilization keep people from utilizing their stress
hormones to defend themselves. When that happens, their hormones still
are being pumped out, but the actions they’re supposed to fuel are thwarted.
Eventually, the activation patterns that were meant to promote coping are
turned back against the organism and now keep fueling inappropriate
fight/flight and freeze responses. In order to return to proper functioning,
this persistent emergency response must come to an end. The body needs to
be restored to a baseline state of safety and relaxation from which it can
mobilize to take action in response to real danger.
My friends and teachers Pat Ogden and Peter Levine have each
developed powerful body-based therapies, sensorimotor psychotherapy29
and somatic experiencing30 to deal with this issue. In these treatment
approaches the story of what has happened takes a backseat to exploring
physical sensations and discovering the location and shape of the imprintsof past trauma on the body. Before plunging into a full-fledged exploration
of the trauma itself, patients are helped to build up internal resources that
foster safe access sensations and emotions that overwhelmed them at the
time of the trauma. Peter Levine calls this process pendulation—gently
moving in and out of accessing internal sensations and traumatic memories.
In this way patients are helped to gradually expand their window of
tolerance.
Once patients can tolerate being aware of their trauma-based physical
experiences, they are likely to discover powerful physical impulses—like
hitting, pushing, or running—that arose during the trauma but were
suppressed in order to survive. These impulses manifest themselves in
subtle body movements such as twisting, turning, or backing away.
Amplifying these movements and experimenting with ways to modify them
begins the process of bringing the incomplete, trauma-related “action
tendencies” to completion and can eventually lead to resolution of the
trauma. Somatic therapies can help patients to relocate themselves in the
present by experiencing that it is safe to move. Feeling the pleasure of
taking effective action restores a sense of agency and a sense of being able
to actively defend and protect themselves.
Back in 1893 Pierre Janet, the first great explorer of trauma, wrote
about “the pleasure of completed action,” and I regularly observe that
pleasure when I practice sensorimotor psychotherapy and somatic
experiencing: When patients can physically experience what it would have
felt like to fight back or run away, they relax, smile, and express a sense of
completion.
When people are forced to submit to overwhelming power, as is true
for most abused children, women trapped in domestic violence, and
incarcerated men and women, they often survive with resigned compliance.
The best way to overcome ingrained patterns of submission is to restore a
physical capacity to engage and defend. One of my favorite body-oriented
ways to build effective fight/flight responses is our local impact center’s
model mugging program, in which women (and increasingly men) are
taught to actively fight off a simulated attack.31 The program started in
Oakland, California, in 1971 after a woman with a fifth-degree black belt in
karate was raped. Wondering how this could have happened to someonewho supposedly could kill with her bare hands, her friends concluded that
she had become de-skilled by fear. In the terms of this book, her executive
functions—her frontal lobes—went off-line, and she froze. The model
mugging program teaches women to recondition the freeze response
through many repetitions of being placed in the “zero hour” (a military term
for the precise moment of an attack) and learning to transform fear into
positive fighting energy.
One of my patients, a college student with a history of unrelenting child
abuse, took the course. When I first met her, she was collapsed, depressed,
and overly compliant. Three months later, during her graduation ceremony,
she successfully fought off a gigantic male attacker who ended up lying
cringing on the floor (shielded from her blows by a thick protective suit)
while she faced him, arms raised in a karate stance, calmly and clearly
yelling no.
Not long afterward, she was walking home from the library after
midnight when three men jumped out of some bushes, yelling: “Bitch, give
us your money.” She later told me that she took that same karate stance and
yelled back: “Okay, guys, I’ve been looking forward to this moment. Who
wants to take me on first?” They ran away. If you’re hunched over and too
afraid to look around, you are easy prey to other people’s sadism, but when
you walk around projecting the message “Don’t mess with me,” you’re not
likely to be bothered.

INTEGRATING TRAUMATIC MEMORIES

People cannot put traumatic events behind until they are able to
acknowledge what has happened and start to recognize the invisible demons
they’re struggling with. Traditional psychotherapy has focused mainly on
constructing a narrative that explains why a person feels a particular way or,
as Sigmund Freud put it back in 1914 in Remembering, Repeating and
Working Through:32 “While the patient lives [the trauma] through as
something real and actual, we have to accomplish the therapeutic task,
which consists chiefly of translating it back again in terms of the past.”
Telling the story is important; without stories, memory becomes frozen; and
without memory you cannot imagine how things can be different. But as wesaw in part 4, telling a story about the event does not guarantee that the
traumatic memories will be laid to rest.
There is a reason for that. When people remember an ordinary event,
they do not also relive the physical sensations, emotions, images, smells, or
sounds associated with that event. In contrast, when people fully recall their
traumas, they “have” the experience: They are engulfed by the sensory or
emotional elements of the past. The brain scans of Stan and Ute Lawrence,
the accident victims in chapter 4, show how this happens. When Stan was
remembering his horrendous accident, two key areas in his brain went
blank: the area that provides a sense of time and perspective, which makes
it possible to know that “that was then, but I am safe now,” and another area
that integrates the images, sounds, and sensations of trauma into a coherent
story. When those parts of the brain are knocked out, you experience
something not as an event with a beginning, a middle, and an end but in
fragments of sensations, images, and emotions.
A trauma can be successfully processed only if all those brain
structures are kept online. In Stan’s case, eye movement desensitization and
reprocessing (EMDR) allowed him to access his memories of the accident
without being overwhelmed by them. When the brain areas whose absence
is responsible for flashbacks can be kept online while remembering what
has happened, people can integrate their traumatic memories as belonging
to the past.
Ute’s dissociation (as you recall, she shut down completely)
complicated recovery in a different way. None of the brain structures
necessary to engage in the present were online, so that dealing with the
trauma was simply impossible. Without a brain that is alert and present
there can be no integration and resolution. She needed to be helped to
increase her window of tolerance before she could deal with her PTSD
symptoms.
Hypnosis was the most widely practiced treatment for trauma from the
late 1800s, the time of Pierre Janet and Sigmund Freud, until after World
War II. On YouTube you can still watch the documentary Let There Be
Light, by the great Hollywood director John Huston, which shows men
undergoing hypnosis to treat “war neurosis.” Hypnosis fell out of favor in
the early 1990s and there have been no recent studies of its effectiveness for
treating PTSD. However, hypnosis can induce a state of relative calm fromwhich patients can observe their traumatic experiences without being
overwhelmed by them. Since that capacity to quietly observe oneself is a
critical factor in the integration of traumatic memories, it is likely that
hypnosis, in some form, will make a comeback.

COGNITIVE BEHAVIORAL THERAPY (CBT)

During their training most psychologists are taught cognitive behavioral
therapy. CBT was first developed to treat phobias such as fear of spiders,
airplanes, or heights, to help patients compare their irrational fears with
harmless realities. Patients are gradually desensitized from their irrational
fears by bringing to mind what they are most afraid of, using their
narratives and images (“imaginal exposure”), or they are placed in actual
(but actually safe) anxiety-provoking situations (“in vivo exposure”), or
they are exposed to virtual-reality, computer-simulated scenes, for example,
in the case of combat-related PTSD, fighting in the streets of Fallujah.
The idea behind cognitive behavioral treatment is that when patients
are repeatedly exposed to the stimulus without bad things actually
happening, they gradually will become less upset; the bad memories will
have become associated with “corrective” information of being safe.33 CBT
also tries to help patients deal with their tendency to avoid, as in “I don’t
want to talk about it.”34 It sounds simple, but, as we have seen, reliving
trauma reactivates the brain’s alarm system and knocks out critical brain
areas necessary for integrating the past, making it likely that patients will
relive rather than resolve the trauma.
Prolonged exposure or “flooding” has been studied more thoroughly
than any other PTSD treatment. Patients are asked to “focus their attention
on the traumatic material and . . . not distract themselves with other
thoughts or activities.”35 Research has shown that up to one hundred
minutes of flooding (in which anxiety-provoking triggers are presented in
an intense, sustained form) are required before decreases in anxiety are
reported.36 Exposure sometimes helps to deal with fear and anxiety, but it
has not been proven to help with guilt or other complex emotions.37
In contrast to its effectiveness for irrational fears such as spiders, CBT
has not done so well for traumatized individuals, particularly those withhistories of childhood abuse. Only about one in three participants with
PTSD who finish research studies show some improvement.38 Those who
complete CBT treatment usually have fewer PTSD symptoms, but they
rarely recover completely: Most continue to have substantial problems with
their health, work, or mental well-being.39
In the largest published study of CBT for PTSD more than one-third of
the patients dropped out; the rest had a significant number of adverse
reactions. Most of the women in the study still suffered from full-blown
PTSD after three months in the study, and only 15 percent no longer had
major PTSD symptoms.40 A thorough analysis of all the scientific studies of
CBT show that it works about as well as being in a supportive therapy
relationship.41 The poorest outcome in exposure treatments occurs in
patients who suffer from “mental defeat”—those who have given up.42
Being traumatized is not just an issue of being stuck in the past; it is
just as much a problem of not being fully alive in the present. One form of
exposure treatment is virtual-reality therapy in which veterans wear high-
tech goggles that make it possible to refight the battle of Fallujah in lifelike
detail. As far as I know, the US Marines performed very well in combat.
The problem is that they cannot tolerate being home. Recent studies of
Australian combat veterans show that their brains are rewired to be alert for
emergencies, at the expense of being focused on the small details of
everyday life.43 (We’ll learn more about this in chapter 19, on
neurofeedback.) More than virtual-reality therapy, traumatized patients need
“real world” therapy, which helps them to feel as alive when walking
through the local supermarket or playing with their kids as they did in the
streets of Baghdad.
Patients can benefit from reliving their trauma only if they are not
overwhelmed by it. A good example is a study of Vietnam veterans
conducted in the early 1990s by my colleague Roger Pitman.44 I visited
Roger’s lab every week during that time, since we were conducting the
study of brain opioids in PTSD that I discussed in chapter 2. Roger would
show me the videotapes of his treatment sessions and we would discuss
what we observed. He and his colleagues pushed the veterans to talk
repeatedly about every detail of their experiences in Vietnam, but the
investigators had to stop the study because many patients became panickedby their flashbacks, and the dread often persisted after the sessions. Some
never returned, while many of those who stayed with the study became
more depressed, violent, and fearful; some coped with their increased
symptoms by increasing their alcohol consumption, which led to further
violence and humiliation, as some of their families called the police to take
them to a hospital.

DESENSITIZATION

Over the past two decades the prevailing treatment taught to psychology
students has been some form of systematic desensitization: helping patients
become less reactive to certain emotions and sensations. But is this the
correct goal? Maybe the issue is not desensitization but integration: putting
the traumatic event into its proper place in the overall arc of one’s life.
Desensitization makes me think of the small boy—he must have been
about five—I saw in front of my house recently. His hulking father was
yelling at him at the top of his voice as the boy rode his tricycle down my
street. The kid was unfazed, while my heart was racing and I felt an impulse
to deck the guy. How much brutality had it taken to numb a child this young
to his father’s brutality? His indifference to his father’s yelling must have
been the result of prolonged exposure, but, I wondered, at what price? Yes,
we can take drugs that blunt our emotions or we can learn to desensitize
ourselves. As medical students we learned to stay analytical when we had to
treat children with third-degree burns. But, as the neuroscientist Jean
Decety at the University of Chicago has shown, desensitization to our own
or to other people’s pain tends to lead to an overall blunting of emotional
sensitivity.45
A 2010 report on 49,425 veterans with newly diagnosed PTSD from
the Iraq and Afghanistan wars who sought care from the VA showed that
fewer than one out of ten actually completed the recommended treatment.46
As in Pitman’s Vietnam veterans, exposure treatment, as currently
practiced, rarely works for them. We can only “process” horrendous
experiences if they do not overwhelm us. And that means that other
approaches are necessary.

DRUGS TO SAFELY ACCESS TRAUMA?

When I was a medical student, I spent the summer of 1966 working for Jan
Bastiaans, a professor at Leiden University in the Netherlands who was
known for his work treating Holocaust survivors with LSD. He claimed to
have achieved spectacular results, but when colleagues inspected his
archives, they found few data to support his claims. The potential of mind-
altering substances for trauma treatment was subsequently neglected until
2000, when Michael Mithoefer and his colleagues in South Carolina
received FDA permission to conduct an experiment with MDMA (ecstasy).
MDMA was classified as a controlled substance in 1985 after having been
used for years as a recreational drug. As with Prozac and other psychotropic
agents, we don’t know exactly how MDMA works, but it is known to
increase concentrations of a number of important hormones including
oxytocin, vasopressin, cortisol, and prolactin.47 Most relevant for trauma
treatment, it increases people’s awareness of themselves; they frequently
report a heightened sense of compassionate energy, accompanied by
curiosity, clarity, confidence, creativity, and connectedness. Mithoefer and
his colleagues were looking for a medication that would enhance the
effectiveness of psychotherapy, and they became interested in MDMA
because it decreases fear, defensiveness, and numbing, as well as helping to
access inner experience.48 They thought MDMA might enable patients to
stay within the window of tolerance so they could revisit their traumatic
memories without suffering overwhelming physiological and emotional
arousal.
The initial pilot studies have supported that expectation.49 The first
study, involving combat veterans, firefighters, and police officers with
PTSD, had positive results. In the next study, of a group of twenty victims
of assault who had been unresponsive to previous forms of therapy, twelve
subjects received MDMA and eight received an inactive placebo. Sitting or
lying in a comfortable room, they then all received two eight-hour
psychotherapy sessions, mainly using internal family systems (IFS) therapy,
the subject of chapter 17 of this book. Two months later 83 percent of the
patients who received MDMA plus psychotherapy were considered
completely cured, compared with 25 percent of the placebo group. None of
the patients had adverse side effects. Perhaps most interesting, when theparticipants were interviewed more than a year after the study was
completed, they had maintained their gains.
By being able to observe the trauma from the calm, mindful state that
IFS calls Self (a term I’ll discuss further in chapter 17), mind and brain are
in a position to integrate the trauma into the overall fabric of life. This is
very different from traditional desensitization techniques, which are about
blunting a person’s response to past horrors. This is about association and
integration—making a horrendous event that overwhelmed you in the past
into a memory of something that happened a long time ago.
Nonetheless, psychedelic substances are powerful agents with a
troubled history. They can easily be misused through careless
administration and poor maintenance of therapeutic boundaries. It is to be
hoped that MDMA will not be another magic cure released from Pandora’s
box.

WHAT ABOUT MEDICATIONS?

People have always used drugs to deal with traumatic stress. Each culture and each generation has its preferences—gin, vodka, beer, or whiskey; hashish, marijuana, cannabis, or ganja; cocaine; opioids like oxycontin; tranquilizers such as Valium, Xanax, and Klonopin. When people are desperate, they will do just about anything to feel calmer and more in
control.

Mainstream psychiatry follows this tradition. Over the past decade the Departments of Defense and Veterans Affairs combined have spent over $4.5 billion on antidepressants, antipsychotics, and antianxiety drugs. A June 2010 internal report from the Defense Department’s Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other controlled substances.

However, drugs cannot “cure” trauma; they can only dampen the expressions of a disturbed physiology. And they do not teach the lasting lessons of self-regulation. They can help to control feelings and behavior, but always at a price—because they work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure. Some of my colleagues remain optimistic: I keep attending meetings where serious scientists discuss their quest for the elusive magic bullet that will miraculously reset the fear circuits of the brain (as if traumatic stress involved only one simple brain circuit). I also regularly prescribe medications.

Just about every group of psychotropic agents has been used to treat some aspect of PTSD. The serotonin reuptake inhibitors (SSRIs) such as Prozac, Zoloft, Effexor, and Paxil have been most thoroughly studied, and they can make feelings less intense and life more manageable. Patients on SSRIs often feel calmer and more in control; feeling less overwhelmed often makes it easier to engage in therapy. Other patients feel blunted by SSRIs—they feel they’re “losing their edge.” I approach it as an empirical question: Let’s see what works, and only the patient can be the judge of that. On the other hand, if one SSRI does not work, it’s worth trying another, because they all have slightly different effects. It’s interesting that the SSRIs are widely used to treat depression, but in a study in which we compared Prozac with eye movement desensitization and reprocessing (EMDR) for patients with PTSD, many of whom were also depressed, EMDR proved to be a more effective antidepressant than Prozac. I’ll return to that subject in chapter 15.

Propranolol

Medicines that target the autonomic nervous system, like propranolol or clonidine, can help to decrease hyperarousal and reactivity to stress. 
This family of drugs works by blocking the physical effects of adrenaline, the fuel of arousal, and thus reduces nightmares, insomnia, and reactivity to trauma triggers. 
Blocking adrenaline can help to keep the rational brain online and make choices possible: “Is this really what I want to do?” Since I have started to integrate mindfulness and yoga into my practice, I use these medications less often, except occasionally to help patients sleep more restfully.

Benzodiazepines

Traumatized patients tend to like tranquilizing drugs, benzodiazepines like Klonopin, Valium, Xanax, and Ativan. 
In many ways, they work like alcohol, in that they make people feel calm and keep them from worrying. (Casino owners love customers on benzodiazepines; they don’t get upset when they lose and keep gambling.) But also, like alcohol, benzos weaken inhibitions against saying hurtful things to people we love. 
Most civilian doctors are reluctant to prescribe these drugs, because they have a high addiction potential and they may also interfere with trauma processing.
Patients who stop taking them after prolonged use usually have withdrawal reactions that make them agitated and increase posttraumatic symptoms. I sometimes give my patients low doses of benzodiazepines to use as needed, but not enough to take on a daily basis. They have to choose when to use up their precious supply, and I ask them to keep a diary of what was going on when they decided to take the pill. That gives us a chance to discuss the specific incidents that triggered them.

A few studies have shown that anticonvulsants and mood stabilizers, such as lithium or valproate, can have mildly positive effects, taking the edge off hyperarousal and panic. 

Second-generation antipsychotic agents

The most controversial medications are the so-called second-generation antipsychotic agents, such as Risperdal (Salt: Risperidone) and Seroquel, the largest-selling psychiatric drugs in the United States ($14.6 billion in 2008). Low doses of these agents can be helpful in calming down combat veterans and women with PTSD related to childhood abuse.

Using these drugs is sometimes justified, for example when patients feel completely out of control and unable to sleep or where other methods have failed. But it’s important to keep in mind that these medications work by blocking the dopamine system, the brain’s reward system, which also functions as the engine of pleasure and motivation.

Antipsychotic medications such as Risperdal, Abilify, or Seroquel can significantly dampen the emotional brain and thus make patients less skittish or enraged, but they also may interfere with being able to appreciate subtle signals of pleasure, danger, or satisfaction. They also cause weight gain, increase the chance of developing diabetes, and make patients physically inert, which is likely to further increase their sense of alienation.

These drugs are widely used to treat abused children who are inappropriately diagnosed with bipolar disorder or mood dysregulation disorder. More than half a million children and adolescents in America are now taking antipsychotic drugs, which may calm them down but also interfere with learning age-appropriate skills and developing friendships with other children. A Columbia University study recently found that prescriptions of antipsychotic drugs for privately insured two- to five-year-olds had doubled between 2000 and 2007.61 Only 40 percent of them had received a proper mental health assessment.

Until it lost its patent, the pharmaceutical company Johnson & Johnson doled out LEGO blocks stamped with the word “Risperdal” for the waiting rooms of child psychiatrists. Children from low-income families are four times as likely as the privately insured to receive antipsychotic medicines.

In one year alone Texas Medicaid spent $96 million on antipsychotic drugs for teenagers and children—including three unidentified infants who were given the drugs before their first birthdays. There have been no studies on the effects of psychotropic medications on the developing brain. Dissociation, self-mutilation, fragmented memories, and amnesia generally do not respond to any of these medications.

The Prozac study that I discussed in chapter 2 was the first to discover that traumatized civilians tend to respond much better to medications than do combat veterans. Since then other studies have found similar discrepancies. In this light it is worrisome that the Department of Defense and the VA prescribe enormous quantities of medications to combat soldiers and returning veterans, often without providing other forms of therapy.

Between 2001 and 2011 the VA spent about $1.5 billion on Seroquel and Risperdal, while Defense spent about $90 million during the same period, even though a research paper published in 2001 showed that Risperdal was no more effective than a placebo in treating PTSD.64 Similarly, between 2001 and 2012 the VA spent $72.1 million and Defense spent $44.1 million on benzodiazepines65—medications that clinicians generally avoid prescribing to civilians with PTSD because of their addiction potential and lack of significant effectiveness for PTSD symptoms.

THE ROAD OF RECOVERY IS THE ROAD OF LIFE

In the first chapter of this book I introduced you to a patient named Bill whom I met over thirty years ago at the VA. Bill became one of my longtime patient-teachers, and our relationship is also the story of my evolution of trauma treatment.

Bill had served as a medic in Vietnam in 1967–71, and after he returned, he tried to use the skills he had learned in the army by working ona burn unit in a local hospital. Nursing kept him frazzled, explosive, and on edge, but he had no idea that these problems had anything to do with what he had experienced in Vietnam. After all, the PTSD diagnosis did not yet exist, and Irish working-class guys in Boston didn’t consult shrinks. His nightmares and insomnia subsided a bit after he left nursing and enrolled in a seminary to become a minister. He did not seek help until after his first son was born in 1978.

The baby’s crying triggered unrelenting flashbacks, in which he saw, heard, and smelled burned and mutilated children in Vietnam. He was so out of control that some of my colleagues at the VA wanted to put him in the hospital to treat what they thought was a psychosis. However, as he and I started to work together and he began to feel safe with me, he gradually opened up about what he had witnessed in Vietnam, and he slowly started to tolerate his feelings without becoming overwhelmed. This helped him to refocus on taking care of his family and on finishing his training as a minister. After two years he was a pastor with his own parish, and we felt that our work was done.

I had no further contact with Bill until he called me up eighteen years to the day after I first met him. He was experiencing exactly the same symptoms—flashbacks, terrible nightmares, feelings that he was going crazy—that he’d had right after his baby was born. That son had just turned eighteen, and Bill had accompanied him to register for the draft—at the same armory from which Bill himself had been shipped off to Vietnam. By then I knew much more about treating traumatic stress, and Bill and I dealt with the specific memories of what he had seen, heard, and smelled back in Vietnam, details that he had been too scared to recall when we first met. We could now integrate these memories with EMDR, so that they became stories of what happened long ago instead of instant transports into the hell of Vietnam. Once he felt more settled, he wanted to deal with his childhood: his brutal upbringing and his guilt about having left behind his younger schizophrenic brother when he enlisted for Vietnam, unprotected against their father’s violent outbursts.

Another important theme of our time together was the day-to-day pain Bill confronted as a minister—having to bury adolescents killed in car crashes only a few years after he’d baptized them or having couples he’d married come back in crisis over domestic violence. Bill went on toorganize a support group for fellow clergy faced with similar traumas, and he became an important force in his community.

Bill’s third treatment started five years later, when he developed a serious neurological illness at age fifty-three. He had suddenly started to experience episodic paralysis in several parts of his body, and he was beginning to accept that he would probably spend the rest of his life in a wheelchair. I thought his problems might be due to multiple sclerosis, but his neurologists could not find specific lesions, and they said there was no cure for his condition. He told me how grateful he was for his wife’s support. She already had arranged to have a wheelchair ramp built to the kitchen entrance to their house.
Given his grim prognosis, I urged Bill to find a way to fully feel and befriend the distressing feelings in his body, just as he had learned to tolerate and live with his most painful memories of the war. I suggested that he consult a body worker who had introduced me to Feldenkrais, a gentle, hands-on approach to rearranging physical sensations and muscle movements. When Bill came back to report on how he was doing, he expressed delight with his increased sense of control. I mentioned that I’d recently started to do yoga myself and that we had just opened up a yoga program at the Trauma Center. I invited him to explore that as his next step.
Bill found a local Bikram yoga class, a hot and intense practice usually reserved for young and energetic people. Bill loved it, even though parts of his body occasionally gave way in class. Despite his physical disability, he gained a sense of bodily pleasure and mastery that he had never felt before.
Bill’s psychological treatment had helped him put the horrendous experience of Vietnam in the past. Now befriending his body was keeping him from organizing his life around the loss of physical control. He decided to become certified as a yoga instructor, and he began teaching yoga at his local armory to the veterans who were returning from Iraq and Afghanistan.

Today, ten years later, Bill continues to be fully engaged in life—with his children and grandchildren, through his work with veterans, and in his church. He copes with his physical limitations as an inconvenience. To date he has taught yoga classes to more than 1,300 returning combat veterans. He still regularly suffers from the sudden weakness in his limbs that requires him to sit or lie down. But, like his memories of childhood andVietnam, these episodes do not dominate his existence. They are simply part of the ongoing, evolving story of his life.

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