Praise
for
The
Body
Keeps
the
Score

“This
book
is
a
tour
de
force.
Its
deeply
empathic,
insightful,
and
compassionate
perspective
promises
to
further
humanize
the
treatment
of
trauma
victims,
dramatically
expand
their
repertoire
of
self-regulatory
healing
practices
and
therapeutic
options,
and
also
stimulate
greater
creative
thinking
and
research
on
trauma
and
its
effective
treatment.
The
body
does
keep
the
score,
and
Van
der
Kolk’s
ability
to
demonstrate
this
through
compelling
descriptions
of
the
work
of
others,
his
own
pioneering
trajectory
and
experience
as
the
field
evolved
and
him
along
with
it,
and
above
all,
his
discovery
of
ways
to
work
skillfully
with
people
by
bringing
mindfulness
to
the
body
(as
well
as
to
their
thoughts
and
emotions)
through
yoga,
movement,
and
theater
are
a
wonderful
and
welcome
breath
of
fresh
air
and
possibility
in
the
therapy
world.”
—Jon
Kabat-Zinn,
professor
of
medicine
emeritus,
UMass
Medical
School;
author
of
Full
Catastrophe
Living

“This
exceptional
book
will
be
a
classic
of
modern
psychiatric
thought.
The
impact
of
overwhelming
experience
can
only
be
truly
understood
when
many
disparate
domains
of
knowledge,
such
as
neuroscience,
developmental
psychopathology,
and
interpersonal
neurobiology
are
integrated,
as
this
work
uniquely
does.
There
is
no
other
volume
in
the
field
of
traumatic
stress
that
has
distilled
these
domains
of
science
with
such
rich
historical
and
clinical
perspectives,
and
arrived
at
such
innovative
treatment
approaches.
The
clarity
of
vision
and
breadth
of
wisdom
of
this
unique
but
highly
accessible
work
is
remarkable.
This
book
is
essential
reading
for
anyone
interested
in
understanding
and
treating
traumatic
stress
and
the
scope
of
its
impact
on
society.”
—Alexander
McFarlane
AO,
MB
BS
(Hons)
MD
FRANZCP,
director
of
the
Centre
for
Traumatic
Stress
Studies,
The
University
of
Adelaide,
South
Australia.

“This
is
an
amazing
accomplishment
from
the
neuroscientist
most
responsible
for
the
contemporary
revolution
in
mental
health
toward
the
recognition
that
so
many
mental
problems
are
the
product
of
trauma.
With
the
compelling
writing
of
a
good
novelist,
van
der
Kolk
revisits
his
fascinating
journey
of
discovery
that
has
challenged
established
wisdom
in
psychiatry.
Interspersed
with
that
narrative
are
clear
and
understandable
descriptions
of
the
neurobiology
of
trauma;
explanations
of
the
ineffectiveness
of
traditional
approaches
to
treating
trauma;
and
introductions
to
the
approaches
that
take
patients
beneath
their
cognitive
minds
to
heal
the
parts
of
them
that
remained
frozen
in
the
past.
All
this
is
illustrated
vividly
with
dramatic
case
histories
and
substantiated
with
convincing
research.
This
is
a
watershed
book
that
will
be
remembered
as
tipping
the
scales
within
psychiatry
and
the
culture
at
large
toward
the
recognition
of
the
toll
traumatic
events
and
our
attempts
to
deny
their
impact
take
on
us
all.”
—Richard
Schwartz,
originator,
Internal
Family
Systems
Therapy

“The
Body
Keeps
the
Score
is
clear,
fascinating,
hard
to
put
down,
and
filled
with
powerful
case
histories.
Van
der
Kolk,
the
eminent
impresario
of
trauma
treatment,
who
has
spent
a
career
bringing
together
diverse
trauma
scientists
and
clinicians
and
their
ideas,
while
making
his
own
pivotal
contributions,
describes
what
is
arguably
the
most
important
series
of
breakthroughs
in
mental
health
in
the
last
thirty
years.
We’ve
known
that
psychological
trauma
fragments
the
mind.
Here
we
see
not
only
how
psychological
trauma
also
breaks
connections
within
the
brain,
but
also
between
mind
and
body,
and
learn
about
the
exciting
new
approaches
that
allow
people
with
the
severest
forms
of
trauma
to
put
all
the
parts
back
together
again.”
—Norman
Doidge,
author
of
The
Brain
That
Changes
Itself

“In
The
Body
Keeps
the
Score
we
share
the
author’s
courageous
journey
into
the
parallel
dissociative
worlds
of
trauma
victims
and
the
medical
and
psychological
disciplines
that
are
meant
to
provide
relief.
In
this
compelling
book
we
learn
that
as
our
minds
desperately
try
to
leave
trauma
behind,
our
bodies
keep
us
trapped
in
the
past
with
wordless
emotions
and
feelings.
These
inner
disconnections
cascade
into
ruptures
in
social
relationships
with
disastrous
effects
on
marriages,
families,
and
friendships.
Van
der
Kolk
offers
hope
by
describing
treatments
and
strategies
that
have
successfully
helped
his
patients
reconnect
their
thoughts
with
their
bodies.
We
leave
this
shared
journey
understanding
that
only
through
fostering
self-
awareness
and
gaining
an
inner
sense
of
safety
will
we,
as
a
species,
fully
experience
the
richness
of
life.
—Stephen
W.
Porges,
PhD,
professor
of
psychiatry,
University
of
North
Carolina
at
Chapel
Hill;
author
of
The
Polyvagal
Theory:
Neurophysiological
Foundations
of
Emotions,
Attachment,
Communication,
and
Self-Regulation

“Bessel
van
der
Kolk
is
unequaled
in
his
ability
to
synthesize
the
stunning
developments
in
the
field
of
psychological
trauma
over
the
past
few
decades.
Thanks
in
part
to
his
work,
psychological
trauma—ranging
from
chronic
child
abuse
and
neglect,
to
war
trauma
and
natural
disasters—is
now
generally
recognized
as
a
major
cause
of
individual,
social,
and
cultural
breakdown.
In
this
masterfully
lucid
and
engaging
tour
de
force,
Van
der
Kolk
takes
us—both
specialists
and
the
general
public—
on
his
personal
journey
and
shows
what
he
has
learned
from
his
research,
from
his
colleagues
and
students,
and,
most
important,
from
his
patients.
The
Body
Keeps
the
Score
is,
simply
put,
brilliant.”
—Onno
van
der
Hart,
PhD,
Utrecht
University,
The
Netherlands;
senior
author,
The
Haunted
Self:
Structural
Dissociation
and
the
Treatment
of
Chronic
Traumatization

“The
Body
Keeps
the
Score
articulates
new
and
better
therapies
for
toxic
stress
based
on
a
deep
understanding
of
the
effects
of
trauma
on
brain
development
and
attachment
systems.
This
volume
provides
a
moving
summary
of
what
is
currently
known
about
the
effects
of
trauma
on
individuals
and
societies,
and
introduces
the
healing
potential
of
both
age-
old
and
novel
approaches
to
help
traumatized
children
and
adults
fully
engage
in
the
present.”
—Jessica
Stern,
policy
consultant
on
terrorism;
author
of
Denial:
A
Memoir
of
Terror

“A
book
about
understanding
the
impact
of
trauma
by
one
of
the
true
pioneers
in
the
field.
It
is
a
rare
book
that
integrates
cutting
edge
neuroscience
with
wisdom
and
understanding
about
the
experience
and
meaning
of
trauma,
for
people
who
have
suffered
from
it.
Like
its
author,
this
book
is
wise
and
compassionate,
occasionally
quite
provocative,
and
always
interesting.”
—Glenn
N.
Saxe,
MD,
Arnold
Simon
Professor
and
chairman,
Department
of
Child
and
Adolescent
Psychiatry;
director,
NYU
Child
Study
Center,
New
York
University
School
of
Medicine.
“A
fascinating
exploration
of
a
wide
range
of
therapeutic
treatments
shows
readers
how
to
take
charge
of
the
healing
process,
gain
a
sense
of
safety,
and
find
their
way
out
of
the
morass
of
suffering.”
—Francine
Shapiro,
PhD,
originator
of
EMDR
therapy;
senior
research
fellow,
Emeritus
Mental
Research
Institute;
author
of
Getting
Past
Your
Past

“As
an
attachment
researcher
I
know
that
infants
are
psychobiological
beings.
They
are
as
much
of
the
body
as
they
are
of
the
brain.
Without
language
or
symbols
infants
use
every
one
of
their
biological
systems
to
make
meaning
of
their
self
in
relation
to
the
world
of
things
and
people.
Van
der
Kolk
shows
that
those
very
same
systems
continue
to
operate
at
every
age,
and
that
traumatic
experiences,
especially
chronic
toxic
experience
during
early
development,
produce
psychic
devastation.
With
this
understanding
he
provides
insight
and
guidance
for
survivors,
researchers,
and
clinicians
alike.
Bessel
van
der
Kolk
may
focus
on
the
body
and
trauma,
but
what
a
mind
he
must
have
to
have
written
this
book.”
—Ed
Tronick,
distinguished
professor,
University
of
Massachusetts,
Boston;
author
of
Neurobehavior
and
Social
Emotional
Development
of
Infants
and
Young
Children

“The
Body
Keeps
the
Score
eloquently
articulates
how
overwhelming
experiences
affect
the
development
of
brain,
mind,
and
body
awareness,
all
of
which
are
closely
intertwined.
The
resulting
derailments
have
a
profound
impact
on
the
capacity
for
love
and
work.
This
rich
integration
of
clinical
case
examples
with
ground
breaking
scientific
studies
provides
us
with
a
new
understanding
of
trauma,
which
inevitably
leads
to
the
exploration
of
novel
therapeutic
approaches
that
‘rewire’
the
brain,
and
help
traumatized
people
to
reengage
in
the
present.
This
book
will
provide
traumatized
individuals
with
a
guide
to
healing
and
permanently
change
how
psychologists
and
psychiatrists
think
about
trauma
and
recovery.”
—Ruth
A.
Lanius,
MD,
PhD,
Harris-Woodman
chair
in
Psyche
and
Soma,
professor
of
psychiatry,
and
director
PTSD
research
at
the
University
of
Western
Ontario;
author
of
The
Impact
of
Early
Life
Trauma
on
Health
and
Disease

“When
it
comes
to
understanding
the
impact
of
trauma
and
being
able
to
continue
to
grow
despite
overwhelming
life
experiences,
Bessel
van
der
Kolk
leads
the
way
in
his
comprehensive
knowledge,
clinical
courage,
and
creative
strategies
to
help
us
heal.
The
Body
Keeps
the
Score
is
a
cutting-
edge
offering
for
the
general
reader
to
comprehend
the
complex
effects
of
trauma,
and
a
guide
to
a
wide
array
of
scientifically
informed
approaches
to
not
only
reduce
suffering,
but
to
move
beyond
mere
survival—
and
to
thrive.”
—Daniel
J.
Siegel,
MD,
clinical
professor,
UCLA
School
of
Medicine,
author
of
Brainstorm:
The
Power
and
Purpose
of
the
Teenage
Brain;
Mindsight:
The
New
Science
of
Personal
Transformation;
and
The
Developing
Mind:
How
Relationships
and
the
Brain
Interact
to
Shape
Who
We
Are

“In
this
magnificent
book,
Bessel
van
der
Kolk
takes
the
reader
on
a
captivating
journey
that
is
chock-full
of
riveting
stories
of
patients
and
their
struggles
interpreted
through
history,
research,
and
neuroscience
made
accessible
in
the
words
of
a
gifted
storyteller.
We
are
privy
to
the
author’s
own
courageous
efforts
to
understand
and
treat
trauma
over
the
past
forty
years,
the
results
of
which
have
broken
new
ground
and
challenged
the
status
quo
of
psychiatry
and
psychotherapy.
The
Body
Keeps
the
Score
leaves
us
with
both
a
profound
appreciation
for
and
a
felt
sense
of
the
debilitating
effects
of
trauma,
along
with
hope
for
the
future
through
fascinating
descriptions
of
novel
approaches
to
treatment.
This
outstanding
volume
is
absolutely
essential
reading
not
only
for
therapists
but
for
all
who
seek
to
understand,
prevent,
or
treat
the
immense
suffering
caused
by
trauma.”
—Pat
Ogden
PhD,
founder/educational
director
of
the
Sensorimotor
Psychotherapy
Institute;
author
of
Sensorimotor
Psychotherapy:
Interventions
for
Trauma
and
Attachment

“This
is
masterpiece
of
powerful
understanding
and
brave
heartedness,
one
of
the
most
intelligent
and
helpful
works
on
trauma
I
have
ever
read.
Dr.
Van
der
Kolk
offer
a
brilliant
synthesis
of
clinical
cases,
neuroscience,
powerful
tools
and
caring
humanity,
offering
a
whole
new
level
of
healing
for
the
traumas
carried
by
so
many.”
—Jack
Kornfield,
author
of
A
Path
with
Heart
 VIKING
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by
the
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der
Kolk
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Version_1
To
my
patients,
who
kept
the
score
and
were
the
textbook.
 CONTENTS

Praise
for
The
Body
Keeps
the
Score
Title
Page
Copyright
Dedication
PROLOGUE:
FACING
TRAUMA

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

PART
TWO:
THIS
IS
YOUR
BRAIN
ON
TRAUMA
4.
RUNNING
FOR
YOUR
LIFE:
THE
ANATOMY
OF
SURVIVAL
5.
BODY-BRAIN
CONNECTIONS
6.
LOSING
YOUR
BODY,
LOSING
YOUR
SELF

PART
THREE:
THE
MINDS
OF
CHILDREN
 7.
GETTING
ON
THE
SAME
WAVELENGTH:
ATTACHMENT
AND
ATTUNEMENT
8.
TRAPPED
IN
RELATIONSHIPS:
THE
COST
OF
ABUSE
AND
NEGLECT
9.
WHAT’S
LOVE
GOT
TO
DO
WITH
IT?
10.
DEVELOPMENTAL
TRAUMA:
THE
HIDDEN
EPIDEMIC

PART
FOUR:
THE
IMPRINT
OF
TRAUMA
11.
UNCOVERING
SECRETS:
THE
PROBLEM
OF
TRAUMATIC
MEMORY
12.
THE
UNBEARABLE
HEAVINESS
OF
REMEMBERING

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

ACKNOWLEDGMENTS
APPENDIX:
CONSENSUS
PROPOSED
CRITERIA
FOR
DEVELOPMENTAL
TRAUMA
DISORDER
RESOURCES
FURTHER
READING
NOTES
INDEX
 PROLOGUE

FACING
TRAUMA

O ne
does
not
have
be
a
combat
soldier,
or
visit
a
refugee
camp
in
Syria
or
the
Congo
to
encounter
trauma.
Trauma
happens
to
us,
our
friends,
our
families,
and
our
neighbors.
Research
by
the
Centers
for
Disease
Control
and
Prevention
has
shown
that
one
in
five
Americans
was
sexually
molested
as
a
child;
one
in
four
was
beaten
by
a
parent
to
the
point
of
a
mark
being
left
on
their
body;
and
one
in
three
couples
engages
in
physical
violence.
A
quarter
of
us
grew
up
with
alcoholic
relatives,
and
one
out
of
eight
witnessed
their
mother
being
beaten
or
hit.1
As
human
beings
we
belong
to
an
extremely
resilient
species.
Since
time
immemorial
we
have
rebounded
from
our
relentless
wars,
countless
disasters
(both
natural
and
man-made),
and
the
violence
and
betrayal
in
our
own
lives.
But
traumatic
experiences
do
leave
traces,
whether
on
a
large
scale
(on
our
histories
and
cultures)
or
close
to
home,
on
our
families,
with
dark
secrets
being
imperceptibly
passed
down
through
generations.
They
also
leave
traces
on
our
minds
and
emotions,
on
our
capacity
for
joy
and
intimacy,
and
even
on
our
biology
and
immune
systems.
Trauma
affects
not
only
those
who
are
directly
exposed
to
it,
but
also
those
around
them.
Soldiers
returning
home
from
combat
may
frighten
their
families
with
their
rages
and
emotional
absence.
The
wives
of
men
who
suffer
from
PTSD
tend
to
become
depressed,
and
the
children
of
depressed
mothers
are
at
risk
of
growing
up
insecure
and
anxious.
Having
been
exposed
to
family
violence
as
a
child
often
makes
it
difficult
to
establish
stable,
trusting
relationships
as
an
adult.
Trauma,
by
definition,
is
unbearable
and
intolerable.
Most
rape
victims,
combat
soldiers,
and
children
who
have
been
molested
become
so
upset
when
they
think
about
what
they
experienced
that
they
try
to
push
it
out
of
their
minds,
trying
to
act
as
if
nothing
happened,
and
move
on.
It
takes
tremendous
energy
to
keep
functioning
while
carrying
the
memory
of
terror,
and
the
shame
of
utter
weakness
and
vulnerability.
While
we
all
want
to
move
beyond
trauma,
the
part
of
our
brain
that
is
devoted
to
ensuring
our
survival
(deep
below
our
rational
brain)
is
not
very
good
at
denial.
Long
after
a
traumatic
experience
is
over,
it
may
be
reactivated
at
the
slightest
hint
of
danger
and
mobilize
disturbed
brain
circuits
and
secrete
massive
amounts
of
stress
hormones.
This
precipitates
unpleasant
emotions
intense
physical
sensations,
and
impulsive
and
aggressive
actions.
These
posttraumatic
reactions
feel
incomprehensible
and
overwhelming.
Feeling
out
of
control,
survivors
of
trauma
often
begin
to
fear
that
they
are
damaged
to
the
core
and
beyond
redemption.

 • • • 

The
first
time
I
remember
being
drawn
to
study
medicine
was
at
a
summer
camp
when
I
was
about
fourteen
years
old.
My
cousin
Michael
kept
me
up
all
night
explaining
the
intricacies
of
how
kidneys
work,
how
they
secrete
the
body’s
waste
materials
and
then
reabsorb
the
chemicals
that
keep
the
system
in
balance.
I
was
riveted
by
his
account
of
the
miraculous
way
the
body
functions.
Later,
during
every
stage
of
my
medical
training,
whether
I
was
studying
surgery,
cardiology,
or
pediatrics,
it
was
obvious
to
me
that
the
key
to
healing
was
understanding
how
the
human
organism
works.
When
I
began
my
psychiatry
rotation,
however,
I
was
struck
by
the
contrast
between
the
incredible
complexity
of
the
mind
and
the
ways
that
we
human
beings
are
connected
and
attached
to
one
another,
and
how
little
psychiatrists
knew
about
the
origins
of
the
problems
they
were
treating.
Would
it
be
possible
one
day
to
know
as
much
about
brains,
minds,
and
love
as
we
do
about
the
other
systems
that
make
up
our
organism?
We
are
obviously
still
years
from
attaining
that
sort
of
detailed
understanding,
but
the
birth
of
three
new
branches
of
science
has
led
to
an
explosion
of
knowledge
about
the
effects
of
psychological
trauma,
abuse,
and
neglect.
Those
new
disciplines
are
neuroscience,
the
study
of
how
the
brain
supports
mental
processes;
developmental
psychopathology,
the
study
of
the
impact
of
adverse
experiences
on
the
development
of
mind
and
brain;
and
interpersonal
neurobiology,
the
study
of
how
our
behavior
influences
the
emotions,
biology,
and
mind-sets
of
those
around
us.
Research
from
these
new
disciplines
has
revealed
that
trauma
produces
actual
physiological
changes,
including
a
recalibration
of
the
brain’s
alarm
system,
an
increase
in
stress
hormone
activity,
and
alterations
in
the
system
that
filters
relevant
information
from
irrelevant.
We
now
know
that
trauma
compromises
the
brain
area
that
communicates
the
physical,
embodied
feeling
of
being
alive.
These
changes
explain
why
traumatized
individuals
become
hypervigilant
to
threat
at
the
expense
of
spontaneously
engaging
in
their
day-to-day
lives.
They
also
help
us
understand
why
traumatized
people
so
often
keep
repeating
the
same
problems
and
have
such
trouble
learning
from
experience.
We
now
know
that
their
behaviors
are
not
the
result
of
moral
failings
or
signs
of
lack
of
willpower
or
bad
character—they
are
caused
by
actual
changes
in
the
brain.
This
vast
increase
in
our
knowledge
about
the
basic
processes
that
underlie
trauma
has
also
opened
up
new
possibilities
to
palliate
or
even
reverse
the
damage.
We
can
now
develop
methods
and
experiences
that
utilize
the
brain’s
own
natural
neuroplasticity
to
help
survivors
feel
fully
alive
in
the
present
and
move
on
with
their
lives.
There
are
fundamentally
three
avenues:
1)
top
down,
by
talking,
(re-)
connecting
with
others,
and
allowing
ourselves
to
know
and
understand
what
is
going
on
with
us,
while
processing
the
memories
of
the
trauma;
2)
by
taking
medicines
that
shut
down
inappropriate
alarm
reactions,
or
by
utilizing
other
technologies
that
change
the
way
the
brain
organizes
information,
and
3)
bottom
up:
by
allowing
the
body
to
have
experiences
that
deeply
and
viscerally
contradict
the
helplessness,
rage,
or
collapse
that
result
from
trauma.
Which
one
of
these
is
best
for
any
particular
survivor
is
an
empirical
question.
Most
people
I
have
worked
with
require
a
combination.
This
has
been
my
life’s
work.
In
this
effort
I
have
been
supported
by
my
colleagues
and
students
at
the
Trauma
Center,
which
I
founded
thirty
years
ago.
Together
we
have
treated
thousands
of
traumatized
children
and
adults:
victims
of
child
abuse,
natural
disasters,
wars,
accidents,
and
human
trafficking;
people
who
have
suffered
assaults
by
intimates
and
strangers.
We
have
a
long
tradition
of
discussing
all
our
patients
in
great
depth
at
weekly
treatment
team
meetings
and
carefully
tracking
how
well
different
forms
of
treatment
work
for
particular
individuals.
 Our
principal
mission
has
always
been
to
take
care
of
the
children
and
adults
who
have
come
to
us
for
treatment,
but
from
the
very
beginning
we
also
have
dedicated
ourselves
to
conducting
research
to
explore
the
effects
of
traumatic
stress
on
different
populations
and
to
determine
what
treatments
work
for
whom.
We
have
been
supported
by
research
grants
from
the
National
Institute
of
Mental
Health,
the
National
Center
for
Complementary
and
Alternative
Medicine,
the
Centers
for
Disease
Control,
and
a
number
of
private
foundations
to
study
the
efficacy
of
many
different
forms
of
treatment,
from
medications
to
talking,
yoga,
EMDR,
theater,
and
neurofeedback.
The
challenge
is:
How
can
people
gain
control
over
the
residues
of
past
trauma
and
return
to
being
masters
of
their
own
ship?
Talking,
understanding,
and
human
connections
help,
and
drugs
can
dampen
hyperactive
alarm
systems.
But
we
will
also
see
that
the
imprints
from
the
past
can
be
transformed
by
having
physical
experiences
that
directly
contradict
the
helplessness,
rage,
and
collapse
that
are
part
of
trauma,
and
thereby
regaining
self-mastery.
I
have
no
preferred
treatment
modality,
as
no
single
approach
fits
everybody,
but
I
practice
all
the
forms
of
treatment
that
I
discuss
in
this
book.
Each
one
of
them
can
produce
profound
changes,
depending
on
the
nature
of
the
particular
problem
and
the
makeup
of
the
individual
person.
I
wrote
this
book
to
serve
as
both
a
guide
and
an
invitation—an
invitation
to
dedicate
ourselves
to
facing
the
reality
of
trauma,
to
explore
how
best
to
treat
it,
and
to
commit
ourselves,
as
a
society,
to
using
every
means
we
have
to
prevent
it.
 PART
ONE
THE
REDISCOVERY
OF
TRAUMA
 CHAPTER
1

LESSONS
FROM
VIETNAM
VETERANS

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

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

T he
Tuesday
after
the
Fourth
of
July
weekend,
1978,
was
my
first
day
as
a
staff
psychiatrist
at
the
Boston
Veterans
Administration
Clinic.
As
I
was
hanging
a
reproduction
of
my
favorite
Breughel
painting,
“The
Blind
Leading
the
Blind,”
on
the
wall
of
my
new
office,
I
heard
a
commotion
in
the
reception
area
down
the
hall.
A
moment
later
a
large,
disheveled
man
in
a
stained
three-piece
suit,
carrying
a
copy
of
Soldier
of
Fortune
magazine
under
his
arm,
burst
through
my
door.
He
was
so
agitated
and
so
clearly
hungover
that
I
wondered
how
I
could
possibly
help
this
hulking
man.
I
asked
him
to
take
a
seat,
and
tell
me
what
I
could
do
for
him.
His
name
was
Tom.
Ten
years
earlier
he
had
been
in
the
Marines,
doing
his
service
in
Vietnam.
He
had
spent
the
holiday
weekend
holed
up
in
his
downtown-Boston
law
office,
drinking
and
looking
at
old
photographs,
rather
than
with
his
family.
He
knew
from
previous
years’
experience
that
the
noise,
the
fireworks,
the
heat,
and
the
picnic
in
his
sister’s
backyard
against
the
backdrop
of
dense
early-summer
foliage,
all
of
which
reminded
him
of
Vietnam,
would
drive
him
crazy.
When
he
got
upset
he
was
afraid
to
be
around
his
family
because
he
behaved
like
a
monster
with
his
wife
and
two
young
boys.
The
noise
of
his
kids
made
him
so
agitated
that
he
would
storm
out
of
the
house
to
keep
himself
from
hurting
them.
Only
drinking
himself
into
oblivion
or
riding
his
Harley-Davidson
at
dangerously
high
speeds
helped
him
to
calm
down.
Nighttime
offered
no
relief—his
sleep
was
constantly
interrupted
by
nightmares
about
an
ambush
in
a
rice
paddy
back
in
’Nam,
in
which
all
the
members
of
his
platoon
were
killed
or
wounded.
He
also
had
terrifying
flashbacks
in
which
he
saw
dead
Vietnamese
children.
The
nightmares
were
so
horrible
that
he
dreaded
falling
asleep
and
he
often
stayed
up
for
most
of
the
night,
drinking.
In
the
morning
his
wife
would
find
him
passed
out
on
the
living
room
couch,
and
she
and
the
boys
had
to
tiptoe
around
him
while
she
made
them
breakfast
before
taking
them
to
school.
Filling
me
in
on
his
background,
Tom
said
that
he
had
graduated
from
high
school
in
1965,
the
valedictorian
of
his
class.
In
line
with
his
family
tradition
of
military
service
he
enlisted
in
the
Marine
Corps
immediately
after
graduation.
His
father
had
served
in
World
War
II
in
General
Patton’s
army,
and
Tom
never
questioned
his
father’s
expectations.
Athletic,
intelligent,
and
an
obvious
leader,
Tom
felt
powerful
and
effective
after
finishing
basic
training,
a
member
of
a
team
that
was
prepared
for
just
about
anything.
In
Vietnam
he
quickly
became
a
platoon
leader,
in
charge
of
eight
other
Marines.
Surviving
slogging
through
the
mud
while
being
strafed
by
machine-gun
fire
can
leave
people
feeling
pretty
good
about
themselves—
and
their
comrades.
At
the
end
of
his
tour
of
duty
Tom
was
honorably
discharged,
and
all
he
wanted
was
to
put
Vietnam
behind
him.
Outwardly
that’s
exactly
what
he
did.
He
attended
college
on
the
GI
Bill,
graduated
from
law
school,
married
his
high
school
sweetheart,
and
had
two
sons.
Tom
was
upset
by
how
difficult
it
was
to
feel
any
real
affection
for
his
wife,
even
though
her
letters
had
kept
him
alive
in
the
madness
of
the
jungle.
Tom
went
through
the
motions
of
living
a
normal
life,
hoping
that
by
faking
it
he
would
learn
to
become
his
old
self
again.
He
now
had
a
thriving
law
practice
and
a
picture-
perfect
family,
but
he
sensed
he
wasn’t
normal;
he
felt
dead
inside.
Although
Tom
was
the
first
veteran
I
had
ever
encountered
on
a
professional
basis,
many
aspects
of
his
story
were
familiar
to
me.
I
grew
up
in
postwar
Holland,
playing
in
bombed-out
buildings,
the
son
of
a
man
who
had
been
such
an
outspoken
opponent
of
the
Nazis
that
he
had
been
sent
to
an
internment
camp.
My
father
never
talked
about
his
war
experiences,
but
he
was
given
to
outbursts
of
explosive
rage
that
stunned
me
as
a
little
boy.
How
could
the
man
I
heard
quietly
going
down
the
stairs
every
morning
to
pray
and
read
the
Bible
while
the
rest
of
the
family
slept
have
such
a
terrifying
temper?
How
could
someone
whose
life
was
devoted
to
the
pursuit
of
social
justice
be
so
filled
with
anger?
I
witnessed
the
same
puzzling
behavior
in
my
uncle,
who
had
been
captured
by
the
Japanese
in
the
Dutch
East
Indies
(now
Indonesia)
and
sent
as
a
slave
laborer
to
Burma,
where
he
worked
on
the
famous
bridge
over
the
river
Kwai.
He
also
rarely
mentioned
the
war,
and
he,
too,
often
erupted
into
uncontrollable
rages.
As
I
listened
to
Tom,
I
wondered
if
my
uncle
and
my
father
had
had
nightmares
and
flashbacks—if
they,
too,
had
felt
disconnected
from
their
loved
ones
and
unable
to
find
any
real
pleasure
in
their
lives.
Somewhere
in
the
back
of
my
mind
there
must
also
have
been
my
memories
of
my
frightened—and
often
frightening—mother,
whose
own
childhood
trauma
was
sometimes
alluded
to
and,
I
now
believe,
was
frequently
reenacted.
She
had
the
unnerving
habit
of
fainting
when
I
asked
her
what
her
life
was
like
as
a
little
girl
and
then
blaming
me
for
making
her
so
upset.
Reassured
by
my
obvious
interest,
Tom
settled
down
to
tell
me
just
how
scared
and
confused
he
was.
He
was
afraid
that
he
was
becoming
just
like
his
father,
who
was
always
angry
and
rarely
talked
with
his
children—
except
to
compare
them
unfavorably
with
his
comrades
who
had
lost
their
lives
around
Christmas
1944,
during
the
Battle
of
the
Bulge.
As
the
session
was
drawing
to
a
close,
I
did
what
doctors
typically
do:
I
focused
on
the
one
part
of
Tom’s
story
that
I
thought
I
understood—his
nightmares.
As
a
medical
student
I
had
worked
in
a
sleep
laboratory,
observing
people’s
sleep/dream
cycles,
and
had
assisted
in
writing
some
articles
about
nightmares.
I
had
also
participated
in
some
early
research
on
the
beneficial
effects
of
the
psychoactive
drugs
that
were
just
coming
into
use
in
the
1970s.
So,
while
I
lacked
a
true
grasp
of
the
scope
of
Tom’s
problems,
the
nightmares
were
something
I
could
relate
to,
and
as
an
enthusiastic
believer
in
better
living
through
chemistry,
I
prescribed
a
drug
that
we
had
found
to
be
effective
in
reducing
the
incidence
and
severity
of
nightmares.
I
scheduled
Tom
for
a
follow-up
visit
two
weeks
later.
When
he
returned
for
his
appointment,
I
eagerly
asked
Tom
how
the
medicines
had
worked.
He
told
me
he
hadn’t
taken
any
of
the
pills.
Trying
to
conceal
my
irritation,
I
asked
him
why.
“I
realized
that
if
I
take
the
pills
and
the
nightmares
go
away,”
he
replied,
“I
will
have
abandoned
my
friends,
and
their
deaths
will
have
been
in
vain.
I
need
to
be
a
living
memorial
to
my
friends
who
died
in
Vietnam.”
I
was
stunned:
Tom’s
loyalty
to
the
dead
was
keeping
him
from
living
his
own
life,
just
as
his
father’s
devotion
to
his
friends
had
kept
him
from
living.
Both
father’s
and
son’s
experiences
on
the
battlefield
had
rendered
the
rest
of
their
lives
irrelevant.
How
had
that
happened,
and
what
could
we
do
about
it?
That
morning
I
realized
I
would
probably
spend
the
rest
of
my
professional
life
trying
to
unravel
the
mysteries
of
trauma.
How
do
horrific
experiences
cause
people
to
become
hopelessly
stuck
in
the
past?
What
happens
in
people’s
minds
and
brains
that
keeps
them
frozen,
trapped
in
a
place
they
desperately
wish
to
escape?
Why
did
this
man’s
war
not
come
to
an
end
in
February
1969,
when
his
parents
embraced
him
at
Boston’s
Logan
International
Airport
after
his
long
flight
back
from
Da
Nang?
Tom’s
need
to
live
out
his
life
as
a
memorial
to
his
comrades
taught
me
that
he
was
suffering
from
a
condition
much
more
complex
than
simply
having
bad
memories
or
damaged
brain
chemistry—or
altered
fear
circuits
in
the
brain.
Before
the
ambush
in
the
rice
paddy,
Tom
had
been
a
devoted
and
loyal
friend,
someone
who
enjoyed
life,
with
many
interests
and
pleasures.
In
one
terrifying
moment,
trauma
had
transformed
everything.
During
my
time
at
the
VA
I
got
to
know
many
men
who
responded
similarly.
Faced
with
even
minor
frustrations,
our
veterans
often
flew
instantly
into
extreme
rages.
The
public
areas
of
the
clinic
were
pockmarked
with
the
impacts
of
their
fists
on
the
drywall,
and
security
was
kept
constantly
busy
protecting
claims
agents
and
receptionists
from
enraged
veterans.
Of
course,
their
behavior
scared
us,
but
I
also
was
intrigued.
At
home
my
wife
and
I
were
coping
with
similar
problems
in
our
toddlers,
who
regularly
threw
temper
tantrums
when
told
to
eat
their
spinach
or
to
put
on
warm
socks.
Why
was
it,
then,
that
I
was
utterly
unconcerned
about
my
kids’
immature
behavior
but
deeply
worried
by
what
was
going
on
with
the
vets
(aside
from
their
size,
of
course,
which
gave
them
the
potential
to
inflict
much
more
harm
than
my
two-footers
at
home)?
The
reason
was
that
I
felt
perfectly
confident
that,
with
proper
care,
my
kids
would
gradually
learn
to
deal
with
frustrations
and
disappointments,
but
I
was
skeptical
that
I
would
be
able
to
help
my
veterans
reacquire
the
skills
of
self-control
and
self-regulation
that
they
had
lost
in
the
war.
Unfortunately,
nothing
in
my
psychiatric
training
had
prepared
me
to
deal
with
any
of
the
challenges
that
Tom
and
his
fellow
veterans
presented.
I
went
down
to
the
medical
library
to
look
for
books
on
war
neurosis,
shell
shock,
battle
fatigue,
or
any
other
term
or
diagnosis
I
could
think
of
that
might
shed
light
on
my
patients.
To
my
surprise
the
library
at
the
VA
didn’t
have
a
single
book
about
any
of
these
conditions.
Five
years
after
the
last
American
soldier
left
Vietnam,
the
issue
of
wartime
trauma
was
still
not
on
anybody’s
agenda.
Finally,
in
the
Countway
Library
at
Harvard
Medical
School,
I
discovered
The
Traumatic
Neuroses
of
War,
which
had
been
published
in
1941
by
a
psychiatrist
named
Abram
Kardiner.
It
described
Kardiner’s
observations
of
World
War
I
veterans
and
had
been
released
in
anticipation
of
the
flood
of
shell-shocked
soldiers
expected
to
be
casualties
of
World
War
II.1
Kardiner
reported
the
same
phenomena
I
was
seeing:
After
the
war
his
patients
were
overtaken
by
a
sense
of
futility;
they
became
withdrawn
and
detached,
even
if
they
had
functioned
well
before.
What
Kardiner
called
“traumatic
neuroses,”
today
we
call
posttraumatic
stress
disorder—PTSD.
Kardiner
noted
that
sufferers
from
traumatic
neuroses
develop
a
chronic
vigilance
for
and
sensitivity
to
threat.
His
summation
especially
caught
my
eye:
“The
nucleus
of
the
neurosis
is
a
physioneurosis.”2
In
other
words,
posttraumatic
stress
isn’t
“all
in
one’s
head,”
as
some
people
supposed,
but
has
a
physiological
basis.
Kardiner
understood
even
then
that
the
symptoms
have
their
origin
in
the
entire
body’s
response
to
the
original
trauma.
Kardiner’s
description
corroborated
my
own
observations,
which
was
reassuring,
but
it
provided
me
with
little
guidance
on
how
to
help
the
veterans.
The
lack
of
literature
on
the
topic
was
a
handicap,
but
my
great
teacher,
Elvin
Semrad,
had
taught
us
to
be
skeptical
about
textbooks.
We
had
only
one
real
textbook,
he
said:
our
patients.
We
should
trust
only
what
we
could
learn
from
them—and
from
our
own
experience.
This
sounds
so
simple,
but
even
as
Semrad
pushed
us
to
rely
upon
self-knowledge,
he
also
warned
us
how
difficult
that
process
really
is,
since
human
beings
are
experts
in
wishful
thinking
and
obscuring
the
truth.
I
remember
him
saying:
“The
greatest
sources
of
our
suffering
are
the
lies
we
tell
ourselves.”
Working
at
the
VA
I
soon
discovered
how
excruciating
it
can
be
to
face
reality.
This
was
true
both
for
my
patients
and
for
myself.
We
don’t
really
want
to
know
what
soldiers
go
through
in
combat.
We
do
not
really
want
to
know
how
many
children
are
being
molested
and
abused
in
our
own
society
or
how
many
couples—almost
a
third,
as
it
turns
out—engage
in
violence
at
some
point
during
their
relationship.
We
want
to
think
of
families
as
safe
havens
in
a
heartless
world
and
of
our
own
country
as
populated
by
enlightened,
civilized
people.
We
prefer
to
believe
that
cruelty
occurs
only
in
faraway
places
like
Darfur
or
the
Congo.
It
is
hard
enough
for
observers
to
bear
witness
to
pain.
Is
it
any
wonder,
then,
that
the
traumatized
individuals
themselves
cannot
tolerate
remembering
it
and
that
they
often
resort
to
using
drugs,
alcohol,
or
self-mutilation
to
block
out
their
unbearable
knowledge?
Tom
and
his
fellow
veterans
became
my
first
teachers
in
my
quest
to
understand
how
lives
are
shattered
by
overwhelming
experiences,
and
in
figuring
out
how
to
enable
them
to
feel
fully
alive
again.

TRAUMA
AND
THE
LOSS
OF
SELF
The
first
study
I
did
at
the
VA
started
with
systematically
asking
veterans
what
had
happened
to
them
in
Vietnam.
I
wanted
to
know
what
had
pushed
them
over
the
brink,
and
why
some
had
broken
down
as
a
result
of
that
experience
while
others
had
been
able
to
go
on
with
their
lives.3
Most
of
the
men
I
interviewed
had
gone
to
war
feeling
well
prepared,
drawn
close
by
the
rigors
of
basic
training
and
the
shared
danger.
They
exchanged
pictures
of
their
families
and
girlfriends;
they
put
up
with
one
another’s
flaws.
And
they
were
prepared
to
risk
their
lives
for
their
friends.
Most
of
them
confided
their
dark
secrets
to
a
buddy,
and
some
went
so
far
as
to
share
each
other’s
shirts
and
socks.
Many
of
the
men
had
friendships
similar
to
Tom’s
with
Alex.
Tom
met
Alex,
an
Italian
guy
from
Malden,
Massachusetts,
on
his
first
day
in
country,
and
they
instantly
became
close
friends.
They
drove
their
jeep
together,
listened
to
the
same
music,
and
read
each
other’s
letters
from
home.
They
got
drunk
together
and
chased
the
same
Vietnamese
bar
girls.
 After
about
three
months
in
country
Tom
led
his
squad
on
a
foot
patrol
through
a
rice
paddy
just
before
sunset.
Suddenly
a
hail
of
gunfire
spurted
from
the
green
wall
of
the
surrounding
jungle,
hitting
the
men
around
him
one
by
one.
Tom
told
me
how
he
had
looked
on
in
helpless
horror
as
all
the
members
of
his
platoon
were
killed
or
wounded
in
a
matter
of
seconds.
He
would
never
get
one
image
out
of
his
mind:
the
back
of
Alex’s
head
as
he
lay
facedown
in
the
rice
paddy,
his
feet
in
the
air.
Tom
wept
as
he
recalled,
“He
was
the
only
real
friend
I
ever
had.”
Afterward,
at
night,
Tom
continued
to
hear
the
screams
of
his
men
and
to
see
their
bodies
falling
into
the
water.
Any
sounds,
smells,
or
images
that
reminded
him
of
the
ambush
(like
the
popping
of
firecrackers
on
the
Fourth
of
July)
made
him
feel
just
as
paralyzed,
terrified,
and
enraged
as
he
had
the
day
the
helicopter
evacuated
him
from
the
rice
paddy.
Maybe
even
worse
for
Tom
than
the
recurrent
flashbacks
of
the
ambush
was
the
memory
of
what
happened
afterward.
I
could
easily
imagine
how
Tom’s
rage
about
his
friend’s
death
had
led
to
the
calamity
that
followed.
It
took
him
months
of
dealing
with
his
paralyzing
shame
before
he
could
tell
me
about
it.
Since
time
immemorial
veterans,
like
Achilles
in
Homer’s
Iliad,
have
responded
to
the
death
of
their
comrades
with
unspeakable
acts
of
revenge.
The
day
after
the
ambush
Tom
went
into
a
frenzy
to
a
neighboring
village,
killing
children,
shooting
an
innocent
farmer,
and
raping
a
Vietnamese
woman.
After
that
it
became
truly
impossible
for
him
to
go
home
again
in
any
meaningful
way.
How
can
you
face
your
sweetheart
and
tell
her
that
you
brutally
raped
a
woman
just
like
her,
or
watch
your
son
take
his
first
step
when
you
are
reminded
of
the
child
you
murdered?
Tom
experienced
the
death
of
Alex
as
if
part
of
himself
had
been
forever
destroyed—the
part
that
was
good
and
honorable
and
trustworthy.
Trauma,
whether
it
is
the
result
of
something
done
to
you
or
something
you
yourself
have
done,
almost
always
makes
it
difficult
to
engage
in
intimate
relationships.
After
you
have
experienced
something
so
unspeakable,
how
do
you
learn
to
trust
yourself
or
anyone
else
again?
Or,
conversely,
how
can
you
surrender
to
an
intimate
relationship
after
you
have
been
brutally
violated?
Tom
kept
showing
up
faithfully
for
his
appointments,
as
I
had
become
for
him
a
lifeline—the
father
he’d
never
had,
an
Alex
who
had
survived
the
ambush.
It
takes
enormous
trust
and
courage
to
allow
yourself
to
remember.
One
of
the
hardest
things
for
traumatized
people
is
to
confront
their
shame
about
the
way
they
behaved
during
a
traumatic
episode,
whether
it
is
objectively
warranted
(as
in
the
commission
of
atrocities)
or
not
(as
in
the
case
of
a
child
who
tries
to
placate
her
abuser).
One
of
the
first
people
to
write
about
this
phenomenon
was
Sarah
Haley,
who
occupied
an
office
next
to
mine
at
the
VA
Clinic.
In
an
article
entitled
“When
the
Patient
Reports
Atrocities,”4
which
became
a
major
impetus
for
the
ultimate
creation
of
the
PTSD
diagnosis,
she
discussed
the
well-nigh
intolerable
difficulty
of
talking
about
(and
listening
to)
the
horrendous
acts
that
are
often
committed
by
soldiers
in
the
course
of
their
war
experiences.
It’s
hard
enough
to
face
the
suffering
that
has
been
inflicted
by
others,
but
deep
down
many
traumatized
people
are
even
more
haunted
by
the
shame
they
feel
about
what
they
themselves
did
or
did
not
do
under
the
circumstances.
They
despise
themselves
for
how
terrified,
dependent,
excited,
or
enraged
they
felt.
In
later
years
I
encountered
a
similar
phenomenon
in
victims
of
child
abuse:
Most
of
them
suffer
from
agonizing
shame
about
the
actions
they
took
to
survive
and
maintain
a
connection
with
the
person
who
abused
them.
This
was
particularly
true
if
the
abuser
was
someone
close
to
the
child,
someone
the
child
depended
on,
as
is
so
often
the
case.
The
result
can
be
confusion
about
whether
one
was
a
victim
or
a
willing
participant,
which
in
turn
leads
to
bewilderment
about
the
difference
between
love
and
terror;
pain
and
pleasure.
We
will
return
to
this
dilemma
throughout
this
book.

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

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

STUCK
IN
TRAUMA
Our
clinic
was
inundated
with
veterans
seeking
psychiatric
help.
However,
because
of
an
acute
shortage
of
qualified
doctors,
all
we
could
do
was
put
most
of
them
on
a
waiting
list,
even
as
they
continued
brutalizing
themselves
and
their
families.
We
began
seeing
a
sharp
increase
in
arrests
of
veterans
for
violent
offenses
and
drunken
brawls—as
well
as
an
alarming
number
of
suicides.
I
received
permission
to
start
a
group
for
young
Vietnam
veterans
to
serve
as
a
sort
of
holding
tank
until
“real”
therapy
could
start.
At
the
opening
session
for
a
group
of
former
Marines,
the
first
man
to
speak
flatly
declared,
“I
do
not
want
to
talk
about
the
war.”
I
replied
that
the
members
could
discuss
anything
they
wanted.
After
half
an
hour
of
excruciating
silence,
one
veteran
finally
started
to
talk
about
his
helicopter
crash.
To
my
amazement
the
rest
immediately
came
to
life,
speaking
with
great
intensity
about
their
traumatic
experiences.
All
of
them
returned
the
following
week
and
the
week
after.
In
the
group
they
found
resonance
and
meaning
in
what
had
previously
been
only
sensations
of
terror
and
emptiness.
They
felt
a
renewed
sense
of
the
comradeship
that
had
been
so
vital
to
their
war
experience.
They
insisted
that
I
had
to
be
part
of
their
newfound
unit
and
gave
me
a
Marine
captain’s
uniform
for
my
birthday.
In
retrospect
that
gesture
revealed
part
of
the
problem:
You
were
either
in
or
out—you
either
belonged
to
the
unit
or
you
were
nobody.
After
trauma
the
world
becomes
sharply
divided
between
those
who
know
and
those
who
don’t.
People
who
have
not
shared
the
traumatic
experience
cannot
be
trusted,
because
they
can’t
understand
it.
Sadly,
this
often
includes
spouses,
children,
and
co-workers.
Later
I
led
another
group,
this
time
for
veterans
of
Patton’s
army—men
now
well
into
their
seventies,
all
old
enough
to
be
my
father.
We
met
on
Monday
mornings
at
eight
o’clock.
In
Boston
winter
snowstorms
occasionally
paralyze
the
public
transit
system,
but
to
my
amazement
all
of
them
showed
up
even
during
blizzards,
some
of
them
trudging
several
miles
through
the
snow
to
reach
the
VA
Clinic.
For
Christmas
they
gave
me
a
1940s
GI-issue
wristwatch.
As
had
been
the
case
with
my
group
of
Marines,
I
could
not
be
their
doctor
unless
they
made
me
one
of
them.
Moving
as
these
experiences
were,
the
limits
of
group
therapy
became
clear
when
I
urged
the
men
to
talk
about
the
issues
they
confronted
in
their
daily
lives:
their
relationships
with
their
wives,
children,
girlfriends,
and
family;
dealing
with
their
bosses
and
finding
satisfaction
in
their
work;
their
heavy
use
of
alcohol.
Their
typical
response
was
to
balk
and
resist
and
instead
recount
yet
again
how
they
had
plunged
a
dagger
through
the
heart
of
a
German
soldier
in
the
Hürtgen
Forest
or
how
their
helicopter
had
been
shot
down
in
the
jungles
of
Vietnam.
Whether
the
trauma
had
occurred
ten
years
in
the
past
or
more
than
forty,
my
patients
could
not
bridge
the
gap
between
their
wartime
experiences
and
their
current
lives.
Somehow
the
very
event
that
caused
them
so
much
pain
had
also
become
their
sole
source
of
meaning.
They
felt
fully
alive
only
when
they
were
revisiting
their
traumatic
past.

DIAGNOSING
POSTTRAUMATIC
STRESS
In
those
early
days
at
the
VA,
we
labeled
our
veterans
with
all
sorts
of
diagnoses—alcoholism,
substance
abuse,
depression,
mood
disorder,
even
schizophrenia—and
we
tried
every
treatment
in
our
textbooks.
But
for
all
our
efforts
it
became
clear
that
we
were
actually
accomplishing
very
little.
The
powerful
drugs
we
prescribed
often
left
the
men
in
such
a
fog
that
they
could
barely
function.
When
we
encouraged
them
to
talk
about
the
precise
details
of
a
traumatic
event,
we
often
inadvertently
triggered
a
full-blown
flashback,
rather
than
helping
them
resolve
the
issue.
Many
of
them
dropped
out
of
treatment
because
we
were
not
only
failing
to
help
but
also
sometimes
making
things
worse.
A
turning
point
arrived
in
1980,
when
a
group
of
Vietnam
veterans,
aided
by
the
New
York
psychoanalysts
Chaim
Shatan
and
Robert
J.
Lifton,
successfully
lobbied
the
American
Psychiatric
Association
to
create
a
new
diagnosis:
posttraumatic
stress
disorder
(PTSD),
which
described
a
cluster
of
symptoms
that
was
common,
to
a
greater
or
lesser
extent,
to
all
of
our
veterans.
Systematically
identifying
the
symptoms
and
grouping
them
together
into
a
disorder
finally
gave
a
name
to
the
suffering
of
people
who
were
overwhelmed
by
horror
and
helplessness.
With
the
conceptual
framework
of
PTSD
in
place,
the
stage
was
set
for
a
radical
change
in
our
understanding
of
our
patients.
This
eventually
led
to
an
explosion
of
research
and
attempts
at
finding
effective
treatments.
Inspired
by
the
possibilities
presented
by
this
new
diagnosis,
I
proposed
a
study
on
the
biology
of
traumatic
memories
to
the
VA.
Did
the
memories
of
those
suffering
from
PTSD
differ
from
those
of
others?
For
most
people
the
memory
of
an
unpleasant
event
eventually
fades
or
is
transformed
into
something
more
benign.
But
most
of
our
patients
were
unable
to
make
their
past
into
a
story
that
happened
long
ago.7
The
opening
line
of
the
grant
rejection
read:
“It
has
never
been
shown
that
PTSD
is
relevant
to
the
mission
of
the
Veterans
Administration.”
Since
then,
of
course,
the
mission
of
the
VA
has
become
organized
around
the
diagnosis
of
PTSD
and
brain
injury,
and
considerable
resources
are
dedicated
to
applying
“evidence-based
treatments”
to
traumatized
war
veterans.
But
at
the
time
things
were
different
and,
unwilling
to
keep
working
in
an
organization
whose
view
of
reality
was
so
at
odds
with
my
own,
I
handed
in
my
resignation;
in
1982
I
took
a
position
at
the
Massachusetts
Mental
Health
Center,
the
Harvard
teaching
hospital
where
I
had
trained
to
become
a
psychiatrist.
My
new
responsibility
was
to
teach
a
fledgling
area
of
study:
psychopharmacology,
the
administration
of
drugs
to
alleviate
mental
illness.
 In
my
new
job
I
was
confronted
on
an
almost
daily
basis
with
issues
I
thought
I
had
left
behind
at
the
VA.
My
experience
with
combat
veterans
had
so
sensitized
me
to
the
impact
of
trauma
that
I
now
listened
with
a
very
different
ear
when
depressed
and
anxious
patients
told
me
stories
of
molestation
and
family
violence.
I
was
particularly
struck
by
how
many
female
patients
spoke
of
being
sexually
abused
as
children.
This
was
puzzling,
as
the
standard
textbook
of
psychiatry
at
the
time
stated
that
incest
was
extremely
rare
in
the
United
States,
occurring
about
once
in
every
million
women.8
Given
that
there
were
then
only
about
one
hundred
million
women
living
in
the
United
States,
I
wondered
how
forty
seven,
almost
half
of
them,
had
found
their
way
to
my
office
in
the
basement
of
the
hospital.
Furthermore,
the
textbook
said,
“There
is
little
agreement
about
the
role
of
father-daughter
incest
as
a
source
of
serious
subsequent
psychopathology.”
My
patients
with
incest
histories
were
hardly
free
of
“subsequent
psychopathology”—they
were
profoundly
depressed,
confused,
and
often
engaged
in
bizarrely
self-harmful
behaviors,
such
as
cutting
themselves
with
razor
blades.
The
textbook
went
on
to
practically
endorse
incest,
explaining
that
“such
incestuous
activity
diminishes
the
subject’s
chance
of
psychosis
and
allows
for
a
better
adjustment
to
the
external
world.”9
In
fact,
as
it
turned
out,
incest
had
devastating
effects
on
women’s
well-being.
In
many
ways
these
patients
were
not
so
different
from
the
veterans
I
had
just
left
behind
at
the
VA.
They
also
had
nightmares
and
flashbacks.
They
also
alternated
between
occasional
bouts
of
explosive
rage
and
long
periods
of
being
emotionally
shut
down.
Most
of
them
had
great
difficulty
getting
along
with
other
people
and
had
trouble
maintaining
meaningful
relationships.
As
we
now
know,
war
is
not
the
only
calamity
that
leaves
human
lives
in
ruins.
While
about
a
quarter
of
the
soldiers
who
serve
in
war
zones
are
expected
to
develop
serious
posttraumatic
problems,10
the
majority
of
Americans
experience
a
violent
crime
at
some
time
during
their
lives,
and
more
accurate
reporting
has
revealed
that
twelve
million
women
in
the
United
States
have
been
victims
of
rape.
More
than
half
of
all
rapes
occur
in
girls
below
age
fifteen.11
For
many
people
the
war
begins
at
home:
Each
year
about
three
million
children
in
the
United
States
are
reported
as
victims
of
child
abuse
and
neglect.
One
million
of
these
cases
are
serious
and
credible
enough
to
force
local
child
protective
services
or
the
courts
to
take
action.12
In
other
words,
for
every
soldier
who
serves
in
a
war
zone
abroad,
there
are
ten
children
who
are
endangered
in
their
own
homes.
This
is
particularly
tragic,
since
it
is
very
difficult
for
growing
children
to
recover
when
the
source
of
terror
and
pain
is
not
enemy
combatants
but
their
own
caretakers.

A
NEW
UNDERSTANDING
In
the
three
decades
since
I
met
Tom,
we
have
learned
an
enormous
amount
not
only
about
the
impact
and
manifestations
of
trauma
but
also
about
ways
to
help
traumatized
people
find
their
way
back.
Since
the
early
1990s
brain-
imaging
tools
have
started
to
show
us
what
actually
happens
inside
the
brains
of
traumatized
people.
This
has
proven
essential
to
understanding
the
damage
inflicted
by
trauma
and
has
guided
us
to
formulate
entirely
new
avenues
of
repair.
We
have
also
begun
to
understand
how
overwhelming
experiences
affect
our
innermost
sensations
and
our
relationship
to
our
physical
reality
—the
core
of
who
we
are.
We
have
learned
that
trauma
is
not
just
an
event
that
took
place
sometime
in
the
past;
it
is
also
the
imprint
left
by
that
experience
on
mind,
brain,
and
body.
This
imprint
has
ongoing
consequences
for
how
the
human
organism
manages
to
survive
in
the
present.
Trauma
results
in
a
fundamental
reorganization
of
the
way
mind
and
brain
manage
perceptions.
It
changes
not
only
how
we
think
and
what
we
think
about,
but
also
our
very
capacity
to
think.
We
have
discovered
that
helping
victims
of
trauma
find
the
words
to
describe
what
has
happened
to
them
is
profoundly
meaningful,
but
usually
it
is
not
enough.
The
act
of
telling
the
story
doesn’t
necessarily
alter
the
automatic
physical
and
hormonal
responses
of
bodies
that
remain
hypervigilant,
prepared
to
be
assaulted
or
violated
at
any
time.
For
real
change
to
take
place,
the
body
needs
to
learn
that
the
danger
has
passed
and
to
live
in
the
reality
of
the
present.
Our
search
to
understand
trauma
has
led
us
to
think
differently
not
only
about
the
structure
of
the
mind
but
also
about
the
processes
by
which
it
heals.
 CHAPTER
2

REVOLUTIONS
IN
UNDERSTANDING
MIND
AND
BRAIN

The
greater
the
doubt,
the
greater
the
awakening;
the
smaller
the
doubt,
the
smaller
the
awakening.
No
doubt,
no
awakening.
—C.-C.
Chang,
The
Practice
of
Zen

You
live
through
that
little
piece
of
time
that
is
yours,
but
that
piece
of
time
is
not
only
your
own
life,
it
is
the
summing-up
of
all
the
other
lives
that
are
simultaneous
with
yours. . . .
What
you
are
is
an
expression
of
History.
—Robert
Penn
Warren,
World
Enough
and
Time

I n
the
late
1960s,
during
a
year
off
between
my
first
and
second
years
of
medical
school,
I
became
an
accidental
witness
to
a
profound
transition
in
the
medical
approach
to
mental
suffering.
I
had
landed
a
plum
job
as
an
attendant
on
a
research
ward
at
the
Massachusetts
Mental
Health
Center,
where
I
was
in
charge
of
organizing
recreational
activities
for
the
patients.
MMHC
had
long
been
considered
one
of
the
finest
psychiatric
hospitals
in
the
country,
a
jewel
in
the
crown
of
the
Harvard
Medical
School
teaching
empire.
The
goal
of
the
research
on
my
ward
was
to
determine
whether
psychotherapy
or
medication
was
the
best
way
to
treat
young
people
who
had
suffered
a
first
mental
breakdown
diagnosed
as
schizophrenia.
 The
talking
cure,
an
offshoot
of
Freudian
psychoanalysis,
was
still
the
primary
treatment
for
mental
illness
at
MMHC.
However,
in
the
early
1950s
a
group
of
French
scientists
had
discovered
a
new
compound,
chlorpromazine
(sold
under
the
brand
name
Thorazine),
that
could
“tranquilize”
patients
and
make
them
less
agitated
and
delusional.
That
inspired
hope
that
drugs
could
be
developed
to
treat
serious
mental
problems
such
as
depression,
panic,
anxiety,
and
mania,
as
well
as
to
manage
some
of
the
most
disturbing
symptoms
of
schizophrenia.
As
an
attendant
I
had
nothing
to
do
with
the
research
aspect
of
the
ward
and
was
never
told
what
treatment
any
of
the
patients
was
receiving.
They
were
all
close
to
my
age—college
students
from
Harvard,
MIT,
and
Boston
University.
Some
had
tried
to
kill
themselves;
others
cut
themselves
with
knives
or
razor
blades;
several
had
attacked
their
roommates
or
had
otherwise
terrified
their
parents
or
friends
with
their
unpredictable,
irrational
behavior.
My
job
was
to
keep
them
involved
in
normal
activities
for
college
students,
such
as
eating
at
the
local
pizza
parlor,
camping
in
a
nearby
state
forest,
attending
Red
Sox
games,
and
sailing
on
the
Charles
River.
Totally
new
to
the
field,
I
sat
in
rapt
attention
during
ward
meetings,
trying
to
decipher
the
patients’
complicated
speech
and
logic.
I
also
had
to
learn
to
deal
with
their
irrational
outbursts
and
terrified
withdrawal.
One
morning
I
found
a
patient
standing
like
a
statue
in
her
bedroom
with
one
arm
raised
in
a
defensive
gesture,
her
face
frozen
in
fear.
She
remained
there,
immobile,
for
at
least
twelve
hours.
The
doctors
gave
me
the
name
for
her
condition,
catatonia,
but
even
the
textbooks
I
consulted
didn’t
tell
me
what
could
be
done
about
it.
We
just
let
it
run
its
course.

TRAUMA
BEFORE
DAWN
I
spent
many
nights
and
weekends
on
the
unit,
which
exposed
me
to
things
the
doctors
never
saw
during
their
brief
visits.
When
patients
could
not
sleep,
they
often
wandered
in
their
tightly
wrapped
bathrobes
into
the
darkened
nursing
station
to
talk.
The
quiet
of
the
night
seemed
to
help
them
open
up,
and
they
told
me
stories
about
having
been
hit,
assaulted,
or
molested,
often
by
their
own
parents,
sometimes
by
relatives,
classmates,
or
neighbors.
They
shared
memories
of
lying
in
bed
at
night,
helpless
and
terrified,
hearing
their
mother
being
beaten
by
their
father
or
a
boyfriend,
hearing
their
parents
yell
horrible
threats
at
each
other,
hearing
the
sounds
of
furniture
breaking.
Others
told
me
about
fathers
who
came
home
drunk
—hearing
their
footsteps
on
the
landing
and
how
they
waited
for
them
to
come
in,
pull
them
out
of
bed,
and
punish
them
for
some
imagined
offense.
Several
of
the
women
recalled
lying
awake,
motionless,
waiting
for
the
inevitable—a
brother
or
father
coming
in
to
molest
them.
During
morning
rounds
the
young
doctors
presented
their
cases
to
their
supervisors,
a
ritual
that
the
ward
attendants
were
allowed
to
observe
in
silence.
They
rarely
mentioned
stories
like
the
ones
I’d
heard.
However,
many
later
studies
have
confirmed
the
relevance
of
those
midnight
confessions:
We
now
know
that
more
than
half
the
people
who
seek
psychiatric
care
have
been
assaulted,
abandoned,
neglected,
or
even
raped
as
children,
or
have
witnessed
violence
in
their
families.1
But
such
experiences
seemed
to
be
off
the
table
during
rounds.
I
was
often
surprised
by
the
dispassionate
way
patients’
symptoms
were
discussed
and
by
how
much
time
was
spent
on
trying
to
manage
their
suicidal
thoughts
and
self-
destructive
behaviors,
rather
than
on
understanding
the
possible
causes
of
their
despair
and
helplessness.
I
was
also
struck
by
how
little
attention
was
paid
to
their
accomplishments
and
aspirations;
whom
they
cared
for,
loved,
or
hated;
what
motivated
and
engaged
them,
what
kept
them
stuck,
and
what
made
them
feel
at
peace—the
ecology
of
their
lives.
A
few
years
later,
as
a
young
doctor,
I
was
confronted
with
an
especially
stark
example
of
the
medical
model
in
action.
I
was
then
moonlighting
at
a
Catholic
hospital,
doing
physical
examinations
on
women
who’d
been
admitted
to
receive
electroshock
treatment
for
depression.
Being
my
curious
immigrant
self,
I’d
look
up
from
their
charts
to
ask
them
about
their
lives.
Many
of
them
spilled
out
stories
about
painful
marriages,
difficult
children,
and
guilt
over
abortions.
As
they
spoke,
they
visibly
brightened
and
often
thanked
me
effusively
for
listening
to
them.
Some
of
them
wondered
if
they
really
still
needed
electroshock
after
having
gotten
so
much
off
their
chests.
I
always
felt
sad
at
the
end
of
these
meetings,
knowing
that
the
treatments
that
would
be
administered
the
following
morning
would
erase
all
memory
of
our
conversation.
I
did
not
last
long
in
that
job.
On
my
days
off
from
the
ward
at
MMHC,
I
often
went
to
the
Countway
Library
of
Medicine
to
learn
more
about
the
patients
I
was
supposed
to
help.
One
Saturday
afternoon
I
came
across
a
treatise
that
is
still
revered
today:
Eugen
Bleuler’s
1911
textbook
Dementia
Praecox.
Bleuler’s
observations
were
fascinating:

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

This
made
me
wonder:
Our
patients
had
hallucinations—the
doctors
routinely
asked
about
them
and
noted
them
as
signs
of
how
disturbed
the
patients
were.
But
if
the
stories
I’d
heard
in
the
wee
hours
were
true,
could
it
be
that
these
“hallucinations”
were
in
fact
the
fragmented
memories
of
real
experiences?
Were
hallucinations
just
the
concoctions
of
sick
brains?
Could
people
make
up
physical
sensations
they
had
never
experienced?
Was
there
a
clear
line
between
creativity
and
pathological
imagination?
Between
memory
and
imagination?
These
questions
remain
unanswered
to
this
day,
but
research
has
shown
that
people
who’ve
been
abused
as
children
often
feel
sensations
(such
as
abdominal
pain)
that
have
no
obvious
physical
cause;
they
hear
voices
warning
of
danger
or
accusing
them
of
heinous
crimes.
There
was
no
question
that
many
patients
on
the
ward
engaged
in
violent,
bizarre,
and
self-destructive
behaviors,
particularly
when
they
felt
frustrated,
thwarted,
or
misunderstood.
They
threw
temper
tantrums,
hurled
plates,
smashed
windows,
and
cut
themselves
with
shards
of
glass.
At
that
time
I
had
no
idea
why
someone
might
react
to
a
simple
request
(“Let
me
clean
that
goop
out
of
your
hair”)
with
rage
or
terror.
I
usually
followed
the
lead
of
the
experienced
nurses,
who
signaled
when
to
back
off
or,
if
that
did
not
work,
to
restrain
a
patient.
I
was
surprised
and
alarmed
by
the
satisfaction
I
sometimes
felt
after
I’d
wrestled
a
patient
to
the
floor
so
a
nurse
could
give
an
injection,
and
I
gradually
realized
how
much
of
our
professional
training
was
geared
to
helping
us
stay
in
control
in
the
face
of
terrifying
and
confusing
realities.
Sylvia
was
a
gorgeous
nineteen-year-old
Boston
University
student
who
usually
sat
alone
in
the
corner
of
the
ward,
looking
frightened
to
death
and
virtually
mute,
but
whose
reputation
as
the
girlfriend
of
an
important
Boston
mafioso
gave
her
an
aura
of
mystery.
After
she
refused
to
eat
for
more
than
a
week
and
rapidly
started
to
lose
weight,
the
doctors
decided
to
force-feed
her.
It
took
three
of
us
to
hold
her
down,
another
to
push
the
rubber
feeding
tube
down
her
throat,
and
a
nurse
to
pour
the
liquid
nutrients
into
her
stomach.
Later,
during
a
midnight
confession,
Sylvia
spoke
timidly
and
hesitantly
about
her
childhood
sexual
abuse
by
her
brother
and
uncle.
I
realized
then
our
display
of
“caring”
must
have
felt
to
her
much
like
a
gang
rape.
This
experience,
and
others
like
it,
helped
me
formulate
this
rule
for
my
students:
If
you
do
something
to
a
patient
that
you
would
not
do
to
your
friends
or
children,
consider
whether
you
are
unwittingly
replicating
a
trauma
from
the
patient’s
past.
In
my
role
as
recreation
leader
I
noticed
other
things:
As
a
group
the
patients
were
strikingly
clumsy
and
physically
uncoordinated.
When
we
went
camping,
most
of
them
stood
helplessly
by
as
I
pitched
the
tents.
We
almost
capsized
once
in
a
squall
on
the
Charles
River
because
they
huddled
rigidly
in
the
lee,
unable
to
grasp
that
they
needed
to
shift
position
to
balance
the
boat.
In
volleyball
games
the
staff
members
invariably
were
much
better
coordinated
than
the
patients.
Another
characteristic
they
shared
was
that
even
their
most
relaxed
conversations
seemed
stilted,
lacking
the
natural
flow
of
gestures
and
facial
expressions
that
are
typical
among
friends.
The
relevance
of
these
observations
became
clear
only
after
I’d
met
the
body-based
therapists
Peter
Levine
and
Pat
Ogden;
in
the
later
chapters
I’ll
have
a
lot
to
say
about
how
trauma
is
held
in
people’s
bodies.

MAKING
SENSE
OF
SUFFERING
After
my
year
on
the
research
ward
I
resumed
medical
school
and
then,
as
a
newly
minted
MD,
returned
to
MMHC
to
be
trained
as
a
psychiatrist,
a
program
to
which
I
was
thrilled
to
be
accepted.
Many
famous
psychiatrists
had
trained
there,
including
Eric
Kandel,
who
later
won
the
Nobel
Prize
in
Physiology
and
Medicine.
Allan
Hobson
discovered
the
brain
cells
responsible
for
the
generation
of
dreams
in
a
lab
in
the
hospital
basement
while
I
trained
there,
and
the
first
studies
on
the
chemical
underpinnings
of
depression
were
also
conducted
at
MMHC.
But
for
many
of
us
residents,
the
greatest
draw
was
the
patients.
We
spent
six
hours
each
day
with
them
and
then
met
as
a
group
with
senior
psychiatrists
to
share
our
observations,
pose
our
questions,
and
compete
to
make
the
wittiest
remarks.
Our
great
teacher,
Elvin
Semrad,
actively
discouraged
us
from
reading
psychiatry
textbooks
during
our
first
year.
(This
intellectual
starvation
diet
may
account
for
the
fact
that
most
of
us
later
became
voracious
readers
and
prolific
writers.)
Semrad
did
not
want
our
perceptions
of
reality
to
become
obscured
by
the
pseudocertainties
of
psychiatric
diagnoses.
I
remember
asking
him
once:
“What
would
you
call
this
patient—schizophrenic
or
schizoaffective?”
He
paused
and
stroked
his
chin,
apparently
in
deep
thought.
“I
think
I’d
call
him
Michael
McIntyre,”
he
replied.
Semrad
taught
us
that
most
human
suffering
is
related
to
love
and
loss
and
that
the
job
of
therapists
is
to
help
people
“acknowledge,
experience,
and
bear”
the
reality
of
life—with
all
its
pleasures
and
heartbreak.
“The
greatest
sources
of
our
suffering
are
the
lies
we
tell
ourselves,”
he’d
say,
urging
us
to
be
honest
with
ourselves
about
every
facet
of
our
experience.
He
often
said
that
people
can
never
get
better
without
knowing
what
they
know
and
feeling
what
they
feel.
I
remember
being
surprised
to
hear
this
distinguished
old
Harvard
professor
confess
how
comforted
he
was
to
feel
his
wife’s
bum
against
him
as
he
fell
asleep
at
night.
By
disclosing
such
simple
human
needs
in
himself
he
helped
us
recognize
how
basic
they
were
to
our
lives.
Failure
to
attend
to
them
results
in
a
stunted
existence,
no
matter
how
lofty
our
thoughts
and
worldly
accomplishments.
Healing,
he
told
us,
depends
on
experiential
knowledge:
You
can
be
fully
in
charge
of
your
life
only
if
you
can
acknowledge
the
reality
of
your
body,
in
all
its
visceral
dimensions.
Our
profession,
however,
was
moving
in
a
different
direction.
In
1968
the
American
Journal
of
Psychiatry
had
published
the
results
of
the
study
from
the
ward
where
I’d
been
an
attendant.
They
showed
unequivocally
that
schizophrenic
patients
who
received
drugs
alone
had
a
better
outcome
than
those
who
talked
three
times
a
week
with
the
best
therapists
in
Boston.3
This
study
was
one
of
many
milestones
on
a
road
that
gradually
changed
how
medicine
and
psychiatry
approached
psychological
problems:
from
infinitely
variable
expressions
of
intolerable
feelings
and
relationships
to
a
brain-disease
model
of
discrete
“disorders.”
The
way
medicine
approaches
human
suffering
has
always
been
determined
by
the
technology
available
at
any
given
time.
Before
the
Enlightenment
aberrations
in
behavior
were
ascribed
to
God,
sin,
magic,
witches,
and
evil
spirits.
It
was
only
in
the
nineteenth
century
that
scientists
in
France
and
Germany
began
to
investigate
behavior
as
an
adaptation
to
the
complexities
of
the
world.
Now
a
new
paradigm
was
emerging:
Anger,
lust,
pride,
greed,
avarice,
and
sloth—as
well
as
all
the
other
problems
we
humans
have
always
struggled
to
manage—were
recast
as
“disorders”
that
could
be
fixed
by
the
administration
of
appropriate
chemicals.4
Many
psychiatrists
were
relieved
and
delighted
to
become
“real
scientists,”
just
like
their
med
school
classmates
who
had
laboratories,
animal
experiments,
expensive
equipment,
and
complicated
diagnostic
tests,
and
set
aside
the
wooly-headed
theories
of
philosophers
like
Freud
and
Jung.
A
major
textbook
of
psychiatry
went
so
far
as
to
state:
“The
cause
of
mental
illness
is
now
considered
an
aberration
of
the
brain,
a
chemical
imbalance.”5
Like
my
colleagues,
I
eagerly
embraced
the
pharmacological
revolution.
In
1973
I
became
the
first
chief
resident
in
psychopharmacology
at
MMHC.
I
may
also
have
been
the
first
psychiatrist
in
Boston
to
administer
lithium
to
a
manic-depressive
patient.
(I’d
read
about
John
Cade’s
work
with
lithium
in
Australia,
and
I
received
permission
from
a
hospital
committee
to
try
it.)
On
lithium
a
woman
who
had
been
manic
every
May
for
the
past
thirty-five
years,
and
suicidally
depressed
every
November,
stopped
cycling
and
remained
stable
for
the
three
years
she
was
under
my
care.
I
was
also
part
of
the
first
U.S.
research
team
to
test
the
antipsychotic
Clozaril
on
chronic
patients
who
were
warehoused
in
the
back
wards
of
the
old
insane
asylums.6
Some
of
their
responses
were
miraculous:
People
who
had
spent
much
of
their
lives
locked
in
their
own
separate,
terrifying
realities
were
now
able
to
return
to
their
families
and
communities;
patients
mired
in
darkness
and
despair
started
to
respond
to
the
beauty
of
human
contact
and
the
pleasures
of
work
and
play.
These
amazing
results
made
us
optimistic
that
we
could
finally
conquer
human
misery.
Antipsychotic
drugs
were
a
major
factor
in
reducing
the
number
of
people
living
in
mental
hospitals
in
the
United
States,
from
over
500,000
in
1955
to
fewer
than
100,000
in
1996.7
For
people
today
who
did
not
know
the
world
before
the
advent
of
these
treatments,
the
change
is
almost
unimaginable.
As
a
first-year
medical
student
I
visited
Kankakee
State
Hospital
in
Illinois
and
saw
a
burly
ward
attendant
hose
down
dozens
of
filthy,
naked,
incoherent
patients
in
an
unfurnished
dayroom
supplied
with
gutters
for
the
runoff
water.
This
memory
now
seems
more
like
a
nightmare
than
like
something
I
witnessed
with
my
own
eyes.
My
first
job
after
finishing
my
residency
in
1974
was
as
the
second-to-last
director
of
a
once-
venerable
institution,
the
Boston
State
Hospital,
which
had
formerly
housed
thousands
of
patients
and
been
spread
over
hundreds
of
acres
with
dozens
of
buildings,
including
greenhouses,
gardens,
and
workshops—most
of
them
by
then
in
ruins.
During
my
time
there
patients
were
gradually
dispersed
into
“the
community,”
the
blanket
term
for
the
anonymous
shelters
and
nursing
homes
where
most
of
them
ended
up.
(Ironically,
the
hospital
was
started
as
an
“asylum,”
a
word
meaning
“sanctuary”
that
gradually
took
on
a
sinister
connotation.
It
actually
did
offer
a
sheltered
community
where
everybody
knew
the
patients’
names
and
idiosyncrasies.)
In
1979,
shortly
after
I
went
to
work
at
the
VA,
the
Boston
State
Hospital’s
gates
were
permanently
locked,
and
it
became
a
ghost
town.
During
my
time
at
Boston
State
I
continued
to
work
in
the
MMHC
psychopharmacology
lab,
which
was
now
focusing
on
another
direction
for
research.
In
the
1960s
scientists
at
the
National
Institutes
of
Health
had
begun
to
develop
techniques
for
isolating
and
measuring
hormones
and
neurotransmitters
in
blood
and
the
brain.
Neurotransmitters
are
chemical
messengers
that
carry
information
from
neuron
to
neuron,
enabling
us
to
engage
effectively
with
the
world.
Now
that
scientists
were
finding
evidence
that
abnormal
levels
of
norepinephrine
were
associated
with
depression,
and
of
dopamine
with
schizophrenia,
there
was
hope
that
we
could
develop
drugs
that
target
specific
brain
abnormalities.
That
hope
was
never
fully
realized,
but
our
efforts
to
measure
how
drugs
could
affect
mental
symptoms
led
to
another
profound
change
in
the
profession.
Researchers’
need
for
a
precise
and
systematic
way
to
communicate
their
findings
resulted
in
the
development
of
the
so-called
Research
Diagnostic
Criteria,
to
which
I
contributed
as
a
lowly
research
assistant.
These
eventually
became
the
basis
for
the
first
systematic
system
to
diagnose
psychiatric
problems,
the
American
Psychiatric
Association’s
Diagnostic
and
Statistical
Manual
of
Mental
Disorders
(DSM),
which
is
commonly
referred
to
as
the
“bible
of
psychiatry.”
The
foreword
to
the
landmark
1980
DSM-III
was
appropriately
modest
and
acknowledged
that
this
diagnostic
system
was
imprecise—so
imprecise
that
it
never
should
be
used
for
forensic
or
insurance
purposes.8
As
we
will
see,
that
modesty
was
tragically
short-lived.

INESCAPABLE
SHOCK
Preoccupied
with
so
many
lingering
questions
about
traumatic
stress,
I
became
intrigued
with
the
idea
that
the
nascent
field
of
neuroscience
could
provide
some
answers
and
started
to
attend
the
meetings
of
the
American
College
of
Neuropsychopharmacology
(ACNP).
In
1984
the
ACNP
offered
many
fascinating
lectures
about
drug
development,
but
it
was
not
until
a
few
hours
before
my
scheduled
flight
back
to
Boston
that
I
heard
a
presentation
by
Steven
Maier
of
the
University
of
Colorado,
who
had
collaborated
with
Martin
Seligman
of
the
University
of
Pennsylvania.
His
topic
was
learned
helplessness
in
animals.
Maier
and
Seligman
had
repeatedly
administered
painful
electric
shocks
to
dogs
who
were
trapped
in
locked
cages.
They
called
this
condition
“inescapable
shock.”9
Being
a
dog
lover,
I
realized
that
I
could
never
have
done
such
research
myself,
but
I
was
curious
about
how
this
cruelty
would
affect
the
animals.
After
administering
several
courses
of
electric
shock,
the
researchers
opened
the
doors
of
the
cages
and
then
shocked
the
dogs
again.
A
group
of
control
dogs
who
had
never
been
shocked
before
immediately
ran
away,
but
the
dogs
who
had
earlier
been
subjected
to
inescapable
shock
made
no
attempt
to
flee,
even
when
the
door
was
wide
open—they
just
lay
there,
whimpering
and
defecating.
The
mere
opportunity
to
escape
does
not
necessarily
make
traumatized
animals,
or
people,
take
the
road
to
freedom.
Like
Maier
and
Seligman’s
dogs,
many
traumatized
people
simply
give
up.
Rather
than
risk
experimenting
with
new
options
they
stay
stuck
in
the
fear
they
know.
I
was
riveted
by
Maier’s
account.
What
they
had
done
to
these
poor
dogs
was
exactly
what
had
happened
to
my
traumatized
human
patients.
They,
too,
had
been
exposed
to
somebody
(or
something)
who
had
inflicted
terrible
harm
on
them—harm
they
had
no
way
of
escaping.
I
made
a
rapid
mental
review
of
the
patients
I
had
treated.
Almost
all
had
in
some
way
been
trapped
or
immobilized,
unable
to
take
action
to
stave
off
the
inevitable.
Their
fight/flight
response
had
been
thwarted,
and
the
result
was
either
extreme
agitation
or
collapse.
Maier
and
Seligman
also
found
that
traumatized
dogs
secreted
much
larger
amounts
of
stress
hormones
than
was
normal.
This
supported
what
we
were
beginning
to
learn
about
the
biological
underpinnings
of
traumatic
stress.
A
group
of
young
researchers,
among
them
Steve
Southwick
and
John
Krystal
at
Yale,
Arieh
Shalev
at
Hadassah
Medical
School
in
Jerusalem,
Frank
Putnam
at
the
National
Institute
of
Mental
Health
(NIMH),
and
Roger
Pitman,
later
at
Harvard,
were
all
finding
that
traumatized
people
keep
secreting
large
amounts
of
stress
hormones
long
after
the
actual
danger
has
passed,
and
Rachel
Yehuda
at
Mount
Sinai
in
New
York
confronted
us
with
her
seemingly
paradoxical
findings
that
the
levels
of
the
stress
hormone
cortisol
are
low
in
PTSD.
Her
discoveries
only
started
to
make
sense
when
her
research
clarified
that
cortisol
puts
an
end
to
the
stress
response
by
sending
an
all-safe
signal,
and
that,
in
PTSD,
the
body’s
stress
hormones
do,
in
fact,
not
return
to
baseline
after
the
threat
has
passed.
Ideally
our
stress
hormone
system
should
provide
a
lightning-fast
response
to
threat,
but
then
quickly
return
us
to
equilibrium.
In
PTSD
patients,
however,
the
stress
hormone
system
fails
at
this
balancing
act.
Fight/flight/freeze
signals
continue
after
the
danger
is
over,
and,
as
in
the
case
of
the
dogs,
do
not
return
to
normal.
Instead,
the
continued
secretion
of
stress
hormones
is
expressed
as
agitation
and
panic
and,
in
the
long
term,
wreaks
havoc
with
their
health.
I
missed
my
plane
that
day
because
I
had
to
talk
with
Steve
Maier.
His
workshop
offered
clues
not
only
about
the
underlying
problems
of
my
patients
but
also
potential
keys
to
their
resolution.
For
example,
he
and
Seligman
had
found
that
the
only
way
to
teach
the
traumatized
dogs
to
get
off
the
electric
grids
when
the
doors
were
open
was
to
repeatedly
drag
them
out
of
their
cages
so
they
could
physically
experience
how
they
could
get
away.
I
wondered
if
we
also
could
help
my
patients
with
their
fundamental
orientation
that
there
was
nothing
they
could
do
to
defend
themselves?
Did
my
patients
also
need
to
have
physical
experiences
to
restore
a
visceral
sense
of
control?
What
if
they
could
be
taught
to
physically
move
to
escape
a
potentially
threatening
situation
that
was
similar
to
the
trauma
in
which
they
had
been
trapped
and
immobilized?
As
I
will
discuss
in
the
treatment
part
5
of
this
book,
that
was
one
of
the
conclusions
I
eventually
reached.
 Further
animal
studies
involving
mice,
rats,
cats,
monkeys,
and
elephants
brought
more
intriguing
data.10
For
example,
when
researchers
played
a
loud,
intrusive
sound,
mice
that
had
been
raised
in
a
warm
nest
with
plenty
of
food
scurried
home
immediately.
But
another
group,
raised
in
a
noisy
nest
with
scarce
food
supplies,
also
ran
for
home,
even
after
spending
time
in
more
pleasant
surroundings.11
Scared
animals
return
home,
regardless
of
whether
home
is
safe
or
frightening.
I
thought
about
my
patients
with
abusive
families
who
kept
going
back
to
be
hurt
again.
Are
traumatized
people
condemned
to
seek
refuge
in
what
is
familiar?
If
so,
why,
and
is
it
possible
to
help
them
become
attached
to
places
and
activities
that
are
safe
and
pleasurable?12

ADDICTED
TO
TRAUMA:
THE
PAIN
OF
PLEASURE
AND
THE
PLEASURE
OF
PAIN
One
of
the
things
that
struck
my
colleague
Mark
Greenberg
and
me
when
we
ran
therapy
groups
for
Vietnam
combat
veterans
was
how,
despite
their
feelings
of
horror
and
grief,
many
of
them
seemed
to
come
to
life
when
they
talked
about
their
helicopter
crashes
and
their
dying
comrades.
(Former
New
York
Times
correspondent
Chris
Hedges,
who
covered
a
number
of
brutal
conflicts,
entitled
his
book
War
Is
a
Force
That
Gives
Us
Meaning.13)
Many
traumatized
people
seem
to
seek
out
experiences
that
would
repel
most
of
us,14
and
patients
often
complain
about
a
vague
sense
of
emptiness
and
boredom
when
they
are
not
angry,
under
duress,
or
involved
in
some
dangerous
activity.
My
patient
Julia
was
brutally
raped
at
gunpoint
in
a
hotel
room
at
age
sixteen.
Shortly
thereafter
she
got
involved
with
a
violent
pimp
who
prostituted
her.
He
regularly
beat
her
up.
She
was
repeatedly
jailed
for
prostitution,
but
she
always
went
back
to
her
pimp.
Finally
her
grandparents
intervened
and
paid
for
an
intense
rehab
program.
After
she
successfully
completed
inpatient
treatment,
she
started
working
as
a
receptionist
and
taking
courses
at
a
local
college.
In
her
sociology
class
she
wrote
a
term
paper
about
the
liberating
possibilities
of
prostitution,
for
which
she
read
the
memoirs
of
several
famous
prostitutes.
She
gradually
dropped
all
her
other
courses.
A
brief
relationship
with
a
classmate
quickly
went
sour—he
bored
her
to
tears,
she
said,
and
she
was
repelled
by
his
boxer
shorts.
She
then
picked
up
an
addict
on
the
subway
who
first
beat
her
up
and
then
started
to
stalk
her.
She
finally
became
motivated
to
return
to
treatment
when
she
was
once
again
severely
beaten.
Freud
had
a
term
for
such
traumatic
reenactments:
“the
compulsion
to
repeat.”
He
and
many
of
his
followers
believed
that
reenactments
were
an
unconscious
attempt
to
get
control
over
a
painful
situation
and
that
they
eventually
could
lead
to
mastery
and
resolution.
There
is
no
evidence
for
that
theory—repetition
leads
only
to
further
pain
and
self-hatred.
In
fact,
even
reliving
the
trauma
repeatedly
in
therapy
may
reinforce
preoccupation
and
fixation.
Mark
Greenberg
and
I
decided
to
learn
more
about
attractors—the
things
that
draw
us,
motivate
us,
and
make
us
feel
alive.
Normally
attractors
are
meant
to
make
us
feel
better.
So,
why
are
so
many
people
attracted
to
dangerous
or
painful
situations?
We
eventually
found
a
study
that
explained
how
activities
that
cause
fear
or
pain
can
later
become
thrilling
experiences.15
In
the
1970s
Richard
Solomon
of
the
University
of
Pennsylvania
had
shown
that
the
body
learns
to
adjust
to
all
sorts
of
stimuli.
We
may
get
hooked
on
recreational
drugs
because
they
right
away
make
us
feel
so
good,
but
activities
like
sauna
bathing,
marathon
running,
or
parachute
jumping,
which
initially
cause
discomfort
and
even
terror,
can
ultimately
become
very
enjoyable.
This
gradual
adjustment
signals
that
a
new
chemical
balance
has
been
established
within
the
body,
so
that
marathon
runners,
say,
get
a
sense
of
well-being
and
exhilaration
from
pushing
their
bodies
to
the
limit.
At
this
point,
just
as
with
drug
addiction,
we
start
to
crave
the
activity
and
experience
withdrawal
when
it’s
not
available.
In
the
long
run
people
become
more
preoccupied
with
the
pain
of
withdrawal
than
the
activity
itself.
This
theory
could
explain
why
some
people
hire
someone
to
beat
them,
or
burn
themselves
with
cigarettes.
or
why
they
are
only
attracted
to
people
who
hurt
them.
Fear
and
aversion,
in
some
perverse
way,
can
be
transformed
into
pleasure.
Solomon
hypothesized
that
endorphins—the
morphinelike
chemicals
that
the
brain
secretes
in
response
to
stress—play
a
role
in
the
paradoxical
addictions
he
described.
I
thought
of
his
theory
again
when
my
library
habit
led
me
to
a
paper
titled
“Pain
in
Men
Wounded
in
Battle,”
published
in
1946.
Having
observed
that
75
percent
of
severely
wounded
soldiers
on
the
Italian
front
did
not
request
morphine,
a
surgeon
by
the
name
of
Henry
K.
Beecher
speculated
that
“strong
emotions
can
block
pain.”16
Were
Beecher’s
observations
relevant
to
people
with
PTSD?
Mark
Greenberg,
Roger
Pitman,
Scott
Orr,
and
I
decided
to
ask
eight
Vietnam
combat
veterans
if
they
would
be
willing
to
take
a
standard
pain
test
while
they
watched
scenes
from
a
number
of
movies.
The
first
clip
we
showed
was
from
Oliver
Stone’s
graphically
violent
Platoon
(1986),
and
while
it
ran
we
measured
how
long
the
veterans
could
keep
their
right
hands
in
a
bucket
of
ice
water.
We
then
repeated
this
process
with
a
peaceful
(and
long-forgotten)
movie
clip.
Seven
of
the
eight
veterans
kept
their
hands
in
the
painfully
cold
water
30
percent
longer
during
Platoon.
We
then
calculated
that
the
amount
of
analgesia
produced
by
watching
fifteen
minutes
of
a
combat
movie
was
equivalent
to
that
produced
by
being
injected
with
eight
milligrams
of
morphine,
about
the
same
dose
a
person
would
receive
in
an
emergency
room
for
crushing
chest
pain.
We
concluded
that
Beecher’s
speculation
that
“strong
emotions
can
block
pain”
was
the
result
of
the
release
of
morphinelike
substances
manufactured
in
the
brain.
This
suggested
that
for
many
traumatized
people,
reexposure
to
stress
might
provide
a
similar
relief
from
anxiety.17
It
was
an
interesting
experiment,
but
it
did
not
fully
explain
why
Julia
kept
going
back
to
her
violent
pimp.

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

THE
TRIUMPH
OF
PHARMACOLOGY
It
did
not
take
long
for
pharmacology
to
revolutionize
psychiatry.
Drugs
gave
doctors
a
greater
sense
of
efficacy
and
provided
a
tool
beyond
talk
therapy.
Drugs
also
produced
income
and
profits.
Grants
from
the
pharmaceutical
industry
provided
us
with
laboratories
filled
with
energetic
graduate
students
and
sophisticated
instruments.
Psychiatry
departments,
which
had
always
been
located
in
the
basements
of
hospitals,
started
to
move
up,
both
in
terms
of
location
and
prestige.
One
symbol
of
this
change
occurred
at
MMHC,
where
in
the
early
1990s
the
hospital’s
swimming
pool
was
paved
over
to
make
space
for
a
laboratory,
and
the
indoor
basketball
court
was
carved
up
into
cubicles
for
the
new
medication
clinic.
For
decades
doctors
and
patients
had
democratically
shared
the
pleasures
of
splashing
in
the
pool
and
passing
balls
down
the
court.
I’d
spent
hours
in
the
gym
with
patients
back
when
I
was
a
ward
attendant.
It
was
the
one
place
where
we
all
could
restore
a
sense
of
physical
well-being,
an
island
in
the
midst
of
the
misery
we
faced
every
day.
Now
it
had
become
a
place
for
patients
to
“get
fixed.”
The
drug
revolution
that
started
out
with
so
much
promise
may
in
the
end
have
done
as
much
harm
as
good.
The
theory
that
mental
illness
is
caused
primarily
by
chemical
imbalances
in
the
brain
that
can
be
corrected
by
specific
drugs
has
become
broadly
accepted,
by
the
media
and
the
public
as
well
as
by
the
medical
profession.22
In
many
places
drugs
have
displaced
therapy
and
enabled
patients
to
suppress
their
problems
without
addressing
the
underlying
issues.
Antidepressants
can
make
all
the
difference
in
the
world
in
helping
with
day-to-day
functioning,
and
if
it
comes
to
a
choice
between
taking
a
sleeping
pill
and
drinking
yourself
into
a
stupor
every
night
to
get
a
few
hours
of
sleep,
there
is
no
question
which
is
preferable.
For
people
who
are
exhausted
from
trying
to
make
it
on
their
own
through
yoga
classes,
workout
routines,
or
simply
toughing
it
out,
medications
often
can
bring
life-saving
relief.
The
SSRIs
can
be
very
helpful
in
making
traumatized
people
less
enslaved
by
their
emotions,
but
they
should
only
be
considered
adjuncts
in
their
overall
treatment.23
After
conducting
numerous
studies
of
medications
for
PTSD,
I
have
come
to
realize
that
psychiatric
medications
have
a
serious
downside,
as
they
may
deflect
attention
from
dealing
with
the
underlying
issues.
The
brain-disease
model
takes
control
over
people’s
fate
out
of
their
own
hands
and
puts
doctors
and
insurance
companies
in
charge
of
fixing
their
problems.
Over
the
past
three
decades
psychiatric
medications
have
become
a
mainstay
in
our
culture,
with
dubious
consequences.
Consider
the
case
of
antidepressants.
If
they
were
indeed
as
effective
as
we
have
been
led
to
believe,
depression
should
by
now
have
become
a
minor
issue
in
our
society.
Instead,
even
as
antidepressant
use
continues
to
increase,
it
has
not
made
a
dent
in
hospital
admissions
for
depression.
The
number
of
people
treated
for
depression
has
tripled
over
the
past
two
decades,
and
one
in
ten
Americans
now
take
antidepressants.24
The
new
generation
of
antipsychotics,
such
as
Abilify,
Risperdal,
Zyprexa,
and
Seroquel,
are
the
top-selling
drugs
in
the
United
States.
In
2012
the
public
spent
$1,526,228,000
on
Abilify,
more
than
on
any
other
medication.
Number
three
was
Cymbalta,
an
antidepressant
that
sold
well
over
a
billion
dollars’
worth
of
pills,25
even
though
it
has
never
been
shown
to
be
superior
to
older
antidepressants
like
Prozac,
for
which
much
cheaper
generics
are
available.
Medicaid,
the
government
health
program
for
the
poor,
spends
more
on
antipsychotics
than
on
any
other
class
of
drugs.26
In
2008,
the
most
recent
year
for
which
complete
data
are
available,
it
funded
$3.6
billion
for
antipsychotic
medications,
up
from
$1.65
billion
in
1999.
The
number
of
people
under
the
age
of
twenty
receiving
Medicaid-funded
prescriptions
for
antipsychotic
drugs
tripled
between
1999
and
2008.
On
November
4,
2013,
Johnson
&
Johnson
agreed
to
pay
more
than
$2.2
billion
in
criminal
and
civil
fines
to
settle
accusations
that
it
had
improperly
promoted
the
antipsychotic
drug
Risperdal
to
older
adults,
children,
and
people
with
developmental
disabilities.27
But
nobody
is
holding
the
doctors
who
prescribed
them
accountable.
Half
a
million
children
in
the
United
States
currently
take
antipsychotic
drugs.
Children
from
low-income
families
are
four
times
as
likely
as
privately
insured
children
to
receive
antipsychotic
medicines.
These
medications
often
are
used
to
make
abused
and
neglected
children
more
tractable.
In
2008
19,045
children
age
five
and
under
were
prescribed
antipsychotics
through
Medicaid.28
One
study,
based
on
Medicaid
data
in
thirteen
states,
found
that
12.4
percent
of
children
in
foster
care
received
antipsychotics,
compared
with
1.4
percent
of
Medicaid-eligible
children
in
general.29
These
medications
make
children
more
manageable
and
less
aggressive,
but
they
also
interfere
with
motivation,
play,
and
curiosity,
which
are
indispensable
for
maturing
into
a
well-functioning
and
contributing
member
of
society.
Children
who
take
them
are
also
at
risk
of
becoming
morbidly
obese
and
developing
diabetes.
Meanwhile,
drug
overdoses
involving
a
combination
of
psychiatric
and
pain
medications
continue
to
rise.30
Because
drugs
have
become
so
profitable,
major
medical
journals
rarely
publish
studies
on
nondrug
treatments
of
mental
health
problems.31
Practitioners
who
explore
treatments
are
typically
marginalized
as
“alternative.”
Studies
of
nondrug
treatments
are
rarely
funded
unless
they
involve
so-called
manualized
protocols,
where
patients
and
therapists
go
through
narrowly
prescribed
sequences
that
allow
little
fine-tuning
to
individual
patients’
needs.
Mainstream
medicine
is
firmly
committed
to
a
better
life
through
chemistry,
and
the
fact
that
we
can
actually
change
our
own
physiology
and
inner
equilibrium
by
means
other
than
drugs
is
rarely
considered.

ADAPTATION
OR
DISEASE?
The
brain-disease
model
overlooks
four
fundamental
truths:
(1)
our
capacity
to
destroy
one
another
is
matched
by
our
capacity
to
heal
one
another.
Restoring
relationships
and
community
is
central
to
restoring
well-
being;
(2)
language
gives
us
the
power
to
change
ourselves
and
others
by
communicating
our
experiences,
helping
us
to
define
what
we
know,
and
finding
a
common
sense
of
meaning;
(3)
we
have
the
ability
to
regulate
our
own
physiology,
including
some
of
the
so-called
involuntary
functions
of
the
body
and
brain,
through
such
basic
activities
as
breathing,
moving,
and
touching;
and
(4)
we
can
change
social
conditions
to
create
environments
in
which
children
and
adults
can
feel
safe
and
where
they
can
thrive.
When
we
ignore
these
quintessential
dimensions
of
humanity,
we
deprive
people
of
ways
to
heal
from
trauma
and
restore
their
autonomy.
Being
a
patient,
rather
than
a
participant
in
one’s
healing
process,
separates
suffering
people
from
their
community
and
alienates
them
from
an
inner
sense
of
self.
Given
the
limitations
of
drugs,
I
started
to
wonder
if
we
could
find
more
natural
ways
to
help
people
deal
with
their
post-traumatic
responses.
 CHAPTER
3

LOOKING
INTO
THE
BRAIN:
THE
NEUROSCIENCE
REVOLUTION

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

You
observe
a
lot
by
watching.
—Yogi
Berra

I n
the
early
1990s
novel
brain-imaging
techniques
opened
up
undreamed-
of
capacities
to
gain
a
sophisticated
understanding
about
the
way
the
brain
processes
information.
Gigantic
multimillion-dollar
machines
based
on
advanced
physics
and
computer
technology
rapidly
made
neuroscience
into
one
of
the
most
popular
areas
for
research.
Positron
emission
tomography
(PET)
and,
later,
functional
magnetic
resonance
imaging
(fMRI)
enabled
scientists
to
visualize
how
different
parts
of
the
brain
are
activated
when
people
are
engaged
in
certain
tasks
or
when
they
remember
events
from
the
past.
For
the
first
time
we
could
watch
the
brain
as
it
processed
memories,
sensations,
and
emotions
and
begin
to
map
the
circuits
of
mind
and
consciousness.
The
earlier
technology
of
measuring
brain
chemicals
like
serotonin
or
norepinephrine
had
enabled
scientists
to
look
at
what
fueled
neural
activity,
which
is
a
bit
like
trying
to
understand
a
car’s
engine
by
studying
gasoline.
Neuroimaging
made
it
possible
to
see
inside
the
engine.
By
doing
so
it
has
also
transformed
our
understanding
of
trauma.
Harvard
Medical
School
was
and
is
at
the
forefront
of
the
neuroscience
revolution,
and
in
1994
a
young
psychiatrist,
Scott
Rauch,
was
appointed
as
the
first
director
of
the
Massachusetts
General
Hospital
Neuroimaging
Laboratory.
After
considering
the
most
relevant
questions
that
this
new
technology
could
answer
and
reading
some
articles
I
had
written,
Scott
asked
me
whether
I
thought
we
could
study
what
happens
in
the
brains
of
people
who
have
flashbacks.
I
had
just
finished
a
study
on
how
trauma
is
remembered
(to
be
discussed
in
chapter
12),
in
which
participants
repeatedly
told
me
how
upsetting
it
was
to
be
suddenly
hijacked
by
images,
feelings,
and
sounds
from
the
past.
When
several
said
they
wished
they
knew
what
trick
their
brains
were
playing
on
them
during
these
flashbacks,
I
asked
eight
of
them
if
they
would
be
willing
to
return
to
the
clinic
and
lie
still
inside
a
scanner
(an
entirely
new
experience
that
I
described
in
detail)
while
we
re-created
a
scene
from
the
painful
events
that
haunted
them.
To
my
surprise,
all
eight
agreed,
many
of
them
expressing
their
hope
that
what
we
learned
from
their
suffering
could
help
other
people.
My
research
assistant,
Rita
Fisler,
who
was
working
with
us
prior
to
entering
Harvard
Medical
School,
sat
down
with
every
participant
and
carefully
constructed
a
script
that
re-created
their
trauma
moment
to
moment.
We
deliberately
tried
to
collect
just
isolated
fragments
of
their
experience—particular
images,
sounds,
and
feelings—rather
than
the
entire
story,
because
that
is
how
trauma
is
experienced.
Rita
also
asked
the
participants
to
describe
a
scene
where
they
felt
safe
and
in
control.
One
person
described
her
morning
routine;
another,
sitting
on
the
porch
of
a
farmhouse
in
Vermont
overlooking
the
hills.
We
would
use
this
script
for
a
second
scan,
to
provide
a
baseline
measurement.
After
the
participants
checked
the
scripts
for
accuracy
(reading
silently,
which
is
less
overwhelming
than
hearing
or
speaking),
Rita
made
a
voice
recording
that
would
be
played
back
to
them
while
they
were
in
the
scanner.
A
typical
script:
 You
are
six
years
old
and
getting
ready
for
bed.
You
hear
your
mother
and
father
yelling
at
each
other.
You
are
frightened
and
your
stomach
is
in
a
knot.
You
and
your
younger
brother
and
sister
are
huddled
at
the
top
of
the
stairs.
You
look
over
the
banister
and
see
your
father
holding
your
mother’s
arms
while
she
struggles
to
free
herself.
Your
mother
is
crying,
spitting
and
hissing
like
an
animal.
Your
face
is
flushed
and
you
feel
hot
all
over.
When
your
mother
frees
herself,
she
runs
to
the
dining
room
and
breaks
a
very
expensive
Chinese
vase.
You
yell
at
your
parents
to
stop,
but
they
ignore
you.
Your
mom
runs
upstairs
and
you
hear
her
breaking
the
TV.
Your
little
brother
and
sister
try
to
get
her
to
hide
in
the
closet.
Your
heart
pounds
and
you
are
trembling.

At
this
first
session
we
explained
the
purpose
of
the
radioactive
oxygen
the
participants
would
be
breathing:
As
any
part
of
the
brain
became
more
or
less
metabolically
active,
its
rate
of
oxygen
consumption
would
immediately
change,
which
would
be
picked
up
by
the
scanner.
We
would
monitor
their
blood
pressure
and
heart
rate
throughout
the
procedure,
so
that
these
physiological
signs
could
be
compared
with
brain
activity.
Several
days
later
the
participants
came
to
the
imaging
lab.
Marsha,
a
forty-year-old
schoolteacher
from
a
suburb
outside
of
Boston,
was
the
first
volunteer
to
be
scanned.
Her
script
took
her
back
to
the
day,
thirteen
years
earlier,
when
she
picked
up
her
five-year-old
daughter,
Melissa,
from
day
camp.
As
they
drove
off,
Marsha
heard
a
persistent
beeping,
indicating
that
Melissa’s
seatbelt
was
not
properly
fastened.
When
Marsha
reached
over
to
adjust
the
belt,
she
ran
a
red
light.
Another
car
smashed
into
hers
from
the
right,
instantly
killing
her
daughter.
In
the
ambulance
on
the
way
to
the
emergency
room,
the
seven-month-old
fetus
Marsha
was
carrying
also
died.
Overnight
Marsha
had
changed
from
a
cheerful
woman
who
was
the
life
of
the
party
into
a
haunted
and
depressed
person
filled
with
self-blame.
She
moved
from
classroom
teaching
into
school
administration,
because
working
directly
with
children
had
become
intolerable—as
for
many
parents
who
have
lost
children,
their
happy
laughter
had
become
a
powerful
trigger.
Even
hiding
behind
her
paperwork
she
could
barely
make
it
through
the
day.
In
a
futile
attempt
to
keep
her
feelings
at
bay,
she
coped
by
working
day
and
night.
 I
was
standing
outside
the
scanner
as
Marsha
underwent
the
procedure
and
could
follow
her
physiological
reactions
on
a
monitor.
The
moment
we
turned
on
the
tape
recorder,
her
heart
started
to
race,
and
her
blood
pressure
jumped.
Simply
hearing
the
script
similar
activated
the
same
physiological
responses
that
had
occurred
during
the
accident
thirteen
years
earlier.
After
the
recorded
script
concluded
and
Marsha’s
heart
rate
and
blood
pressure
returned
to
normal,
we
played
her
second
script:
getting
out
of
bed
and
brushing
her
teeth.
This
time
her
heart
rate
and
blood
pressure
did
not
change.
As
she
emerged
from
the
scanner,
Marsha
looked
defeated,
drawn
out,
and
frozen.
Her
breathing
was
shallow,
her
eyes
were
opened
wide,
and
her
shoulders
were
hunched—the
very
image
of
vulnerability
and
defenselessness.
We
tried
to
comfort
her,
but
I
wondered
if
whatever
we
discovered
would
be
worth
the
price
of
her
distress.

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

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

SPEECHLESS
HORROR
Our
most
surprising
finding
was
a
white
spot
in
the
left
frontal
lobe
of
the
cortex,
in
a
region
called
Broca’s
area.
In
this
case
the
change
in
color
meant
that
there
was
a
significant
decrease
in
that
part
of
the
brain.
Broca’s
area
is
one
of
the
speech
centers
of
the
brain,
which
is
often
affected
in
stroke
patients
when
the
blood
supply
to
that
region
is
cut
off.
Without
a
functioning
Broca’s
area,
you
cannot
put
your
thoughts
and
feelings
into
words.
Our
scans
showed
that
Broca’s
area
went
offline
whenever
a
flashback
was
triggered.
In
other
words,
we
had
visual
proof
that
the
effects
of
trauma
are
not
necessarily
different
from—and
can
overlap
with—the
effects
of
physical
lesions
like
strokes.
All
trauma
is
preverbal.
Shakespeare
captures
this
state
of
speechless
terror
in
Macbeth,
after
the
murdered
king’s
body
is
discovered:
“Oh
horror!
horror!
horror!
Tongue
nor
heart
cannot
conceive
nor
name
thee!
Confusion
now
hath
made
his
masterpiece!”
Under
extreme
conditions
people
may
scream
obscenities,
call
for
their
mothers,
howl
in
terror,
or
simply
shut
down.
Victims
of
assaults
and
accidents
sit
mute
and
frozen
in
emergency
rooms;
traumatized
children
“lose
their
tongues”
and
refuse
to
speak.
Photographs
of
combat
soldiers
show
hollow-eyed
men
staring
mutely
into
a
void.
Even
years
later
traumatized
people
often
have
enormous
difficulty
telling
other
people
what
has
happened
to
them.
Their
bodies
reexperience
terror,
rage,
and
helplessness,
as
well
as
the
impulse
to
fight
or
flee,
but
these
feelings
are
almost
impossible
to
articulate.
Trauma
by
nature
drives
us
to
the
edge
of
comprehension,
cutting
us
off
from
language
based
on
common
experience
or
an
imaginable
past.
This
doesn’t
mean
that
people
can’t
talk
about
a
tragedy
that
has
befallen
them.
Sooner
or
later
most
survivors,
like
the
veterans
in
chapter
1,
come
up
with
what
many
of
them
call
their
“cover
story”
that
offers
some
explanation
for
their
symptoms
and
behavior
for
public
consumption.
These
stories,
however,
rarely
capture
the
inner
truth
of
the
experience.
It
is
enormously
difficult
to
organize
one’s
traumatic
experiences
into
a
coherent
account—a
narrative
with
a
beginning,
a
middle,
and
an
end.
Even
a
seasoned
reporter
like
the
famed
CBS
correspondent
Ed
Murrow
struggled
to
convey
the
atrocities
he
saw
when
the
Nazi
concentration
camp
Buchenwald
was
liberated
in
1945:
“I
pray
you
believe
what
I
have
said.
I
reported
what
I
saw
and
heard,
but
only
part
of
it.
For
most
of
it
I
have
no
words.”
When
words
fail,
haunting
images
capture
the
experience
and
return
as
nightmares
and
flashbacks.
In
contrast
to
the
deactivation
of
Broca’s
area,
another
region,
Brodmann’s
area
19,
lit
up
in
our
participants.
This
is
a
region
in
the
visual
cortex
that
registers
images
when
they
first
enter
the
brain.
We
were
surprised
to
see
brain
activation
in
this
area
so
long
after
the
original
experience
of
the
trauma.
Under
ordinary
conditions
raw
images
registered
in
area
19
are
rapidly
diffused
to
other
brain
areas
that
interpret
the
meaning
of
what
has
been
seen.
Once
again,
we
were
witnessing
a
brain
region
rekindled
as
if
the
trauma
were
actually
occurring.
As
we
will
see
in
chapter
12,
which
discusses
memory,
other
unprocessed
sense
fragments
of
trauma,
like
sounds
and
smells
and
physical
sensations,
are
also
registered
separately
from
the
story
itself.
Similar
sensations
often
trigger
a
flashback
that
brings
them
back
into
consciousness,
apparently
unmodified
by
the
passage
of
time.
SHIFTING
TO
ONE
SIDE
OF
THE
BRAIN
The
scans
also
revealed
that
during
flashbacks,
our
subjects’
brains
lit
up
only
on
the
right
side.
Today
there’s
a
huge
body
of
scientific
and
popular
literature
about
the
difference
between
the
right
and
left
brains.
Back
in
the
early
nineties
I
had
heard
that
some
people
had
begun
to
divide
the
world
between
left-brainers
(rational,
logical
people)
and
right-brainers
(the
intuitive,
artistic
ones),
but
I
hadn’t
paid
much
attention
to
this
idea.
However,
our
scans
clearly
showed
that
images
of
past
trauma
activate
the
right
hemisphere
of
the
brain
and
deactivate
the
left.
We
now
know
that
the
two
halves
of
the
brain
do
speak
different
languages.
The
right
is
intuitive,
emotional,
visual,
spatial,
and
tactual,
and
the
left
is
linguistic,
sequential,
and
analytical.
While
the
left
half
of
the
brain
does
all
the
talking,
the
right
half
of
the
brain
carries
the
music
of
experience.
It
communicates
through
facial
expressions
and
body
language
and
by
making
the
sounds
of
love
and
sorrow:
by
singing,
swearing,
crying,
dancing,
or
mimicking.
The
right
brain
is
the
first
to
develop
in
the
womb,
and
it
carries
the
nonverbal
communication
between
mothers
and
infants.
We
know
the
left
hemisphere
has
come
online
when
children
start
to
understand
language
and
learn
how
to
speak.
This
enables
them
to
name
things,
compare
them,
understand
their
interrelations,
and
begin
to
communicate
their
own
unique,
subjective
experiences
to
others.
The
left
and
right
sides
of
the
brain
also
process
the
imprints
of
the
past
in
dramatically
different
ways.2
The
left
brain
remembers
facts,
statistics,
and
the
vocabulary
of
events.
We
call
on
it
to
explain
our
experiences
and
put
them
in
order.
The
right
brain
stores
memories
of
sound,
touch,
smell,
and
the
emotions
they
evoke.
It
reacts
automatically
to
voices,
facial
features,
and
gestures
and
places
experienced
in
the
past.
What
it
recalls
feels
like
intuitive
truth—the
way
things
are.
Even
as
we
enumerate
a
loved
one’s
virtues
to
a
friend,
our
feelings
may
be
more
deeply
stirred
by
how
her
face
recalls
the
aunt
we
loved
at
age
four.3
Under
ordinary
circumstances
the
two
sides
of
the
brain
work
together
more
or
less
smoothly,
even
in
people
who
might
be
said
to
favor
one
side
over
the
other.
However,
having
one
side
or
the
other
shut
down,
even
temporarily,
or
having
one
side
cut
off
entirely
(as
sometimes
happened
in
early
brain
surgery)
is
disabling.
 Deactivation
of
the
left
hemisphere
has
a
direct
impact
on
the
capacity
to
organize
experience
into
logical
sequences
and
to
translate
our
shifting
feelings
and
perceptions
into
words.
(Broca’s
area,
which
blacks
out
during
flashbacks,
is
on
the
left
side.)
Without
sequencing
we
can’t
identify
cause
and
effect,
grasp
the
long-term
effects
of
our
actions,
or
create
coherent
plans
for
the
future.
People
who
are
very
upset
sometimes
say
they
are
“losing
their
minds.”
In
technical
terms
they
are
experiencing
the
loss
of
executive
functioning.
When
something
reminds
traumatized
people
of
the
past,
their
right
brain
reacts
as
if
the
traumatic
event
were
happening
in
the
present.
But
because
their
left
brain
is
not
working
very
well,
they
may
not
be
aware
that
they
are
reexperiencing
and
reenacting
the
past—they
are
just
furious,
terrified,
enraged,
ashamed,
or
frozen.
After
the
emotional
storm
passes,
they
may
look
for
something
or
somebody
to
blame
for
it.
They
behaved
the
way
they
did
way
because
you
were
ten
minutes
late,
or
because
you
burned
the
potatoes,
or
because
you
“never
listen
to
me.”
Of
course,
most
of
us
have
done
this
from
time
to
time,
but
when
we
cool
down,
we
hopefully
can
admit
our
mistake.
Trauma
interferes
with
this
kind
of
awareness,
and,
over
time,
our
research
demonstrated
why.

STUCK
IN
FIGHT
OR
FLIGHT
What
had
happened
to
Marsha
in
the
scanner
gradually
started
to
make
sense.
Thirteen
years
after
her
tragedy
we
had
activated
the
sensations—the
sounds
and
images
from
the
accident—that
were
still
stored
in
her
memory.
When
these
sensations
came
to
the
surface,
they
activated
her
alarm
system,
which
caused
her
to
react
as
if
she
were
back
in
the
hospital
being
told
that
her
daughter
had
died.
The
passage
of
thirteen
years
was
erased.
Her
sharply
increased
heart
rate
and
blood
pressure
readings
reflected
her
physiological
state
of
frantic
alarm.
Adrenaline
is
one
of
the
hormones
that
are
critical
to
help
us
fight
back
or
flee
in
the
face
of
danger.
Increased
adrenaline
was
responsible
for
our
participants’
dramatic
rise
in
heart
rate
and
blood
pressure
while
listening
to
their
trauma
narrative.
Under
normal
conditions
people
react
to
a
threat
with
a
temporary
increase
in
their
stress
hormones.
As
soon
as
the
threat
is
over,
the
hormones
dissipate
and
the
body
returns
to
normal.
The
stress
hormones
of
traumatized
people,
in
contrast,
take
much
longer
to
return
to
baseline
and
spike
quickly
and
disproportionately
in
response
to
mildly
stressful
stimuli.
The
insidious
effects
of
constantly
elevated
stress
hormones
include
memory
and
attention
problems,
irritability,
and
sleep
disorders.
They
also
contribute
to
many
long-term
health
issues,
depending
on
which
body
system
is
most
vulnerable
in
a
particular
individual.
We
now
know
that
there
is
another
possible
response
to
threat,
which
our
scans
aren’t
yet
capable
of
measuring.
Some
people
simply
go
into
denial:
Their
bodies
register
the
threat,
but
their
conscious
minds
go
on
as
if
nothing
has
happened.
However,
even
though
the
mind
may
learn
to
ignore
the
messages
from
the
emotional
brain,
the
alarm
signals
don’t
stop.
The
emotional
brain
keeps
working,
and
stress
hormones
keep
sending
signals
to
the
muscles
to
tense
for
action
or
immobilize
in
collapse.
The
physical
effects
on
the
organs
go
on
unabated
until
they
demand
notice
when
they
are
expressed
as
illness.
Medications,
drugs,
and
alcohol
can
also
temporarily
dull
or
obliterate
unbearable
sensations
and
feelings.
But
the
body
continues
to
keep
the
score.
We
can
interpret
what
happened
to
Marsha
in
the
scanner
from
several
different
perspectives,
each
of
which
has
implications
for
treatment.
We
can
focus
on
the
neurochemical
and
physiological
disruptions
that
were
so
evident
and
make
a
case
that
she
is
suffering
from
a
biochemical
imbalance
that
is
reactivated
whenever
she
is
reminded
of
her
daughter’s
death.
We
might
then
search
for
a
drug
or
a
combination
of
drugs
that
would
damp
down
the
reaction
or,
in
the
best
case,
restore
her
chemical
equilibrium.
Based
on
the
results
of
our
scans,
some
of
my
colleagues
at
MGH
began
investigating
drugs
that
might
make
people
less
responsive
to
the
effects
of
elevated
adrenaline.
We
can
also
make
a
strong
case
that
Marsha
is
hypersensitized
to
her
memories
of
the
past
and
that
the
best
treatment
would
be
some
form
of
desensitization.4
After
repeatedly
rehearsing
the
details
of
the
trauma
with
a
therapist,
her
biological
responses
might
become
muted,
so
that
she
could
realize
and
remember
that
“that
was
then
and
this
is
now,”
rather
than
reliving
the
experience
over
and
over.
For
a
hundred
years
or
more,
every
textbook
of
psychology
and
psychotherapy
has
advised
that
some
method
of
talking
about
distressing
feelings
can
resolve
them.
However,
as
we’ve
seen,
the
experience
of
trauma
itself
gets
in
the
way
of
being
able
to
do
that.
No
matter
how
much
insight
and
understanding
we
develop,
the
rational
brain
is
basically
impotent
to
talk
the
emotional
brain
out
of
its
own
reality.
I
am
continually
impressed
by
how
difficult
it
is
for
people
who
have
gone
through
the
unspeakable
to
convey
the
essence
of
their
experience.
It
is
so
much
easier
for
them
to
talk
about
what
has
been
done
to
them—to
tell
a
story
of
victimization
and
revenge—than
to
notice,
feel,
and
put
into
words
the
reality
of
their
internal
experience.
Our
scans
had
revealed
how
their
dread
persisted
and
could
be
triggered
by
multiple
aspects
of
daily
experience.
They
had
not
integrated
their
experience
into
the
ongoing
stream
of
their
life.
They
continued
to
be
“there”
and
did
not
know
how
to
be
“here”—fully
alive
in
the
present.
Three
years
after
being
a
participant
in
our
study
Marsha
came
to
see
me
as
a
patient.
I
successfully
treated
her
with
EMDR,
the
subject
of
chapter
15.
 PART
TWO
THIS
IS
YOUR
BRAIN
ON
TRAUMA
 CHAPTER
4

RUNNING
FOR
YOUR
LIFE:
THE
ANATOMY
OF
SURVIVAL

Prior
to
the
advent
of
brain,
there
was
no
color
and
no
sound
in
the
universe,
nor
was
there
any
flavor
or
aroma
and
probably
little
sense
and
no
feeling
or
emotion.
Before
brains
the
universe
was
also
free
of
pain
and
anxiety.
—Roger
Sperry1

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

Five-year-old
Noam’s
drawing
made
after
he
witnessed
the
World
Trade
Center
attack
on
9/11.
He
reproduced
the
image
that
haunted
so
many
survivors—people
jumping
to
escape
from
the
inferno—but
with
a
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
on
page
53
shows
the
whole-body
response
to
threat.
When
the
brain’s
alarm
system
is
turned
on,
it
automatically
triggers
preprogrammed
physical
escape
plans
in
the
oldest
parts
of
the
brain.
As
in
other
animals,
the
nerves
and
chemicals
that
make
up
our
basic
brain
structure
have
a
direct
connection
with
our
body.
When
the
old
brain
takes
over,
it
partially
shuts
down
the
higher
brain,
our
conscious
mind,
and
propels
the
body
to
run,
hide,
fight,
or,
on
occasion,
freeze.
By
the
time
we
are
fully
aware
of
our
situation,
our
body
may
already
be
on
the
move.
If
the
fight/flight/freeze
response
is
successful
and
we
escape
the
danger,
we
recover
our
internal
equilibrium
and
gradually
“regain
our
senses.”
AP
PHOTO/PAUL
HAWTHORNE
 ILLINOISPHOTO.COM
Effective
action
versus
immobilization.
Effective
action
(the
result
of
fight/flight)
ends
the
threat.
Immobilization
keeps
the
body
in
a
state
of
inescapable
shock
and
learned
helplessness.
Faced
with
danger
people
automatically
secrete
stress
hormones
to
fuel
resistance
and
escape.
Brain
and
body
are
programmed
to
run
for
home,
where
safety
can
be
restored
and
stress
hormones
can
come
to
rest.
In
these
strapped-down
men
who
are
being
evacuated
far
from
home
after
Hurricane
Katrina
stress
hormone
levels
remain
elevated
and
are
turned
against
the
survivors,
stimulating
ongoing
fear,
depression,
rage,
and
physical
disease.

If
for
some
reason
the
normal
response
is
blocked—for
example,
when
people
are
held
down,
trapped,
or
otherwise
prevented
from
taking
effective
action,
be
it
in
a
war
zone,
a
car
accident,
domestic
violence,
or
a
rape—the
brain
keeps
secreting
stress
chemicals,
and
the
brain’s
electrical
circuits
continue
to
fire
in
vain.2
Long
after
the
actual
event
has
passed,
the
brain
may
keep
sending
signals
to
the
body
to
escape
a
threat
that
no
longer
exists.
Since
at
least
1889,
when
the
French
psychologist
Pierre
Janet
published
the
first
scientific
account
of
traumatic
stress,3
it
has
been
recognized
that
trauma
survivors
are
prone
to
“continue
the
action,
or
rather
the
(futile)
attempt
at
action,
which
began
when
the
thing
happened.”
Being
able
to
move
and
do
something
to
protect
oneself
is
a
critical
factor
in
determining
whether
or
not
a
horrible
experience
will
leave
long-lasting
scars.
 In
this
chapter
I’m
going
to
go
deeper
into
the
brain’s
response
to
trauma.
The
more
neuroscience
discovers
about
the
brain,
the
more
we
realize
that
it
is
a
vast
network
of
interconnected
parts
organized
to
help
us
survive
and
flourish.
Knowing
how
these
parts
work
together
is
essential
to
understanding
how
trauma
affects
every
part
of
the
human
organism
and
can
serve
as
an
indispensable
guide
to
resolving
traumatic
stress.

THE
BRAIN
FROM
BOTTOM
TO
TOP
The
most
important
job
of
the
brain
is
to
ensure
our
survival,
even
under
the
most
miserable
conditions.
Everything
else
is
secondary.
In
order
to
do
that,
brains
need
to:
(1)
generate
internal
signals
that
register
what
our
bodies
need,
such
as
food,
rest,
protection,
sex,
and
shelter;
(2)
create
a
map
of
the
world
to
point
us
where
to
go
to
satisfy
those
needs;
(3)
generate
the
necessary
energy
and
actions
to
get
us
there;
(4)
warn
us
of
dangers
and
opportunities
along
the
way;
and
(5)
adjust
our
actions
based
on
the
requirements
of
the
moment.4
And
since
we
human
beings
are
mammals,
creatures
that
can
only
survive
and
thrive
in
groups,
all
of
these
imperatives
require
coordination
and
collaboration.
Psychological
problems
occur
when
our
internal
signals
don’t
work,
when
our
maps
don’t
lead
us
where
we
need
to
go,
when
we
are
too
paralyzed
to
move,
when
our
actions
do
not
correspond
to
our
needs,
or
when
our
relationships
break
down.
Every
brain
structure
that
I
discuss
has
a
role
to
play
in
these
essential
functions,
and
as
we
will
see,
trauma
can
interfere
with
every
one
of
them.
Our
rational,
cognitive
brain
is
actually
the
youngest
part
of
the
brain
and
occupies
only
about
30
percent
of
the
area
inside
our
skull.
The
rational
brain
is
primarily
concerned
with
the
world
outside
us:
understanding
how
things
and
people
work
and
figuring
out
how
to
accomplish
our
goals,
manage
our
time,
and
sequence
our
actions.
Beneath
the
rational
brain
lie
two
evolutionarily
older,
and
to
some
degree
separate,
brains,
which
are
in
charge
of
everything
else:
the
moment-by-moment
registration
and
management
of
our
body’s
physiology
and
the
identification
of
comfort,
safety,
threat,
hunger,
fatigue,
desire,
longing,
excitement,
pleasure,
and
pain.
The
brain
is
built
from
the
bottom
up.
It
develops
level
by
level
within
every
child
in
the
womb,
just
as
it
did
in
the
course
of
evolution.
The
most
primitive
part,
the
part
that
is
already
online
when
we
are
born,
is
the
ancient
animal
brain,
often
called
the
reptilian
brain.
It
is
located
in
the
brain
stem,
just
above
the
place
where
our
spinal
cord
enters
the
skull.
The
reptilian
brain
is
responsible
for
all
the
things
that
newborn
babies
can
do:
eat,
sleep,
wake,
cry,
breathe;
feel
temperature,
hunger,
wetness,
and
pain;
and
rid
the
body
of
toxins
by
urinating
and
defecating.
The
brain
stem
and
the
hypothalamus
(which
sits
directly
above
it)
together
control
the
energy
levels
of
the
body.
They
coordinate
the
functioning
of
the
heart
and
lungs
and
also
the
endocrine
and
immune
systems,
ensuring
that
these
basic
life-
sustaining
systems
are
maintained
within
the
relatively
stable
internal
balance
known
as
homeostasis.
Breathing,
eating,
sleeping,
pooping,
and
peeing
are
so
fundamental
that
their
significance
is
easily
neglected
when
we’re
considering
the
complexities
of
mind
and
behavior.
However,
if
your
sleep
is
disturbed
or
your
bowels
don’t
work,
or
if
you
always
feel
hungry,
or
if
being
touched
makes
you
want
to
scream
(as
is
often
the
case
with
traumatized
children
and
adults),
the
entire
organism
is
thrown
into
disequilibrium.
It
is
amazing
how
many
psychological
problems
involve
difficulties
with
sleep,
appetite,
touch,
digestion,
and
arousal.
Any
effective
treatment
for
trauma
has
to
address
these
basic
housekeeping
functions
of
the
body.
Right
above
the
reptilian
brain
is
the
limbic
system.
It’s
also
known
as
the
mammalian
brain,
because
all
animals
that
live
in
groups
and
nurture
their
young
possess
one.
Development
of
this
part
of
the
brain
truly
takes
off
after
a
baby
is
born.
It
is
the
seat
of
the
emotions,
the
monitor
of
danger,
the
judge
of
what
is
pleasurable
or
scary,
the
arbiter
of
what
is
or
is
not
important
for
survival
purposes.
It
is
also
a
central
command
post
for
coping
with
the
challenges
of
living
within
our
complex
social
networks.
The
limbic
system
is
shaped
in
response
to
experience,
in
partnership
with
the
infant’s
own
genetic
makeup
and
inborn
temperament.
(As
all
parents
of
more
than
one
child
quickly
notice,
babies
differ
from
birth
in
the
intensity
and
nature
of
their
reactions
to
similar
events.)
Whatever
happens
to
a
baby
contributes
to
the
emotional
and
perceptual
map
of
the
world
that
its
developing
brain
creates.
As
my
colleague
Bruce
Perry
explains
it,
the
brain
is
formed
in
a
“use-dependent
manner.”5
This
is
another
way
of
describing
neuroplasticity,
the
relatively
recent
discovery
that
neurons
that
“fire
together,
wire
together.”
When
a
circuit
fires
repeatedly,
it
can
become
a
default
setting—the
response
most
likely
to
occur.
If
you
feel
safe
and
loved,
your
brain
becomes
specialized
in
exploration,
play,
and
cooperation;
if
you
are
frightened
and
unwanted,
it
specializes
in
managing
feelings
of
fear
and
abandonment.
As
infants
and
toddlers
we
learn
about
the
world
by
moving,
grabbing,
and
crawling
and
by
discovering
what
happens
when
we
cry,
smile,
or
protest.
We
are
constantly
experimenting
with
our
surroundings—how
do
our
interactions
change
the
way
our
bodies
feel?
Attend
any
two-year-old’s
birthday
party
and
notice
how
little
Kimberly
will
engage
you,
play
with
you,
flirt
with
you,
without
any
need
for
language.
These
early
explorations
shape
the
limbic
structures
devoted
to
emotions
and
memory,
but
these
structures
can
also
be
significantly
modified
by
later
experiences:
for
the
better
by
a
close
friendship
or
a
beautiful
first
love,
for
example,
or
for
the
worse
by
a
violent
assault,
relentless
bullying,
or
neglect.
Taken
together
the
reptilian
brain
and
limbic
system
make
up
what
I’ll
call
the
“emotional
brain”
throughout
this
book.6
The
emotional
brain
is
at
the
heart
of
the
central
nervous
system,
and
its
key
task
is
to
look
out
for
your
welfare.
If
it
detects
danger
or
a
special
opportunity—such
as
a
promising
partner—it
alerts
you
by
releasing
a
squirt
of
hormones.
The
resulting
visceral
sensations
(ranging
from
mild
queasiness
to
the
grip
of
panic
in
your
chest)
will
interfere
with
whatever
your
mind
is
currently
focused
on
and
get
you
moving—physically
and
mentally—in
a
different
direction.
Even
at
their
most
subtle,
these
sensations
have
a
huge
influence
on
the
small
and
large
decisions
we
make
throughout
our
lives:
what
we
choose
to
eat,
where
we
like
to
sleep
and
with
whom,
what
music
we
prefer,
whether
we
like
to
garden
or
sing
in
a
choir,
and
whom
we
befriend
and
whom
we
detest.
The
emotional
brain’s
cellular
organization
and
biochemistry
are
simpler
than
those
of
the
neocortex,
our
rational
brain,
and
it
assesses
incoming
information
in
a
more
global
way.
As
a
result,
it
jumps
to
conclusions
based
on
rough
similarities,
in
contrast
with
the
rational
brain,
which
is
organized
to
sort
through
a
complex
set
of
options.
(The
textbook
example
is
leaping
back
in
terror
when
you
see
a
snake—only
to
realize
that
it’s
just
a
coiled
rope.)
The
emotional
brain
initiates
preprogrammed
escape
plans,
like
the
fight-or-flight
responses.
These
muscular
and
physiological
reactions
are
automatic,
set
in
motion
without
any
thought
or
planning
on
our
part,
leaving
our
conscious,
rational
capacities
to
catch
up
later,
often
well
after
the
threat
is
over.
 Finally
we
reach
the
top
layer
of
the
brain,
the
neocortex.
We
share
this
outer
layer
with
other
mammals,
but
it
is
much
thicker
in
us
humans.
In
the
second
year
of
life
the
frontal
lobes,
which
make
up
the
bulk
of
our
neocortex,
begin
to
develop
at
a
rapid
pace.
The
ancient
philosophers
called
seven
years
“the
age
of
reason.”
For
us
first
grade
is
the
prelude
of
things
to
come,
a
life
organized
around
frontal-lobe
capacities:
sitting
still;
keeping
sphincters
in
check;
being
able
to
use
words
rather
than
acting
out;
understanding
abstract
and
symbolic
ideas;
planning
for
tomorrow;
and
being
in
tune
with
teachers
and
classmates.
The
frontal
lobes
are
responsible
for
the
qualities
that
make
us
unique
within
the
animal
kingdom.7
They
enable
us
to
use
language
and
abstract
thought.
They
give
us
our
ability
to
absorb
and
integrate
vast
amounts
of
information
and
attach
meaning
to
it.
Despite
our
excitement
about
the
linguistic
feats
of
chimpanzees
and
rhesus
monkeys,
only
human
beings
command
the
words
and
symbols
necessary
to
create
the
communal,
spiritual,
and
historical
contexts
that
shape
our
lives.
The
frontal
lobes
allow
us
to
plan
and
reflect,
to
imagine
and
play
out
future
scenarios.
They
help
us
to
predict
what
will
happen
if
we
take
one
action
(like
applying
for
a
new
job)
or
neglect
another
(not
paying
the
rent).
They
make
choice
possible
and
underlie
our
astonishing
creativity.
Generations
of
frontal
lobes,
working
in
close
collaboration,
have
created
culture,
which
got
us
from
dug-out
canoes,
horse-drawn
carriages,
and
letters
to
jet
planes,
hybrid
cars,
and
e-mail.
They
also
gave
us
Noam’s
lifesaving
trampoline.

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

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

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

IDENTIFYING
DANGER:
THE
COOK
AND
THE
SMOKE
DETECTOR
Danger
is
a
normal
part
of
life,
and
the
brain
is
in
charge
of
detecting
it
and
organizing
our
response.
Sensory
information
about
the
outside
world
arrives
through
our
eyes,
nose,
ears,
and
skin.
These
sensations
converge
in
the
thalamus,
an
area
inside
the
limbic
system
that
acts
as
the
“cook”
within
the
brain.
The
thalamus
stirs
all
the
input
from
our
perceptions
into
a
fully
blended
autobiographical
soup,
an
integrated,
coherent
experience
of
“this
is
what
is
happening
to
me.”10
The
sensations
are
then
passed
on
in
two
directions—down
to
the
amygdala,
two
small
almond-shaped
structures
that
lie
deeper
in
the
limbic,
unconscious
brain,
and
up
to
the
frontal
lobes,
where
they
reach
our
conscious
awareness.
The
neuroscientist
Joseph
LeDoux
calls
the
pathway
to
the
amygdala
“the
low
road,”
which
is
extremely
fast,
and
that
to
the
frontal
cortex
the
“high
road,”
which
takes
several
milliseconds
longer
in
the
midst
of
an
overwhelmingly
threatening
experience.
However,
processing
by
the
thalamus
can
break
down.
Sights,
sounds,
smells,
and
touch
are
encoded
as
isolated,
dissociated
fragments,
and
normal
memory
processing
disintegrates.
Time
freezes,
so
that
the
present
danger
feels
like
it
will
last
forever.
The
central
function
of
the
amygdala,
which
I
call
the
brain’s
smoke
detector,
is
to
identify
whether
incoming
input
is
relevant
for
our
survival.11
It
does
so
quickly
and
automatically,
with
the
help
of
feedback
from
the
hippocampus,
a
nearby
structure
that
relates
the
new
input
to
past
experiences.
If
the
amygdala
senses
a
threat—a
potential
collision
with
an
oncoming
vehicle,
a
person
on
the
street
who
looks
threatening—it
sends
an
instant
message
down
to
the
hypothalamus
and
the
brain
stem,
recruiting
the
stress-hormone
system
and
the
autonomic
nervous
system
(ANS)
to
orchestrate
a
whole-body
response.
Because
the
amygdala
processes
the
information
it
receives
from
the
thalamus
faster
than
the
frontal
lobes
do,
it
decides
whether
incoming
information
is
a
threat
to
our
survival
even
before
we
are
consciously
aware
of
the
danger.
By
the
time
we
realize
what
is
happening,
our
body
may
already
be
on
the
move.
 The
emotional
brain
has
first
dibs
on
interpreting
incoming
information.
Sensory
Information
about
the
environment
and
body
state
received
by
the
eyes,
ears,
touch,
kinesthetic
sense,
etc.,
converges
on
the
thalamus,
where
it
is
processed,
and
then
passed
on
to
the
amygdala
to
interpret
its
emotional
significance.
This
occurs
with
lightning
speed.
If
a
threat
is
detected
the
amygdala
sends
messages
to
the
hypothalamus
to
secrete
stress
hormones
to
defend
against
that
threat.
The
neuroscientist
Joseph
LeDoux
calls
this
the
low
road.
The
second
neural
pathway,
the
high
road,
runs
from
the
thalamus,
via
the
hippocampus
and
anterior
cingulate,
to
the
prefrontal
cortex,
the
rational
brain,
for
a
conscious
and
much
more
refined
interpretation.
This
takes
several
microseconds
longer.
If
the
interpretation
of
threat
by
the
amygdala
is
too
intense,
and/or
the
filtering
system
from
the
higher
areas
of
the
brain
are
too
weak,
as
often
happens
in
PTSD,
people
lose
control
over
automatic
emergency
responses,
like
prolonged
startle
or
aggressive
outbursts.

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

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

In
PTSD
the
critical
balance
between
the
amygdala
(smoke
detector)
and
the
MPFC
(watchtower)
shifts
radically,
which
makes
it
much
harder
to
control
emotions
and
impulses.
Neuroimaging
studies
of
human
beings
in
highly
emotional
states
reveal
that
intense
fear,
sadness,
and
anger
all
increase
the
activation
of
subcortical
brain
regions
involved
in
emotions
and
significantly
reduce
the
activity
in
various
areas
in
the
frontal
lobe,
particularly
the
MPFC.
When
that
occurs,
the
inhibitory
capacities
of
the
frontal
lobe
break
down,
and
people
“take
leave
of
their
senses”:
They
may
startle
in
response
to
any
loud
sound,
become
enraged
by
small
frustrations,
or
freeze
when
somebody
touches
them.13
Effectively
dealing
with
stress
depends
upon
achieving
a
balance
between
the
smoke
detector
and
the
watchtower.
If
you
want
to
manage
your
emotions
better,
your
brain
gives
you
two
options:
You
can
learn
to
regulate
them
from
the
top
down
or
from
the
bottom
up.
 Knowing
the
difference
between
top
down
and
bottom
up
regulation
is
central
for
understanding
and
treating
traumatic
stress.
Top-down
regulation
involves
strengthening
the
capacity
of
the
watchtower
to
monitor
your
body’s
sensations.
Mindfulness
meditation
and
yoga
can
help
with
this.
Bottom-up
regulation
involves
recalibrating
the
autonomic
nervous
system,
(which,
as
we
have
seen,
originates
in
the
brain
stem).
We
can
access
the
ANS
through
breath,
movement,
or
touch.
Breathing
is
one
of
the
few
body
functions
under
both
conscious
and
autonomic
control.
In
part
5
of
this
book
we’ll
explore
specific
techniques
for
increasing
both
top-down
and
bottom-up
regulation.

THE
RIDER
AND
THE
HORSE
For
now
I
want
to
emphasize
that
emotion
is
not
opposed
to
reason;
our
emotions
assign
value
to
experiences
and
thus
are
the
foundation
of
reason.
Our
self-experience
is
the
product
of
the
balance
between
our
rational
and
our
emotional
brains.
When
these
two
systems
are
in
balance,
we
“feel
like
ourselves.”
However,
when
our
survival
is
at
stake,
these
systems
can
function
relatively
independently.
If,
say,
you
are
driving
along,
chatting
with
a
friend,
and
a
truck
suddenly
looms
in
the
corner
of
your
eye,
you
instantly
stop
talking,
slam
on
the
brakes,
and
turn
your
steering
wheel
to
get
out
of
harm’s
way.
If
your
instinctive
actions
have
saved
you
from
a
collision,
you
may
resume
where
you
left
off.
Whether
you
are
able
to
do
so
depends
largely
on
how
quickly
your
visceral
reactions
subside
to
the
threat.
The
neuroscientist
Paul
MacLean,
who
developed
the
three-part
description
of
the
brain
that
I’ve
used
here,
compared
the
relationship
between
the
rational
brain
and
the
emotional
brain
to
that
between
a
more
or
less
competent
rider
and
his
unruly
horse.14
As
long
as
the
weather
is
calm
and
the
path
is
smooth,
the
rider
can
feel
in
excellent
control.
But
unexpected
sounds
or
threats
from
other
animals
can
make
the
horse
bolt,
forcing
the
rider
to
hold
on
for
dear
life.
Likewise,
when
people
feel
that
their
survival
is
at
stake
or
they
are
seized
by
rages,
longings,
fear,
or
sexual
desires,
they
stop
listening
to
the
voice
of
reason,
and
it
makes
little
sense
to
argue
with
them.
Whenever
the
limbic
system
decides
that
something
is
a
question
of
life
or
death,
the
pathways
between
the
frontal
lobes
and
the
limbic
system
become
extremely
tenuous.
Psychologists
usually
try
to
help
people
use
insight
and
understanding
to
manage
their
behavior.
However,
neuroscience
research
shows
that
very
few
psychological
problems
are
the
result
of
defects
in
understanding;
most
originate
in
pressures
from
deeper
regions
in
the
brain
that
drive
our
perception
and
attention.
When
the
alarm
bell
of
the
emotional
brain
keeps
signaling
that
you
are
in
danger,
no
amount
of
insight
will
silence
it.
I
am
reminded
of
the
comedy
in
which
a
seven-time
recidivist
in
an
anger-
management
program
extols
the
virtue
of
the
techniques
he’s
learned:
“They
are
great
and
work
terrific—as
long
as
you
are
not
really
angry.”
When
our
emotional
and
rational
brains
are
in
conflict
(as
when
we’re
enraged
with
someone
we
love,
frightened
by
someone
we
depend
on,
or
lust
after
someone
who
is
off
limits),
a
tug-of-war
ensues.
This
war
is
largely
played
out
in
the
theater
of
visceral
experience—your
gut,
your
heart,
your
lungs—and
will
lead
to
both
physical
discomfort
and
psychological
misery.
Chapter
6
will
discuss
how
the
brain
and
viscera
interact
in
safety
and
danger,
which
is
key
to
understanding
the
many
physical
manifestations
of
trauma.
I’d
like
to
end
this
chapter
by
examining
two
more
brain
scans
that
illustrate
some
of
the
core
features
of
traumatic
stress:
timeless
reliving;
reexperiencing
images,
sounds,
and
emotions;
and
dissociation.

STAN
AND
UTE’S
BRAINS
ON
TRAUMA
On
a
fine
September
morning
in
1999,
Stan
and
Ute
Lawrence,
a
professional
couple
in
their
forties,
set
out
from
their
home
in
London,
Ontario,
to
attend
a
business
meeting
in
Detroit.
Halfway
through
the
journey
they
ran
into
a
wall
of
dense
fog
that
reduced
visibility
to
zero
in
a
split
second.
Stan
immediately
slammed
on
the
brakes,
coming
to
a
standstill
sideways
on
the
highway,
just
missing
a
huge
truck.
An
eighteen-
wheeler
went
flying
over
the
trunk
of
their
car;
vans
and
cars
slammed
into
them
and
into
each
other.
People
who
got
out
of
their
cars
were
hit
as
they
ran
for
their
lives.
The
ear-splitting
crashes
went
on
and
on—with
each
jolt
from
behind
they
felt
this
would
be
the
one
that
killed
them.
Stan
and
Ute
were
trapped
in
car
number
thirteen
of
an
eighty-seven-car
pileup,
the
worst
road
disaster
in
Canadian
history.15
Then
came
the
eerie
silence.
Stan
struggled
to
open
the
doors
and
windows,
but
the
eighteen-wheeler
that
had
crushed
their
trunk
was
wedged
against
the
car.
Suddenly,
someone
was
pounding
on
their
roof.
A
girl
was
screaming,
“Get
me
out
of
here—I’m
on
fire!”
Helplessly,
they
saw
her
die
as
the
car
she’d
been
in
was
consumed
by
flames.
The
next
thing
they
knew,
a
truck
driver
was
standing
on
the
hood
of
their
car
with
a
fire
extinguisher.
He
smashed
the
windshield
to
free
them,
and
Stan
climbed
through
the
opening.
Turning
around
to
help
his
wife,
he
saw
Ute
sitting
frozen
in
her
seat.
Stan
and
the
truck
driver
lifted
her
out
and
an
ambulance
took
them
to
an
emergency
room.
Aside
from
a
few
cuts,
they
were
found
to
be
physically
unscathed.
At
home
that
night,
neither
Stan
nor
Ute
wanted
to
go
to
sleep.
They
felt
that
if
they
let
go,
they
would
die.
They
were
irritable,
jumpy,
and
on
edge.
That
night,
and
for
many
to
come,
they
drank
copious
quantities
of
wine
to
numb
their
fear.
They
could
not
stop
the
images
that
were
haunting
them
or
the
questions
that
went
on
and
on:
What
if
they’d
left
earlier?
What
if
they
hadn’t
stopped
for
gas?
After
three
months
of
this,
they
sought
help
from
Dr.
Ruth
Lanius,
a
psychiatrist
at
the
University
of
Western
Ontario.
Dr.
Lanius,
who
had
been
my
student
at
the
Trauma
Center
a
few
years
earlier,
told
Stan
and
Ute
she
wanted
to
visualize
their
brains
with
an
fMRI
scan
before
beginning
treatment.
The
fMRI
measures
neural
activity
by
tracking
changes
in
blood
flow
in
the
brain,
and
unlike
the
PET
scan,
it
does
not
require
exposure
to
radiation.
Dr.
Lanius
used
the
same
kind
of
script-
driven
imagery
we
had
used
at
Harvard,
capturing
the
images,
sounds,
smells,
and
other
sensations
Stan
and
Ute
had
experienced
while
they
were
trapped
in
the
car.
Stan
went
first
and
immediately
went
into
a
flashback,
just
as
Marsha
had
in
our
Harvard
study.
He
came
out
of
the
scanner
sweating,
with
his
heart
racing
and
his
blood
pressure
sky
high.
“This
was
just
the
way
I
felt
during
the
accident,”
he
reported.
“I
was
sure
I
was
going
to
die,
and
there
was
nothing
I
could
do
to
save
myself.”
Instead
of
remembering
the
accident
as
something
that
had
happened
three
months
earlier,
Stan
was
reliving
it.
DISSOCIATION
AND
RELIVING
Dissociation
is
the
essence
of
trauma.
The
overwhelming
experience
is
split
off
and
fragmented,
so
that
the
emotions,
sounds,
images,
thoughts,
and
physical
sensations
related
to
the
trauma
take
on
a
life
of
their
own.
The
sensory
fragments
of
memory
intrude
into
the
present,
where
they
are
literally
relived.
As
long
as
the
trauma
is
not
resolved,
the
stress
hormones
that
the
body
secretes
to
protect
itself
keep
circulating,
and
the
defensive
movements
and
emotional
responses
keep
getting
replayed.
Unlike
Stan,
however,
many
people
may
not
be
aware
of
the
connection
between
their
“crazy”
feelings
and
reactions
and
the
traumatic
events
that
are
being
replayed.
They
have
no
idea
why
they
respond
to
some
minor
irritation
as
if
they
were
about
to
be
annihilated.
Flashbacks
and
reliving
are
in
some
ways
worse
that
the
trauma
itself.
A
traumatic
event
has
a
beginning
and
an
end—at
some
point
it
is
over.
But
for
people
with
PTSD
a
flashback
can
occur
at
any
time,
whether
they
are
awake
or
asleep.
There
is
no
way
of
knowing
when
it’s
going
to
occur
again
or
how
long
it
will
last.
People
who
suffer
from
flashbacks
often
organize
their
lives
around
trying
to
protect
against
them.
They
may
compulsively
go
to
the
gym
to
pump
iron
(but
finding
that
they
are
never
strong
enough),
numb
themselves
with
drugs,
or
try
to
cultivate
an
illusory
sense
of
control
in
highly
dangerous
situations
(like
motorcycle
racing,
bungee
jumping,
or
working
as
an
ambulance
driver).
Constantly
fighting
unseen
dangers
is
exhausting
and
leaves
them
fatigued,
depressed,
and
weary.
If
elements
of
the
trauma
are
replayed
again
and
again,
the
accompanying
stress
hormones
engrave
those
memories
ever
more
deeply
in
the
mind.
Ordinary,
day-to-day
events
become
less
and
less
compelling.
Not
being
able
to
deeply
take
in
what
is
going
on
around
them
makes
it
impossible
to
feel
fully
alive.
It
becomes
harder
to
feel
the
joys
and
aggravations
of
ordinary
life,
harder
to
concentrate
on
the
tasks
at
hand.
Not
being
fully
alive
in
the
present
keeps
them
more
firmly
imprisoned
in
the
past.
Triggered
responses
manifest
in
various
ways.
Veterans
may
react
to
the
slightest
cue—like
hitting
a
bump
in
the
road
or
a
seeing
a
kid
playing
in
the
street—as
if
they
were
in
a
war
zone.
They
startle
easily
and
become
enraged
or
numb.
Victims
of
childhood
sexual
abuse
may
anesthetize
their
sexuality
and
then
feel
intensely
ashamed
if
they
become
excited
by
sensations
or
images
that
recall
their
molestation,
even
when
those
sensations
are
the
natural
pleasures
associated
with
particular
body
parts.
If
trauma
survivors
are
forced
to
discuss
their
experiences,
one
person’s
blood
pressure
may
increase
while
another
responds
with
the
beginnings
of
a
migraine
headache.
Still
others
may
shut
down
emotionally
and
not
feel
any
obvious
changes.
However,
in
the
lab
we
have
no
problem
detecting
their
racing
hearts
and
the
stress
hormones
churning
through
their
bodies.
These
reactions
are
irrational
and
largely
outside
people’s
control.
Intense
and
barely
controllable
urges
and
emotions
make
people
feel
crazy
—and
makes
them
feel
they
don’t
belong
to
the
human
race.
Feeling
numb
during
birthday
parties
for
your
kids
or
in
response
to
the
death
of
loved
ones
makes
people
feel
like
monsters.
As
a
result,
shame
becomes
the
dominant
emotion
and
hiding
the
truth
the
central
preoccupation.
They
are
rarely
in
touch
with
the
origins
of
their
alienation.
That
is
where
therapy
comes
in—is
the
beginning
of
bringing
the
emotions
that
were
generated
by
trauma
being
able
to
feel,
the
capacity
to
observe
oneself
online.
However,
the
bottom
line
is
that
the
threat-perception
system
of
the
brain
has
changed,
and
people’s
physical
reactions
are
dictated
by
the
imprint
of
the
past.
The
trauma
that
started
“out
there”
is
now
played
out
on
the
battlefield
of
their
own
bodies,
usually
without
a
conscious
connection
between
what
happened
back
then
and
what
is
going
on
right
now
inside.
The
challenge
is
not
so
much
learning
to
accept
the
terrible
things
that
have
happened
but
learning
how
to
gain
mastery
over
one’s
internal
sensations
and
emotions.
Sensing,
naming,
and
identifying
what
is
going
on
inside
is
the
first
step
to
recovery.

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

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

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

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

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

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

Blanking
out
(dissociation)
in
response
to
being
reminded
of
past
trauma.
In
this
case
almost
every
area
of
the
brain
has
decreased
activation,
interfering
with
thinking,
focus,
and
orientation.
 The
medical
term
for
Ute’s
response
is
depersonalization.18
Anyone
who
deals
with
traumatized
men,
women,
or
children
is
sooner
or
later
confronted
with
blank
stares
and
absent
minds,
the
outward
manifestation
of
the
biological
freeze
reaction.
Depersonalization
is
one
symptom
of
the
massive
dissociation
created
by
trauma.
Stan’s
flashbacks
came
from
his
thwarted
efforts
to
escape
the
crash—cued
by
the
script,
all
his
dissociated,
fragmented
sensations
and
emotions
roared
back
into
the
present.
But
instead
of
struggling
to
escape,
Ute
had
dissociated
her
fear
and
felt
nothing.
I
see
depersonalization
regularly
in
my
office
when
patients
tell
me
horrendous
stories
without
any
feeling.
All
the
energy
drains
out
of
the
room,
and
I
have
to
make
a
valiant
effort
to
keep
paying
attention.
A
lifeless
patient
forces
you
to
work
much
harder
to
keep
the
therapy
alive,
and
I
often
used
to
pray
for
the
hour
to
be
over
quickly.
After
seeing
Ute’s
scan,
I
started
to
take
a
very
different
approach
toward
blanked-out
patients.
With
nearly
every
part
of
their
brains
tuned
out,
they
obviously
cannot
think,
feel
deeply,
remember,
or
make
sense
out
of
what
is
going
on.
Conventional
talk
therapy,
in
those
circumstances,
is
virtually
useless.
In
Ute’s
case
it
was
possible
to
guess
why
she
responded
so
differently
from
Stan.
She
was
utilizing
a
survival
strategy
her
brain
had
learned
in
childhood
to
cope
with
her
mother’s
harsh
treatment.
Ute’s
father
died
when
she
was
nine
years
old,
and
her
mother
subsequently
was
often
nasty
and
demeaning
to
her.
At
some
point
Ute
discovered
that
she
could
blank
out
her
mind
when
her
mother
yelled
at
her.
Thirty-five
years
later,
when
she
was
trapped
in
her
demolished
car,
Ute’s
brain
automatically
went
into
the
same
survival
mode—she
made
herself
disappear.
The
challenge
for
people
like
Ute
is
to
become
alert
and
engaged,
a
difficult
but
unavoidable
task
if
they
want
to
recapture
their
lives.
(Ute
herself
did
recover—she
wrote
a
book
about
her
experiences
and
started
a
successful
journal
called
Mental
Fitness.)
This
is
where
a
bottom-up
approach
to
therapy
becomes
essential.
The
aim
is
actually
to
change
the
patient’s
physiology,
his
or
her
relationship
to
bodily
sensations.
At
the
Trauma
Center
we
work
with
such
basic
measures
as
heart
rate
and
breathing
patterns.
We
help
patients
evoke
and
notice
bodily
sensations
by
tapping
acupressure19
points.
Rhythmic
interactions
with
other
people
are
also
effective—tossing
a
beach
ball
back
and
forth,
bouncing
on
a
Pilates
ball,
drumming,
or
dancing
to
music.
Numbing
is
the
other
side
of
the
coin
in
PTSD.
Many
untreated
trauma
survivors
start
out
like
Stan,
with
explosive
flashbacks,
then
numb
out
later
in
life.
While
reliving
trauma
is
dramatic,
frightening,
and
potentially
self-
destructive,
over
time
a
lack
of
presence
can
be
even
more
damaging.
This
is
a
particular
problem
with
traumatized
children.
The
acting-out
kids
tend
to
get
attention;
the
blanked-out
ones
don’t
bother
anybody
and
are
left
to
lose
their
future
bit
by
bit.

LEARNING
TO
LIVE
IN
THE
PRESENT
The
challenge
of
trauma
treatment
is
not
only
dealing
with
the
past
but,
even
more,
enhancing
the
quality
of
day-to-day
experience.
One
reason
that
traumatic
memories
become
dominant
in
PTSD
is
that
it’s
so
difficult
to
feel
truly
alive
right
now.
When
you
can’t
be
fully
here,
you
go
to
the
places
where
you
did
feel
alive—even
if
those
places
are
filled
with
horror
and
misery.
Many
treatment
approaches
for
traumatic
stress
focus
on
desensitizing
patients
to
their
past,
with
the
expectation
that
reexposure
to
their
traumas
will
reduce
emotional
outbursts
and
flashbacks.
I
believe
that
this
is
based
on
a
misunderstanding
of
what
happens
in
traumatic
stress.
We
must
most
of
all
help
our
patients
to
live
fully
and
securely
in
the
present.
In
order
to
do
that,
we
need
to
help
bring
those
brain
structures
that
deserted
them
when
they
were
overwhelmed
by
trauma
back.
Desensitization
may
make
you
less
reactive,
but
if
you
cannot
feel
satisfaction
in
ordinary
everyday
things
like
taking
a
walk,
cooking
a
meal,
or
playing
with
your
kids,
life
will
pass
you
by.
 CHAPTER
5

BODY-BRAIN
CONNECTIONS

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

T oward
the
end
of
his
career,
in
1872,
Charles
Darwin
published
The
Expression
of
the
Emotions
in
Man
and
Animals.1
Until
recently
most
scientific
discussion
of
Darwin’s
theories
has
focused
on
On
the
Origin
of
Species
(1859)
and
The
Descent
of
Man
(1871).
But
The
Expression
of
the
Emotions
turns
out
to
be
an
extraordinary
exploration
of
the
foundations
of
emotional
life,
filled
with
observations
and
anecdotes
drawn
from
decades
of
inquiry,
as
well
as
close-to-home
stories
of
Darwin’s
children
and
household
pets.
It’s
also
a
landmark
in
book
illustration—one
of
the
first
books
ever
to
include
photographs.
(Photography
was
still
a
relatively
new
technology
and,
like
most
scientists,
Darwin
wanted
to
make
use
of
the
latest
techniques
to
make
his
points.)
It’s
still
in
print
today,
readily
available
in
a
recent
edition
with
a
terrific
introduction
and
commentaries
by
Paul
Ekman,
a
modern
pioneer
in
the
study
of
emotions.
Darwin
starts
his
discussion
by
noting
the
physical
organization
common
to
all
mammals,
including
human
beings—the
lungs,
kidneys,
brains,
digestive
organs,
and
sexual
organs
that
sustain
and
continue
life.
Although
many
scientists
today
would
accuse
him
of
anthropomorphism,
Darwin
stands
with
animal
lovers
when
he
proclaims:
“Man
and
the
higher
animals . . .
[also]
have
instincts
in
common.
All
have
the
same
senses,
intuition,
sensation,
passions,
affections,
and
emotions,
even
the
more
complex
ones
such
as
jealousy,
suspicion,
emulation,
gratitude,
and
magnanimity.”2
He
observes
that
we
humans
share
some
of
the
physical
signs
of
animal
emotion.
Feeling
the
hair
on
the
back
of
your
neck
stand
up
when
you’re
frightened
or
baring
your
teeth
when
you’re
enraged
can
only
be
understood
as
vestiges
of
a
long
evolutionary
process.
 “When
a
man
sneers
or
snarls
at
another,
is
the
corner
of
the
canine
or
eye
tooth
raised
on
the
side
facing
the
man
whom
he
addresses?”
—Charles
Darwin,
1872

For
Darwin
mammalian
emotions
are
fundamentally
rooted
in
biology:
They
are
the
indispensable
source
of
motivation
to
initiate
action.
Emotions
(from
the
Latin
emovere—to
move
out)
give
shape
and
direction
to
whatever
we
do,
and
their
primary
expression
is
through
the
muscles
of
the
face
and
body.
These
facial
and
physical
movements
communicate
our
mental
state
and
intention
to
others:
Angry
expressions
and
threatening
postures
caution
them
to
back
off.
Sadness
attracts
care
and
attention.
Fear
signals
helplessness
or
alerts
us
to
danger.
We
instinctively
read
the
dynamic
between
two
people
simply
from
their
tension
or
relaxation,
their
postures
and
tone
of
voice,
their
changing
facial
expressions.
Watch
a
movie
in
a
language
you
don’t
know,
and
you
can
still
guess
the
quality
of
the
relationship
between
the
characters.
We
often
can
read
other
mammals
(monkeys,
dogs,
horses)
in
the
same
way.
Darwin
goes
on
to
observe
that
the
fundamental
purpose
of
emotions
is
to
initiate
movement
that
will
restore
the
organism
to
safety
and
physical
equilibrium.
Here
is
his
comment
on
the
origin
of
what
today
we
would
call
PTSD:
 Behaviors
to
avoid
or
escape
from
danger
have
clearly
evolved
to
render
each
organism
competitive
in
terms
of
survival.
But
inappropriately
prolonged
escape
or
avoidance
behavior
would
put
the
animal
at
a
disadvantage
in
that
successful
species
preservation
demands
reproduction
which,
in
turn,
depends
upon
feeding,
shelter
and
mating
activities
all
of
which
are
reciprocals
of
avoidance
and
escape.3

In
other
words:
If
an
organism
is
stuck
in
survival
mode,
its
energies
are
focused
on
fighting
off
unseen
enemies,
which
leaves
no
room
for
nurture,
care,
and
love.
For
us
humans,
it
means
that
as
long
as
the
mind
is
defending
itself
against
invisible
assaults,
our
closest
bonds
are
threatened,
along
with
our
ability
to
imagine,
plan,
play,
learn,
and
pay
attention
to
other
people’s
needs.
Darwin
also
wrote
about
body-brain
connections
that
we
are
still
exploring
today.
Intense
emotions
involve
not
only
the
mind
but
also
the
gut
and
the
heart:
“Heart,
guts,
and
brain
communicate
intimately
via
the
‘pneumogastric’
nerve,
the
critical
nerve
involved
in
the
expression
and
management
of
emotions
in
both
humans
and
animals.
When
the
mind
is
strongly
excited,
it
instantly
affects
the
state
of
the
viscera;
so
that
under
excitement
there
will
be
much
mutual
action
and
reaction
between
these,
the
two
most
important
organs
of
the
body.”4
The
first
time
I
encountered
this
passage,
I
reread
it
with
growing
excitement.
Of
course
we
experience
our
most
devastating
emotions
as
gut-
wrenching
feelings
and
heartbreak.
As
long
as
we
register
emotions
primarily
in
our
heads,
we
can
remain
pretty
much
in
control,
but
feeling
as
if
our
chest
is
caving
in
or
we’ve
been
punched
in
the
gut
is
unbearable.
We’ll
do
anything
to
make
these
awful
visceral
sensations
go
away,
whether
it
is
clinging
desperately
to
another
human
being,
rendering
ourselves
insensible
with
drugs
or
alcohol,
or
taking
a
knife
to
the
skin
to
replace
overwhelming
emotions
with
definable
sensations.
How
many
mental
health
problems,
from
drug
addiction
to
self-injurious
behavior,
start
as
attempts
to
cope
with
the
unbearable
physical
pain
of
our
emotions?
If
Darwin
was
right,
the
solution
requires
finding
ways
to
help
people
alter
the
inner
sensory
landscape
of
their
bodies.
Until
recently,
this
bidirectional
communication
between
body
and
mind
was
largely
ignored
by
Western
science,
even
as
it
had
long
been
central
to
traditional
healing
practices
in
many
other
parts
of
the
world,
notably
in
India
and
China.
Today
it
is
transforming
our
understanding
of
trauma
and
recovery.

A
WINDOW
INTO
THE
NERVOUS
SYSTEM
All
of
the
little
signs
we
instinctively
register
during
a
conversation—the
muscle
shifts
and
tensions
in
the
other
person’s
face,
eye
movements
and
pupil
dilation,
pitch
and
speed
of
the
voice—as
well
as
the
fluctuations
in
our
own
inner
landscape—salivation,
swallowing,
breathing,
and
heart
rate
—are
linked
by
a
single
regulatory
system.5
All
are
a
product
of
the
synchrony
between
the
two
branches
of
the
autonomic
nervous
system
(ANS):
the
sympathetic,
which
acts
as
the
body’s
accelerator,
and
the
parasympathetic,
which
serves
as
its
brake.6
These
are
the
“reciprocals”
Darwin
spoke
of,
and
working
together
they
play
an
important
role
in
managing
the
body’s
energy
flow,
one
preparing
for
its
expenditure,
the
other
for
its
conservation.
The
sympathetic
nervous
system
(SNS)
is
responsible
for
arousal,
including
the
fight-or-flight
response
(Darwin’s
“escape
or
avoidance
behavior”).
Almost
two
thousand
years
ago
the
Roman
physician
Galen
gave
it
the
name
“sympathetic”
because
he
observed
that
it
functioned
with
the
emotions
(sym
pathos).
The
SNS
moves
blood
to
the
muscles
for
quick
action,
partly
by
triggering
the
adrenal
glands
to
squirt
out
adrenaline,
which
speeds
up
the
heart
rate
and
increases
blood
pressure.
The
second
branch
of
the
ANS
is
the
parasympathetic
(“against
emotions”)
nervous
system
(PNS),
which
promotes
self-preservative
functions
like
digestion
and
wound
healing.
It
triggers
the
release
of
acetylcholine
to
put
a
brake
on
arousal,
slowing
the
heart
down,
relaxing
muscles,
and
returning
breathing
to
normal.
As
Darwin
pointed
out,
“feeding,
shelter,
and
mating
activities”
depend
on
the
PNS.
There
is
a
simple
way
to
experience
these
two
systems
for
yourself.
Whenever
you
take
a
deep
breath,
you
activate
the
SNS.
The
resulting
burst
of
adrenaline
speeds
up
your
heart,
which
explains
why
many
athletes
take
a
few
short,
deep
breaths
before
starting
competition.
Exhaling,
in
turn,
activates
the
PNS,
which
slows
down
the
heart.
If
you
take
a
yoga
or
a
meditation
class,
your
instructor
will
probably
urge
you
to
pay
particular
attention
to
the
exhalation,
since
deep,
long
breaths
out
help
calm
you
down.
As
we
breathe,
we
continually
speed
up
and
slow
down
the
heart,
and
because
of
that
the
interval
between
two
successive
heartbeats
is
never
precisely
the
same.
A
measurement
called
heart
rate
variability
(HRV)
can
be
used
to
test
the
flexibility
of
this
system,
and
good
HRV—the
more
fluctuation,
the
better—is
a
sign
that
the
brake
and
accelerator
in
your
arousal
system
are
both
functioning
properly
and
in
balance.
We
had
a
breakthrough
when
we
acquired
an
instrument
to
measure
HRV,
and
I
will
explain
in
chapter
16
how
we
can
use
HRV
to
help
treat
PTSD.

THE
NEURAL
LOVE
CODE7
In
1994
Stephen
Porges,
who
was
a
researcher
at
the
University
of
Maryland
at
the
time
we
started
our
investigation
of
HRV,
and
who
is
now
at
the
University
of
North
Carolina,
introduced
the
Polyvagal
Theory,
which
built
on
Darwin’s
observations
and
added
another
140
years
of
scientific
discoveries
to
those
early
insights.
(Polyvagal
refers
to
the
many
branches
of
the
vagus
nerve—Darwin’s
“pneumogastric
nerve”—which
connects
numerous
organs,
including
the
brain,
lungs,
heart,
stomach,
and
intestines.)
The
Polyvagal
Theory
provided
us
with
a
more
sophisticated
understanding
of
the
biology
of
safety
and
danger,
one
based
on
the
subtle
interplay
between
the
visceral
experiences
of
our
own
bodies
and
the
voices
and
faces
of
the
people
around
us.
It
explained
why
a
kind
face
or
a
soothing
tone
of
voice
can
dramatically
alter
the
way
we
feel.
It
clarified
why
knowing
that
we
are
seen
and
heard
by
the
important
people
in
our
lives
can
make
us
feel
calm
and
safe,
and
why
being
ignored
or
dismissed
can
precipitate
rage
reactions
or
mental
collapse.
It
helped
us
understand
why
focused
attunement
with
another
person
can
shift
us
out
of
disorganized
and
fearful
states.8
In
short,
Porges’s
theory
made
us
look
beyond
the
effects
of
fight
or
flight
and
put
social
relationships
front
and
center
in
our
understanding
of
trauma.
It
also
suggested
new
approaches
to
healing
that
focus
on
strengthening
the
body’s
system
for
regulating
arousal.
Human
beings
are
astoundingly
attuned
to
subtle
emotional
shifts
in
the
people
(and
animals)
around
them.
Slight
changes
in
the
tension
of
the
brow,
wrinkles
around
the
eyes,
curvature
of
the
lips,
and
angle
of
the
neck
quickly
signal
to
us
how
comfortable,
suspicious,
relaxed,
or
frightened
someone
is.9
Our
mirror
neurons
register
their
inner
experience,
and
our
own
bodies
make
internal
adjustments
to
whatever
we
notice.
Just
so,
the
muscles
of
our
own
faces
give
others
clues
about
how
calm
or
excited
we
feel,
whether
our
heart
is
racing
or
quiet,
and
whether
we’re
ready
to
pounce
on
them
or
run
away.
When
the
message
we
receive
from
another
person
is
“You’re
safe
with
me,”
we
relax.
If
we’re
lucky
in
our
relationships,
we
also
feel
nourished,
supported,
and
restored
as
we
look
into
the
face
and
eyes
of
the
other.
Our
culture
teaches
us
to
focus
on
personal
uniqueness,
but
at
a
deeper
level
we
barely
exist
as
individual
organisms.
Our
brains
are
built
to
help
us
function
as
members
of
a
tribe.
We
are
part
of
that
tribe
even
when
we
are
by
ourselves,
whether
listening
to
music
(that
other
people
created),
watching
a
basketball
game
on
television
(our
own
muscles
tensing
as
the
players
run
and
jump),
or
preparing
a
spreadsheet
for
a
sales
meeting
(anticipating
the
boss’s
reactions).
Most
of
our
energy
is
devoted
to
connecting
with
others.
If
we
look
beyond
the
list
of
specific
symptoms
that
entail
formal
psychiatric
diagnoses,
we
find
that
almost
all
mental
suffering
involves
either
trouble
in
creating
workable
and
satisfying
relationships
or
difficulties
in
regulating
arousal
(as
in
the
case
of
habitually
becoming
enraged,
shut
down,
overexcited,
or
disorganized).
Usually
it’s
a
combination
of
both.
The
standard
medical
focus
on
trying
to
discover
the
right
drug
to
treat
a
particular
“disorder”
tends
to
distract
us
from
grappling
with
how
our
problems
interfere
with
our
functioning
as
members
of
our
tribe.

SAFETY
AND
RECIPROCITY
A
few
years
ago
I
heard
Jerome
Kagan,
a
distinguished
emeritus
professor
of
child
psychology
at
Harvard,
say
to
the
Dalai
Lama
that
for
every
act
of
cruelty
in
this
world
there
are
hundreds
of
small
acts
of
kindness
and
connection.
His
conclusion:
“To
be
benevolent
rather
than
malevolent
is
probably
a
true
feature
of
our
species.”
Being
able
to
feel
safe
with
other
people
is
probably
the
single
most
important
aspect
of
mental
health;
safe
connections
are
fundamental
to
meaningful
and
satisfying
lives.
Numerous
studies
of
disaster
response
around
the
globe
have
shown
that
social
support
is
the
most
powerful
protection
against
becoming
overwhelmed
by
stress
and
trauma.
Social
support
is
not
the
same
as
merely
being
in
the
presence
of
others.
The
critical
issue
is
reciprocity:
being
truly
heard
and
seen
by
the
people
around
us,
feeling
that
we
are
held
in
someone
else’s
mind
and
heart.
For
our
physiology
to
calm
down,
heal,
and
grow
we
need
a
visceral
feeling
of
safety.
No
doctor
can
write
a
prescription
for
friendship
and
love:
These
are
complex
and
hard-earned
capacities.
You
don’t
need
a
history
of
trauma
to
feel
self-conscious
and
even
panicked
at
a
party
with
strangers—but
trauma
can
turn
the
whole
world
into
a
gathering
of
aliens.
Many
traumatized
people
find
themselves
chronically
out
of
sync
with
the
people
around
them.
Some
find
comfort
in
groups
where
they
can
replay
their
combat
experiences,
rape,
or
torture
with
others
who
have
similar
backgrounds
or
experiences.
Focusing
on
a
shared
history
of
trauma
and
victimization
alleviates
their
searing
sense
of
isolation,
but
usually
at
the
price
of
having
to
deny
their
individual
differences:
Members
can
belong
only
if
they
conform
to
the
common
code.
Isolating
oneself
into
a
narrowly
defined
victim
group
promotes
a
view
of
others
as
irrelevant
at
best
and
dangerous
at
worst,
which
eventually
only
leads
to
further
alienation.
Gangs,
extremist
political
parties,
and
religious
cults
may
provide
solace,
but
they
rarely
foster
the
mental
flexibility
needed
to
be
fully
open
to
what
life
has
to
offer
and
as
such
cannot
liberate
their
members
from
their
traumas.
Well-functioning
people
are
able
to
accept
individual
differences
and
acknowledge
the
humanity
of
others.
In
the
past
two
decades
it
has
become
widely
recognized
that
when
adults
or
children
are
too
skittish
or
shut
down
to
derive
comfort
from
human
beings,
relationships
with
other
mammals
can
help.
Dogs
and
horses
and
even
dolphins
offer
less
complicated
companionship
while
providing
the
necessary
sense
of
safety.
Dogs
and
horses,
in
particular,
are
now
extensively
used
to
treat
some
groups
of
trauma
patients.10

THREE
LEVELS
OF
SAFETY
After
trauma
the
world
is
experienced
with
a
different
nervous
system
that
has
an
altered
perception
of
risk
and
safety.
Porges
coined
the
word
“neuroception”
to
describe
the
capacity
to
evaluate
relative
danger
and
safety
in
one’s
environment.
When
we
try
to
help
people
with
faulty
neuroception,
the
great
challenge
is
finding
ways
to
reset
their
physiology,
so
that
their
survival
mechanisms
stop
working
against
them.
This
means
helping
them
to
respond
appropriately
to
danger
but,
even
more,
to
recover
the
capacity
to
experience
safety,
relaxation,
and
true
reciprocity.
I
have
extensively
interviewed
and
treated
six
people
who
survived
plane
crashes.
Two
reported
having
lost
consciousness
during
the
incident;
even
though
they
were
not
physically
injured,
they
collapsed
mentally.
Two
went
into
a
panic
and
stayed
frantic
until
well
after
we
had
started
treatment.
Two
remained
calm
and
resourceful
and
helped
evacuate
fellow
passengers
from
the
burning
wreckage.
I’ve
found
a
similar
range
of
responses
in
survivors
of
rape,
car
crashes,
and
torture.
In
the
previous
chapter
we
saw
the
radically
different
reactions
of
Stan
and
Ute
as
they
relived
the
highway
disaster
they’d
experienced
side
by
side.
What
accounts
for
this
spectrum
of
responses:
focused,
collapsed,
or
frantic?
Porges’s
theory
provides
an
explanation:
The
autonomic
nervous
system
regulates
three
fundamental
physiological
states.
The
level
of
safety
determines
which
one
of
these
is
activated
at
any
particular
time.
Whenever
we
feel
threatened,
we
instinctively
turn
to
the
first
level,
social
engagement.
We
call
out
for
help,
support,
and
comfort
from
the
people
around
us.
But
if
no
one
comes
to
our
aid,
or
we’re
in
immediate
danger,
the
organism
reverts
to
a
more
primitive
way
to
survive:
fight
or
flight.
We
fight
off
our
attacker,
or
we
run
to
a
safe
place.
However,
if
this
fails—we
can’t
get
away,
we’re
held
down
or
trapped—the
organism
tries
to
preserve
itself
by
shutting
down
and
expending
as
little
energy
as
possible.
We
are
then
in
a
state
of
freeze
or
collapse.
This
is
where
the
many-branched
vagus
nerve
comes
in,
and
I’ll
describe
its
anatomy
briefly
because
it’s
central
to
understanding
how
people
deal
with
trauma.
The
social-engagement
system
depends
on
nerves
that
have
their
origin
in
the
brain
stem
regulatory
centers,
primarily
the
vagus—also
known
as
the
tenth
cranial
nerve—together
with
adjoining
nerves
that
activate
the
muscles
of
the
face,
throat,
middle
ear,
and
voice
box
or
larynx.
When
the
“ventral
vagal
complex”
(VVC)
runs
the
show,
we
smile
when
others
smile
at
us,
we
nod
our
heads
when
we
agree,
and
we
frown
when
friends
tell
us
of
their
misfortunes.
When
the
VVC
is
engaged,
it
also
sends
signals
down
to
our
heart
and
lungs,
slowing
down
our
heart
rate
and
increasing
the
depth
of
breathing.
As
a
result,
we
feel
calm
and
relaxed,
centered,
or
pleasurably
aroused.

The
many-branched
vagus.
The
vagus
nerve
(which
Darwin
called
the
pneumogastric
nerve)
registers
heartbreak
and
gut-wrenching
feelings.
When
a
person
becomes
upset,
the
throat
gets
dry,
the
voice
becomes
tense,
the
heart
speeds
up,
and
respiration
becomes
rapid
and
shallow.
 COURTESY
OF
NED
KALIN,
MD
Three
responses
to
threat.
1.
The
social
engagement
system:
an
alarmed
monkey
signals
danger
and
calls
for
help.
VVC.
2.
Fight
or
flight:
Teeth
bared,
the
face
of
rage
and
terror.
SNS.
3.
Collapse:
The
body
signals
defeat
and
withdraws.
DVC.

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

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

HOW
WE
BECOME
HUMAN
In
Porges’s
grand
theory
the
VVC
evolved
in
mammals
to
support
an
increasingly
complex
social
life.
All
mammals,
including
human
beings,
band
together
to
mate,
nurture
their
young,
defend
against
common
enemies,
and
coordinate
hunting
and
food
acquisition.
The
more
efficiently
the
VVC
synchronizes
the
activity
of
the
sympathetic
and
parasympathetic
nervous
systems,
the
better
the
physiology
of
each
individual
will
be
attuned
to
that
of
other
members
of
the
tribe.
Thinking
about
the
VVC
in
this
way
illuminates
how
parents
naturally
help
their
kids
to
regulate
themselves.
Newborn
babies
are
not
very
social;
they
sleep
most
of
the
time
and
wake
up
when
they’re
hungry
or
wet.
After
having
been
fed
they
may
spend
a
little
time
looking
around,
fussing,
or
staring,
but
they
will
soon
be
asleep
again,
following
their
own
internal
rhythms.
Early
in
life
they
are
pretty
much
at
the
mercy
of
the
alternating
tides
of
their
sympathetic
and
parasympathetic
nervous
systems,
and
their
reptilian
brain
runs
most
of
the
show.
But
day
by
day,
as
we
coo
and
smile
and
cluck
at
them,
we
stimulate
the
growth
of
synchronicity
in
the
developing
VVC.
These
interactions
help
to
bring
our
babies’
emotional
arousal
systems
into
sync
with
their
surroundings.
The
VVC
controls
sucking,
swallowing,
facial
expression,
and
the
sounds
produced
by
the
larynx.
When
these
functions
are
stimulated
in
an
infant,
they
are
accompanied
by
a
sense
of
pleasure
and
safety,
which
helps
create
the
foundation
for
all
future
social
behavior.14
As
my
friend
Ed
Tronick
taught
me
a
long
time
ago,
the
brain
is
a
cultural
organ—
experience
shapes
the
brain.
Being
in
tune
with
other
members
of
our
species
via
the
VVC
is
enormously
rewarding.
What
begins
as
the
attuned
play
of
mother
and
child
continues
with
the
rhythmicity
of
a
good
basketball
game,
the
synchrony
of
tango
dancing,
and
the
harmony
of
choral
singing
or
playing
a
piece
of
jazz
or
chamber
music—all
of
which
foster
a
deep
sense
of
pleasure
and
connection.
We
can
speak
of
trauma
when
that
system
fails:
when
you
beg
for
your
life,
but
the
assailant
ignores
your
pleas;
when
you
are
a
terrified
child
lying
in
bed,
hearing
your
mother
scream
as
her
boyfriend
beats
her
up;
when
you
see
your
buddy
trapped
under
a
piece
of
metal
that
you’re
not
strong
enough
to
lift;
when
you
want
to
push
away
the
priest
who
is
abusing
you,
but
you’re
afraid
you’ll
be
punished.
Immobilization
is
at
the
root
of
most
traumas.
When
that
occurs
the
DVC
is
likely
to
take
over:
Your
heart
slows
down,
your
breathing
becomes
shallow,
and,
zombielike,
you
lose
touch
with
yourself
and
your
surroundings.
You
dissociate,
faint
and
collapse.
DEFEND
OR
RELAX?
Steve
Porges
helped
me
realize
that
the
natural
state
of
mammals
is
to
be
somewhat
on
guard.
However,
in
order
to
feel
emotionally
close
to
another
human
being,
our
defensive
system
must
temporarily
shut
down.
In
order
to
play,
mate,
and
nurture
our
young,
the
brain
needs
to
turn
off
its
natural
vigilance.
Many
traumatized
individuals
are
too
hypervigilant
to
enjoy
the
ordinary
pleasures
that
life
has
to
offer,
while
others
are
too
numb
to
absorb
new
experiences—or
to
be
alert
to
signs
of
real
danger.
When
the
smoke
detectors
of
the
brain
malfunction,
people
no
longer
run
when
they
should
be
trying
to
escape
or
fight
back
when
they
should
be
defending
themselves.
The
landmark
ACE
(Adverse
Childhood
Experiences)
study,
which
I’ll
discuss
in
more
detail
in
chapter
9,
showed
that
women
who
had
an
early
history
of
abuse
and
neglect
were
seven
times
more
likely
to
be
raped
in
adulthood.
Women
who,
as
children,
had
witnessed
their
mothers
being
assaulted
by
their
partners
had
a
vastly
increased
chance
to
fall
victim
to
domestic
violence.15
Many
people
feel
safe
as
long
as
they
can
limit
their
social
contact
to
superficial
conversations,
but
actual
physical
contact
can
trigger
intense
reactions.
However,
as
Porges
points
out,
achieving
any
sort
of
deep
intimacy—a
close
embrace,
sleeping
with
a
mate,
and
sex—requires
allowing
oneself
to
experience
immobilization
without
fear.16
It
is
especially
challenging
for
traumatized
people
to
discern
when
they
are
actually
safe
and
to
be
able
to
activate
their
defenses
when
they
are
in
danger.
This
requires
having
experiences
that
can
restore
the
sense
of
physical
safety,
a
topic
to
which
we’ll
return
many
times
in
the
chapters
that
follow.

NEW
APPROACHES
TO
TREATMENT
If
we
understand
that
traumatized
children
and
adults
get
stuck
in
fight/flight
or
in
chronic
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.
The
body
keeps
the
score:17
If
the
memory
of
trauma
is
encoded
in
the
viscera,
in
heartbreaking
and
gut-wrenching
emotions,
in
autoimmune
disorders
and
skeletal/muscular
problems,
and
if
mind/brain/visceral
communication
is
the
royal
road
to
emotion
regulation,
this
demands
a
radical
shift
in
our
therapeutic
assumptions.
 CHAPTER
6

LOSING
YOUR
BODY,
LOSING
YOUR
SELF

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

S herry
walked
into
my
office
with
her
shoulders
slumped,
her
chin
nearly
touching
her
chest.
Even
before
we
spoke
a
word,
her
body
was
telling
me
that
she
was
afraid
to
face
the
world.
I
also
noticed
that
her
long
sleeves
only
partially
covered
the
scabs
on
her
forearms.
After
sitting
down,
she
told
me
in
a
high-pitched
monotone
that
she
couldn’t
stop
herself
from
picking
at
the
skin
on
her
arms
and
chest
until
she
bled.
As
far
back
as
Sherry
could
remember,
her
mother
had
run
a
foster
home,
and
their
house
was
often
packed
with
as
many
as
fifteen
strange,
disruptive,
frightened,
and
frightening
kids
who
disappeared
as
suddenly
as
they
arrived.
Sherry
had
grown
up
taking
care
of
these
transient
children,
feeling
that
there
was
no
room
for
her
and
her
needs.
“I
know
I
wasn’t
wanted,”
she
told
me.
“I’m
not
sure
when
I
first
realized
that,
but
I’ve
thought
about
things
that
my
mother
said
to
me,
and
the
signs
were
always
there.
She’d
tell
me,
‘You
know,
I
don’t
think
you
belong
in
this
family.
I
think
they
gave
us
the
wrong
baby.’
And
she’d
say
it
with
a
smile
on
her
face.
But,
of
course,
people
often
pretend
to
joke
when
they
say
something
serious.”
 Over
the
years
our
research
team
has
repeatedly
found
that
chronic
emotional
abuse
and
neglect
can
be
just
as
devastating
as
physical
abuse
and
sexual
molestation.1
Sherry
turned
out
to
be
a
living
example
of
these
findings:
Not
being
seen,
not
being
known,
and
having
nowhere
to
turn
to
feel
safe
is
devastating
at
any
age,
but
it
is
particularly
destructive
for
young
children,
who
are
still
trying
to
find
their
place
in
the
world.
Sherry
had
graduated
from
college,
but
she
now
worked
in
a
joyless
clerical
job,
lived
alone
with
her
cats,
and
had
no
close
friends.
When
I
asked
her
about
men,
she
told
me
that
her
only
“relationship”
had
been
with
a
man
who’d
kidnapped
her
while
she
was
on
a
college
vacation
in
Florida.
He’d
held
her
captive
and
raped
her
repeatedly
for
five
consecutive
days.
She
remembered
having
been
curled
up,
terrified
and
frozen
for
most
of
that
time,
until
she
realized
she
could
try
to
get
away.
She
escaped
by
simply
walking
out
while
he
was
in
the
bathroom.
When
she
called
her
mother
collect
for
help,
her
mother
refused
to
take
the
call.
Sherry
finally
managed
to
get
home
with
assistance
from
a
domestic
violence
shelter.
Sherry
told
me
that
she’d
started
to
pick
at
her
skin
because
it
gave
her
some
relief
from
feeling
numb.
The
physical
sensations
made
her
feel
more
alive
but
also
deeply
ashamed—she
knew
she
was
addicted
to
these
actions
but
could
not
stop
them.
She’d
consulted
many
mental
health
professionals
before
me
and
had
been
questioned
repeatedly
about
her
“suicidal
behavior.”
She’d
also
been
subjected
to
involuntary
hospitalization
by
a
psychiatrist
who
refused
to
treat
her
unless
she
could
promise
that
she
would
never
pick
at
herself
again.
However,
in
my
experience,
patients
who
cut
themselves
or
pick
at
their
skin
like
Sherry,
are
seldom
suicidal
but
are
trying
to
make
themselves
feel
better
in
the
only
way
they
know.
This
is
a
difficult
concept
for
many
people
to
understand.
As
I
discussed
in
the
previous
chapter,
the
most
common
response
to
distress
is
to
seek
out
people
we
like
and
trust
to
help
us
and
give
us
the
courage
to
go
on.
We
may
also
calm
down
by
engaging
in
a
physical
activity
like
biking
or
going
to
the
gym.
We
start
learning
these
ways
of
regulating
our
feelings
from
the
first
moment
someone
feeds
us
when
we’re
hungry,
covers
us
when
we’re
cold,
or
rocks
us
when
we’re
hurt
or
scared.
But
if
no
one
has
ever
looked
at
you
with
loving
eyes
or
broken
out
in
a
smile
when
she
sees
you;
if
no
one
has
rushed
to
help
you
(but
instead
said,
“Stop
crying,
or
I’ll
give
you
something
to
cry
about”),
then
you
need
to
discover
other
ways
of
taking
care
of
yourself.
You
are
likely
to
experiment
with
anything—drugs,
alcohol,
binge
eating,
or
cutting—that
offers
some
kind
of
relief.
While
Sherry
dutifully
came
to
every
appointment
and
answered
my
questions
with
great
sincerity,
I
did
not
feel
we
were
making
the
sort
of
vital
connection
that
is
necessary
for
therapy
to
work.
Struck
by
how
frozen
and
uptight
she
was,
I
suggested
that
she
see
Liz,
a
massage
therapist
I
had
worked
with
previously.
During
their
first
meeting
Liz
positioned
Sherry
on
the
massage
table,
then
moved
to
the
end
of
the
table
and
gently
held
Sherry’s
feet.
Lying
there
with
her
eyes
closed,
Sherry
suddenly
yelled
in
a
panic:
“Where
are
you?”
Somehow
Sherry
had
lost
track
of
Liz,
even
though
Liz
was
right
there,
with
her
hands
on
Sherry’s
feet.
Sherry
was
one
of
the
first
patients
who
taught
me
about
the
extreme
disconnection
from
the
body
that
so
many
people
with
histories
of
trauma
and
neglect
experience.
I
discovered
that
my
professional
training,
with
its
focus
on
understanding
and
insight,
had
largely
ignored
the
relevance
of
the
living,
breathing
body,
the
foundation
of
our
selves.
Sherry
knew
that
picking
her
skin
was
a
destructive
thing
to
do
and
that
it
was
related
to
her
mother’s
neglect,
but
understanding
the
source
of
the
impulse
made
no
difference
in
helping
her
control
it.

LOSING
YOUR
BODY
Once
I
was
alerted
to
this,
I
was
amazed
to
discover
how
many
of
my
patients
told
me
they
could
not
feel
whole
areas
of
their
bodies.
Sometimes
I’d
ask
them
to
close
their
eyes
and
tell
me
what
I
had
put
into
their
outstretched
hands.
Whether
it
was
a
car
key,
a
quarter,
or
a
can
opener,
they
often
could
not
even
guess
what
they
were
holding—their
sensory
perceptions
simply
weren’t
working.
I
talked
this
over
with
my
friend
Alexander
McFarlane
in
Australia,
who
had
observed
the
same
phenomenon.
In
his
laboratory
in
Adelaide
he
had
studied
the
question:
How
do
we
know
without
looking
at
it
that
we’re
holding
a
car
key?
Recognizing
an
object
in
the
palm
of
your
hand
requires
sensing
its
shape,
weight,
temperature,
texture,
and
position.
Each
of
those
distinct
sensory
experiences
is
transmitted
to
a
different
part
of
the
brain,
which
then
needs
to
integrate
them
into
a
single
perception.
McFarlane
found
that
people
with
PTSD
often
have
trouble
putting
the
picture
together.2
When
our
senses
become
muffled,
we
no
longer
feel
fully
alive.
In
an
article
called
“What
Is
an
Emotion?”
(1884),3
William
James,
the
father
of
American
psychology,
reported
a
striking
case
of
“sensory
insensibility”
in
a
woman
he
interviewed:
“I
have . . .
no
human
sensations,”
she
told
him.
“[I
am]
surrounded
by
all
that
can
render
life
happy
and
agreeable,
still
to
me
the
faculty
of
enjoyment
and
of
feeling
is
wanting. . . .
Each
of
my
senses,
each
part
of
my
proper
self,
is
as
it
were
separated
from
me
and
can
no
longer
afford
me
any
feeling;
this
impossibility
seems
to
depend
upon
a
void
which
I
feel
in
the
front
of
my
head,
and
to
be
due
to
the
diminution
of
the
sensibility
over
the
whole
surface
of
my
body,
for
it
seems
to
me
that
I
never
actually
reach
the
objects
which
I
touch.
All
this
would
be
a
small
matter
enough,
but
for
its
frightful
result,
which
is
that
of
the
impossibility
of
any
other
kind
of
feeling
and
of
any
sort
of
enjoyment,
although
I
experience
a
need
and
desire
of
them
that
render
my
life
an
incomprehensible
torture.”
This
response
to
trauma
raises
an
important
question:
How
can
traumatized
people
learn
to
integrate
ordinary
sensory
experiences
so
that
they
can
live
with
the
natural
flow
of
feeling
and
feel
secure
and
complete
in
their
bodies?

HOW
DO
WE
KNOW
WE’RE
ALIVE?
Most
early
neuroimaging
studies
of
traumatized
people
were
like
those
we’ve
seen
in
chapter
3;
they
focused
on
how
subjects
reacted
to
specific
reminders
of
the
trauma.
Then,
in
2004,
my
colleague
Ruth
Lanius,
who
scanned
Stan
and
Ute
Lawrence’s
brains,
posed
a
new
question:
What
happens
in
the
brains
of
trauma
survivors
when
they
are
not
thinking
about
the
past?
Her
studies
on
the
idling
brain,
the
“default
state
network”
(DSN),
opened
up
a
whole
new
chapter
in
understanding
how
trauma
affects
self-
awareness,
specifically
sensory
self-awareness.4
Dr.
Lanius
recruited
a
group
of
sixteen
“normal”
Canadians
to
lie
in
a
brain
scanner
while
thinking
about
nothing
in
particular.
This
is
not
easy
for
anyone
to
do—as
long
as
we
are
awake,
our
brains
are
churning—but
she
asked
them
to
focus
their
attention
on
their
breathing
and
try
to
empty
their
minds
as
much
as
possible.
She
then
repeated
the
same
experiment
with
eighteen
people
who
had
histories
of
severe,
chronic
childhood
abuse.
What
is
your
brain
doing
when
you
have
nothing
in
particular
on
your
mind?
It
turns
out
that
you
pay
attention
to
yourself:
The
default
state
activates
the
brain
areas
that
work
together
to
create
your
sense
of
“self.”
When
Ruth
looked
at
the
scans
of
her
normal
subjects,
she
found
activation
of
DSN
regions
that
previous
researchers
had
described.
I
like
to
call
this
the
Mohawk
of
self-awareness,
the
midline
structures
of
the
brain,
starting
out
right
above
our
eyes,
running
through
the
center
of
the
brain
all
the
way
to
the
back.
All
these
midline
structures
are
involved
in
our
sense
of
self.
The
largest
bright
region
at
the
back
of
the
brain
is
the
posterior
cingulate,
which
gives
us
a
physical
sense
of
where
we
are—our
internal
GPS.
It
is
strongly
connected
to
the
medial
prefrontal
cortex
(MPFC),
the
watchtower
I
discussed
in
chapter
4.
(This
connection
doesn’t
show
up
on
the
scan
because
the
fMRI
can’t
measure
it.)
It
is
also
connected
with
brain
areas
that
register
sensations
coming
from
the
rest
of
the
body:
the
insula,
which
relays
messages
from
the
viscera
to
the
emotional
centers;
the
parietal
lobes,
which
integrate
sensory
information;
and
the
anterior
cingulate,
which
coordinates
emotions
and
thinking.
All
of
these
areas
contribute
to
consciousness.
 Locating
the
self.
The
Mohawk
of
self-awareness.
Starting
from
the
front
of
the
brain
(at
right),
this
consists
of:
the
orbital
prefrontal
cortex,
the
medial
prefrontal
cortex,
the
anterior
cingulate,
the
posterior
cingulate,
and
the
insula.
In
individuals
with
histories
of
chronic
trauma
the
same
regions
show
sharply
decreased
activity,
making
it
difficult
to
register
internal
states
and
assessing
the
personal
relevance
of
incoming
information.

The
contrast
with
the
scans
of
the
eighteen
chronic
PTSD
patients
with
severe
early-life
trauma
was
startling.
There
was
almost
no
activation
of
any
of
the
self-sensing
areas
of
the
brain:
The
MPFC,
the
anterior
cingulate,
the
parietal
cortex,
and
the
insula
did
not
light
up
at
all;
the
only
area
that
showed
a
slight
activation
was
the
posterior
cingulate,
which
is
responsible
for
basic
orientation
in
space.
There
could
be
only
one
explanation
for
such
results:
In
response
to
the
trauma
itself,
and
in
coping
with
the
dread
that
persisted
long
afterward,
these
patients
had
learned
to
shut
down
the
brain
areas
that
transmit
the
visceral
feelings
and
emotions
that
accompany
and
define
terror.
Yet
in
everyday
life,
those
same
brain
areas
are
responsible
for
registering
the
entire
range
of
emotions
and
sensations
that
form
the
foundation
of
our
self-
awareness,
our
sense
of
who
we
are.
What
we
witnessed
here
was
a
tragic
adaptation:
In
an
effort
to
shut
off
terrifying
sensations,
they
also
deadened
their
capacity
to
feel
fully
alive.
The
disappearance
of
medial
prefrontal
activation
could
explain
why
so
many
traumatized
people
lose
their
sense
of
purpose
and
direction.
I
used
to
be
surprised
by
how
often
my
patients
asked
me
for
advice
about
the
most
ordinary
things,
and
then
by
how
rarely
they
followed
it.
Now
I
understood
that
their
relationship
with
their
own
inner
reality
was
impaired.
How
could
they
make
decisions,
or
put
any
plan
into
action,
if
they
couldn’t
define
what
they
wanted
or,
to
be
more
precise,
what
the
sensations
in
their
bodies,
the
basis
of
all
emotions,
were
trying
to
tell
them?
The
lack
of
self-awareness
in
victims
of
chronic
childhood
trauma
is
sometimes
so
profound
that
they
cannot
recognize
themselves
in
a
mirror.
Brain
scans
show
that
this
is
not
the
result
of
mere
inattention:
The
structures
in
charge
of
self-recognition
may
be
knocked
out
along
with
the
structures
related
to
self-experience.
When
Ruth
Lanius
showed
me
her
study,
a
phrase
from
my
classical
high
school
education
came
back
to
me.
The
mathematician
Archimedes,
teaching
about
the
lever,
is
supposed
to
have
said:
“Give
me
a
place
to
stand
and
I
will
move
the
world.”
Or,
as
the
great
twentieth-century
body
therapist
Moshe
Feldenkrais
put
it:
“You
can’t
do
what
you
want
till
you
know
what
you’re
doing.”
The
implications
are
clear:
to
feel
present
you
have
to
know
where
you
are
and
be
aware
of
what
is
going
on
with
you.
If
the
self-sensing
system
breaks
down
we
need
to
find
ways
to
reactivate
it.

THE
SELF-SENSING
SYSTEM
It
was
fascinating
to
see
how
much
Sherry
benefited
from
her
massage
therapy.
She
felt
more
relaxed
and
adventurous
in
her
day-to-day
life
and
she
was
also
more
relaxed
and
open
with
me.
She
became
truly
involved
in
her
therapy
and
was
genuinely
curious
about
her
behavior,
thoughts,
and
feelings.
She
stopped
picking
at
her
skin,
and
when
summer
came
she
started
to
spend
evenings
sitting
outside
on
her
stoop,
chatting
with
her
neighbors.
She
even
joined
a
church
choir,
a
wonderful
experience
of
group
synchrony.
It
was
at
about
this
time
that
I
met
Antonio
Damasio
at
a
small
think
tank
that
Dan
Schacter,
the
chair
of
the
psychology
department
at
Harvard,
had
organized.
In
a
series
of
brilliant
scientific
articles
and
books
Damasio
clarified
the
relationship
among
body
states,
emotions,
and
survival.
A
neurologist
who
has
treated
hundreds
of
people
with
various
forms
of
brain
damage,
he
became
fascinated
with
consciousness
and
with
identifying
the
areas
of
the
brain
necessary
for
knowing
what
you
feel.
He
has
devoted
his
career
to
mapping
out
what
is
responsible
for
our
experience
of
“self.”
The
Feeling
of
What
Happens
is,
for
me,
his
most
important
book,
and
reading
it
was
a
revelation.5
Damasio
starts
by
pointing
out
the
deep
divide
between
our
sense
of
self
and
the
sensory
life
of
our
bodies.
As
he
poetically
explains,
“Sometimes
we
use
our
minds
not
to
discover
facts,
but
to
hide
them. . . .
One
of
the
things
the
screen
hides
most
effectively
is
the
body,
our
own
body,
by
which
I
mean
the
ins
of
it,
its
interiors.
Like
a
veil
thrown
over
the
skin
to
secure
its
modesty,
the
screen
partially
removes
from
the
mind
the
inner
states
of
the
body,
those
that
constitute
the
flow
of
life
as
it
wanders
in
the
journey
of
each
day.”6
He
goes
on
to
describe
how
this
“screen”
can
work
in
our
favor
by
enabling
us
to
attend
to
pressing
problems
in
the
outside
world.
Yet
it
has
a
cost:
“It
tends
to
prevent
us
from
sensing
the
possible
origin
and
nature
of
what
we
call
self.”7
Building
on
the
century-old
work
of
William
James,
Damasio
argues
that
the
core
of
our
self-awareness
rests
on
the
physical
sensations
that
convey
the
inner
states
of
the
body:

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

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

THE
SELF
UNDER
THREAT
In
2000
Damasio
and
his
colleagues
published
an
article
in
the
world’s
foremost
scientific
publication,
Science,
which
reported
that
reliving
a
strong
negative
emotion
causes
significant
changes
in
the
brain
areas
that
receive
nerve
signals
from
the
muscles,
gut,
and
skin—areas
that
are
crucial
for
regulating
basic
bodily
functions.
The
team’s
brain
scans
showed
that
recalling
an
emotional
event
from
the
past
causes
us
to
actually
reexperience
the
visceral
sensations
felt
during
the
original
event.
Each
type
of
emotion
produced
a
characteristic
pattern,
distinct
from
the
others.
For
example,
a
particular
part
of
the
brain
stem
was
“active
in
sadness
and
anger,
but
not
in
happiness
or
fear.”10
All
of
these
brain
regions
are
below
the
limbic
system,
to
which
emotions
are
traditionally
assigned,
yet
we
acknowledge
their
involvement
every
time
we
use
one
of
the
common
expressions
that
link
strong
emotions
with
the
body:
“You
make
me
sick”;
“It
made
my
skin
crawl”;
“I
was
all
choked
up”;
“My
heart
sank”;
“He
makes
me
bristle.”
The
elementary
self
system
in
the
brain
stem
and
limbic
system
is
massively
activated
when
people
are
faced
with
the
threat
of
annihilation,
which
results
in
an
overwhelming
sense
of
fear
and
terror
accompanied
by
intense
physiological
arousal.
To
people
who
are
reliving
a
trauma,
nothing
makes
sense;
they
are
trapped
in
a
life-or-death
situation,
a
state
of
paralyzing
fear
or
blind
rage.
Mind
and
body
are
constantly
aroused,
as
if
they
are
in
imminent
danger.
They
startle
in
response
to
the
slightest
noises
and
are
frustrated
by
small
irritations.
Their
sleep
is
chronically
disturbed,
and
food
often
loses
its
sensual
pleasures.
This
in
turn
can
trigger
desperate
attempts
to
shut
those
feelings
down
by
freezing
and
dissociation.11
How
do
people
regain
control
when
their
animal
brains
are
stuck
in
a
fight
for
survival?
If
what
goes
on
deep
inside
our
animal
brains
dictates
how
we
feel,
and
if
our
body
sensations
are
orchestrated
by
subcortical
(subconscious)
brain
structures,
how
much
control
over
them
can
we
actually
have?

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

to
draw
out
the
sensory
information
that
is
blocked
and
frozen
by
trauma;
to
help
patients
befriend
(rather
than
suppress)
the
energies
released
by
that
inner
experience;
to
complete
the
self-preserving
physical
actions
that
were
thwarted
when
they
were
trapped,
restrained,
or
immobilized
by
terror.

Our
gut
feelings
signal
what
is
safe,
life
sustaining,
or
threatening,
even
if
we
cannot
quite
explain
why
we
feel
a
particular
way.
Our
sensory
interiority
continuously
sends
us
subtle
messages
about
the
needs
of
our
organism.
Gut
feelings
also
help
us
to
evaluate
what
is
going
on
around
us.
They
warn
us
that
the
guy
who
is
approaching
feels
creepy,
but
they
also
convey
that
a
room
with
western
exposure
surrounded
by
daylilies
makes
us
feel
serene.
If
you
have
a
comfortable
connection
with
your
inner
sensations
—if
you
can
trust
them
to
give
you
accurate
information—you
will
feel
in
charge
of
your
body,
your
feelings,
and
your
self.
However,
traumatized
people
chronically
feel
unsafe
inside
their
bodies:
The
past
is
alive
in
the
form
of
gnawing
interior
discomfort.
Their
bodies
are
constantly
bombarded
by
visceral
warning
signs,
and,
in
an
attempt
to
control
these
processes,
they
often
become
expert
at
ignoring
their
gut
feelings
and
in
numbing
awareness
of
what
is
played
out
inside.
They
learn
to
hide
from
their
selves.
The
more
people
try
to
push
away
and
ignore
internal
warning
signs,
the
more
likely
they
are
to
take
over
and
leave
them
bewildered,
confused,
and
ashamed.
People
who
cannot
comfortably
notice
what
is
going
on
inside
become
vulnerable
to
respond
to
any
sensory
shift
either
by
shutting
down
or
by
going
into
a
panic—they
develop
a
fear
of
fear
itself.
We
now
know
that
panic
symptoms
are
maintained
largely
because
the
individual
develops
a
fear
of
the
bodily
sensations
associated
with
panic
attacks.
The
attack
may
be
triggered
by
something
he
or
she
knows
is
irrational,
but
fear
of
the
sensations
keeps
them
escalating
into
a
full-body
emergency.
“Scared
stiff”
and
“frozen
in
fear”
(collapsing
and
going
numb)
describe
precisely
what
terror
and
trauma
feel
like.
They
are
its
visceral
foundation.
The
experience
of
fear
derives
from
primitive
responses
to
threat
where
escape
is
thwarted
in
some
way.
People’s
lives
will
be
held
hostage
to
fear
until
that
visceral
experience
changes.
The
price
for
ignoring
or
distorting
the
body’s
messages
is
being
unable
to
detect
what
is
truly
dangerous
or
harmful
for
you
and,
just
as
bad,
what
is
safe
or
nourishing.
Self-regulation
depends
on
having
a
friendly
relationship
with
your
body.
Without
it
you
have
to
rely
on
external
regulation—from
medication,
drugs
like
alcohol,
constant
reassurance,
or
compulsive
compliance
with
the
wishes
of
others.
Many
of
my
patients
respond
to
stress
not
by
noticing
and
naming
it
but
by
developing
migraine
headaches
or
asthma
attacks.15
Sandy,
a
middle-aged
visiting
nurse,
told
me
she’d
felt
terrified
and
lonely
as
a
child,
unseen
by
her
alcoholic
parents.
She
dealt
with
this
by
becoming
deferential
to
everybody
she
depended
on
(including
me,
her
therapist).
Whenever
her
husband
made
an
insensitive
remark,
she
would
come
down
with
an
asthma
attack.
By
the
time
she
noticed
that
she
couldn’t
breathe,
it
was
too
late
for
an
inhaler
to
be
effective,
and
she
had
to
be
taken
to
the
emergency
room.
Suppressing
our
inner
cries
for
help
does
not
stop
our
stress
hormones
from
mobilizing
the
body.
Even
though
Sandy
had
learned
to
ignore
her
relationship
problems
and
block
out
her
physical
distress
signals,
they
showed
up
in
symptoms
that
demanded
her
attention.
Her
therapy
focused
on
identifying
the
link
between
her
physical
sensations
and
her
emotions,
and
I
also
encouraged
her
to
enroll
in
a
kickboxing
program.
She
had
no
emergency
room
visits
during
the
three
years
she
was
my
patient.
Somatic
symptoms
for
which
no
clear
physical
basis
can
be
found
are
ubiquitous
in
traumatized
children
and
adults.
They
can
include
chronic
back
and
neck
pain,
fibromyalgia,
migraines,
digestive
problems,
spastic
colon/irritable
bowel
syndrome,
chronic
fatigue,
and
some
forms
of
asthma.16
Traumatized
children
have
fifty
times
the
rate
of
asthma
as
their
nontraumatized
peers.17
Studies
have
shown
that
many
children
and
adults
with
fatal
asthma
attacks
were
not
aware
of
having
breathing
problems
before
the
attacks.

ALEXITHYMIA:
NO
WORDS
FOR
FEELINGS
I
had
a
widowed
aunt
with
a
painful
trauma
history
who
became
an
honorary
grandmother
to
our
children.
She
came
on
frequent
visits
that
were
marked
by
much
doing—making
curtains,
rearranging
kitchen
shelves,
sewing
children’s
clothes—and
very
little
talking.
She
was
always
eager
to
please,
but
it
was
difficult
to
figure
out
what
she
enjoyed.
After
several
days
of
exchanging
pleasantries,
conversation
would
come
to
a
halt,
and
I’d
have
to
work
hard
to
fill
the
long
silences.
On
the
last
day
of
her
visits
I’d
drive
her
to
the
airport,
where
she’d
give
me
a
stiff
good-bye
hug
while
tears
streamed
down
her
face.
Without
a
trace
of
irony
she’d
then
complain
that
the
cold
wind
at
Logan
International
Airport
made
her
eyes
water.
Her
body
felt
the
sadness
that
her
mind
couldn’t
register—she
was
leaving
our
young
family,
her
closest
living
relatives.
Psychiatrists
call
this
phenomenon
alexithymia—Greek
for
not
having
words
for
feelings.
Many
traumatized
children
and
adults
simply
cannot
describe
what
they
are
feeling
because
they
cannot
identify
what
their
physical
sensations
mean.
They
may
look
furious
but
deny
that
they
are
angry;
they
may
appear
terrified
but
say
that
they
are
fine.
Not
being
able
to
discern
what
is
going
on
inside
their
bodies
causes
them
to
be
out
of
touch
with
their
needs,
and
they
have
trouble
taking
care
of
themselves,
whether
it
involves
eating
the
right
amount
at
the
right
time
or
getting
the
sleep
they
need.
Like
my
aunt,
alexithymics
substitute
the
language
of
action
for
that
of
emotion.
When
asked,
“How
would
you
feel
if
you
saw
a
truck
coming
at
you
at
eighty
miles
per
hour?”
most
people
would
say,
“I’d
be
terrified”
or
“I’d
be
frozen
with
fear.”
An
alexithymic
might
reply,
“How
would
I
feel?
I
don’t
know. . . .
I’d
get
out
of
the
way.”18
They
tend
to
register
emotions
as
physical
problems
rather
than
as
signals
that
something
deserves
their
attention.
Instead
of
feeling
angry
or
sad,
they
experience
muscle
pain,
bowel
irregularities,
or
other
symptoms
for
which
no
cause
can
be
found.
About
three
quarters
of
patients
with
anorexia
nervosa,
and
more
than
half
of
all
patients
with
bulimia,
are
bewildered
by
their
emotional
feelings
and
have
great
difficulty
describing
them.19
When
researchers
showed
pictures
of
angry
or
distressed
faces
to
people
with
alexithymia,
they
could
not
figure
out
what
those
people
were
feeling.20
One
of
the
first
people
who
taught
me
about
alexithymia
was
the
psychiatrist
Henry
Krystal,
who
worked
with
more
than
a
thousand
Holocaust
survivors
in
his
effort
to
understand
massive
psychic
trauma.21
Krystal,
himself
a
concentration
camp
survivor,
found
that
many
of
his
patients
were
professionally
successful,
but
their
intimate
relationships
were
bleak
and
distant.
Suppressing
their
feelings
had
made
it
possible
to
attend
to
the
business
of
the
world,
but
at
a
price.
They
learned
to
shut
down
their
once
overwhelming
emotions,
and,
as
a
result,
they
no
longer
recognized
what
they
were
feeling.
Few
of
them
had
any
interest
in
therapy.
Paul
Frewen
at
the
University
of
Western
Ontario
did
a
series
of
brain
scans
of
people
with
PTSD
who
suffered
from
alexithymia.
One
of
the
participants
told
him:
“I
don’t
know
what
I
feel,
it’s
like
my
head
and
body
aren’t
connected.
I’m
living
in
a
tunnel,
a
fog,
no
matter
what
happens
it’s
the
same
reaction—numbness,
nothing.
Having
a
bubble
bath
and
being
burned
or
raped
is
the
same
feeling.
My
brain
doesn’t
feel.”
Frewen
and
his
colleague
Ruth
Lanius
found
that
the
more
people
were
out
of
touch
with
their
feelings,
the
less
activity
they
had
in
the
self-sensing
areas
of
the
brain.22
 Because
traumatized
people
often
have
trouble
sensing
what
is
going
on
in
their
bodies,
they
lack
a
nuanced
response
to
frustration.
They
either
react
to
stress
by
becoming
“spaced
out”
or
with
excessive
anger.
Whatever
their
response,
they
often
can’t
tell
what
is
upsetting
them.
This
failure
to
be
in
touch
with
their
bodies
contributes
to
their
well-documented
lack
of
self-
protection
and
high
rates
of
revictimization23
and
also
to
their
remarkable
difficulties
feeling
pleasure,
sensuality,
and
having
a
sense
of
meaning.
People
with
alexithymia
can
get
better
only
by
learning
to
recognize
the
relationship
between
their
physical
sensations
and
their
emotions,
much
as
colorblind
people
can
only
enter
the
world
of
color
by
learning
to
distinguish
and
appreciate
shades
of
gray.
Like
my
aunt
and
Henry
Krystal’s
patients,
they
usually
are
reluctant
to
do
that:
Most
seem
to
have
made
an
unconscious
decision
that
it
is
better
to
keep
visiting
doctors
and
treating
ailments
that
don’t
heal
than
to
do
the
painful
work
of
facing
the
demons
of
the
past.

DEPERSONALIZATION
One
step
further
down
on
the
ladder
to
self-oblivion
is
depersonalization—
losing
your
sense
of
yourself.
Ute’s
brain
scan
in
chapter
4
is,
in
its
very
blankness,
a
vivid
illustration
of
depersonalization.
Depersonalization
is
common
during
traumatic
experiences.
I
was
once
mugged
late
at
night
in
a
park
close
to
my
home
and,
floating
above
the
scene,
saw
myself
lying
in
the
snow
with
a
small
head
wound,
surrounded
by
three
knife-wielding
teenagers.
I
dissociated
the
pain
of
their
stab
wounds
on
my
hands
and
did
not
feel
the
slightest
fear
as
I
calmly
negotiated
for
the
return
of
my
emptied
wallet.
I
did
not
develop
PTSD,
partly,
I
think,
because
I
was
intensely
curious
about
having
an
experience
I
had
studied
so
closely
in
others,
and
partly
because
I
had
the
delusion
that
I
would
be
able
make
a
drawing
of
my
muggers
to
show
to
the
police.
Of
course,
they
were
never
caught,
but
my
fantasy
of
revenge
must
have
given
me
a
satisfying
sense
of
agency.
Traumatized
people
are
not
so
fortunate
and
feel
separated
from
their
bodies.
One
particularly
good
description
of
depersonalization
comes
from
the
German
psychoanalyst
Paul
Schilder,
writing
in
Berlin
in
1928:24
“To
the
depersonalized
individual
the
world
appears
strange,
peculiar,
foreign,
dream-like.
Objects
appear
at
times
strangely
diminished
in
size,
at
times
flat.
Sounds
appear
to
come
from
a
distance. . . .
The
emotions
likewise
undergo
marked
alteration.
Patients
complain
that
they
are
capable
of
experiencing
neither
pain
nor
pleasure. . . .
They
have
become
strangers
to
themselves.”
I
was
fascinated
to
learn
that
a
group
of
neuroscientists
at
the
University
of
Geneva25
had
induced
similar
out-of-body
experiences
by
delivering
mild
electric
current
to
a
specific
spot
in
the
brain,
the
temporal
parietal
junction.
In
one
patient
this
produced
a
sensation
that
she
was
hanging
from
the
ceiling,
looking
down
at
her
body;
in
another
it
induced
an
eerie
feeling
that
someone
was
standing
behind
her.
This
research
confirms
what
our
patients
tell
us:
that
the
self
can
be
detached
from
the
body
and
live
a
phantom
existence
on
its
own.
Similarly,
Lanius
and
Frewen,
as
well
as
a
group
of
researchers
at
the
University
of
Groningen
in
the
Netherlands,26
did
brain
scans
on
people
who
dissociated
their
terror
and
found
that
the
fear
centers
of
the
brain
simply
shut
down
as
they
recalled
the
event.

BEFRIENDING
THE
BODY
Trauma
victims
cannot
recover
until
they
become
familiar
with
and
befriend
the
sensations
in
their
bodies.
Being
frightened
means
that
you
live
in
a
body
that
is
always
on
guard.
Angry
people
live
in
angry
bodies.
The
bodies
of
child-abuse
victims
are
tense
and
defensive
until
they
find
a
way
to
relax
and
feel
safe.
In
order
to
change,
people
need
to
become
aware
of
their
sensations
and
the
way
that
their
bodies
interact
with
the
world
around
them.
Physical
self-awareness
is
the
first
step
in
releasing
the
tyranny
of
the
past.
How
can
people
open
up
to
and
explore
their
internal
world
of
sensations
and
emotions?
In
my
practice
I
begin
the
process
by
helping
my
patients
to
first
notice
and
then
describe
the
feelings
in
their
bodies—not
emotions
such
as
anger
or
anxiety
or
fear
but
the
physical
sensations
beneath
the
emotions:
pressure,
heat,
muscular
tension,
tingling,
caving
in,
feeling
hollow,
and
so
on.
I
also
work
on
identifying
the
sensations
associated
with
relaxation
or
pleasure.
I
help
them
become
aware
of
their
breath,
their
gestures
and
movements.
I
ask
them
to
pay
attention
to
subtle
shifts
in
their
bodies,
such
as
tightness
in
their
chests
or
gnawing
in
their
bellies,
when
they
talk
about
negative
events
that
they
claim
did
not
bother
them.
Noticing
sensations
for
the
first
time
can
be
quite
distressing,
and
it
may
precipitate
flashbacks
in
which
people
curl
up
or
assume
defensive
postures.
These
are
somatic
reenactments
of
the
undigested
trauma
and
most
likely
represent
the
postures
they
assumed
when
the
trauma
occurred.
Images
and
physical
sensations
may
deluge
patients
at
this
point,
and
the
therapist
must
be
familiar
with
ways
to
stem
torrents
of
sensation
and
emotion
to
prevent
them
from
becoming
retraumatized
by
accessing
the
past.
(Schoolteachers,
nurses,
and
police
officers
are
often
very
skilled
at
soothing
terror
reactions
because
many
of
them
are
confronted
almost
daily
with
out-of-control
or
painfully
disorganized
people.)
All
too
often,
however,
drugs
such
as
Abilify,
Zyprexa,
and
Seroquel,
are
prescribed
instead
of
teaching
people
the
skills
to
deal
with
such
distressing
physical
reactions.
Of
course,
medications
only
blunt
sensations
and
do
nothing
to
resolve
them
or
transform
them
from
toxic
agents
into
allies.
The
most
natural
way
for
human
beings
to
calm
themselves
when
they
are
upset
is
by
clinging
to
another
person.
This
means
that
patients
who
have
been
physically
or
sexually
violated
face
a
dilemma:
They
desperately
crave
touch
while
simultaneously
being
terrified
of
body
contact.
The
mind
needs
to
be
reeducated
to
feel
physical
sensations,
and
the
body
needs
to
be
helped
to
tolerate
and
enjoy
the
comforts
of
touch.
Individuals
who
lack
emotional
awareness
are
able,
with
practice,
to
connect
their
physical
sensations
to
psychological
events.
Then
they
can
slowly
reconnect
with
themselves.27

CONNECTING
WITH
YOURSELF,
CONNECTING
WITH
OTHERS
I’ll
end
this
chapter
with
one
final
study
that
demonstrates
the
cost
of
losing
your
body.
After
Ruth
Lanius
and
her
group
scanned
the
idling
brain,
they
focused
on
another
question
from
everyday
life:
What
happens
in
chronically
traumatized
people
when
they
make
face-to-face
contact?
 Many
patients
who
come
to
my
office
are
unable
to
make
eye
contact.
I
immediately
know
how
distressed
they
are
by
their
difficulty
meeting
my
gaze.
It
always
turns
out
that
they
feel
disgusting
and
that
they
can’t
stand
having
me
see
how
despicable
they
are.
It
never
occurred
to
me
that
these
intense
feelings
of
shame
would
be
reflected
in
abnormal
brain
activation.
Ruth
Lanius
once
again
showed
that
mind
and
brain
are
indistinguishable—
what
happens
in
one
is
registered
in
the
other.
Ruth
bought
an
expensive
device
that
presents
a
video
character
to
a
person
lying
in
a
scanner.
(In
this
case,
the
cartoon
resembled
a
kindly
Richard
Gere.)
The
figure
can
approach
either
head
on
(looking
directly
at
the
person)
or
at
a
forty-five-degree
angle
with
an
averted
gaze.
This
made
it
possible
to
compare
the
effects
of
direct
eye
contact
on
brain
activation
with
those
of
an
averted
gaze.28
The
most
striking
difference
between
normal
controls
and
survivors
of
chronic
trauma
was
in
activation
of
the
prefrontal
cortex
in
response
to
a
direct
eye
gaze.
The
prefrontal
cortex
(PFC)
normally
helps
us
to
assess
the
person
coming
toward
us,
and
our
mirror
neurons
help
to
pick
up
his
intentions.
However,
the
subjects
with
PTSD
did
not
activate
any
part
of
their
frontal
lobe,
which
means
they
could
not
muster
any
curiosity
about
the
stranger.
They
just
reacted
with
intense
activation
deep
inside
their
emotional
brains,
in
the
primitive
areas
known
as
the
Periaqueductal
Gray,
which
generates
startle,
hypervigilance,
cowering,
and
other
self-protective
behaviors.
There
was
no
activation
of
any
part
of
the
brain
involved
in
social
engagement.
In
response
to
being
looked
at
they
simply
went
into
survival
mode.
What
does
this
mean
for
their
ability
to
make
friends
and
get
along
with
others?
What
does
it
mean
for
their
therapy?
Can
people
with
PTSD
trust
a
therapist
with
their
deepest
fears?
To
have
genuine
relationships
you
have
to
be
able
to
experience
others
as
separate
individuals,
each
with
his
or
her
particular
motivations
and
intentions.
While
you
need
to
be
able
to
stand
up
for
yourself,
you
also
need
to
recognize
that
other
people
have
their
own
agendas.
Trauma
can
make
all
that
hazy
and
gray.
 PART
THREE
THE
MINDS
OF
CHILDREN
 CHAPTER
7

GETTING
ON
THE
SAME
WAVELENGTH:
ATTACHMENT
AND
ATTUNEMENT

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

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

As
they
told
us
these
stories,
our
patients
got
very
excited
and
disorganized.
We
had
to
take
considerable
time
out
at
the
water
cooler
and
going
for
walks
before
we
could
show
them
the
next
card.
It
was
little
wonder
that
almost
all
of
them
had
been
diagnosed
with
ADHD,
and
most
were
on
Ritalin—though
the
drug
certainly
didn’t
seem
to
dampen
their
arousal
in
this
situation.
The
abused
kids
gave
similar
responses
to
a
seemingly
innocuous
picture
of
a
pregnant
woman
silhouetted
against
a
window.
When
we
showed
it
to
the
seven-year-old
girl
who’d
been
sexually
abused
at
age
four,
she
talked
about
penises
and
vaginas
and
repeatedly
asked
Nina
questions
like
“How
many
people
have
you
humped?”
Like
several
of
the
other
sexually
abused
girls
in
the
study,
she
became
so
agitated
that
we
had
to
stop.
A
seven-year-old
girl
from
the
control
group
picked
up
the
wistful
mood
of
the
picture:
Her
story
was
about
a
widowed
lady
sadly
looking
out
the
window,
missing
her
husband.
But
in
the
end,
the
lady
found
a
loving
man
to
be
a
good
father
to
her
baby.
 In
card
after
card
we
saw
that,
despite
their
alertness
to
trouble,
the
children
who
had
not
been
abused
still
trusted
in
an
essentially
benign
universe;
they
could
imagine
ways
out
of
bad
situations.
They
seemed
to
feel
protected
and
safe
within
their
own
families.
They
also
felt
loved
by
at
least
one
of
their
parents,
which
seemed
to
make
a
substantial
difference
in
their
eagerness
to
engage
in
schoolwork
and
to
learn.
The
responses
of
the
clinic
children
were
alarming.
The
most
innocent
images
stirred
up
intense
feelings
of
danger,
aggression,
sexual
arousal,
and
terror.
We
had
not
selected
these
photos
because
they
had
some
hidden
meaning
that
sensitive
people
could
uncover;
they
were
ordinary
images
of
everyday
life.
We
could
only
conclude
that
for
abused
children,
the
whole
world
is
filled
with
triggers.
As
long
as
they
can
imagine
only
disastrous
outcomes
to
relatively
benign
situations,
anybody
walking
into
a
room,
any
stranger,
any
image,
on
a
screen
or
on
a
billboard
might
be
perceived
as
a
harbinger
of
catastrophe.
In
this
light
the
bizarre
behavior
of
the
kids
at
the
children’s
clinic
made
perfect
sense.2
To
my
amazement,
staff
discussions
on
the
unit
rarely
mentioned
the
horrific
real-life
experiences
of
the
children
and
the
impact
of
those
traumas
on
their
feelings,
thinking,
and
self-regulation.
Instead,
their
medical
records
were
filled
with
diagnostic
labels:
“conduct
disorder”
or
“oppositional
defiant
disorder”
for
the
angry
and
rebellious
kids;
or
“bipolar
disorder.”
ADHD
was
a
“comorbid”
diagnosis
for
almost
all.
Was
the
underlying
trauma
being
obscured
by
this
blizzard
of
diagnoses?
Now
we
faced
two
big
challenges.
One
was
to
learn
whether
the
different
worldview
of
normal
children
could
account
for
their
resilience
and,
on
a
deeper
level,
how
each
child
actually
creates
her
map
of
the
world.
The
other,
equally
crucial,
question
was:
Is
it
possible
to
help
the
minds
and
brains
of
brutalized
children
to
redraw
their
inner
maps
and
incorporate
a
sense
of
trust
and
confidence
in
the
future?

MEN
WITHOUT
MOTHERS
The
scientific
study
of
the
vital
relationship
between
infants
and
their
mothers
was
started
by
upper-class
Englishmen
who
were
torn
from
their
families
as
young
boys
to
be
sent
off
to
boarding
schools,
where
they
were
raised
in
regimented
same-sex
settings.
The
first
time
I
visited
the
famed
Tavistock
Clinic
in
London
I
noticed
a
collection
of
black-and-white
photographs
of
these
great
twentieth-century
psychiatrists
hanging
on
the
wall
going
up
the
main
staircase:
John
Bowlby,
Wilfred
Bion,
Harry
Guntrip,
Ronald
Fairbairn,
and
Donald
Winnicott.
Each
of
them,
in
his
own
way,
had
explored
how
our
early
experiences
become
prototypes
for
all
our
later
connections
with
others,
and
how
our
most
intimate
sense
of
self
is
created
in
our
minute-to-minute
exchanges
with
our
caregivers.
Scientists
study
what
puzzles
them
most,
so
that
they
often
become
experts
in
subjects
that
others
take
for
granted.
(Or,
as
the
attachment
researcher
Beatrice
Beebe
once
told
me,
“most
research
is
me-search.”)
These
men
who
studied
the
role
of
mothers
in
children’s
lives
had
themselves
been
sent
off
to
school
at
a
vulnerable
age,
sometime
between
six
and
ten,
long
before
they
should
have
faced
the
world
alone.
Bowlby
himself
told
me
that
just
such
boarding-school
experiences
probably
inspired
George
Orwell’s
novel
1984,
which
brilliantly
expresses
how
human
beings
may
be
induced
to
sacrifice
everything
they
hold
dear
and
true—including
their
sense
of
self—for
the
sake
of
being
loved
and
approved
of
by
someone
in
a
position
of
authority.
Since
Bowlby
was
close
friends
with
the
Murrays,
I
had
a
chance
to
talk
with
him
about
his
work
whenever
he
visited
Harvard.
He
was
born
into
an
aristocratic
family
(his
father
was
surgeon
to
the
King’s
household),
and
he
trained
in
psychology,
medicine,
and
psychoanalysis
at
the
temples
of
the
British
establishment.
After
attending
Cambridge
University,
he
worked
with
delinquent
boys
in
London’s
East
End,
a
notoriously
rough
and
crime-ridden
neighborhood
that
was
largely
destroyed
during
the
Blitz.
During
and
after
his
service
in
World
War
II,
he
observed
the
effects
of
wartime
evacuations
and
group
nurseries
that
separated
young
children
from
their
families.
He
also
studied
the
effect
of
hospitalization,
showing
that
even
brief
separations
(parents
back
then
were
not
allowed
to
visit
overnight)
compounded
the
children’s
suffering.
By
the
late
1940s
Bowlby
had
become
persona
non
grata
in
the
British
psychoanalytic
community,
as
a
result
of
his
radical
claim
that
children’s
disturbed
behavior
was
a
response
to
actual
life
experiences—to
neglect,
brutality,
and
separation—
rather
than
the
product
of
infantile
sexual
fantasies.
Undaunted,
he
devoted
the
rest
of
his
life
to
developing
what
came
to
be
called
attachment
theory.3

A
SECURE
BASE
As
we
enter
this
world
we
scream
to
announce
our
presence.
Someone
immediately
engages
with
us,
bathes
us,
swaddles
us,
and
fills
our
stomachs,
and,
best
of
all,
our
mother
may
put
us
on
her
belly
or
breast
for
delicious
skin-to-skin
contact.
We
are
profoundly
social
creatures;
our
lives
consist
of
finding
our
place
within
the
community
of
human
beings.
I
love
the
expression
of
the
great
French
psychiatrist
Pierre
Janet:
“Every
life
is
a
piece
of
art,
put
together
with
all
means
available.”
As
we
grow
up,
we
gradually
learn
to
take
care
of
ourselves,
both
physically
and
emotionally,
but
we
get
our
first
lessons
in
self-care
from
the
way
that
we
are
cared
for.
Mastering
the
skill
of
self-regulation
depends
to
a
large
degree
on
how
harmonious
our
early
interactions
with
our
caregivers
are.
Children
whose
parents
are
reliable
sources
of
comfort
and
strength
have
a
lifetime
advantage—a
kind
of
buffer
against
the
worst
that
fate
can
hand
them.
John
Bowlby
realized
that
children
are
captivated
by
faces
and
voices
and
are
exquisitely
sensitive
to
facial
expression,
posture,
tone
of
voice,
physiological
changes,
tempo
of
movement
and
incipient
action.
He
saw
this
inborn
capacity
as
a
product
of
evolution,
essential
to
the
survival
of
these
helpless
creatures.
Children
are
also
programmed
to
choose
one
particular
adult
(or
at
most
a
few)
with
whom
their
natural
communication
system
develops.
This
creates
a
primary
attachment
bond.
The
more
responsive
the
adult
is
to
the
child,
the
deeper
the
attachment
and
the
more
likely
the
child
will
develop
healthy
ways
of
responding
to
the
people
around
him.
Bowlby
would
often
visit
Regent’s
Park
in
London,
where
he
would
make
systematic
observations
of
the
interactions
between
children
and
their
mothers.
While
the
mothers
sat
quietly
on
park
benches,
knitting
or
reading
the
paper,
the
kids
would
wander
off
to
explore,
occasionally
looking
over
their
shoulders
to
ascertain
that
Mum
was
still
watching.
But
when
a
neighbor
stopped
by
and
absorbed
his
mother’s
interest
with
the
latest
gossip,
the
kids
would
run
back
and
stay
close,
making
sure
he
still
had
her
attention.
When
infants
and
young
children
notice
that
their
mothers
are
not
fully
engaged
with
them,
they
become
nervous.
When
their
mothers
disappear
from
sight,
they
may
cry
and
become
inconsolable,
but
as
soon
as
their
mothers
return,
they
quiet
down
and
resume
their
play.
Bowlby
saw
attachment
as
the
secure
base
from
which
a
child
moves
out
into
the
world.
Over
the
subsequent
five
decades
research
has
firmly
established
that
having
a
safe
haven
promotes
self-reliance
and
instills
a
sense
of
sympathy
and
helpfulness
to
others
in
distress.
From
the
intimate
give-and-take
of
the
attachment
bond
children
learn
that
other
people
have
feelings
and
thoughts
that
are
both
similar
to
and
different
from
theirs.
In
other
words,
they
get
“in
sync”
with
their
environment
and
with
the
people
around
them
and
develop
the
self-awareness,
empathy,
impulse
control,
and
self-motivation
that
make
it
possible
to
become
contributing
members
of
the
larger
social
culture.
These
qualities
were
painfully
missing
in
the
kids
at
our
Children’s
Clinic.
THE
DANCE
OF
ATTUNEMENT
Children
become
attached
to
whoever
functions
as
their
primary
caregiver.
But
the
nature
of
that
attachment—whether
it
is
secure
or
insecure—makes
a
huge
difference
over
the
course
of
a
child’s
life.
Secure
attachment
develops
when
caregiving
includes
emotional
attunement.
Attunement
starts
at
the
most
subtle
physical
levels
of
interaction
between
babies
and
their
caretakers,
and
it
gives
babies
the
feeling
of
being
met
and
understood.
As
Edinburgh-based
attachment
researcher
Colwyn
Trevarthen
says:
“The
brain
coordinates
rhythmic
body
movements
and
guides
them
to
act
in
sympathy
with
other
people’s
brains.
Infants
hear
and
learn
musicality
from
their
mother’s
talk,
even
before
birth.”4
In
chapter
4
I
described
the
discovery
of
mirror
neurons,
the
brain-to-
brain
links
that
give
us
our
capacity
for
empathy.
Mirror
neurons
start
functioning
as
soon
as
babies
are
born.
When
researcher
Andrew
Meltzoff
at
the
University
of
Oregon
pursed
his
lips
or
stuck
out
his
tongue
at
six-
hour-old
babies,
they
promptly
mirrored
his
actions.5
(Newborns
can
focus
their
eyes
only
on
objects
within
eight
to
twelve
inches—just
enough
see
the
person
who
is
holding
them).
Imitation
is
our
most
fundamental
social
skill.
It
assures
that
we
automatically
pick
up
and
reflect
the
behavior
of
our
parents,
teachers,
and
peers.
Most
parents
relate
to
their
babies
so
spontaneously
that
they
are
barely
aware
of
how
attunement
unfolds.
But
an
invitation
from
a
friend,
the
attachment
researcher
Ed
Tronick,
gave
me
the
chance
to
observe
that
process
more
closely.
Through
a
one-way
mirror
at
Harvard’s
Laboratory
of
Human
Development,
I
watched
a
mother
playing
with
her
two-month-old
son,
who
was
propped
in
an
infant
seat
facing
her.
They
were
cooing
to
each
other
and
having
a
wonderful
time—until
the
mother
leaned
in
to
nuzzle
him
and
the
baby,
in
his
excitement,
yanked
on
her
hair.
The
mother
was
caught
unawares
and
yelped
with
pain,
pushing
away
his
hand
while
her
face
contorted
with
anger.
The
baby
let
go
immediately,
and
they
pulled
back
physically
from
each
other.
For
both
of
them
the
source
of
delight
had
become
a
source
of
distress.
Obviously
frightened,
the
baby
brought
his
hands
up
to
his
face
to
block
out
the
sight
of
his
angry
mother.
The
mother,
in
turn,
realizing
that
her
baby
was
upset,
refocused
on
him,
making
soothing
sounds
in
an
attempt
to
smooth
things
over.
The
infant
still
had
his
eyes
covered,
but
his
craving
for
connection
soon
reemerged.
He
started
peeking
out
to
see
if
the
coast
was
clear,
while
his
mother
reached
toward
him
with
a
concerned
expression.
As
she
started
to
tickle
his
belly,
he
dropped
his
arms
and
broke
into
a
happy
giggle,
and
harmony
was
reestablished.
Infant
and
mother
were
attuned
again.
This
entire
sequence
of
delight,
rupture,
repair,
and
new
delight
took
slightly
less
than
twelve
seconds.
Tronick
and
other
researchers
have
now
shown
that
when
infants
and
caregivers
are
in
sync
on
an
emotional
level,
they’re
also
in
sync
physically.6
Babies
can’t
regulate
their
own
emotional
states,
much
less
the
changes
in
heart
rate,
hormone
levels,
and
nervous-system
activity
that
accompany
emotions.
When
a
child
is
in
sync
with
his
caregiver,
his
sense
of
joy
and
connection
is
reflected
in
his
steady
heartbeat
and
breathing
and
a
low
level
of
stress
hormones.
His
body
is
calm;
so
are
his
emotions.
The
moment
this
music
is
disrupted—as
it
often
is
in
the
course
of
a
normal
day
—all
these
physiological
factors
change
as
well.
You
can
tell
equilibrium
has
been
restored
when
the
physiology
calms
down.
We
soothe
newborns,
but
parents
soon
start
teaching
their
children
to
tolerate
higher
levels
of
arousal,
a
job
that
is
often
assigned
to
fathers.
(I
once
heard
the
psychologist
John
Gottman
say,
“Mothers
stroke,
and
fathers
poke.”)
Learning
how
to
manage
arousal
is
a
key
life
skill,
and
parents
must
do
it
for
babies
before
babies
can
do
it
for
themselves.
If
that
gnawing
sensation
in
his
belly
makes
a
baby
cry,
the
breast
or
bottle
arrives.
If
he’s
scared,
someone
holds
and
rocks
him
until
he
calms
down.
If
his
bowels
erupt,
someone
comes
to
make
him
clean
and
dry.
Associating
intense
sensations
with
safety,
comfort,
and
mastery
is
the
foundation
of
self-
regulation,
self-soothing,
and
self-nurture,
a
theme
to
which
I
return
throughout
this
book.
A
secure
attachment
combined
with
the
cultivation
of
competency
builds
an
internal
locus
of
control,
the
key
factor
in
healthy
coping
throughout
life.7
Securely
attached
children
learn
what
makes
them
feel
good;
they
discover
what
makes
them
(and
others)
feel
bad,
and
they
acquire
a
sense
of
agency:
that
their
actions
can
change
how
they
feel
and
how
others
respond.
Securely
attached
kids
learn
the
difference
between
situations
they
can
control
and
situations
where
they
need
help.
They
learn
that
they
can
play
an
active
role
when
faced
with
difficult
situations.
In
contrast,
children
with
histories
of
abuse
and
neglect
learn
that
their
terror,
pleading,
and
crying
do
not
register
with
their
caregiver.
Nothing
they
can
do
or
say
stops
the
beating
or
brings
attention
and
help.
In
effect
they’re
being
conditioned
to
give
up
when
they
face
challenges
later
in
life.

BECOMING
REAL
Bowlby’s
contemporary,
the
pediatrician
and
psychoanalyst
Donald
Winnicott,
is
the
father
of
modern
studies
of
attunement.
His
minute
observations
of
mothers
and
children
started
with
the
way
mothers
hold
their
babies.
He
proposed
that
these
physical
interactions
lay
the
groundwork
for
a
baby’s
sense
of
self—and,
with
that,
a
lifelong
sense
of
identity.
The
way
a
mother
holds
her
child
underlies
“the
ability
to
feel
the
body
as
the
place
where
the
psyche
lives.”8
This
visceral
and
kinesthetic
sensation
of
how
our
bodies
are
met
lays
the
foundation
for
what
we
experience
as
“real.”9
Winnicott
thought
that
the
vast
majority
of
mothers
did
just
fine
in
their
attunement
to
their
infants—it
does
not
require
extraordinary
talent
to
be
what
he
called
a
“good
enough
mother.”10
But
things
can
go
seriously
wrong
when
mothers
are
unable
to
tune
in
to
their
baby’s
physical
reality.
If
a
mother
cannot
meet
her
baby’s
impulses
and
needs,
“the
baby
learns
to
become
the
mother’s
idea
of
what
the
baby
is.”
Having
to
discount
its
inner
sensations,
and
trying
to
adjust
to
its
caregiver’s
needs,
means
the
child
perceives
that
“something
is
wrong”
with
the
way
it
is.
Children
who
lack
physical
attunement
are
vulnerable
to
shutting
down
the
direct
feedback
from
their
bodies,
the
seat
of
pleasure,
purpose,
and
direction.
In
the
years
since
Bowlby’s
and
Winnicott’s
ideas
were
introduced,
attachment
research
around
the
world
has
shown
that
the
vast
majority
of
children
are
securely
attached.
When
they
grow
up,
their
history
of
reliable,
responsive
caregiving
will
help
to
keep
fear
and
anxiety
at
bay.
Barring
exposure
to
some
overwhelming
life
event—trauma—that
breaks
down
the
self-regulatory
system,
they
will
maintain
a
fundamental
state
of
emotional
security
throughout
their
lives.
Secure
attachment
also
forms
a
template
for
children’s
relationships.
They
pick
up
what
others
are
feeling
and
early
on
learn
to
tell
a
game
from
reality,
and
they
develop
a
good
nose
for
phony
situations
or
dangerous
people.
Securely
attached
children
usually
become
pleasant
playmates
and
have
lots
of
self-affirming
experiences
with
their
peers.
Having
learned
to
be
in
tune
with
other
people,
they
tend
to
notice
subtle
changes
in
voices
and
faces
and
to
adjust
their
behavior
accordingly.
They
learn
to
live
within
a
shared
understanding
of
the
world
and
are
likely
to
become
valued
members
of
the
community.
This
upward
spiral
can,
however,
be
reversed
by
abuse
or
neglect.
Abused
kids
are
often
very
sensitive
to
changes
in
voices
and
faces,
but
they
tend
to
respond
to
them
as
threats
rather
than
as
cues
for
staying
in
sync.
Dr.
Seth
Pollak
of
the
University
of
Wisconsin
showed
a
series
of
faces
to
a
group
of
normal
eight-year-olds
and
compared
their
responses
with
those
of
a
group
of
abused
children
the
same
age.
Looking
at
this
spectrum
of
angry
to
sad
expressions,
the
abused
kids
were
hyperalert
to
the
slightest
features
of
anger.11

COPYRIGHT
©
2000,
AMERICAN
PSYCHOLOGICAL
ASSOCIATION

This
is
one
reason
abused
children
so
easily
become
defensive
or
scared.
Imagine
what
it’s
like
to
make
your
way
through
a
sea
of
faces
in
the
school
corridor,
trying
to
figure
out
who
might
assault
you.
Children
who
overreact
to
their
peers’
aggression,
who
don’t
pick
up
on
other
kids’
needs,
who
easily
shut
down
or
lose
control
of
their
impulses,
are
likely
to
be
shunned
and
left
out
of
sleepovers
or
play
dates.
Eventually
they
may
learn
to
cover
up
their
fear
by
putting
up
a
tough
front.
Or
they
may
spend
more
and
more
time
alone,
watching
TV
or
playing
computer
games,
falling
even
further
behind
on
interpersonal
skills
and
emotional
self-regulation.
The
need
for
attachment
never
lessens.
Most
human
beings
simply
cannot
tolerate
being
disengaged
from
others
for
any
length
of
time.
People
who
cannot
connect
through
work,
friendships,
or
family
usually
find
other
ways
of
bonding,
as
through
illnesses,
lawsuits,
or
family
feuds.
Anything
is
preferable
to
that
godforsaken
sense
of
irrelevance
and
alienation.
A
few
years
ago,
on
Christmas
Eve,
I
was
called
to
examine
a
fourteen-
year-old
boy
at
the
Suffolk
County
Jail.
Jack
had
been
arrested
for
breaking
into
the
house
of
neighbors
who
were
away
on
vacation.
The
burglar
alarm
was
howling
when
the
police
found
him
in
the
living
room.
 The
first
question
I
asked
Jack
was
who
he
expected
would
visit
him
in
jail
on
Christmas.
“Nobody,”
he
told
me.
“Nobody
ever
pays
attention
to
me.”
It
turned
out
that
he
had
been
caught
during
break-ins
numerous
times
before.
He
knew
the
police,
and
they
knew
him.
With
delight
in
his
voice,
he
told
me
that
when
the
cops
saw
him
standing
in
the
middle
of
the
living
room,
they
yelled,
“Oh
my
God,
it’s
Jack
again,
that
little
motherfucker.”
Somebody
recognized
him;
somebody
knew
his
name.
A
little
while
later
Jack
confessed,
“You
know,
that
is
what
makes
it
worthwhile.”
Kids
will
go
to
almost
any
length
to
feel
seen
and
connected.

LIVING
WITH
THE
PARENTS
YOU
HAVE
Children
have
a
biological
instinct
to
attach—they
have
no
choice.
Whether
their
parents
or
caregivers
are
loving
and
caring
or
distant,
insensitive,
rejecting,
or
abusive,
children
will
develop
a
coping
style
based
on
their
attempt
to
get
at
least
some
of
their
needs
met.
We
now
have
reliable
ways
to
assess
and
identify
these
coping
styles,
thanks
largely
to
the
work
of
two
American
scientists,
Mary
Ainsworth
and
Mary
Main,
and
their
colleagues,
who
conducted
thousands
of
hours
of
observation
of
mother-infant
pairs
over
many
years.
Based
on
these
studies,
Ainsworth
created
a
research
tool
called
the
Strange
Situation,
which
looks
at
how
an
infant
reacts
to
temporary
separation
from
the
mother.
Just
as
Bowlby
had
observed,
securely
attached
infants
are
distressed
when
their
mother
leaves
them,
but
they
show
delight
when
she
returns,
and
after
a
brief
check-in
for
reassurance,
they
settle
down
and
resume
their
play.
But
with
infants
who
are
insecurely
attached,
the
picture
is
more
complex.
Children
whose
primary
caregiver
is
unresponsive
or
rejecting
learn
to
deal
with
their
anxiety
in
two
distinct
ways.
The
researchers
noticed
that
some
seemed
chronically
upset
and
demanding
with
their
mothers,
while
others
were
more
passive
and
withdrawn.
In
both
groups
contact
with
the
mothers
failed
to
settle
them
down—they
did
not
return
to
play
contentedly,
as
happens
in
secure
attachment.
In
one
pattern,
called
“avoidant
attachment,”
the
infants
look
like
nothing
really
bothers
them—they
don’t
cry
when
their
mother
goes
away
and
they
ignore
her
when
she
comes
back.
However,
this
does
not
mean
that
they
are
unaffected.
In
fact,
their
chronically
increased
heart
rates
show
that
they
are
in
a
constant
state
of
hyperarousal.
My
colleagues
and
I
call
this
pattern
“dealing
but
not
feeling.”12
Most
mothers
of
avoidant
infants
seem
to
dislike
touching
their
children.
They
have
trouble
snuggling
and
holding
them,
and
they
don’t
use
their
facial
expressions
and
voices
to
create
pleasurable
back-and-forth
rhythms
with
their
babies.
In
another
pattern,
called
“anxious”
or
“ambivalent”
attachment,
the
infants
constantly
draw
attention
to
themselves
by
crying,
yelling,
clinging,
or
screaming:
They
are
“feeling
but
not
dealing.”13
They
seem
to
have
concluded
that
unless
they
make
a
spectacle,
nobody
is
going
to
pay
attention
to
them.
They
become
enormously
upset
when
they
do
not
know
where
their
mother
is
but
derive
little
comfort
from
her
return.
And
even
though
they
don’t
seem
to
enjoy
her
company,
they
stay
passively
or
angrily
focused
on
her,
even
in
situations
when
other
children
would
rather
play.14
Attachment
researchers
think
that
the
three
“organized”
attachment
strategies
(secure,
avoidant,
and
anxious)
work
because
they
elicit
the
best
care
a
particular
caregiver
is
capable
of
providing.
Infants
who
encounter
a
consistent
pattern
of
care—even
if
it’s
marked
by
emotional
distance
or
insensitivity—can
adapt
to
maintain
the
relationship.
That
does
not
mean
that
there
are
no
problems:
Attachment
patterns
often
persist
into
adulthood.
Anxious
toddlers
tend
to
grow
into
anxious
adults,
while
avoidant
toddlers
are
likely
to
become
adults
who
are
out
of
touch
with
their
own
feelings
and
those
of
others.
(As
in,
“There’s
nothing
wrong
with
a
good
spanking.
I
got
hit
and
it
made
me
the
success
I
am
today.”)
In
school
avoidant
children
are
likely
to
bully
other
kids,
while
the
anxious
children
are
often
their
victims.15
However,
development
is
not
linear,
and
many
life
experiences
can
intervene
to
change
these
outcomes.
But
there
is
another
group
that
is
less
stably
adapted,
a
group
that
makes
up
the
bulk
of
the
children
we
treat
and
a
substantial
proportion
of
the
adults
who
are
seen
in
psychiatric
clinics.
Some
twenty
years
ago,
Mary
Main
and
her
colleagues
at
Berkeley
began
to
identify
a
group
of
children
(about
15
percent
of
those
they
studied)
who
seemed
to
be
unable
to
figure
out
how
to
engage
with
their
caregivers.
The
critical
issue
turned
out
to
be
that
the
caregivers
themselves
were
a
source
of
distress
or
terror
to
the
children.16
Children
in
this
situation
have
no
one
to
turn
to,
and
they
are
faced
with
an
unsolvable
dilemma;
their
mothers
are
simultaneously
necessary
for
survival
and
a
source
of
fear.17
They
“can
neither
approach
(the
secure
and
ambivalent
‘strategies’),
shift
[their]
attention
(the
avoidant
‘strategy’),
nor
flee.”18
If
you
observe
such
children
in
a
nursery
school
or
attachment
laboratory,
you
see
them
look
toward
their
parents
when
they
enter
the
room
and
then
quickly
turn
away.
Unable
to
choose
between
seeking
closeness
and
avoiding
the
parent,
they
may
rock
on
their
hands
and
knees,
appear
to
go
into
a
trance,
freeze
with
their
arms
raised,
or
get
up
to
greet
their
parent
and
then
fall
to
the
ground.
Not
knowing
who
is
safe
or
whom
they
belong
to,
they
may
be
intensely
affectionate
with
strangers
or
may
trust
nobody.
Main
called
this
pattern
“disorganized
attachment.”
Disorganized
attachment
is
“fright
without
solution.”19

BECOMING
DISORGANIZED
WITHIN
Conscientious
parents
often
become
alarmed
when
they
discover
attachment
research,
worrying
that
their
occasional
impatience
or
their
ordinary
lapses
in
attunement
may
permanently
damage
their
kids.
In
real
life
there
are
bound
to
be
misunderstandings,
inept
responses,
and
failures
of
communication.
Because
mothers
and
fathers
miss
cues
or
are
simply
preoccupied
with
other
matters,
infants
are
frequently
left
to
their
own
devices
to
discover
how
they
can
calm
themselves
down.
Within
limits
this
is
not
a
problem.
Kids
need
to
learn
to
handle
frustrations
and
disappointments.
With
“good
enough”
caregivers,
children
learn
that
broken
connections
can
be
repaired.
The
critical
issue
is
whether
they
can
incorporate
a
feeling
of
being
viscerally
safe
with
their
parents
or
other
caregivers.20
In
a
study
of
attachment
patterns
in
over
two
thousand
infants
in
“normal”
middle-class
environments,
62
percent
were
found
to
be
secure,
15
percent
avoidant,
9
percent
anxious
(also
known
as
ambivalent),
and
15
percent
disorganized.21
Interestingly,
this
large
study
showed
that
the
child’s
gender
and
basic
temperament
have
little
effect
on
attachment
style;
for
example,
children
with
“difficult”
temperaments
are
not
more
likely
to
develop
a
disorganized
style.
Kids
from
lower
socioeconomic
groups
are
more
likely
to
be
disorganized,22
with
parents
often
severely
stressed
by
economic
and
family
instability.
Children
who
don’t
feel
safe
in
infancy
have
trouble
regulating
their
moods
and
emotional
responses
as
they
grow
older.
By
kindergarten,
many
disorganized
infants
are
either
aggressive
or
spaced
out
and
disengaged,
and
they
go
on
to
develop
a
range
of
psychiatric
problems.23
They
also
show
more
physiological
stress,
as
expressed
in
heart
rate,
heart
rate
variability,24
stress
hormone
responses,
and
lowered
immune
factors.25
Does
this
kind
of
biological
dysregulation
automatically
reset
to
normal
as
a
child
matures
or
is
moved
to
a
safe
environment?
So
far
as
we
know,
it
does
not.
Parental
abuse
is
not
the
only
cause
of
disorganized
attachment:
Parents
who
are
preoccupied
with
their
own
trauma,
such
as
domestic
abuse
or
rape
or
the
recent
death
of
a
parent
or
sibling,
may
also
be
too
emotionally
unstable
and
inconsistent
to
offer
much
comfort
and
protection.26,27
While
all
parents
need
all
the
help
they
can
get
to
help
raise
secure
children,
traumatized
parents,
in
particular,
need
help
to
be
attuned
to
their
children’s
needs.
Caregivers
often
don’t
realize
that
they
are
out
of
tune.
I
vividly
remember
a
videotape
Beatrice
Beebe
showed
me.28
It
featured
a
young
mother
playing
with
her
three-month-old
infant.
Everything
was
going
well
until
the
baby
pulled
back
and
turned
his
head
away,
signaling
that
he
needed
a
break.
But
the
mother
did
not
pick
up
on
his
cue,
and
she
intensified
her
efforts
to
engage
him
by
bringing
her
face
closer
to
his
and
increasing
the
volume
of
her
voice.
When
he
recoiled
even
more,
she
kept
bouncing
and
poking
him.
Finally
he
started
to
scream,
at
which
point
the
mother
put
him
down
and
walked
away,
looking
crestfallen.
She
obviously
felt
terrible,
but
she
had
simply
missed
the
relevant
cues.
It’s
easy
to
imagine
how
this
kind
of
misattunement,
repeated
over
and
over
again,
can
gradually
lead
to
a
chronic
disconnection.
(Anyone
who’s
raised
a
colicky
or
hyperactive
baby
knows
how
quickly
stress
rises
when
nothing
seems
to
make
a
difference.)
Chronically
failing
to
calm
her
baby
down
and
establish
an
enjoyable
face-to-face
interaction,
the
mother
is
likely
to
come
to
perceive
him
as
a
difficult
child
who
makes
her
feel
like
a
failure,
and
give
up
on
trying
to
comfort
her
child.
In
practice
it
often
is
difficult
to
distinguish
the
problems
that
result
from
disorganized
attachment
from
those
that
result
from
trauma:
They
are
often
intertwined.
My
colleague
Rachel
Yehuda
studied
rates
of
PTSD
in
adult
New
Yorkers
who
had
been
assaulted
or
raped.29
Those
whose
mothers
were
Holocaust
survivors
with
PTSD
had
a
significantly
higher
rate
of
developing
serious
psychological
problems
after
these
traumatic
experiences.
The
most
reasonable
explanation
is
that
their
upbringing
had
left
them
with
a
vulnerable
physiology,
making
it
difficult
for
them
to
regain
their
equilibrium
after
being
violated.
Yehuda
found
a
similar
vulnerability
in
the
children
of
pregnant
women
who
were
in
the
World
Trade
Center
that
fatal
day
in
2001.30
Similarly,
the
reactions
of
children
to
painful
events
are
largely
determined
by
how
calm
or
stressed
their
parents
are.
My
former
student
Glenn
Saxe,
now
chairman
of
the
Department
of
Child
and
Adolescent
Psychiatry
at
NYU,
showed
that
when
children
were
hospitalized
for
treatment
of
severe
burns,
the
development
of
PTSD
could
be
predicted
by
how
safe
they
felt
with
their
mothers.31
The
security
of
their
attachment
to
their
mothers
predicted
the
amount
of
morphine
that
was
required
to
control
their
pain—the
more
secure
the
attachment,
the
less
painkiller
was
needed.
Another
colleague,
Claude
Chemtob,
who
directs
the
Family
Trauma
Research
Program
at
NYU
Langone
Medical
Center,
studied
112
New
York
City
children
who
had
directly
witnessed
the
terrorist
attacks
on
9/11.32
Children
whose
mothers
were
diagnosed
with
PTSD
or
depression
during
follow-up
were
six
times
more
likely
to
have
significant
emotional
problems
and
eleven
times
more
likely
to
be
hyperaggressive
in
response
to
their
experience.
Children
whose
fathers
had
PTSD
showed
behavioral
problems
as
well,
but
Chemtob
discovered
that
this
effect
was
indirect
and
was
transmitted
via
the
mother.
(Living
with
an
irascible,
withdrawn,
or
terrified
spouse
is
likely
to
impose
a
major
psychological
burden
on
the
partner,
including
depression.)
If
you
have
no
internal
sense
of
security,
it
is
difficult
to
distinguish
between
safety
and
danger.
If
you
feel
chronically
numbed
out,
potentially
dangerous
situations
may
make
you
feel
alive.
If
you
conclude
that
you
must
be
a
terrible
person
(because
why
else
would
your
parents
have
you
treated
that
way?),
you
start
expecting
other
people
to
treat
you
horribly.
You
probably
deserve
it,
and
anyway,
there
is
nothing
you
can
do
about
it.
When
disorganized
people
carry
self-perceptions
like
these,
they
are
set
up
to
be
traumatized
by
subsequent
experiences.33

THE
LONG-TERM
EFFECTS
OF
DISORGANIZED
ATTACHMENT
In
the
early
1980s
my
colleague
Karlen
Lyons-Ruth,
a
Harvard
attachment
researcher,
began
to
videotape
face-to-face
interactions
between
mothers
and
their
infants
at
six
months,
twelve
months
and
eighteen
months.
She
taped
them
again
when
the
children
were
five
years
old
and
once
more
when
they
were
seven
or
eight.34
All
were
from
high-risk
families:
100
percent
met
federal
poverty
guidelines,
and
almost
half
the
mothers
were
single
parents.
Disorganized
attachment
showed
up
in
two
different
ways:
One
group
of
mothers
seemed
to
be
too
preoccupied
with
their
own
issues
to
attend
to
their
infants.
They
were
often
intrusive
and
hostile;
they
alternated
between
rejecting
their
infants
and
acting
as
if
they
expected
them
to
respond
to
their
needs.
Another
group
of
mothers
seemed
helpless
and
fearful.
They
often
came
across
as
sweet
or
fragile,
but
they
didn’t
know
how
to
be
the
adult
in
the
relationship
and
seemed
to
want
their
children
to
comfort
them.
They
failed
to
greet
their
children
after
having
been
away
and
did
not
pick
them
up
when
the
children
were
distressed.
The
mothers
didn’t
seem
to
be
doing
these
things
deliberately—they
simply
didn’t
know
how
to
be
attuned
to
their
kids
and
respond
to
their
cues
and
thus
failed
to
comfort
and
reassure
them.
The
hostile/intrusive
mothers
were
more
likely
to
have
childhood
histories
of
physical
abuse
and/or
of
witnessing
domestic
violence,
while
the
withdrawn/dependent
mothers
were
more
likely
to
have
histories
of
sexual
abuse
or
parental
loss
(but
not
physical
abuse).35
I
have
always
wondered
how
parents
come
to
abuse
their
kids.
After
all,
raising
healthy
offspring
is
at
the
very
core
of
our
human
sense
of
purpose
and
meaning.
What
could
drive
parents
to
deliberately
hurt
or
neglect
their
children?
Karlen’s
research
provided
me
with
one
answer:
Watching
her
videos,
I
could
see
the
children
becoming
more
and
more
inconsolable,
sullen,
or
resistant
to
their
misattuned
mothers.
At
the
same
time,
the
mothers
became
increasingly
frustrated,
defeated,
and
helpless
in
their
interactions.
Once
the
mother
comes
to
see
the
child
not
as
her
partner
in
an
attuned
relationship
but
as
a
frustrating,
enraging,
disconnected
stranger,
the
stage
is
set
for
subsequent
abuse.
About
eighteen
years
later,
when
these
kids
were
around
twenty
years
old,
Lyons-Ruth
did
a
follow-up
study
to
see
how
they
were
coping.
Infants
with
seriously
disrupted
emotional
communication
patterns
with
their
mothers
at
eighteen
months
grew
up
to
become
young
adults
with
an
unstable
sense
of
self,
self-damaging
impulsivity
(including
excessive
spending,
promiscuous
sex,
substance
abuse,
reckless
driving,
and
binge
eating),
inappropriate
and
intense
anger,
and
recurrent
suicidal
behavior.
Karlen
and
her
colleagues
had
expected
that
hostile/intrusive
behavior
on
the
part
of
the
mothers
would
be
the
most
powerful
predictor
of
mental
instability
in
their
adult
children,
but
they
discovered
otherwise.
Emotional
withdrawal
had
the
most
profound
and
long-lasting
impact.
Emotional
distance
and
role
reversal
(in
which
mothers
expected
the
kids
to
look
after
them)
were
specifically
linked
to
aggressive
behavior
against
self
and
others
in
the
young
adults.

DISSOCIATION:
KNOWING
AND
NOT
KNOWING
Lyons-Ruth
was
particularly
interested
in
the
phenomenon
of
dissociation,
which
is
manifested
in
feeling
lost,
overwhelmed,
abandoned,
and
disconnected
from
the
world
and
in
seeing
oneself
as
unloved,
empty,
helpless,
trapped,
and
weighed
down.
She
found
a
“striking
and
unexpected”
relationship
between
maternal
disengagement
and
misattunement
during
the
first
two
years
of
life
and
dissociative
symptoms
in
early
adulthood.
Lyons-Ruth
concludes
that
infants
who
are
not
truly
seen
and
known
by
their
mothers
are
at
high
risk
to
grow
into
adolescents
who
are
unable
to
know
and
to
see.”36
Infants
who
live
in
secure
relationships
learn
to
communicate
not
only
their
frustrations
and
distress
but
also
their
emerging
selves—their
interests,
preferences,
and
goals.
Receiving
a
sympathetic
response
cushions
infants
(and
adults)
against
extreme
levels
of
frightened
arousal.
But
if
your
caregivers
ignore
your
needs,
or
resent
your
very
existence,
you
learn
to
anticipate
rejection
and
withdrawal.
You
cope
as
well
as
you
can
by
blocking
out
your
mother’s
hostility
or
neglect
and
act
as
if
it
doesn’t
matter,
but
your
body
is
likely
to
remain
in
a
state
of
high
alert,
prepared
to
ward
off
blows,
deprivation,
or
abandonment.
Dissociation
means
simultaneously
knowing
and
not
knowing.37
Bowlby
wrote:
“What
cannot
be
communicated
to
the
[m]other
cannot
be
communicated
to
the
self.”38
If
you
cannot
tolerate
what
you
know
or
feel
what
you
feel,
the
only
option
is
denial
and
dissociation.39
Maybe
the
most
devastating
long-term
effect
of
this
shutdown
is
not
feeling
real
inside,
a
condition
we
saw
in
the
kids
in
the
Children’s
Clinic
and
that
we
see
in
the
children
and
adults
who
come
to
the
Trauma
Center.
When
you
don’t
feel
real
nothing
matters,
which
makes
it
impossible
to
protect
yourself
from
danger.
Or
you
may
resort
to
extremes
in
an
effort
to
feel
something—
even
cutting
yourself
with
a
razor
blade
or
getting
into
fistfights
with
strangers.
Karlen’s
research
showed
that
dissociation
is
learned
early:
Later
abuse
or
other
traumas
did
not
account
for
dissociative
symptoms
in
young
adults.40
Abuse
and
trauma
accounted
for
many
other
problems,
but
not
for
chronic
dissociation
or
aggression
against
self.
The
critical
underlying
issue
was
that
these
patients
didn’t
know
how
to
feel
safe.
Lack
of
safety
within
the
early
caregiving
relationship
led
to
an
impaired
sense
of
inner
reality,
excessive
clinging,
and
self-damaging
behavior:
Poverty,
single
parenthood,
or
maternal
psychiatric
symptoms
did
not
predict
these
symptoms.
This
does
not
imply
that
child
abuse
is
irrelevant41,
but
that
the
quality
of
early
caregiving
is
critically
important
in
preventing
mental
health
problems,
independent
of
other
traumas.42
For
that
reason
treatment
needs
to
address
not
only
the
imprints
of
specific
traumatic
events
but
also
the
consequences
of
not
having
been
mirrored,
attuned
to,
and
given
consistent
care
and
affection:
dissociation
and
loss
of
self-regulation.

RESTORING
SYNCHRONY
Early
attachment
patterns
create
the
inner
maps
that
chart
our
relationships
throughout
life,
not
only
in
terms
of
what
we
expect
from
others,
but
also
in
terms
of
how
much
comfort
and
pleasure
we
can
experience
in
their
presence.
I
doubt
that
the
poet
e.
e.
cummings
could
have
written
his
joyous
lines
“i
like
my
body
when
it
is
with
your
body. . . .
muscles
better
and
nerves
more”
if
his
earliest
experiences
had
been
frozen
faces
and
hostile
glances.43
Our
relationship
maps
are
implicit,
etched
into
the
emotional
brain
and
not
reversible
simply
by
understanding
how
they
were
created.
You
may
realize
that
your
fear
of
intimacy
has
something
to
do
with
your
mother’s
postpartum
depression
or
with
the
fact
that
she
herself
was
molested
as
a
child,
but
that
alone
is
unlikely
to
open
you
to
happy,
trusting
engagement
with
others.
However,
that
realization
may
help
you
to
start
exploring
other
ways
to
connect
in
relationships—both
for
your
own
sake
and
in
order
to
not
pass
on
an
insecure
attachment
to
your
own
children.
In
part
5
I’ll
discuss
a
number
of
approaches
to
healing
damaged
attunement
systems
through
training
in
rhythmicity
and
reciprocity.44
Being
in
synch
with
oneself
and
with
others
requires
the
integration
of
our
body-based
senses—vision,
hearing,
touch,
and
balance.
If
this
did
not
happen
in
infancy
and
early
childhood,
there
is
an
increased
chance
of
later
sensory
integration
problems
(to
which
trauma
and
neglect
are
by
no
means
the
only
pathways).
Being
in
synch
means
resonating
through
sounds
and
movements
that
connect,
which
are
embedded
in
the
daily
sensory
rhythms
of
cooking
and
cleaning,
going
to
bed
and
waking
up.
Being
in
synch
may
mean
sharing
funny
faces
and
hugs,
expressing
delight
or
disapproval
at
the
right
moments,
tossing
balls
back
and
forth,
or
singing
together.
At
the
Trauma
Center,
we
have
developed
programs
to
coach
parents
in
connection
and
attunement,
and
my
patients
have
told
me
about
many
other
ways
to
get
themselves
in
synch,
ranging
from
choral
singing
and
ballroom
dancing
to
joining
basketball
teams,
jazz
bands
and
chamber
music
groups.
All
of
these
foster
a
sense
of
attunement
and
communal
pleasure.
 CHAPTER
8

TRAPPED
IN
RELATIONSHIPS:
THE
COST
OF
ABUSE
AND
NEGLECT

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

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

TERROR
AND
NUMBNESS
As
we
talked,
Marilyn
told
me
that
Michael
was
the
first
man
she’d
taken
home
in
more
than
five
years,
but
this
was
not
the
first
time
she’d
lost
control
when
a
man
spent
the
night
with
her.
She
repeated
that
she
always
felt
uptight
and
spaced
out
when
she
was
alone
with
a
man,
and
there
had
been
other
times
when
she’d
“come
to”
in
her
apartment,
cowering
in
a
corner,
unable
to
remember
clearly
what
had
happened.
Marilyn
also
said
she
felt
as
if
she
was
just
“going
through
the
motions”
of
having
a
life.
Except
for
when
she
was
at
the
club
playing
tennis
or
at
work
in
the
operating
room,
she
usually
felt
numb.
A
few
years
earlier
she’d
found
that
she
could
relieve
her
numbness
by
scratching
herself
with
a
razor
blade,
but
she
had
become
frightened
when
she
found
that
she
was
cutting
herself
more
and
more
deeply,
and
more
and
more
often,
to
get
relief.
She
had
tried
alcohol,
too,
but
that
reminded
her
of
her
dad
and
his
out-of-control
drinking,
which
made
her
feel
disgusted
with
herself.
So,
instead,
she
played
tennis
fanatically,
whenever
she
could.
That
made
her
feel
alive.
When
I
asked
her
about
her
past,
Marilyn
said
she
guessed
that
she
“must
have
had”
a
happy
childhood,
but
she
could
remember
very
little
from
before
age
twelve.
She
told
me
she’d
been
a
timid
adolescent,
until
she
had
a
violent
confrontation
with
her
alcoholic
father
when
she
was
sixteen
and
ran
away
from
home.
She
worked
her
way
through
community
college
and
went
on
to
get
a
degree
in
nursing
without
any
help
from
her
parents.
She
felt
ashamed
that
during
this
time
she’d
slept
around,
which
she
described
as
“looking
for
love
in
all
the
wrong
places.”

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

Truth,
like
love
and
sleep,
resents
Approaches
that
are
too
intense.1
 I
call
this
Auden’s
rule,
and
in
keeping
with
it
I
deliberately
did
not
push
Marilyn
to
tell
me
what
she
remembered.
In
fact,
I’ve
learned
that
it’s
not
important
for
me
to
know
every
detail
of
a
patient’s
trauma.
What
is
critical
is
that
the
patients
themselves
learn
to
tolerate
feeling
what
they
feel
and
knowing
what
they
know.
This
may
take
weeks
or
even
years.
I
decided
to
start
Marilyn’s
treatment
by
inviting
her
to
join
an
established
therapy
group
where
she
could
find
support
and
acceptance
before
facing
the
engine
of
her
distrust,
shame,
and
rage.
As
I
expected,
Marilyn
arrived
at
the
first
group
meeting
looking
terrified,
much
like
the
girl
in
her
family
portrait;
she
was
withdrawn
and
did
not
reach
out
to
anybody.
I’d
chosen
this
group
for
her
because
its
members
had
always
been
helpful
and
accepting
of
new
members
who
were
too
scared
to
talk.
They
knew
from
their
own
experience
that
unlocking
secrets
is
a
gradual
process.
But
this
time
they
surprised
me,
asking
so
many
intrusive
questions
about
Marilyn’s
love
life
that
I
recalled
her
drawing
of
the
little
girl
under
assault.
It
was
almost
as
though
Marilyn
had
unwittingly
enlisted
the
group
to
repeat
her
traumatic
past.
I
intervened
to
help
her
set
some
boundaries
about
what
she’d
talk
about,
and
she
began
to
settle
in.
Three
months
later
Marilyn
told
the
group
that
she
had
stumbled
and
fallen
a
few
times
on
the
sidewalk
between
the
subway
and
my
office.
She
worried
that
her
eyesight
was
beginning
to
fail:
She’d
also
been
missing
a
lot
of
tennis
balls
recently.
I
thought
again
about
her
drawing
and
the
wild
child
with
the
huge,
terrified
eyes.
Was
this
some
sort
of
“conversion
reaction,”
in
which
patients
express
their
conflicts
by
losing
function
in
some
part
of
their
body?
Many
soldiers
in
both
world
wars
had
suffered
paralysis
that
couldn’t
be
traced
to
physical
injuries,
and
I
had
seen
cases
of
“hysterical
blindness”
in
Mexico
and
India
Still,
as
a
physician,
I
wasn’t
about
to
conclude
without
further
assessment
that
this
was
“all
in
her
head.”
I
referred
her
to
colleagues
at
the
Massachusetts
Eye
and
Ear
Infirmary
and
asked
them
to
do
a
very
thorough
workup.
Several
weeks
later
the
tests
came
back.
Marilyn
had
lupus
erythematosus
of
her
retina,
an
autoimmune
disease
that
was
eroding
her
vision,
and
she
would
need
immediate
treatment.
I
was
appalled:
Marilyn
was
the
third
person
that
year
whom
I’d
suspected
of
having
an
incest
history
and
who
was
then
diagnosed
with
an
autoimmune
disease—a
disease
in
which
the
body
starts
attacking
itself.
 After
making
sure
that
Marilyn
was
getting
the
proper
medical
care,
I
consulted
with
two
of
my
colleagues
at
Massachusetts
General,
psychiatrist
Scott
Wilson
and
Richard
Kradin,
who
ran
the
immunology
laboratory
there.
I
told
them
Marilyn’s
story,
showed
them
the
picture
she’d
drawn,
and
asked
them
to
collaborate
on
a
study.
They
generously
volunteered
their
time
and
the
considerable
expense
of
a
full
immunology
workup.
We
recruited
twelve
women
with
incest
histories
who
were
not
taking
any
medications,
plus
twelve
women
who
had
never
been
traumatized
and
who
also
did
not
take
meds—a
surprisingly
difficult
control
group
to
find.
(Marilyn
was
not
in
the
study;
we
generally
do
not
ask
our
clinical
patients
to
be
part
of
our
research
efforts.)
When
the
study
was
completed
and
the
data
analyzed,
Rich
reported
that
the
group
of
incest
survivors
had
abnormalities
in
their
CD45
RA-to-
RO
ratio,
compared
with
their
nontraumatized
peers.
CD45
cells
are
the
“memory
cells”
of
the
immune
system.
Some
of
them,
called
RA
cells,
have
been
activated
by
past
exposure
to
toxins;
they
quickly
respond
to
environmental
threats
they
have
encountered
before.
The
RO
cells,
in
contrast,
are
kept
in
reserve
for
new
challenges;
they
are
turned
on
to
deal
with
threats
the
body
has
not
met
previously.
The
RA-to-RO
ratio
is
the
balance
between
cells
that
recognize
known
toxins
and
cells
that
wait
for
new
information
to
activate.
In
patients
with
histories
of
incest,
the
proportion
of
RA
cells
that
are
ready
to
pounce
is
larger
than
normal.
This
makes
the
immune
system
oversensitive
to
threat,
so
that
it
is
prone
to
mount
a
defense
when
none
is
needed,
even
when
this
means
attacking
the
body’s
own
cells.
Our
study
showed
that,
on
a
deep
level,
the
bodies
of
incest
victims
have
trouble
distinguishing
between
danger
and
safety.
This
means
that
the
imprint
of
past
trauma
does
not
consist
only
of
distorted
perceptions
of
information
coming
from
the
outside;
the
organism
itself
also
has
a
problem
knowing
how
to
feel
safe.
The
past
is
impressed
not
only
on
their
minds,
and
in
misinterpretations
of
innocuous
events
(as
when
Marilyn
attacked
Michael
because
he
accidentally
touched
her
in
her
sleep),
but
also
on
the
very
core
of
their
beings:
in
the
safety
of
their
bodies.2

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

LEARNING
TO
REMEMBER
About
a
year
into
Marilyn’s
group,
another
member,
Mary,
asked
permission
to
talk
about
what
had
happened
to
her
when
she
was
thirteen
years
old.
Mary
worked
as
a
prison
guard,
and
she
was
involved
in
a
sadomasochistic
relationship
with
another
woman.
She
wanted
the
group
to
know
her
background
in
the
hope
that
they
would
become
more
tolerant
of
her
extreme
reactions,
such
as
her
tendency
to
shut
down
or
blow
up
in
response
to
the
slightest
provocation.
Struggling
to
get
the
words
out,
Mary
told
us
that
one
evening,
when
she
was
thirteen
years
old,
she
was
raped
by
her
older
brother
and
a
gang
of
his
friends.
The
rape
resulted
in
pregnancy,
and
her
mother
gave
her
an
abortion
at
home,
on
the
kitchen
table.
The
group
sensitively
tuned
in
to
what
Mary
was
sharing
and
comforted
her
through
her
sobbing.
I
was
profoundly
moved
by
their
empathy—they
were
consoling
Mary
in
a
way
that
they
must
have
wished
somebody
had
comforted
them
when
they
first
confronted
their
traumas.
When
time
ran
out,
Marilyn
asked
if
she
could
take
a
few
more
minutes
to
talk
about
what
she
had
experienced
during
the
session.
The
group
agreed,
and
she
told
us:
“Hearing
that
story,
I
wonder
if
I
may
have
been
sexually
abused
myself.”
My
mouth
must
have
dropped
open.
Based
on
her
family
drawing,
I
had
always
assumed
that
she
was
aware,
at
least
on
some
level,
that
this
was
the
case.
She
had
reacted
like
an
incest
victim
in
her
response
to
Michael,
and
she
chronically
behaved
as
if
the
world
were
a
terrifying
place.
Yet
even
though
she’d
drawn
a
girl
who
was
being
sexually
molested,
she—or
at
least
her
cognitive,
verbal
self—had
no
idea
what
had
actually
happened
to
her.
Her
immune
system,
her
muscles,
and
her
fear
system
all
had
kept
the
score,
but
her
conscious
mind
lacked
a
story
that
could
communicate
the
experience.
She
reenacted
her
trauma
in
her
life,
but
she
had
no
narrative
to
refer
to.
As
we
will
see
in
chapter
12,
traumatic
memory
differs
in
complex
ways
from
normal
recall,
and
it
involves
many
layers
of
mind
and
brain.
Triggered
by
Mary’s
story,
and
spurred
on
by
the
nightmares
that
followed,
Marilyn
began
individual
therapy
with
me
in
which
she
started
to
deal
with
her
past.
At
first
she
experienced
waves
of
intense,
free-floating
terror.
She
tried
stopping
for
several
weeks,
but
when
she
found
she
could
no
longer
sleep
and
had
to
take
time
off
from
work,
she
continued
our
sessions.
As
she
told
me
later:
“My
only
criterion
for
whether
a
situation
is
harmful
is
feeling,
‘This
is
going
to
kill
me
if
I
don’t
get
out.’”
I
began
to
teach
Marilyn
calming
techniques,
such
as
focusing
on
breathing
deeply—in
and
out,
in
and
out,
at
six
breaths
a
minute—while
following
the
sensations
of
the
breath
in
her
body.
This
was
combined
with
tapping
acupressure
points,
which
helped
her
not
to
become
overwhelmed.
We
also
worked
on
mindfulness:
Learning
to
keep
her
mind
alive
while
allowing
her
body
to
feel
the
feelings
that
she
had
come
to
dread
slowly
enabled
Marilyn
to
stand
back
and
observe
her
experience,
rather
than
being
immediately
hijacked
by
her
feelings.
She
had
tried
to
dampen
or
abolish
those
feelings
with
alcohol
and
exercise,
but
now
she
began
to
feel
safe
enough
to
begin
to
remember
what
had
happened
to
her
as
a
girl.
As
she
gained
ownership
over
her
physical
sensations,
she
also
began
to
be
able
to
tell
the
difference
between
past
and
present:
Now
if
she
felt
someone’s
leg
brush
against
her
in
the
night,
she
might
be
able
to
recognize
it
as
Michael’s
leg,
the
leg
of
the
handsome
tennis
partner
she’d
invited
to
her
apartment.
That
leg
did
not
belong
to
anyone
else,
and
its
touch
didn’t
mean
someone
was
trying
to
molest
her.
Being
still
enabled
her
to
know—fully,
physically
know—that
she
was
a
thirty-four-year-old
woman
and
not
a
little
girl.
When
Marilyn
finally
began
to
access
her
memories,
they
emerged
as
flashbacks
of
the
wallpaper
in
her
childhood
bedroom.
She
realized
that
this
was
what
she
had
focused
on
when
her
father
raped
her
when
she
was
eight
years
old.
His
molestation
had
scared
her
beyond
her
capacity
to
endure,
so
she
had
needed
to
push
it
out
of
her
memory
bank.
After
all,
she
had
to
keep
living
with
this
man,
her
father,
who
had
assaulted
her.
Marilyn
remembered
having
turned
to
her
mother
for
protection,
but
when
she
ran
to
her
and
tried
to
hide
herself
by
burying
her
face
in
her
mother’s
skirt,
she
was
met
with
only
a
limp
embrace.
At
times
her
mother
remained
silent;
at
others
she
cried
or
angrily
scolded
Marilyn
for
“making
Daddy
so
angry.”
The
terrified
child
found
no
one
to
protect
her,
to
offer
strength
or
shelter.
As
Roland
Summit
wrote
in
his
classic
study
The
Child
Sexual
Abuse
Accommodation
Syndrome:
“Initiation,
intimidation,
stigmatization,
isolation,
helplessness
and
self-blame
depend
on
a
terrifying
reality
of
child
sexual
abuse.
Any
attempts
by
the
child
to
divulge
the
secret
will
be
countered
by
an
adult
conspiracy
of
silence
and
disbelief.
‘Don’t
worry
about
things
like
that;
that
could
never
happen
in
our
family.’
‘How
could
you
ever
think
of
such
a
terrible
thing?’
‘Don’t
let
me
ever
hear
you
say
anything
like
that
again!’
The
average
child
never
asks
and
never
tells.”3
After
forty
years
of
doing
this
work
I
still
regularly
hear
myself
saying,
“That’s
unbelievable,”
when
patients
tell
me
about
their
childhoods.
They
often
are
as
incredulous
as
I
am—how
could
parents
inflict
such
torture
and
terror
on
their
own
child?
Part
of
them
continues
to
insist
that
they
must
have
made
the
experience
up
or
that
they
are
exaggerating.
All
of
them
are
ashamed
about
what
happened
to
them,
and
they
blame
themselves—on
some
level
they
firmly
believe
that
these
terrible
things
were
done
to
them
because
they
are
terrible
people.
Marilyn
now
began
to
explore
how
the
powerless
child
had
learned
to
shut
down
and
comply
with
whatever
was
asked
of
her.
She
had
done
so
by
making
herself
disappear:
The
moment
she
heard
her
father’s
footsteps
in
the
corridor
outside
her
bedroom,
she
would
“put
her
head
in
the
clouds.”
Another
patient
of
mine
who
had
a
similar
experience
made
a
drawing
that
depicts
how
that
process
works.
When
her
father
started
to
touch
her,
she
made
herself
disappear;
she
floated
up
to
the
ceiling,
looking
down
on
some
other
little
girl
in
the
bed.4
She
was
glad
that
it
was
not
really
her—it
was
some
other
girl
who
was
being
molested.

Looking
at
these
heads
separated
from
their
bodies
by
an
impenetrable
fog
really
opened
my
eyes
to
the
experience
of
dissociation,
which
is
so
common
among
incest
victims.
Marilyn
herself
later
realized
that,
as
an
adult,
she
had
continued
to
float
up
to
the
ceiling
when
she
found
herself
in
a
sexual
situation.
In
the
period
when
she’d
been
more
sexually
active,
a
partner
would
occasionally
tell
her
how
amazing
she’d
been
in
bed—that
he’d
barely
recognized
her,
that
she’d
even
talked
differently.
Usually
she
did
not
remember
what
had
happened,
but
at
other
times
she’d
become
angry
and
aggressive.
She
had
no
sense
of
who
she
really
was
sexually,
so
she
gradually
withdrew
from
dating
altogether—until
Michael.
HATING
YOUR
HOME
Children
have
no
choice
who
their
parents
are,
nor
can
they
understand
that
parents
may
simply
be
too
depressed,
enraged,
or
spaced
out
to
be
there
for
them
or
that
their
parents’
behavior
may
have
little
to
do
with
them.
Children
have
no
choice
but
to
organize
themselves
to
survive
within
the
families
they
have.
Unlike
adults,
they
have
no
other
authorities
to
turn
to
for
help—their
parents
are
the
authorities.
They
cannot
rent
an
apartment
or
move
in
with
someone
else:
Their
very
survival
hinges
on
their
caregivers.
Children
sense—even
if
it
they
are
not
explicitly
threatened—that
if
they
talked
about
their
beatings
or
molestation
to
teachers
they
would
be
punished.
Instead,
they
focus
their
energy
on
not
thinking
about
what
has
happened
and
not
feeling
the
residues
of
terror
and
panic
in
their
bodies.
Because
they
cannot
tolerate
knowing
what
they
have
experienced,
they
also
cannot
understand
that
their
anger,
terror,
or
collapse
has
anything
to
do
with
that
experience.
They
don’t
talk;
they
act
and
deal
with
their
feelings
by
being
enraged,
shut
down,
compliant,
or
defiant.
Children
are
also
programmed
to
be
fundamentally
loyal
to
their
caretakers,
even
if
they
are
abused
by
them.
Terror
increases
the
need
for
attachment,
even
if
the
source
of
comfort
is
also
the
source
of
terror.
I
have
never
met
a
child
below
the
age
of
ten
who
was
tortured
at
home
(and
who
had
broken
bones
and
burned
skin
to
show
for
it)
who,
if
given
the
option,
would
not
have
chosen
to
stay
with
his
or
her
family
rather
than
being
placed
in
a
foster
home.
Of
course,
clinging
to
one’s
abuser
is
not
exclusive
to
childhood.
Hostages
have
put
up
bail
for
their
captors,
expressed
a
wish
to
marry
them,
or
had
sexual
relations
with
them;
victims
of
domestic
violence
often
cover
up
for
their
abusers.
Judges
often
tell
me
how
humiliated
they
feel
when
they
try
to
protect
victims
of
domestic
violence
by
issuing
restraining
orders,
only
to
find
out
that
many
of
them
secretly
allow
their
partners
to
return.
It
took
Marilyn
a
long
time
before
she
was
ready
to
talk
about
her
abuse:
She
was
not
ready
to
violate
her
loyalty
to
her
family—deep
inside
she
felt
that
she
still
needed
them
to
protect
her
against
her
fears.
The
price
of
this
loyalty
is
unbearable
feelings
of
loneliness,
despair,
and
the
inevitable
rage
of
helplessness.
Rage
that
has
nowhere
to
go
is
redirected
against
the
self,
in
the
form
of
depression,
self-hatred,
and
self-destructive
actions.
One
of
my
patients
told
me,
“It
is
like
hating
your
home,
your
kitchen
and
pots
and
pans,
your
bed,
your
chairs,
your
table,
your
rugs.”
Nothing
feels
safe—least
of
all
your
own
body.
Learning
to
trust
is
a
major
challenge.
One
of
my
other
patients,
a
schoolteacher
whose
grandfather
raped
her
repeatedly
before
she
was
six,
sent
me
the
following
e-mail:
“I
started
mulling
the
danger
of
opening
up
with
you
in
traffic
on
the
way
home
after
our
therapy
appointment,
and
then,
as
I
merged
into
Route
124,
I
realized
that
I
had
broken
the
rule
of
not
getting
attached,
to
you
and
to
my
students.”
During
our
next
meeting
she
told
me
she
had
also
been
raped
by
her
lab
instructor
in
college.
I
asked
her
whether
she
had
sought
help
and
made
a
complaint
against
him.
“I
couldn’t
make
myself
cross
the
road
to
the
clinic,”
she
replied.
“I
was
desperate
for
help,
but
as
I
stood
there,
I
felt
very
deeply
that
I
would
only
be
hurt
even
more.
And
that
might
well
have
been
true.
Of
course,
I
had
to
hide
what
had
happened
from
my
parents—
and
from
everyone
else.”
After
I
told
her
that
I
was
concerned
about
what
was
going
on
with
her,
she
wrote
me
another
e-mail:
“I’m
trying
to
remind
myself
that
I
didn’t
do
anything
to
deserve
such
treatment.
I
don’t
think
I
have
ever
had
anyone
look
at
me
like
that
and
say
they
were
worried
about
me,
and
I
am
holding
on
to
it
like
a
treasure:
the
idea
that
I
am
worth
being
worried
about
by
someone
I
respect
and
who
does
understand
how
deeply
I
am
struggling
now.”
In
order
to
know
who
we
are—to
have
an
identity—we
must
know
(or
at
least
feel
that
we
know)
what
is
and
what
was
“real.”
We
must
observe
what
we
see
around
us
and
label
it
correctly;
we
must
also
be
able
trust
our
memories
and
be
able
to
tell
them
apart
from
our
imagination.
Losing
the
ability
to
make
these
distinctions
is
one
sign
of
what
psychoanalyst
William
Niederland
called
“soul
murder.”
Erasing
awareness
and
cultivating
denial
are
often
essential
to
survival,
but
the
price
is
that
you
lose
track
of
who
you
are,
of
what
you
are
feeling,
and
of
what
and
whom
you
can
trust.5

REPLAYING
THE
TRAUMA
One
memory
of
Marilyn’s
childhood
trauma
came
to
her
in
a
dream
in
which
she
felt
as
if
she
were
being
choked
and
was
unable
to
breathe.
A
white
tea
towel
was
wrapped
around
her
hands,
and
then
she
was
lifted
up
with
the
towel
around
her
neck,
so
that
she
could
not
touch
the
ground
with
her
feet.
She
woke
in
a
panic,
thinking
that
she
was
surely
going
to
die.
Her
dream
reminded
me
of
the
nightmares
war
veterans
had
reported
to
me:
seeing
the
precise,
unadulterated
images
of
faces
and
body
parts
they
had
encountered
in
battle.
These
dreams
were
so
terrifying
that
they
tried
to
not
fall
asleep
at
night;
only
daytime
napping,
which
was
not
associated
with
nocturnal
ambushes,
felt
halfway
safe.
During
this
stage
of
therapy
Marilyn
was
repeatedly
flooded
with
images
and
sensations
related
to
the
choking
dream.
She
remembered
sitting
in
the
kitchen
as
a
four-year-old
with
swollen
eyes,
a
sore
neck,
and
a
bloody
nose,
while
her
father
and
brother
laughed
at
her
and
called
her
a
stupid,
stupid
girl.
One
day
Marilyn
reported,
“As
I
was
brushing
my
teeth
last
evening,
I
was
overcome
with
feelings
of
thrashing
around.
I
was
like
a
fish
out
of
water,
violently
turning
my
body
as
I
fought
against
the
lack
of
air.
I
sobbed
and
choked
as
I
brushed
my
teeth.
Panic
was
rising
up
out
of
my
chest
with
the
feeling
of
thrashing.
I
had
to
use
every
bit
of
strength
I
had
not
to
scream,
‘NONONONONONO,’
as
I
stood
over
the
sink.”
She
went
to
bed
and
fell
asleep
but
woke
up
like
clockwork
every
two
hours
during
the
rest
of
the
night.
Trauma
is
not
stored
as
a
narrative
with
an
orderly
beginning,
middle,
and
end.
As
I’ll
discuss
in
detail
in
chapters
11
and
12,
memories
initially
return
as
they
did
for
Marilyn:
as
flashbacks
that
contain
fragments
of
the
experience,
isolated
images,
sounds,
and
body
sensations
that
initially
have
no
context
other
than
fear
and
panic.
When
Marilyn
was
a
child,
she
had
no
way
of
giving
voice
to
the
unspeakable,
and
it
would
have
made
no
difference
anyway—nobody
was
listening.
Like
so
many
survivors
of
childhood
abuse,
Marilyn
exemplified
the
power
of
the
life
force,
the
will
to
live
and
to
own
one’s
life,
the
energy
that
counteracts
the
annihilation
of
trauma.
I
gradually
came
to
realize
that
the
only
thing
that
makes
it
possible
to
do
the
work
of
healing
trauma
is
awe
at
the
dedication
to
survival
that
enabled
my
patients
to
endure
their
abuse
and
then
to
endure
the
dark
nights
of
the
soul
that
inevitably
occur
on
the
road
to
recovery.
 CHAPTER
9

WHAT’S
LOVE
GOT
TO
DO
WITH
IT?

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

H ow
do
we
organize
our
thinking
with
regard
to
individuals
like
Marilyn,
Mary,
and
Kathy,
and
what
can
we
do
to
help
them?
The
way
we
define
their
problems,
our
diagnosis,
will
determine
how
we
approach
their
care.
Such
patients
typically
receive
five
or
six
different
unrelated
diagnoses
in
the
course
of
their
psychiatric
treatment.
If
their
doctors
focus
on
their
mood
swings,
they
will
be
identified
as
bipolar
and
prescribed
lithium
or
valproate.
If
the
professionals
are
most
impressed
with
their
despair,
they
will
be
told
they
are
suffering
from
major
depression
and
given
antidepressants.
If
the
doctors
focus
on
their
restlessness
and
lack
of
attention,
they
may
be
categorized
as
ADHD
and
treated
with
Ritalin
or
other
stimulants.
And
if
the
clinic
staff
happens
to
take
a
trauma
history,
and
the
patient
actually
volunteers
the
relevant
information,
he
or
she
might
receive
the
diagnosis
of
PTSD.
None
of
these
diagnoses
will
be
completely
off
the
mark,
and
none
of
them
will
begin
to
meaningfully
describe
who
these
patients
are
and
what
they
suffer
from.
 Psychiatry,
as
a
subspecialty
of
medicine,
aspires
to
define
mental
illness
as
precisely
as,
let’s
say,
cancer
of
the
pancreas,
or
streptococcal
infection
of
the
lungs.
However,
given
the
complexity
of
mind,
brain,
and
human
attachment
systems,
we
have
not
come
even
close
to
achieving
that
sort
of
precision.
Understanding
what
is
“wrong”
with
people
currently
is
more
a
question
of
the
mind-set
of
the
practitioner
(and
of
what
insurance
companies
will
pay
for)
than
of
verifiable,
objective
facts.
The
first
serious
attempt
to
create
a
systematic
manual
of
psychiatric
diagnoses
occurred
in
1980,
with
the
release
of
the
third
edition
of
the
Diagnostic
and
Statistical
Manual
of
Mental
Disorders,
the
official
list
of
all
mental
diseases
recognized
by
the
American
Psychiatric
Association
(APA).
The
preamble
to
the
DSM-III
warned
explicitly
that
its
categories
were
insufficiently
precise
to
be
used
in
forensic
settings
or
for
insurance
purposes.
Nonetheless
it
gradually
became
an
instrument
of
enormous
power:
Insurance
companies
require
a
DSM
diagnosis
for
reimbursement,
until
recently
all
research
funding
was
based
on
DSM
diagnoses,
and
academic
programs
are
organized
around
DSM
categories.
DSM
labels
quickly
found
their
way
into
the
larger
culture
as
well.
Millions
of
people
know
that
Tony
Soprano
suffered
from
panic
attacks
and
depression
and
that
Carrie
Mathison
of
Homeland
struggles
with
bipolar
disorder.
The
manual
has
become
a
virtual
industry
that
has
earned
the
American
Psychiatric
Association
well
over
$100
million.1
The
question
is:
Has
it
provided
comparable
benefits
for
the
patients
it
is
meant
to
serve?
A
psychiatric
diagnosis
has
serious
consequences:
Diagnosis
informs
treatment,
and
getting
the
wrong
treatment
can
have
disastrous
effects.
Also,
a
diagnostic
label
is
likely
to
attach
to
people
for
the
rest
of
their
lives
and
have
a
profound
influence
on
how
they
define
themselves.
I
have
met
countless
patients
who
told
me
that
they
“are”
bipolar
or
borderline
or
that
they
“have”
PTSD,
as
if
they
had
been
sentenced
to
remain
in
an
underground
dungeon
for
the
rest
of
their
lives,
like
the
Count
of
Monte
Cristo.
None
of
these
diagnoses
takes
into
account
the
unusual
talents
that
many
of
our
patients
develop
or
the
creative
energies
they
have
mustered
to
survive.
All
too
often
diagnoses
are
mere
tallies
of
symptoms,
leaving
patients
such
as
Marilyn,
Kathy,
and
Mary
likely
to
be
viewed
as
out-of-
control
women
who
need
to
be
straightened
out.
 The
dictionary
defines
diagnosis
as
“a.
The
act
or
process
of
identifying
or
determining
the
nature
and
cause
of
a
disease
or
injury
through
evaluation
of
patient
history,
examination,
and
review
of
laboratory
data.
b.
The
opinion
derived
from
such
an
evaluation.”2
In
this
chapter,
and
the
next,
I
will
discuss
the
chasm
between
official
diagnoses
and
what
our
patients
actually
suffer
from
and
discuss
how
my
colleagues
and
I
have
tried
to
change
the
way
patients
with
chronic
trauma
histories
are
diagnosed.

HOW
DO
YOU
TAKE
A
TRAUMA
HISTORY?
In
1985
I
started
to
collaborate
with
psychiatrist
Judith
Herman,
whose
first
book,
Father-Daughter
Incest,
had
recently
been
published.
We
were
both
working
at
Cambridge
Hospital
(one
of
Harvard’s
teaching
hospitals)
and,
sharing
an
interest
in
how
trauma
had
affected
the
lives
of
our
patients,
we
began
to
meet
regularly
and
compare
notes.
We
were
struck
by
how
many
of
our
patients
who
were
diagnosed
with
borderline
personality
disorder
(BPD)
told
us
horror
stories
about
their
childhoods.
BPD
is
marked
by
clinging
but
highly
unstable
relationships,
extreme
mood
swings,
and
self-
destructive
behavior,
including
self-mutilation
and
repeated
suicide
attempts.
In
order
to
uncover
whether
there
was,
in
fact,
a
relationship
between
childhood
trauma
and
BPD,
we
designed
a
formal
scientific
study
and
sent
off
a
grant
proposal
to
the
National
Institutes
of
Health.
It
was
rejected.
Undeterred,
Judy
and
I
decided
to
finance
the
study
ourselves,
and
we
found
an
ally
in
Chris
Perry,
the
director
of
research
at
Cambridge
Hospital,
who
was
funded
by
the
National
Institutes
of
Mental
Health
to
study
BPD
and
other
near
neighbor
diagnoses,
so
called
personality
disorders,
in
patients
recruited
from
the
Cambridge
Hospital.
He
had
collected
volumes
of
valuable
data
on
these
subjects
but
had
never
inquired
about
childhood
abuse
and
neglect.
Even
though
he
did
not
hide
his
skepticism
about
our
proposal,
he
was
very
generous
to
us
and
arranged
for
us
to
interview
fifty-
five
patients
from
the
hospital’s
outpatient
department,
and
he
agreed
to
compare
our
findings
with
records
in
the
large
database
he
had
already
collected.
 The
first
question
Judy
and
I
faced
was:
How
do
you
take
a
trauma
history?
You
can’t
ask
a
patient
point
blank:
“Were
you
molested
as
a
kid?”
or
“Did
your
father
beat
you
up?”
How
many
would
trust
a
complete
stranger
with
such
delicate
information?
Keeping
in
mind
that
people
universally
feel
ashamed
about
the
traumas
they
have
experienced,
we
designed
an
interview
instrument,
the
Traumatic
Antecedents
Questionnaire
(TAQ).3
The
interview
started
with
a
series
of
simple
questions:
“Where
do
you
live,
and
who
do
you
live
with?”;
“Who
pays
the
bills
and
who
does
the
cooking
and
cleaning?”
It
progressed
gradually
to
more
revealing
questions:
“Who
do
you
rely
on
in
your
daily
life?”
As
in:
When
you’re
sick,
who
does
the
shopping
or
takes
you
to
the
doctor?
“Who
do
you
talk
to
when
you
are
upset?”
In
other
words,
who
provides
you
with
emotional
and
practical
support?
Some
patients
gave
us
surprising
answers:
“my
dog”
or
“my
therapist”—or
“nobody.”
We
then
asked
similar
questions
about
their
childhood:
Who
lived
in
the
household?
How
often
did
you
move?
Who
was
your
primary
caretaker?
Many
of
the
patients
reported
frequent
relocations
that
required
them
to
change
schools
in
the
middle
of
the
year.
Several
had
primary
caregivers
who
had
gone
to
jail,
been
placed
in
a
mental
hospital,
or
joined
the
military.
Others
had
moved
from
foster
home
to
foster
home
or
had
lived
with
a
string
of
different
relatives.
The
next
section
of
the
questionnaire
addressed
childhood
relationships:
“Who
in
your
family
was
affectionate
to
you?”
“Who
treated
you
as
a
special
person?”
This
was
followed
by
a
critical
question—one
that,
to
my
knowledge,
had
never
before
been
asked
in
a
scientific
study:
“Was
there
anybody
who
you
felt
safe
with
growing
up?”
One
out
of
four
patients
we
interviewed
could
not
recall
anyone
they
had
felt
safe
with
as
a
child.
We
checked
“nobody”
on
our
work
sheets
and
did
not
comment,
but
we
were
stunned.
Imagine
being
a
child
and
not
having
a
source
of
safety,
making
your
way
into
the
world
unprotected
and
unseen.
The
questions
continued:
“Who
made
the
rules
at
home
and
enforced
the
discipline?”
“How
were
kids
kept
in
line—by
talking,
scolding,
spanking,
hitting,
locking
you
up?”
“How
did
your
parents
solve
their
disagreements?”
By
then
the
floodgates
had
usually
opened,
and
many
patients
were
volunteering
detailed
information
about
their
childhoods.
One
woman
had
witnessed
her
little
sister
being
raped;
another
told
us
she’d
had
her
first
sexual
experience
at
age
eight—with
her
grandfather.
Men
and
women
reported
lying
awake
at
night
listening
to
furniture
crashing
and
parents
screaming;
a
young
man
had
come
down
to
the
kitchen
and
found
his
mother
lying
in
a
pool
of
blood.
Others
talked
about
not
being
picked
up
at
elementary
school
or
coming
home
to
find
an
empty
house
and
spending
the
night
alone.
One
woman
who
made
her
living
as
a
cook
had
learned
to
prepare
meals
for
her
family
after
her
mother
was
jailed
on
a
drug
conviction.
Another
had
been
nine
when
she
grabbed
and
steadied
the
car’s
steering
wheel
because
her
drunken
mother
was
swerving
down
a
four-lane
highway
during
rush
hour.
Our
patients
did
not
have
the
option
to
run
away
or
escape;
they
had
nobody
to
turn
to
and
no
place
to
hide.
Yet
they
somehow
had
to
manage
their
terror
and
despair.
They
probably
went
to
school
the
next
morning
and
tried
to
pretend
that
everything
was
fine.
Judy
and
I
realized
that
the
BPD
group’s
problems—dissociation,
desperate
clinging
to
whomever
might
be
enlisted
to
help—had
probably
started
off
as
ways
of
dealing
with
overwhelming
emotions
and
inescapable
brutality.
After
our
interviews
Judy
and
I
met
to
code
our
patients’
answers—that
is,
to
translate
them
into
numbers
for
computer
analysis,
and
Chris
Perry
then
collated
them
with
the
extensive
information
on
these
patients
he
had
stored
on
Harvard’s
mainframe
computer.
One
Saturday
morning
in
April
he
left
us
a
message
asking
us
to
come
to
his
office.
There
we
found
a
huge
stack
of
printouts,
on
top
of
which
Chris
had
placed
a
Gary
Larson
cartoon
of
a
group
of
scientists
studying
dolphins
and
being
puzzled
by
“those
strange
‘aw
blah
es
span
yol’
sounds.”
The
data
had
convinced
him
that
unless
you
understand
the
language
of
trauma
and
abuse,
you
cannot
really
understand
BPD.
As
we
later
reported
in
the
American
Journal
of
Psychiatry,
81
percent
of
the
patients
diagnosed
with
BPD
at
Cambridge
Hospital
reported
severe
histories
of
child
abuse
and/or
neglect;
in
the
vast
majority
the
abuse
began
before
age
seven.4
This
finding
was
particularly
important
because
it
suggested
that
the
impact
of
abuse
depends,
at
least
in
part,
on
the
age
at
which
it
begins.
Later
research
by
Martin
Teicher
at
McLean
Hospital
showed
that
different
forms
of
abuse
have
different
impacts
on
various
brain
areas
at
different
stages
of
development.5
Although
numerous
studies
have
since
replicated
our
findings,6
I
still
regularly
get
scientific
papers
to
review
that
say
things
like
“It
has
been
hypothesized
that
borderline
patients
may
have
histories
of
childhood
trauma.”
When
does
a
hypothesis
become
a
scientifically
established
fact?
Our
study
clearly
supported
the
conclusions
of
John
Bowlby.

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

Bowlby
noticed
that
when
children
must
disown
powerful
experiences
they
have
had,
this
creates
serious
problems,
including
“chronic
distrust
of
other
people,
inhibition
of
curiosity,
distrust
of
their
own
senses,
and
the
tendency
to
find
everything
unreal.”7
As
we
will
see,
this
has
important
implications
for
treatment.
Our
study
expanded
our
thinking
beyond
the
impact
of
particular
horrendous
events,
the
focus
of
the
PTSD
diagnosis,
to
look
at
the
long-
term
effects
of
brutalization
and
neglect
in
caregiving
relationships.
It
also
raised
another
critical
question:
What
therapies
are
effective
for
people
with
a
history
of
abuse,
particularly
those
who
feel
chronically
suicidal
and
deliberately
hurt
themselves?

SELF-HARM
During
my
training
I
was
called
from
my
bed
at
around
3:00
a.m.
three
nights
in
a
row
to
stitch
up
a
woman
who
had
slashed
her
neck
with
whatever
sharp
object
she
could
lay
her
hands
on.
She
told
me,
somewhat
triumphantly,
that
cutting
herself
made
her
feel
much
better.
Ever
since
then
I’d
asked
myself
why.
Why
do
some
people
deal
with
being
upset
by
playing
three
sets
of
tennis
or
drinking
a
stiff
martini,
while
others
carve
their
arms
with
razor
blades?
Our
study
showed
that
having
a
history
of
childhood
sexual
and
physical
abuse
was
a
strong
predictor
of
repeated
suicide
attempts
and
self-cutting.8
I
wondered
if
their
suicidal
ruminations
had
started
when
they
were
very
young
and
whether
they
had
found
comfort
in
plotting
their
escape
by
hoping
to
die
or
doing
damage
to
themselves.
Does
inflicting
harm
on
oneself
begin
as
a
desperate
attempt
to
gain
some
sense
of
control?
Chris
Perry’s
database
had
follow-up
information
on
all
the
patients
who
were
treated
in
the
hospital’s
outpatient
clinics,
including
reports
on
suicidality
and
self-destructive
behavior.
After
three
years
of
therapy
approximately
two-thirds
of
the
patients
had
markedly
improved.
Now
the
question
was,
which
members
of
the
group
had
benefited
from
therapy
and
which
had
continued
to
feel
suicidal
and
self-destructive?
Comparing
the
patients’
ongoing
behavior
with
our
TAQ
interviews
provided
some
answers.
The
patients
who
remained
self-destructive
had
told
us
that
they
did
not
remember
feeling
safe
with
anybody
as
a
child;
they
had
reported
being
abandoned,
shuttled
from
place
to
place,
and
generally
left
to
their
own
devices.
I
concluded
that,
if
you
carry
a
memory
of
having
felt
safe
with
somebody
long
ago,
the
traces
of
that
earlier
affection
can
be
reactivated
in
attuned
relationships
when
you
are
an
adult,
whether
these
occur
in
daily
life
or
in
good
therapy.
However,
if
you
lack
a
deep
memory
of
feeling
loved
and
safe,
the
receptors
in
the
brain
that
respond
to
human
kindness
may
simply
fail
to
develop.9
If
that
is
the
case,
how
can
people
learn
to
calm
themselves
down
and
feel
grounded
in
their
bodies?
Again,
this
has
important
implications
for
therapy,
and
I’ll
return
to
this
question
throughout
part
5,
on
treatment.

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

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

One
out
of
ten
individuals
responded
yes
to
the
question
“Did
a
parent
or
other
adult
in
the
household
often
or
very
often
swear
at
you,
insult
you,
or
put
you
down?”
More
than
a
quarter
responded
yes
to
the
questions
“Did
one
of
your
parents
often
or
very
often
push,
grab,
slap,
or
throw
something
at
you?”
and
“Did
one
of
your
parents
often
or
very
often
hit
you
so
hard
that
you
had
marks
or
were
injured?”
In
other
words,
more
than
a
quarter
of
the
U.S.
population
is
likely
to
have
been
repeatedly
physically
abused
as
a
child.
To
the
questions
“Did
an
adult
or
person
at
least
5
years
older
ever
have
you
touch
their
body
in
a
sexual
way?”
and
“Did
an
adult
or
person
at
least
5
years
older
ever
attempt
oral,
anal,
or
vaginal
intercourse
with
you?”
28
percent
of
women
and
16
percent
of
men
responded
affirmatively.
One
in
eight
people
responded
positively
to
the
questions:
“As
a
child,
did
you
witness
your
mother
sometimes,
often,
or
very
often
pushed,
grabbed,
slapped,
or
had
something
thrown
at
her?”
“As
a
child,
did
you
witness
your
mother
sometimes,
often,
or
very
often
kicked,
bitten,
hit
with
a
fist,
or
hit
with
something
hard?”15

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

WHEN
PROBLEMS
ARE
REALLY
SOLUTIONS
Twelve
years
after
he
originally
treated
her,
Felitti
again
saw
the
woman
whose
dramatic
weight
loss
and
gain
had
started
him
on
his
quest.
She
told
him
that
she’d
subsequently
had
bariatric
surgery
but
that
after
she’d
lost
ninety-six
pounds
she’d
become
suicidal.
It
had
taken
five
psychiatric
hospitalizations
and
three
courses
of
electroshock
to
control
her
suicidality.
Felitti
points
out
that
obesity,
which
is
considered
a
major
public
health
problem,
may
in
fact
be
a
personal
solution
for
many.
Consider
the
implications:
If
you
mistake
someone’s
solution
for
a
problem
to
be
eliminated,
not
only
are
they
likely
to
fail
treatment,
as
often
happens
in
addiction
programs,
but
other
problems
may
emerge.
 One
female
rape
victim
told
Felitti,
“Overweight
is
overlooked,
and
that’s
the
way
I
need
to
be.”19
Weight
can
protect
men,
as
well.
Felitti
recalls
two
guards
at
a
state
prison
in
his
obesity
program.
They
promptly
regained
the
weight
they
had
lost,
because
they
felt
a
lot
safer
being
the
biggest
guy
on
the
cellblock.
Another
male
patient
became
obese
after
his
parents
divorced
and
he
moved
in
with
his
violent
alcoholic
grandfather.
He
explained:
“It
wasn’t
that
I
ate
because
I
was
hungry
and
all
of
that.
It
was
just
a
place
for
me
to
feel
safe.
All
the
way
from
kindergarten
I
used
to
get
beat
up
all
the
time.
When
I
got
the
weight
on
it
didn’t
happen
anymore.”
The
ACE
study
group
concluded:
“Although
widely
understood
to
be
harmful
to
health,
each
adaptation
[such
as
smoking,
drinking,
drugs,
obesity]
is
notably
difficult
to
give
up.
Little
consideration
is
given
to
the
possibility
that
many
long-term
health
risks
might
also
be
personally
beneficial
in
the
short
term.
We
repeatedly
hear
from
patients
of
the
benefits
of
these
‘health
risks.’
The
idea
of
the
problem
being
a
solution,
while
understandably
disturbing
to
many,
is
certainly
in
keeping
with
the
fact
that
opposing
forces
routinely
coexist
in
biological
systems. . . .
What
one
sees,
the
presenting
problem,
is
often
only
the
marker
for
the
real
problem,
which
lies
buried
in
time,
concealed
by
patient
shame,
secrecy
and
sometimes
amnesia—and
frequently
clinician
discomfort.”

CHILD
ABUSE:
OUR
NATION’S
LARGEST
PUBLIC
HEALTH
PROBLEM
The
first
time
I
heard
Robert
Anda
present
the
results
of
the
ACE
study,
he
could
not
hold
back
his
tears.
In
his
career
at
the
CDC
he
had
previously
worked
in
several
major
risk
areas,
including
tobacco
research
and
cardiovascular
health.
But
when
the
ACE
study
data
started
to
appear
on
his
computer
screen,
he
realized
that
they
had
stumbled
upon
the
gravest
and
most
costly
public
health
issue
in
the
United
States:
child
abuse.
He
had
calculated
that
its
overall
costs
exceeded
those
of
cancer
or
heart
disease
and
that
eradicating
child
abuse
in
America
would
reduce
the
overall
rate
of
depression
by
more
than
half,
alcoholism
by
two-thirds,
and
suicide,
IV
drug
use,
and
domestic
violence
by
three-quarters.20
It
would
also
have
a
dramatic
effect
on
workplace
performance
and
vastly
decrease
the
need
for
incarceration.
When
the
surgeon
general’s
report
on
smoking
and
health
was
published
in
1964,
it
unleashed
a
decades-long
legal
and
medical
campaign
that
has
changed
daily
life
and
long-term
health
prospects
for
millions.
The
number
of
American
smokers
fell
from
42
percent
of
adults
in
1965
to
19
percent
in
2010,
and
it
is
estimated
that
nearly
800,000
deaths
from
lung
cancer
were
prevented
between
1975
and
2000.21
The
ACE
study,
however,
has
had
no
such
effect.
Follow-up
studies
and
papers
are
still
appearing
around
the
world,
but
the
day-to-day
reality
of
children
like
Marilyn
and
the
children
in
outpatient
clinics
and
residential
treatment
centers
around
the
country
remains
virtually
the
same.
Only
now
they
receive
high
doses
of
psychotropic
agents,
which
makes
them
more
tractable
but
which
also
impairs
their
ability
to
feel
pleasure
and
curiosity,
to
grow
and
develop
emotionally
and
intellectually,
and
to
become
contributing
members
of
society.
 CHAPTER
10

DEVELOPMENTAL
TRAUMA:
THE
HIDDEN
EPIDEMIC

The
notion
that
early
childhood
adverse
experiences
lead
to
substantial
developmental
disruptions
is
more
clinical
intuition
than
a
research-based
fact.
There
is
no
known
evidence
of
developmental
disruptions
that
were
preceded
in
time
in
a
causal
fashion
by
any
type
of
trauma
syndrome.
—From
the
American
Psychiatric
Association’s
rejection
of
a
Developmental
Trauma
Disorder
diagnosis,
May
2011

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

T here
are
hundreds
of
thousands
of
children
like
the
ones
I
am
about
to
describe,
and
they
absorb
enormous
resources,
often
without
appreciable
benefit.
They
end
up
filling
our
jails,
our
welfare
rolls,
and
our
medical
clinics.
Most
of
the
public
knows
them
only
as
statistics.
Tens
of
thousands
of
schoolteachers,
probation
officers,
welfare
workers,
judges,
and
mental
health
professionals
spend
their
days
trying
to
help
them,
and
the
taxpayer
pays
the
bills.
Anthony
was
only
two
and
a
half
when
he
was
referred
to
our
Trauma
Center
by
a
child-care
center
because
its
employees
could
not
manage
his
constant
biting
and
pushing,
his
refusal
to
take
naps,
and
his
intractable
crying,
head
banging,
and
rocking.
He
did
not
feel
safe
with
any
staff
member
and
fluctuated
between
despondent
collapse
and
angry
defiance.
When
we
met
with
him
and
his
mother,
he
anxiously
clung
to
her,
hiding
his
face,
while
she
kept
saying,
“Don’t
be
such
a
baby.”
He
startled
when
a
door
banged
somewhere
down
the
corridor
and
then
burrowed
deeper
into
his
mom’s
lap.
When
she
pushed
him
away,
he
sat
in
a
corner
and
started
to
bang
his
head.
“He
just
does
that
to
bug
me,”
his
mother
remarked.
When
we
asked
about
her
own
background,
she
told
us
that
she’d
been
abandoned
by
her
parents
and
raised
by
a
series
of
relatives
who
hit
her,
ignored
her,
and
started
to
sexually
abuse
her
at
age
thirteen.
She’d
become
pregnant
by
a
drunken
boyfriend
who
left
her
when
she
told
him
she
was
carrying
his
child.
Anthony
was
just
like
his
father,
she
said—a
good-for-nothing.
She
had
had
numerous
violent
rows
with
subsequent
boyfriends,
but
she
was
sure
that
this
had
happened
too
late
at
night
for
Anthony
to
notice.
If
Anthony
were
admitted
to
a
hospital,
he
would
likely
be
diagnosed
with
a
host
of
different
psychiatric
disorders:
depression,
oppositional
defiant
disorder,
anxiety,
reactive
attachment
disorder,
ADHD,
and
PTSD.
None
of
these
diagnoses,
however,
would
clarify
what
was
wrong
with
Anthony:
that
he
was
scared
to
death
and
fighting
for
his
life,
and
he
did
not
trust
that
his
mother
could
help
him.
Then
there’s
Maria,
a
fifteen-year-old
Latina,
one
of
the
more
than
half
a
million
kids
in
the
United
States
who
grow
up
in
foster
care
and
residential
treatment
programs.
Maria
is
obese
and
aggressive.
She
has
a
history
of
sexual,
physical,
and
emotional
abuse
and
has
lived
in
more
than
twenty
out-of-home
placements
since
age
eight.
The
pile
of
medical
charts
that
arrived
with
her
described
her
as
mute,
vengeful,
impulsive,
reckless,
and
self-harming,
with
extreme
mood
swings
and
an
explosive
temper.
She
describes
herself
as
“garbage,
worthless,
rejected.”
 After
multiple
suicide
attempts
Maria
was
placed
in
one
of
our
residential
treatment
centers.
Initially
she
was
mute
and
withdrawn
and
became
violent
when
people
got
too
close
to
her.
After
other
approaches
failed
to
work,
she
was
placed
in
an
equine
therapy
program
where
she
groomed
her
horse
daily
and
learned
simple
dressage.
Two
years
later
I
spoke
with
Maria
at
her
high
school
graduation.
She
had
been
accepted
by
a
four-year
college.
When
I
asked
her
what
had
helped
her
most,
she
answered,
“The
horse
I
took
care
of.”
She
told
me
that
she
first
started
to
feel
safe
with
her
horse;
he
was
there
every
day,
patiently
waiting
for
her,
seemingly
glad
upon
her
approach.
She
started
to
feel
a
visceral
connection
with
another
creature
and
began
to
talk
to
him
like
a
friend.
Gradually
she
started
talking
with
the
other
kids
in
the
program
and,
eventually,
with
her
counselor.
Virginia
is
a
thirteen-year-old
adopted
white
girl.
She
was
taken
away
from
her
biological
mother
because
of
the
mother’s
drug
abuse;
after
her
first
adoptive
mother
fell
ill
and
died,
she
moved
from
foster
home
to
foster
home
before
being
adopted
again.
Virginia
was
seductive
with
any
male
who
crossed
her
path,
and
she
reported
sexual
and
physical
abuse
by
various
babysitters
and
temporary
caregivers.
She
came
to
our
residential
treatment
program
after
thirteen
crisis
hospitalizations
for
suicide
attempts.
The
staff
described
her
as
isolated,
controlling,
explosive,
sexualized,
intrusive,
vindictive,
and
narcissistic.
She
described
herself
as
disgusting
and
said
she
wished
she
were
dead.
The
diagnoses
in
her
chart
were
bipolar
disorder,
intermittent
explosive
disorder,
reactive
attachment
disorder,
attention
deficit
disorder
(ADD)
hyperactive
subtype,
oppositional
defiant
disorder
(ODD),
and
substance
use
disorder.
But
who,
really,
is
Virginia?
How
can
we
help
her
have
a
life?1
We
can
hope
to
solve
the
problems
of
these
children
only
if
we
correctly
define
what
is
going
on
with
them
and
do
more
than
developing
new
drugs
to
control
them
or
trying
to
find
“the”
gene
that
is
responsible
for
their
“disease.”
The
challenge
is
to
find
ways
to
help
them
lead
productive
lives
and,
in
so
doing,
save
hundreds
of
millions
of
dollars
of
taxpayers’
money.
That
process
starts
with
facing
the
facts.

BAD
GENES?
With
such
pervasive
problems
and
such
dysfunctional
parents
we
would
be
tempted
to
ascribe
their
problems
simply
to
bad
genes.
Technology
always
produces
new
directions
for
research,
and
when
it
became
possible
to
do
genetic
testing,
psychiatry
became
committed
to
finding
the
genetic
causes
of
mental
illness.
Finding
a
genetic
link
seemed
particularly
relevant
for
schizophrenia,
a
fairly
common
(affecting
about
1
percent
of
the
population),
severe,
and
perplexing
form
of
mental
illness
and
one
that
clearly
runs
in
families.
And
yet
after
thirty
years
and
millions
upon
millions
of
dollars’
worth
of
research,
we
have
failed
to
find
consistent
genetic
patterns
for
schizophrenia—or
for
any
other
psychiatric
illness,
for
that
matter.2
Some
of
my
colleagues
have
also
worked
hard
to
discover
genetic
factors
that
predispose
people
to
develop
traumatic
stress.3
That
quest
continues,
but
so
far
it
has
failed
to
yield
any
solid
answers.4
Recent
research
has
swept
away
the
simple
idea
that
“having”
a
particular
gene
produces
a
particular
result.
It
turns
out
that
many
genes
work
together
to
influence
a
single
outcome.
Even
more
important,
genes
are
not
fixed;
life
events
can
trigger
biochemical
messages
that
turn
them
on
or
off
by
attaching
methyl
groups,
a
cluster
of
carbon
and
hydrogen
atoms,
to
the
outside
of
the
gene
(a
process
called
methylation),
making
it
more
or
less
sensitive
to
messages
from
the
body.
While
life
events
can
change
the
behavior
of
the
gene,
they
do
not
alter
its
fundamental
structure.
Methylation
patterns,
however,
can
be
passed
on
to
offspring—a
phenomenon
known
as
epigenetics.
Once
again,
the
body
keeps
the
score,
at
the
deepest
levels
of
the
organism.
One
of
the
most
cited
experiments
in
epigenetics
was
conducted
by
McGill
University
researcher
Michael
Meaney,
who
studies
newborn
rat
pups
and
their
mothers.5
He
discovered
that
how
much
a
mother
rat
licks
and
grooms
her
pups
during
the
first
twelve
hours
after
their
birth
permanently
affects
the
brain
chemicals
that
respond
to
stress—and
modifies
the
configuration
of
over
a
thousand
genes.
The
rat
pups
that
are
intensively
licked
by
their
mothers
are
braver
and
produce
lower
levels
of
stress
hormones
under
stress
than
rats
whose
mothers
are
less
attentive.
They
also
recover
more
quickly—an
equanimity
that
lasts
throughout
their
lives.
They
develop
thicker
connections
in
the
hippocampus,
a
key
center
for
learning
and
memory,
and
they
perform
better
in
an
important
rodent
skill—finding
their
way
through
mazes.
 We
are
just
beginning
to
learn
that
stressful
experiences
affect
gene
expression
in
humans,
as
well.
Children
whose
pregnant
mothers
had
been
trapped
in
unheated
houses
in
a
prolonged
ice
storm
in
Quebec
had
major
epigenetic
changes
compared
with
the
children
of
mothers
whose
heat
had
been
restored
within
a
day.6
McGill
researcher
Moshe
Szyf
compared
the
epigenetic
profiles
of
hundreds
of
children
born
into
the
extreme
ends
of
social
privilege
in
the
United
Kingdom
and
measured
the
effects
of
child
abuse
on
both
groups.
Differences
in
social
class
were
associated
with
distinctly
different
epigenetic
profiles,
but
abused
children
in
both
groups
had
in
common
specific
modifications
in
seventy-three
genes.
In
Szyf’s
words,
“Major
changes
to
our
bodies
can
be
made
not
just
by
chemicals
and
toxins,
but
also
in
the
way
the
social
world
talks
to
the
hard-wired
world.”7,8

MONKEYS
CLARIFY
OLD
QUESTIONS
ABOUT
NATURE
VERSUS
NURTURE
One
of
the
clearest
ways
of
understanding
how
the
quality
of
parenting
and
environment
affects
the
expression
of
genes
comes
from
the
work
of
Stephen
Suomi,
chief
of
the
National
Institutes
of
Health’s
Laboratory
of
Comparative
Ethology.9
For
more
than
forty
years
Suomi
has
been
studying
the
transmission
of
personality
through
generations
of
rhesus
monkeys,
which
share
95
percent
of
human
genes,
a
number
exceeded
only
by
chimpanzees
and
bonobos.
Like
humans,
rhesus
monkeys
live
in
large
social
groups
with
complex
alliances
and
status
relationships,
and
only
members
who
can
synchronize
their
behavior
with
the
demands
of
the
troop
survive
and
flourish.
Rhesus
monkeys
are
also
like
humans
in
their
attachment
patterns.
Their
infants
depend
on
intimate
physical
contact
with
their
mothers,
and
just
as
Bowlby
observed
in
humans,
they
develop
by
exploring
their
reactions
to
their
environment,
running
back
to
their
mothers
whenever
they
feel
scared
or
lost.
Once
they
become
more
independent,
play
with
their
peers
is
the
primary
way
they
learn
to
get
along
in
life.
Suomi
identified
two
personality
types
that
consistently
ran
into
trouble:
uptight,
anxious
monkeys,
who
become
fearful,
withdrawn,
and
depressed
even
in
situations
where
other
monkeys
will
play
and
explore;
and
highly
aggressive
monkeys,
who
make
so
much
trouble
that
they
are
often
shunned,
beaten
up,
or
killed.
Both
types
are
biologically
different
from
their
peers.
Abnormalities
in
arousal
levels,
stress
hormones,
and
metabolism
of
brain
chemicals
like
serotonin
can
be
detected
within
the
first
few
weeks
of
life,
and
neither
their
biology
nor
their
behavior
tends
to
change
as
they
mature.
Suomi
discovered
a
wide
range
of
genetically
driven
behaviors.
For
example,
the
uptight
monkeys
(classified
as
such
on
the
basis
of
both
their
behavior
and
their
high
cortisol
levels
at
six
months)
will
consume
more
alcohol
in
experimental
situations
than
the
others
when
they
reach
the
age
of
four.
The
genetically
aggressive
monkeys
also
overindulge
—but
they
binge
drink
to
the
point
of
passing
out,
while
the
uptight
monkeys
seem
to
drink
to
calm
down.
And
yet
the
social
environment
also
contributes
significantly
to
behavior
and
biology.
The
uptight,
anxious
females
don’t
play
well
with
others
and
thus
often
lack
social
support
when
they
give
birth
and
are
at
high
risk
for
neglecting
or
abusing
their
firstborns.
But
when
these
females
belong
to
a
stable
social
group
they
often
become
diligent
mothers
who
carefully
watch
out
for
their
young.
Under
some
conditions
being
an
anxious
mom
can
provide
much
needed
protection.
The
aggressive
mothers,
on
the
other
hand,
did
not
provide
any
social
advantages:
very
punitive
with
their
offspring,
there
is
lots
of
hitting,
kicking,
and
biting.
If
the
infants
survive,
their
mothers
usually
keep
them
from
making
friends
with
their
peers.
In
real
life
it
is
impossible
to
tell
whether
people’s
aggressive
or
uptight
behavior
is
the
result
of
parents’
genes
or
of
having
been
raised
by
an
abusive
mother—or
both.
But
in
a
monkey
lab
you
can
take
newborns
with
vulnerable
genes
away
from
their
biological
mothers
and
have
them
raised
by
supportive
mothers
or
in
playgroups
with
peers.
Young
monkeys
who
are
taken
away
from
their
mothers
at
birth
and
brought
up
solely
with
their
peers
become
intensely
attached
to
them.
They
desperately
cling
to
one
another
and
don’t
peel
away
enough
to
engage
in
healthy
exploration
and
play.
What
little
play
there
is
lacks
the
complexity
and
imagination
typical
of
normal
monkeys.
These
monkeys
grow
up
to
be
uptight:
scared
in
new
situations
and
lacking
in
curiosity.
Regardless
of
their
genetic
predisposition,
peer-raised
monkeys
overreact
to
minor
stresses:
Their
cortisol
increases
much
more
in
response
to
loud
noises
than
does
that
of
monkeys
who
were
raised
by
their
mothers.
Their
serotonin
metabolism
is
even
more
abnormal
than
that
of
the
monkeys
who
are
genetically
predisposed
to
aggression
but
who
were
raised
by
their
own
mothers.
This
leads
to
the
conclusion
that,
at
least
in
monkeys,
early
experience
has
at
least
as
much
impact
on
biology
as
heredity
does.
Monkeys
and
humans
share
the
same
two
variants
of
the
serotonin
gene
(known
as
the
short
and
long
serotonin
transporter
alleles).
In
humans
the
short
allele
has
been
associated
with
impulsivity,
aggression,
sensation
seeking,
suicide
attempts,
and
severe
depression.
Suomi
showed
that,
at
least
in
monkeys,
the
environment
shapes
how
these
genes
affect
behavior.
Monkeys
with
the
short
allele
that
were
raised
by
an
adequate
mother
behaved
normally
and
had
no
deficit
in
their
serotonin
metabolism.
Those
who
were
raised
with
their
peers
became
aggressive
risk
takers.10
Similarly,
New
Zealand
researcher
Alec
Roy
found
that
humans
with
the
short
allele
had
higher
rates
of
depression
than
those
with
the
long
version
but
that
this
was
true
only
if
they
also
had
a
childhood
history
of
abuse
or
neglect.
The
conclusion
is
clear:
Children
who
are
fortunate
enough
to
have
an
attuned
and
attentive
parent
are
not
going
to
develop
this
genetically
related
problem.11
Suomi’s
work
supports
everything
we’ve
learned
from
our
colleagues
who
study
human
attachment
and
from
our
own
clinical
research:
Safe
and
protective
early
relationships
are
critical
to
protect
children
from
long-term
problems.
In
addition,
even
parents
with
their
own
genetic
vulnerabilities
can
pass
on
that
protection
to
the
next
generation
provided
that
they
are
given
the
right
support.

THE
NATIONAL
CHILD
TRAUMATIC
STRESS
NETWORK
Nearly
every
medical
disease,
from
cancer
to
retinitis
pigmentosa,
has
advocacy
groups
that
promote
the
study
and
treatment
of
that
particular
condition.
But
until
2001,
when
the
National
Child
Traumatic
Stress
Network
was
established
by
an
act
of
Congress,
there
was
no
comprehensive
organization
dedicated
to
the
research
and
treatment
of
traumatized
children.
 In
1998
I
received
a
call
from
Adam
Cummings
from
the
Nathan
Cummings
Foundation
telling
me
that
they
were
interested
in
studying
the
effects
of
trauma
on
learning.
I
told
them
that
while
some
very
good
work
had
been
done
on
that
subject,12
there
was
no
forum
to
implement
the
discoveries
that
had
already
been
made.
The
mental,
biological,
or
moral
development
of
traumatized
children
was
not
being
systematically
taught
to
child-care
workers,
to
pediatricians,
or
in
graduate
schools
of
psychology
or
social
work.
Adam
and
I
agreed
that
we
had
to
address
this
problem.
Some
eight
months
later
we
convened
a
think
tank
that
included
representatives
from
the
U.S.
Department
of
Health
and
Human
Services
and
the
U.S.
Department
of
Justice,
Senator
Ted
Kennedy’s
health-care
adviser,
and
a
group
of
my
colleagues
who
specialized
in
childhood
trauma.
We
all
were
familiar
with
the
basics
of
how
trauma
affects
the
developing
mind
and
brain,
and
we
all
were
aware
that
childhood
trauma
is
radically
different
from
traumatic
stress
in
fully
formed
adults.
The
group
concluded
that,
if
we
hoped
to
ever
put
the
issue
of
childhood
trauma
firmly
on
the
map,
there
needed
to
be
a
national
organization
that
would
promote
both
the
study
of
childhood
trauma
and
the
education
of
teachers,
judges,
ministers,
foster
parents,
physicians,
probation
officers,
nurses,
and
mental
health
professionals—anyone
who
deals
with
abused
and
traumatized
kids.
One
member
of
our
work
group,
Bill
Harris,
had
extensive
experience
with
child-related
legislation,
and
he
went
to
work
with
Senator
Kennedy’s
staff
to
craft
our
ideas
into
law.
The
bill
establishing
the
National
Child
Traumatic
Stress
Network
was
ushered
through
the
Senate
with
overwhelming
bipartisan
support,
and
since
2001
it
has
grown
from
a
collaborative
network
of
17
sites
to
more
than
150
centers
nationwide.
Led
by
coordinating
centers
at
Duke
University
and
UCLA,
the
NCTSN
includes
universities,
hospitals,
tribal
agencies,
drug
rehab
programs,
mental
health
clinics,
and
graduate
schools.
Each
of
the
sites,
in
turn,
collaborates
with
local
school
systems,
hospitals,
welfare
agencies,
homeless
shelters,
juvenile
justice
programs,
and
domestic
violence
shelters,
with
a
total
of
well
over
8,300
affiliated
partners.
Once
the
NCTSN
was
up
and
running,
we
had
the
means
to
assemble
a
clearer
profile
of
traumatized
kids
in
every
part
of
the
country.
My
Trauma
Center
colleague
Joseph
Spinazzola
led
a
survey
that
examined
the
records
of
nearly
two
thousand
children
and
adolescents
from
agencies
across
the
network.13
We
soon
confirmed
what
we
had
suspected:
The
vast
majority
came
from
extremely
dysfunctional
families.
More
than
half
had
been
emotionally
abused
and/or
had
a
caregiver
who
was
too
impaired
to
care
for
their
needs.
Almost
50
percent
had
temporarily
lost
caregivers
to
jail,
treatment
programs,
or
military
service
and
had
been
looked
after
by
strangers,
foster
parents,
or
distant
relatives.
About
half
reported
having
witnessed
domestic
violence,
and
a
quarter
were
also
victims
of
sexual
and
/or
physical
abuse.
In
other
words,
the
children
and
adolescents
in
the
survey
were
mirrors
of
the
middle-aged,
middle-class
Kaiser
Permanente
patients
with
high
ACE
scores
that
Vincent
Felitti
had
studied
in
the
Adverse
Childhood
Experiences
(ACE)
Study.

THE
POWER
OF
DIAGNOSIS
In
the
1970s
there
was
no
way
to
classify
the
wide-ranging
symptoms
of
hundreds
of
thousands
of
returning
Vietnam
veterans.
As
we
saw
in
the
opening
chapters
of
this
book,
this
forced
clinicians
to
improvise
the
treatment
of
their
patients
and
prevented
them
from
being
able
to
systematically
study
what
approaches
actually
worked.
The
adoption
of
the
PTSD
diagnosis
by
the
DSM
III
in
1980
led
to
extensive
scientific
studies
and
to
the
development
of
effective
treatments,
which
turned
out
to
be
relevant
not
only
to
combat
veterans
but
also
to
victims
of
a
range
of
traumatic
events,
including
rape,
assault,
and
motor
vehicle
accidents.14
An
example
of
the
far-ranging
power
of
having
a
specific
diagnosis
is
the
fact
that
between
2007
and
2010
the
Department
of
Defense
spent
more
than
$2.7
billion
for
the
treatment
of
and
research
on
PTSD
in
combat
veterans,
while
in
fiscal
year
2009
alone
the
Department
of
Veterans
Affairs
spent
$24.5
million
on
in-house
PTSD
research.
The
DSM
definition
of
PTSD
is
quite
straightforward:
A
person
is
exposed
to
a
horrendous
event
“that
involved
actual
or
threatened
death
or
serious
injury,
or
a
threat
to
the
physical
integrity
of
self
or
others,”
causing
“intense
fear,
helplessness,
or
horror,”
which
results
in
a
variety
of
manifestations:
intrusive
reexperiencing
of
the
event
(flashbacks,
bad
dreams,
feeling
as
if
the
event
were
occurring),
persistent
and
crippling
avoidance
(of
people,
places,
thoughts,
or
feelings
associated
with
the
trauma,
sometimes
with
amnesia
for
important
parts
of
it),
and
increased
arousal
(insomnia,
hypervigilance,
or
irritability).
This
description
suggests
a
clear
story
line:
A
person
is
suddenly
and
unexpectedly
devastated
by
an
atrocious
event
and
is
never
the
same
again.
The
trauma
may
be
over,
but
it
keeps
being
replayed
in
continually
recycling
memories
and
in
a
reorganized
nervous
system.
How
relevant
was
this
definition
to
the
children
we
were
seeing?
After
a
single
traumatic
incident—a
dog
bite,
an
accident,
or
witnessing
a
school
shooting—children
can
indeed
develop
basic
PTSD
symptoms
similar
to
those
of
adults,
even
if
they
live
in
safe
and
supportive
homes.
As
a
result
of
having
the
PTSD
diagnosis,
we
now
can
treat
those
problems
quite
effectively.
In
the
case
of
the
troubled
children
with
histories
of
abuse
and
neglect
who
show
up
in
clinics,
schools,
hospitals,
and
police
stations,
the
traumatic
roots
of
their
behaviors
are
less
obvious,
particularly
because
they
rarely
talk
about
having
been
hit,
abandoned,
or
molested,
even
when
asked.
Eighty
two
percent
of
the
traumatized
children
seen
in
the
National
Child
Traumatic
Stress
Network
do
not
meet
diagnostic
criteria
for
PTSD.15
Because
they
often
are
shut
down,
suspicious,
or
aggressive
they
now
receive
pseudoscientific
diagnoses
such
as
“oppositional
defiant
disorder,”
meaning
“This
kid
hates
my
guts
and
won’t
do
anything
I
tell
him
to
do,”
or
“disruptive
mood
dysregulation
disorder,”
meaning
he
has
temper
tantrums.
Having
as
many
problems
as
they
do,
these
kids
accumulate
numerous
diagnoses
over
time.
Before
they
reach
their
twenties,
many
patients
have
been
given
four,
five,
six,
or
more
of
these
impressive
but
meaningless
labels.
If
they
receive
treatment
at
all,
they
get
whatever
is
being
promulgated
as
the
method
of
management
du
jour:
medications,
behavioral
modification,
or
exposure
therapy.
These
rarely
work
and
often
cause
more
damage.
As
the
NCTSN
treated
more
and
more
kids,
it
became
increasingly
obvious
that
we
needed
a
diagnosis
that
captured
the
reality
of
their
experience.
We
began
with
a
database
of
nearly
twenty
thousand
kids
who
were
being
treated
in
various
sites
within
the
network
and
collected
all
the
research
articles
we
could
find
on
abused
and
neglected
kids.
These
were
winnowed
down
to
130
particularly
relevant
studies
that
reported
on
more
than
one
hundred
thousand
children
and
adolescents
worldwide.
A
core
work
group
of
twelve
clinician/researchers
specializing
in
childhood
trauma16
then
convened
twice
a
year
for
four
years
to
draft
a
proposal
for
an
appropriate
diagnosis,
which
we
decided
to
call
Developmental
Trauma
Disorder.17
As
we
organized
our
findings,
we
discovered
a
consistent
profile:
(1)
a
pervasive
pattern
of
dysregulation,
(2)
problems
with
attention
and
concentration,
and
(3)
difficulties
getting
along
with
themselves
and
others.
These
children’s
moods
and
feelings
rapidly
shifted
from
one
extreme
to
another—from
temper
tantrums
and
panic
to
detachment,
flatness,
and
dissociation.
When
they
got
upset
(which
was
much
of
the
time),
they
could
neither
calm
themselves
down
nor
describe
what
they
were
feeling.
Having
a
biological
system
that
keeps
pumping
out
stress
hormones
to
deal
with
real
or
imagined
threats
leads
to
physical
problems:
sleep
disturbances,
headaches,
unexplained
pain,
oversensitivity
to
touch
or
sound.
Being
so
agitated
or
shut
down
keeps
them
from
being
able
to
focus
their
attention
and
concentration.
To
relieve
their
tension,
they
engage
in
chronic
masturbation,
rocking,
or
self-harming
activities
(biting,
cutting,
burning,
and
hitting
themselves,
pulling
their
hair
out,
picking
at
their
skin
until
it
bled).
It
also
leads
to
difficulties
with
language
processing
and
fine-
motor
coordination.
Spending
all
their
energy
on
staying
in
control,
they
usually
have
trouble
paying
attention
to
things,
like
schoolwork,
that
are
not
directly
relevant
to
survival,
and
their
hyperarousal
makes
them
easily
distracted.
Having
been
frequently
ignored
or
abandoned
leaves
them
clinging
and
needy,
even
with
the
people
who
have
abused
them.
Having
been
chronically
beaten,
molested,
and
otherwise
mistreated,
they
can
not
help
but
define
themselves
as
defective
and
worthless.
They
come
by
their
self-
loathing,
sense
of
defectiveness,
and
worthlessness
honestly.
Was
it
any
surprise
that
they
didn’t
trust
anyone?
Finally,
the
combination
of
feeling
fundamentally
despicable
and
overreacting
to
slight
frustrations
makes
it
difficult
for
them
to
make
friends.
We
published
the
first
articles
about
our
findings,
developed
a
validated
rating
scale,18
and
collected
data
on
about
350
kids
and
their
parents
or
foster
parents
to
establish
that
this
one
diagnosis,
Developmental
Trauma
Disorder,
captured
the
full
range
of
what
was
wrong
with
these
children.
It
would
enable
us
to
give
them
a
single
diagnosis,
as
opposed
to
multiple
labels,
and
would
firmly
locate
the
origin
of
their
problems
in
a
combination
of
trauma
and
compromised
attachment.
 In
February
2009
we
submitted
our
proposed
new
diagnosis
of
Developmental
Trauma
Disorder
to
the
American
Psychiatric
Association,
stating
the
following
in
a
cover
letter:

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

Shortly
after
submitting
our
proposal,
I
gave
a
talk
on
Developmental
Trauma
Disorder
in
Washington
DC
to
a
meeting
of
the
mental
health
commissioners
from
across
the
country.
They
offered
to
support
our
initiative
by
writing
a
letter
to
the
APA.
The
letter
began
by
pointing
out
that
the
National
Association
of
State
Mental
Health
Program
Directors
served
6.1
million
people
annually,
with
a
budget
of
$29.5
billion,
and
concluded:
“We
urge
the
APA
to
add
developmental
trauma
to
its
list
of
priority
areas
to
clarify
and
better
characterize
its
course
and
clinical
sequelae
and
to
emphasize
the
strong
need
to
address
developmental
trauma
in
the
assessment
of
patients.”
I
felt
confident
that
this
letter
would
ensure
that
the
APA
would
take
our
proposal
seriously,
but
several
months
after
our
submission,
Matthew
Friedman,
executive
director
of
the
National
Center
for
PTSD
and
chair
of
the
relevant
DSM
subcommittee,
informed
us
that
DTD
was
unlikely
to
be
included
in
the
DSM-5.
The
consensus,
he
wrote,
was
that
no
new
diagnosis
was
required
to
fill
a
“missing
diagnostic
niche.”
One
million
children
who
are
abused
and
neglected
every
year
in
the
United
States
a
“diagnostic
niche”?
The
letter
went
on:
“The
notion
that
early
childhood
adverse
experiences
lead
to
substantial
developmental
disruptions
is
more
clinical
intuition
than
a
research-based
fact.
This
statement
is
commonly
made
but
cannot
be
backed
up
by
prospective
studies.”
In
fact,
we
had
included
several
prospective
studies
in
our
proposal.
Let’s
look
at
just
two
of
them
here.

HOW
RELATIONSHIPS
SHAPE
DEVELOPMENT
Beginning
in
1975
and
continuing
for
almost
thirty
years,
Alan
Sroufe
and
his
colleagues
tracked
180
children
and
their
families
through
the
Minnesota
Longitudinal
Study
of
Risk
and
Adaptation.19
At
the
time
the
study
began
there
was
an
intense
debate
about
the
role
of
nature
versus
nurture,
and
temperament
versus
environment
in
human
development,
and
this
study
set
out
to
answer
those
questions.
Trauma
was
not
yet
a
popular
topic,
and
child
abuse
and
neglect
were
not
a
central
focus
of
this
study—at
least
initially,
until
they
emerged
as
the
most
important
predictors
of
adult
functioning.
Working
with
local
medical
and
social
agencies,
the
researchers
recruited
first-time
(Caucasian)
mothers
who
were
poor
enough
to
qualify
for
public
assistance
but
who
had
different
backgrounds
and
different
kinds
and
levels
of
support
available
for
parenting.
The
study
began
three
months
before
the
children
were
born
and
followed
the
children
for
thirty
years
into
adulthood,
assessing
and,
where
relevant,
measuring
all
the
major
aspects
of
their
functioning
and
all
the
significant
circumstances
of
their
lives.
It
considered
several
fundamental
questions:
How
do
children
learn
to
pay
attention
while
regulating
their
arousal
(i.e.,
avoiding
extreme
highs
or
lows)
and
keeping
their
impulses
under
control?
What
kinds
of
supports
do
they
need,
and
when
are
these
needed?
After
extensive
interviews
and
testing
of
the
prospective
parents,
the
study
really
got
off
the
ground
in
the
newborn
nursery,
where
researchers
observed
the
newborns
and
interviewed
the
nurses
caring
for
them.
They
then
made
home
visits
seven
and
ten
days
after
birth.
Before
the
children
entered
first
grade,
they
and
their
parents
were
carefully
assessed
a
total
of
fifteen
times.
After
that,
the
children
were
interviewed
and
tested
at
regular
intervals
until
age
twenty-eight,
with
continuing
input
from
mothers
and
teachers.
Sroufe
and
his
colleagues
found
that
quality
of
care
and
biological
factors
were
closely
interwoven.
It
is
fascinating
to
see
how
the
Minnesota
results
echo—though
with
far
greater
complexity—what
Stephen
Suomi
found
in
his
primate
laboratory.
Nothing
was
written
in
stone.
Neither
the
mother’s
personality,
nor
the
infant’s
neurological
anomalies
at
birth,
nor
its
IQ,
nor
its
temperament—including
its
activity
level
and
reactivity
to
stress
—predicted
whether
a
child
would
develop
serious
behavioral
problems
in
adolescence.20
The
key
issue,
rather,
was
the
nature
of
the
parent-child
relationship:
how
parents
felt
about
and
interacted
with
their
kids.
As
with
Suomi’s
monkeys,
the
combination
of
vulnerable
infants
and
inflexible
caregivers
made
for
clingy,
uptight
kids.
Insensitive,
pushy,
and
intrusive
behavior
on
the
part
of
the
parents
at
six
months
predicted
hyperactivity
and
attention
problems
in
kindergarten
and
beyond.21
Focusing
on
many
facets
of
development,
particularly
relationships
with
caregivers,
teachers,
and
peers,
Sroufe
and
his
colleagues
found
that
caregivers
not
only
help
keep
arousal
within
manageable
bounds
but
also
help
infants
develop
their
own
ability
to
regulate
their
arousal.
Children
who
were
regularly
pushed
over
the
edge
into
overarousal
and
disorganization
did
not
develop
proper
attunement
of
their
inhibitory
and
excitatory
brain
systems
and
grew
up
expecting
that
they
would
lose
control
if
something
upsetting
happened.
This
was
a
vulnerable
population,
and
by
late
adolescence
half
of
them
had
diagnosable
mental
health
problems.
There
were
clear
patterns:
The
children
who
received
consistent
caregiving
became
well-regulated
kids,
while
erratic
caregiving
produced
kids
who
were
chronically
physiologically
aroused.
The
children
of
unpredictable
parents
often
clamored
for
attention
and
became
intensely
frustrated
in
the
face
of
small
challenges.
Their
persistent
arousal
made
them
chronically
anxious.
Constantly
looking
for
reassurance
got
in
the
way
of
playing
and
exploration,
and,
as
a
result,
they
grew
up
chronically
nervous
and
nonadventurous.
Early
parental
neglect
or
harsh
treatment
led
to
behavior
problems
in
school
and
predicted
troubles
with
peers
and
a
lack
of
empathy
for
the
distress
of
others.22
This
set
up
a
vicious
cycle:
Their
chronic
arousal,
coupled
with
lack
of
parental
comfort,
made
them
disruptive,
oppositional,
and
aggressive.
Disruptive
and
aggressive
kids
are
unpopular
and
provoke
further
rejection
and
punishment,
not
only
from
their
caregivers
but
also
from
their
teachers
and
peers.23
Sroufe
also
learned
a
great
deal
about
resilience:
the
capacity
to
bounce
back
from
adversity.
By
far
the
most
important
predictor
of
how
well
his
subjects
coped
with
life’s
inevitable
disappointments
was
the
level
of
security
established
with
their
primary
caregiver
during
the
first
two
years
of
life.
Sroufe
informally
told
me
that
he
thought
that
resilience
in
adulthood
could
be
predicted
by
how
lovable
mothers
rated
their
kids
at
age
two.24

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

THE
DSM-5:
A
VERITABLE
SMORGASBORD
OF
“DIAGNOSES”
When
DSM-5
was
published
in
May
2013
it
included
some
three
hundred
disorders
in
its
945
pages.
It
offers
a
veritable
smorgasbord
of
possible
labels
for
the
problems
associated
with
severe
early-life
trauma,
including
some
new
ones
such
as
Disruptive
Mood
Regulation
Disorder,26
Non-
suicidal
Self
Injury,
Intermittent
Explosive
Disorder,
Dysregulated
Social
Engagement
Disorder,
and
Disruptive
Impulse
Control
Disorder.27
Before
the
late
nineteenth
century
doctors
classified
illnesses
according
to
their
surface
manifestations,
like
fevers
and
pustules,
which
was
not
unreasonable,
given
that
they
had
little
else
to
go
on.28
This
changed
when
scientists
like
Louis
Pasteur
and
Robert
Koch
discovered
that
many
diseases
were
caused
by
bacteria
that
were
invisible
to
the
naked
eye.
Medicine
then
was
transformed
by
its
attempts
to
discover
ways
to
get
rid
of
those
organisms
rather
than
just
treating
the
boils
and
the
fevers
that
they
caused.
With
DSM-5
psychiatry
firmly
regressed
to
early-nineteenth-century
medical
practice.
Despite
the
fact
that
we
know
the
origin
of
many
of
the
problems
it
identifies,
its
“diagnoses”
describe
surface
phenomena
that
completely
ignore
the
underlying
causes.
Even
before
DSM-5
was
released,
the
American
Journal
of
Psychiatry
published
the
results
of
validity
tests
of
various
new
diagnoses,
which
indicated
that
the
DSM
largely
lacks
what
in
the
world
of
science
is
known
as
“reliability”—the
ability
to
produce
consistent,
replicable
results.
In
other
words,
it
lacks
scientific
validity.
Oddly,
the
lack
of
reliability
and
validity
did
not
keep
the
DSM-5
from
meeting
its
deadline
for
publication,
despite
the
near-universal
consensus
that
it
represented
no
improvement
over
the
previous
diagnostic
system.29
Could
the
fact
that
the
APA
had
earned
$100
million
on
the
DSM-IV
and
is
slated
to
take
in
a
similar
amount
with
the
DSM-5
(because
all
mental
health
practitioners,
many
lawyers,
and
other
professionals
will
be
obliged
to
purchase
the
latest
edition)
be
the
reason
we
have
this
new
diagnostic
system?
Diagnostic
reliability
isn’t
an
abstract
issue:
If
doctors
can’t
agree
on
what
ails
their
patients,
there
is
no
way
they
can
provide
proper
treatment.
When
there’s
no
relationship
between
diagnosis
and
cure,
a
mislabeled
patient
is
bound
to
be
a
mistreated
patient.
You
would
not
want
to
have
your
appendix
removed
when
you
are
suffering
from
a
kidney
stone,
and
you
would
not
want
have
somebody
labeled
as
“oppositional”
when,
in
fact,
his
behavior
is
rooted
in
an
attempt
to
protect
himself
against
real
danger.
In
a
statement
released
in
June
2011,
the
British
Psychological
Society
complained
to
the
APA
that
the
sources
of
psychological
suffering
in
the
DSM-5
were
identified
“as
located
within
individuals”
and
overlooked
the
“undeniable
social
causation
of
many
such
problems.”30
This
was
in
addition
to
a
flood
of
protest
from
American
professionals,
including
leaders
of
the
American
Psychological
Association
and
the
American
Counseling
Association.
Why
are
relationships
or
social
conditions
left
out?
31
If
you
pay
attention
only
to
faulty
biology
and
defective
genes
as
the

cause
of
mental
problems
and
ignore
abandonment,
abuse,
and
deprivation,
you
are
likely
to
run
into
as
many
dead
ends
as
previous
generations
did
blaming
it
all
on
terrible
mothers.
The
most
stunning
rejection
of
the
DSM-5
came
from
the
National
Institute
of
Mental
Health,
which
funds
most
psychiatric
research
in
America.
In
April
2013,
a
few
weeks
before
DSM-5
was
formally
released,
NIMH
director
Thomas
Insel
announced
that
his
agency
could
no
longer
support
DSM’s
“symptom-based
diagnosis.”32
Instead
the
institute
would
focus
its
funding
on
what
are
called
Research
Domain
Criteria
(RDoC)33
to
create
a
framework
for
studies
that
would
cut
across
current
diagnostic
categories.
For
example,
one
of
the
NIMH
domains
is
“Arousal/Modulatory
Systems
(Arousal,
Circadian
Rhythm,
Sleep
and
Wakefulness),”
which
are
disturbed
to
varying
degrees
in
many
patients.
Like
the
DSM-5,
the
RDoC
framework
conceptualizes
mental
illnesses
solely
as
brain
disorders.
This
means
that
future
research
funding
will
explore
the
brain
circuits
“and
other
neurobiological
measures”
that
underlie
mental
problems.
Insel
sees
this
as
a
first
step
toward
the
sort
of
“precision
medicine
that
has
transformed
cancer
diagnosis
and
treatment.”
Mental
illness,
however,
is
not
at
all
like
cancer:
Humans
are
social
animals,
and
mental
problems
involve
not
being
able
to
get
along
with
other
people,
not
fitting
in,
not
belonging,
and
in
general
not
being
able
to
get
on
the
same
wavelength.
Everything
about
us—our
brains,
our
minds,
and
our
bodies—is
geared
toward
collaboration
in
social
systems.
This
is
our
most
powerful
survival
strategy,
the
key
to
our
success
as
a
species,
and
it
is
precisely
this
that
breaks
down
in
most
forms
of
mental
suffering.
As
we
saw
in
part
2,
the
neural
connections
in
brain
and
body
are
vitally
important
for
understanding
human
suffering,
but
it
is
important
not
to
ignore
the
foundations
of
our
humanity:
relationships
and
interactions
that
shape
our
minds
and
brains
when
we
are
young
and
that
give
substance
and
meaning
to
our
entire
lives.
People
with
histories
of
abuse,
neglect,
or
severe
deprivation
will
remain
mysterious
and
largely
untreated
unless
we
heed
the
admonition
of
Alan
Sroufe:
“To
fully
understand
how
we
become
the
persons
we
are—the
complex,
step-by-step
evolution
of
our
orientations,
capacities,
and
behavior
over
time—requires
more
than
a
list
of
ingredients,
however
important
any
one
of
them
might
be.
It
requires
an
understanding
of
the
process
of
development,
how
all
of
these
factors
work
together
in
an
ongoing
way
over
time.”34
Frontline
mental
health
workers—overwhelmed
and
underpaid
social
workers
and
therapists
alike—seem
to
agree
with
our
approach.
Shortly
after
the
APA
rejected
Developmental
Trauma
Disorder
for
inclusion
in
the
DSM,
thousands
of
clinicians
from
around
the
country
sent
small
contributions
to
the
Trauma
Center
to
help
us
conduct
a
large
scientific
study,
known
as
a
field
trial,
to
further
study
DTD.
That
support
has
enabled
us
to
interview
hundreds
of
kids,
parents,
foster
parents,
and
mental
health
workers
at
five
different
network
sites
over
the
last
few
years
with
scientifically
constructed
interview
tools.
The
first
results
from
these
studies
have
now
been
published,
and
more
will
appear
as
this
book
is
going
to
print.35

WHAT
DIFFERENCE
WOULD
DTD
MAKE?
One
answer
is
that
it
would
focus
research
and
treatment
(not
to
mention
funding)
on
the
central
principles
that
underlie
the
protean
symptoms
of
chronically
traumatized
children
and
adults:
pervasive
biological
and
emotional
dysregulation,
failed
or
disrupted
attachment,
problems
staying
focused
and
on
track,
and
a
hugely
deficient
sense
of
coherent
personal
identity
and
competence.
These
issues
transcend
and
include
almost
all
diagnostic
categories,
but
treatment
that
doesn’t
put
them
front
and
center
is
more
than
likely
to
miss
the
mark.
Our
great
challenge
is
to
apply
the
lessons
of
neuroplasticity,
the
flexibility
of
brain
circuits,
to
rewire
the
brains
and
reorganize
the
minds
of
people
who
have
been
programmed
by
life
itself
to
experience
others
as
threats
and
themselves
as
helpless.
Social
support
is
a
biological
necessity,
not
an
option,
and
this
reality
should
be
the
backbone
of
all
prevention
and
treatment.
Recognizing
the
profound
effects
of
trauma
and
deprivation
on
child
development
need
not
lead
to
blaming
parents.
We
can
assume
that
parents
do
the
best
they
can,
but
all
parents
need
help
to
nurture
their
kids.
Nearly
every
industrialized
nation,
with
the
exception
of
the
United
States,
recognizes
this
and
provides
some
form
of
guaranteed
support
to
families.
James
Heckman,
winner
of
the
2000
Nobel
Prize
in
Economics,
has
shown
that
quality
early-childhood
programs
that
involve
parents
and
promote
basic
skills
in
disadvantaged
children
more
than
pay
for
themselves
in
improved
outcomes.36
In
the
early
1970s
psychologist
David
Olds
was
working
in
a
Baltimore
day-care
center
where
many
of
the
preschoolers
came
from
homes
wracked
by
poverty,
domestic
violence,
and
drug
abuse.
Aware
that
only
addressing
the
children’s
problems
at
school
was
not
sufficient
to
improve
their
home
conditions,
he
started
a
home-visitation
program
in
which
skilled
nurses
helped
mothers
to
provide
a
safe
and
stimulating
environment
for
their
children
and,
in
the
process,
to
imagine
a
better
future
for
themselves.
Twenty
years
later,
the
children
of
the
home-visitation
mothers
were
not
only
healthier
but
also
less
likely
to
report
having
been
abused
or
neglected
than
a
similar
group
whose
mothers
had
not
been
visited.
They
also
were
more
likely
to
have
finished
school,
to
have
stayed
out
of
jail,
and
to
be
working
in
well-paying
jobs.
Economists
have
calculated
that
every
dollar
invested
in
high-quality
home
visitation,
day
care,
and
preschool
programs
results
in
seven
dollars
of
savings
on
welfare
payments,
health-care
costs,
substance-abuse
treatment,
and
incarceration,
plus
higher
tax
revenues
due
to
better-paying
jobs.37
When
I
go
to
Europe
to
teach,
I
often
am
contacted
by
officials
at
the
ministries
of
health
in
the
Scandinavian
countries,
the
United
Kingdom,
Germany,
or
the
Netherlands
and
asked
to
spend
an
afternoon
with
them
sharing
the
latest
research
on
the
treatment
of
traumatized
children,
adolescents,
and
their
families.
The
same
is
true
for
many
of
my
colleagues.
These
countries
have
already
made
a
commitment
to
universal
health
care,
ensuring
a
guaranteed
minimum
wage,
paid
parental
leave
for
both
parents
after
a
child
is
born,
and
high-quality
childcare
for
all
working
mothers.
Could
this
approach
to
public
health
have
something
to
do
with
the
fact
that
the
incarceration
rate
in
Norway
is
71/100,000,
in
the
Netherlands
81/100,000,
and
the
US
781/100,000,
while
the
crime
rate
in
those
countries
is
much
lower
than
in
ours,
and
the
cost
of
medical
care
about
half?
Seventy
percent
of
prisoners
in
California
spent
time
in
foster
care
while
growing
up.
The
United
States
spends
$84
billion
per
year
to
incarcerate
people
at
approximately
$44,000
per
prisoner;
the
northern
European
countries
a
fraction
of
that
amount.
Instead,
they
invest
in
helping
parents
to
raise
their
children
in
safe
and
predictable
surroundings.
Their
academic
test
scores
and
crime
rates
seem
to
reflect
the
success
of
those
investments.
 PART
FOUR
THE
IMPRINT
OF
TRAUMA
 CHAPTER
11

UNCOVERING
SECRETS:
THE
PROBLEM
OF
TRAUMATIC
MEMORY

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

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

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

NORMAL
VERSUS
TRAUMATIC
MEMORY
We
all
know
how
fickle
memory
is;
our
stories
change
and
are
constantly
revised
and
updated.
When
my
brothers,
sisters,
and
I
talk
about
events
in
our
childhood,
we
always
end
up
feeling
that
we
grew
up
in
different
families—so
many
of
our
memories
simply
do
not
match.
Such
autobiographical
memories
are
not
precise
reflections
of
reality;
they
are
stories
we
tell
to
convey
our
personal
take
on
our
experience.
The
extraordinary
capacity
of
the
human
mind
to
rewrite
memory
is
illustrated
in
the
Grant
Study
of
Adult
Development,
which
has
systematically
followed
the
psychological
and
physical
health
of
more
than
two
hundred
Harvard
men
from
their
sophomore
years
of
1939–44
to
the
present.2
Of
course,
the
designers
of
the
study
could
not
have
anticipated
that
most
of
the
participants
would
go
off
to
fight
in
World
War
II,
but
we
can
now
track
the
evolution
of
their
wartime
memories.
The
men
were
interviewed
in
detail
about
their
war
experiences
in
1945/1946
and
again
in
1989/1990.
Four
and
a
half
decades
later,
the
majority
gave
very
different
accounts
from
the
narratives
recorded
in
their
immediate
postwar
interviews:
With
the
passage
of
time,
events
had
been
bleached
of
their
intense
horror.
In
contrast,
those
who
had
been
traumatized
and
subsequently
developed
PTSD
did
not
modify
their
accounts;
their
memories
were
preserved
essentially
intact
forty-five
years
after
the
war
ended.
Whether
we
remember
a
particular
event
at
all,
and
how
accurate
our
memories
of
it
are,
largely
depends
on
how
personally
meaningful
it
was
and
how
emotional
we
felt
about
it
at
the
time.
The
key
factor
is
our
level
of
arousal.
We
all
have
memories
associated
with
particular
people,
songs,
smells,
and
places
that
stay
with
us
for
a
long
time.
Most
of
us
still
have
precise
memories
of
where
we
were
and
what
we
saw
on
Tuesday,
September
11,
2001,
but
only
a
fraction
of
us
recall
anything
in
particular
about
September
10.
Most
day-to-day
experience
passes
immediately
into
oblivion.
On
ordinary
days
we
don’t
have
much
to
report
when
we
come
home
in
the
evening.
The
mind
works
according
to
schemes
or
maps,
and
incidents
that
fall
outside
the
established
pattern
are
most
likely
to
capture
our
attention.
If
we
get
a
raise
or
a
friend
tells
us
some
exciting
news,
we
will
retain
the
details
of
the
moment,
at
least
for
a
while.
We
remember
insults
and
injuries
best:
The
adrenaline
that
we
secrete
to
defend
against
potential
threats
helps
to
engrave
those
incidents
into
our
minds.
Even
if
the
content
of
the
remark
fades,
our
dislike
for
the
person
who
made
it
usually
persists.
When
something
terrifying
happens,
like
seeing
a
child
or
a
friend
get
hurt
in
an
accident,
we
will
retain
an
intense
and
largely
accurate
memory
of
the
event
for
a
long
time.
As
James
McGaugh
and
colleagues
have
shown,
the
more
adrenaline
you
secrete,
the
more
precise
your
memory
will
be.3
But
that
is
true
only
up
to
a
certain
point.
Confronted
with
horror—
especially
the
horror
of
“inescapable
shock”—this
system
becomes
overwhelmed
and
breaks
down.
Of
course,
we
cannot
monitor
what
happens
during
a
traumatic
experience,
but
we
can
reactivate
the
trauma
in
the
laboratory,
as
was
done
for
the
brain
scans
in
chapters
3
and
4.
When
memory
traces
of
the
original
sounds,
images,
and
sensations
are
reactivated,
the
frontal
lobe
shuts
down,
including,
as
we’ve
seen,
the
region
necessary
to
put
feelings
into
words,4
the
region
that
creates
our
sense
of
location
in
time,
and
the
thalamus,
which
integrates
the
raw
data
of
incoming
sensations.
At
this
point
the
emotional
brain,
which
is
not
under
conscious
control
and
cannot
communicate
in
words,
takes
over.
The
emotional
brain
(the
limbic
area
and
the
brain
stem)
expresses
its
altered
activation
through
changes
in
emotional
arousal,
body
physiology,
and
muscular
action.
Under
ordinary
conditions
these
two
memory
systems—rational
and
emotional—collaborate
to
produce
an
integrated
response.
But
high
arousal
not
only
changes
the
balance
between
them
but
also
disconnects
other
brain
areas
necessary
for
the
proper
storage
and
integration
of
incoming
information,
such
as
the
hippocampus
and
the
thalamus.5
As
a
result,
the
imprints
of
traumatic
experiences
are
organized
not
as
coherent
logical
narratives
but
in
fragmented
sensory
and
emotional
traces:
images,
sounds,
and
physical
sensations.6
Julian
saw
a
man
with
outstretched
arms,
a
pew,
a
staircase,
a
strip
poker
game;
he
felt
a
sensation
in
his
penis,
a
panicked
sense
of
dread.
But
there
was
little
or
no
story.

UNCOVERING
THE
SECRETS
OF
TRAUMA
In
the
late
nineteenth
century,
when
medicine
first
began
the
systematic
study
of
mental
problems,
the
nature
of
traumatic
memory
was
one
of
the
central
topics
under
discussion.
In
France
and
England
a
prodigious
number
of
articles
were
published
on
a
syndrome
known
as
“railway
spine,”
a
psychological
aftermath
of
railroad
accidents
that
included
loss
of
memory.
The
greatest
advances,
however,
came
in
the
study
of
hysteria,
a
mental
disorder
characterized
by
emotional
outbursts,
susceptibility
to
suggestion,
and
contractions
and
paralyses
of
the
muscles
that
could
not
be
explained
by
simple
anatomy.7
Once
considered
an
affliction
of
unstable
or
malingering
women
(the
name
comes
from
the
Greek
word
for
“womb”),
hysteria
now
became
a
window
into
the
mysteries
of
mind
and
body.
The
names
of
some
of
the
greatest
pioneers
in
neurology
and
psychiatry,
such
as
Jean-Martin
Charcot,
Pierre
Janet,
and
Sigmund
Freud,
are
associated
with
the
discovery
that
trauma
is
at
the
root
of
hysteria,
particularly
the
trauma
of
childhood
sexual
abuse.8
These
early
researchers
referred
to
traumatic
memories
as
“pathogenic
secrets”9
or
“mental
parasites,”10
because
as
much
as
the
sufferers
wanted
to
forget
whatever
had
happened,
their
memories
kept
forcing
themselves
into
consciousness,
trapping
them
in
an
ever-renewing
present
of
existential
horror.11
The
interest
in
hysteria
was
particularly
strong
in
France,
and,
as
so
often
happens,
its
roots
lay
in
the
politics
of
the
day.
Jean-Martin
Charcot,
who
is
widely
regarded
as
the
father
of
neurology
and
whose
pupils,
such
as
Gilles
de
la
Tourette,
lent
their
names
to
numerous
neurological
diseases,
was
also
active
in
politics.
After
Emperor
Napoleon
III
abdicated
in
1870,
there
was
a
struggle
between
the
monarchists
(the
old
order
backed
by
the
clergy),
and
the
advocates
of
the
fledgling
French
Republic,
who
believed
in
science
and
in
secular
democracy.
Charcot
believed
that
women
would
be
a
critical
factor
in
this
struggle,
and
his
investigation
of
hysteria
“offered
a
scientific
explanation
for
phenomena
such
as
demonic
possession
states,
witchcraft,
exorcism,
and
religious
ecstasy.”12
Charcot
conducted
meticulous
studies
of
the
physiological
and
neurological
correlates
of
hysteria
in
both
men
and
women,
all
of
which
emphasized
embodied
memory
and
a
lack
of
language.
For
example,
in
1889
he
published
the
case
of
a
patient
named
LeLog,
who
developed
paralysis
of
the
legs
after
being
involved
in
a
traffic
accident
with
a
horse-
drawn
cart.
Although
Lelog
fell
to
the
ground
and
lost
consciousness,
his
legs
appeared
unhurt,
and
there
were
no
neurological
signs
that
would
indicate
a
physical
cause
for
his
paralysis.
Charcot
discovered
that
just
before
Lelog
passed
out,
he
saw
the
wheels
of
the
cart
approaching
him
and
strongly
believed
he
would
be
run
over.
He
noted
that
“the
patient . . .
does
not
preserve
any
recollection. . . .
Questions
addressed
to
him
upon
this
point
are
attended
with
no
result.
He
knows
nothing
or
almost
nothing.”13
Like
many
other
patients
at
the
Salpêtrière,
Lelog
expressed
his
experience
physically:
Instead
of
remembering
the
accident,
he
developed
paralysis
of
his
legs.14
 PAINTING
BY
ANDRE
BROUILLET
Jean-Martin
Charcot
presents
the
case
of
a
patient
with
hysteria.
Charcot
transformed
La
Salpêtrière,
an
ancient
asylum
for
the
poor
of
Paris,
which
he
transformed
into
a
modern
hospital.
Notice
the
patient’s
dramatic
posture.

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

AMNESIA,
DISSOCIATION,
AND
REENACTMENT
Janet
was
the
first
to
point
out
the
difference
between
“narrative
memory”—the
stories
people
tell
about
trauma—and
traumatic
memory
itself.
One
of
his
case
histories
was
the
story
of
Irène,
a
young
woman
who
was
hospitalized
following
her
mother’s
death
from
tuberculosis.17
Irène
had
nursed
her
mother
for
many
months
while
continuing
to
work
outside
the
home
to
support
her
alcoholic
father
and
pay
for
her
mother’s
medical
care.
When
her
mother
finally
died,
Irène—exhausted
from
stress
and
lack
of
sleep—tried
for
several
hours
to
revive
the
corpse,
calling
out
to
her
mother
and
trying
to
force
medicine
down
her
throat.
At
one
point
the
lifeless
body
dropped
off
the
bed
while
Irène’s
drunken
father
lay
passed
out
nearby.
Even
after
an
aunt
arrived
and
started
preparing
for
the
burial,
Irène’s
denial
persisted.
She
had
to
be
persuaded
to
attend
the
funeral,
and
she
laughed
throughout
the
service.
A
few
weeks
later
she
was
brought
to
the
Salpêtrière,
where
Janet
took
over
her
case.
In
addition
to
amnesia
for
her
mother’s
death,
Irène
suffered
from
another
symptom:
Several
times
a
week
she
would
stare,
trancelike,
at
an
empty
bed,
ignore
whatever
was
going
on
around
her,
and
begin
to
care
for
an
imaginary
person.
She
meticulously
reproduced,
rather
than
remembered,
the
details
of
her
mother’s
death.
Traumatized
people
simultaneously
remember
too
little
and
too
much.
On
the
one
hand,
Irène
had
no
conscious
memory
of
her
mother’s
death—
she
could
not
tell
the
story
of
what
had
happened.
On
the
other
she
was
compelled
to
physically
act
out
the
events
of
her
mother’s
death.
Janet’s
term
“automatism”
conveys
the
involuntary,
unconscious
nature
of
her
actions.
Janet
treated
Irène
for
several
months,
mainly
with
hypnosis.
At
the
end
he
asked
her
again
about
her
mother’s
death.
Irène
started
to
cry
and
said,
“Don’t
remind
me
of
those
terrible
things. . . .
My
mother
was
dead
and
my
father
was
a
complete
drunk,
as
always.
I
had
to
take
care
of
her
dead
body
all
night
long.
I
did
a
lot
of
silly
things
in
order
to
revive
her. . . .
In
the
morning
I
lost
my
mind.”
Not
only
was
Irène
able
tell
the
story,
but
she
had
also
recovered
her
emotions:
“I
feel
very
sad
and
abandoned.”
Janet
now
called
her
memory
“complete”
because
it
now
was
accompanied
by
the
appropriate
feelings.
Janet
noted
significant
differences
between
ordinary
and
traumatic
memory.
Traumatic
memories
are
precipitated
by
specific
triggers.
In
Julian’s
case
the
trigger
was
his
girlfriend’s
seductive
comments;
in
Irène’s
it
was
a
bed.
When
one
element
of
a
traumatic
experience
is
triggered,
other
elements
are
likely
to
automatically
follow.
Traumatic
memory
is
not
condensed:
It
took
Irène
three
to
four
hours
to
reenact
her
story,
but
when
she
was
finally
able
to
tell
what
had
happened
it
took
less
than
a
minute.
The
traumatic
enactment
serves
no
function.
In
contrast,
ordinary
memory
is
adaptive;
our
stories
are
flexible
and
can
be
modified
to
fit
the
circumstances.
Ordinary
memory
is
essentially
social;
it’s
a
story
that
we
tell
for
a
purpose:
in
Irène’s
case,
to
enlist
her
doctor’s
help
and
comfort;
in
Julian’s
case,
to
recruit
me
to
join
his
search
for
justice
and
revenge.
But
there
is
nothing
social
about
traumatic
memory.
Julian’s
rage
at
his
girlfriend’s
remark
served
no
useful
purpose.
Reenactments
are
frozen
in
time,
unchanging,
and
they
are
always
lonely,
humiliating,
and
alienating
experiences.
Janet
coined
the
term
“dissociation”
to
describe
the
splitting
off
and
isolation
of
memory
imprints
that
he
saw
in
his
patients.
He
was
also
prescient
about
the
heavy
cost
of
keeping
these
traumatic
memories
at
bay.
He
later
wrote
that
when
patients
dissociate
their
traumatic
experience,
they
become
“attached
to
an
insurmountable
obstacle”:18
“[U]nable
to
integrate
their
traumatic
memories,
they
seem
to
lose
their
capacity
to
assimilate
new
experiences
as
well.
It
is . . .
as
if
their
personality
has
definitely
stopped
at
a
certain
point,
and
cannot
enlarge
any
more
by
the
addition
or
assimilation
of
new
elements.”19
He
predicted
that
unless
they
became
aware
of
the
split-off
elements
and
integrated
them
into
a
story
that
had
happened
in
the
past
but
was
now
over,
they
would
experience
a
slow
decline
in
their
personal
and
professional
functioning.
This
phenomenon
has
now
been
well
documented
in
contemporary
research.20
Janet
discovered
that,
while
it
is
normal
to
change
and
distort
one’s
memories,
people
with
PTSD
are
unable
to
put
the
actual
event,
the
source
of
those
memories,
behind
them.
Dissociation
prevents
the
trauma
from
becoming
integrated
within
the
conglomerated,
ever-shifting
stores
of
autobiographical
memory,
in
essence
creating
a
dual
memory
system.
Normal
memory
integrates
the
elements
of
each
experience
into
the
continuous
flow
of
self-experience
by
a
complex
process
of
association;
think
of
a
dense
but
flexible
network
where
each
element
exerts
a
subtle
influence
on
many
others.
But
in
Julian’s
case,
the
sensations,
thoughts,
and
emotions
of
the
trauma
were
stored
separately
as
frozen,
barely
comprehensible
fragments.
If
the
problem
with
PTSD
is
dissociation,
the
goal
of
treatment
would
be
association:
integrating
the
cut-off
elements
of
the
trauma
into
the
ongoing
narrative
of
life,
so
that
the
brain
can
recognize
that
“that
was
then,
and
this
is
now.”

THE
ORIGINS
OF
THE
“TALKING
CURE”
Psychoanalysis
was
born
on
the
wards
of
the
Salpêtrière.
In
1885
Freud
went
to
Paris
to
work
with
Charcot,
and
he
later
named
his
firstborn
son
Jean-Martin
in
Charcot’s
honor.
In
1893
Freud
and
his
Viennese
mentor,
Josef
Breuer,
cited
both
Charcot
and
Janet
in
a
brilliant
paper
on
the
cause
of
hysteria.
“Hysterics
suffer
mainly
from
reminiscences,”
they
proclaim,
and
go
on
to
note
that
these
memories
are
not
subject
to
the
“wearing
away
process”
of
normal
memories
but
“persist
for
a
long
time
with
astonishing
freshness.”
Nor
can
traumatized
people
control
when
they
will
emerge:
“We
must . . .
mention
another
remarkable
fact . . .
namely,
that
these
memories,
unlike
other
memories
of
their
past
lives,
are
not
at
the
patients’
disposal.
On
the
contrary,
these
experiences
are
completely
absent
from
the
patients’
memory
when
they
are
in
a
normal
psychical
state,
or
are
only
present
in
a
highly
summary
form.”21
(All
italics
in
the
quoted
passages
are
Breuer
and
Freud’s.)
Breuer
and
Freud
believed
that
traumatic
memories
were
lost
to
ordinary
consciousness
either
because
“circumstances
made
a
reaction
impossible,”
or
because
they
started
during
“severely
paralyzing
affects,
such
as
fright.”
In
1896
Freud
boldly
claimed
that
“the
ultimate
cause
of
hysteria
is
always
the
seduction
of
the
child
by
an
adult.”22
Then,
faced
with
his
own
evidence
of
an
epidemic
of
abuse
in
the
best
families
of
Vienna—one,
he
noted,
that
would
implicate
his
own
father—he
quickly
began
to
retreat.
Psychoanalysis
shifted
to
an
emphasis
on
unconscious
wishes
and
fantasies,
though
Freud
occasionally
kept
acknowledging
the
reality
of
sexual
abuse.23
After
the
horrors
of
World
War
I
confronted
him
with
the
reality
of
combat
neuroses,
Freud
reaffirmed
that
lack
of
verbal
memory
is
central
in
trauma
and
that,
if
a
person
does
not
remember,
he
is
likely
to
act
out:
“[H]e
reproduces
it
not
as
a
memory
but
as
an
action;
he
repeats
it,
without
knowing,
of
course,
that
he
is
repeating,
and
in
the
end,
we
understand
that
this
is
his
way
of
remembering.”24
The
lasting
legacy
of
Breuer
and
Freud’s
1893
paper
is
what
we
now
call
the
“talking
cure”:
“[W]e
found,
to
our
great
surprise,
at
first,
that
each
individual
hysterical
symptom
immediately
and
permanently
disappeared
when
we
had
succeeded
in
bringing
clearly
to
light
the
memory
of
the
event
by
which
it
was
provoked
and
in
arousing
its
accompanying
affect,
and
when
the
patient
had
described
that
event
in
the
greatest
possible
detail
and
had
put
the
affect
into
words
(all
italics
in
original).
Recollection
without
affect
almost
invariably
produces
no
result.”
They
explain
that
unless
there
is
an
“energetic
reaction”
to
the
traumatic
event,
the
affect
“remains
attached
to
the
memory”
and
cannot
be
discharged.
The
reaction
can
be
discharged
by
an
action—“from
tears
to
acts
of
revenge.”
“But
language
serves
as
a
substitute
for
action;
by
its
help,
an
affect
can
be
‘abreacted’
almost
as
effectively.”
“It
will
now
be
understood,”
they
conclude,
“how
it
is
that
the
psychotherapeutic
procedure
which
we
have
described
in
these
pages
has
a
curative
effect.
It
brings
to
an
end
the
operative
force . . .
which
was
not
abreacted
in
the
first
instance
[i.e.,
at
the
time
of
the
trauma],
by
allowing
its
strangulated
affect
to
find
a
way
out
through
speech;
and
it
subjects
it
to
associative
correction
by
introducing
it
into
normal
consciousness.”
Even
though
psychoanalysis
is
today
in
eclipse,
the
“talking
cure”
has
lived
on,
and
psychologists
have
generally
assumed
that
telling
the
trauma
story
in
great
detail
will
help
people
to
leave
it
behind.
That
is
also
a
basic
premise
of
cognitive
behavioral
therapy
(CBT),
which
today
is
taught
in
graduate
psychology
courses
around
the
world.
Although
the
diagnostic
labels
have
changed,
we
continue
to
see
patients
similar
to
those
described
by
Charcot,
Janet,
and
Freud.
In
1986
my
colleagues
and
I
wrote
up
the
case
of
a
woman
who
had
been
a
cigarette
girl
at
Boston’s
Cocoanut
Grove
nightclub
when
it
burned
down
in
1942.25
During
the
1970s
and
1980s
she
annually
reenacted
her
escape
on
Newbury
Street,
a
few
blocks
from
the
original
location,
which
resulted
in
her
being
hospitalized
with
diagnoses
like
schizophrenia
and
bipolar
disorder.
In
1989
I
reported
on
a
Vietnam
veteran
who
yearly
staged
an
“armed
robbery”
on
the
exact
anniversary
of
a
buddy’s
death.26
He
would
put
a
finger
in
his
pants
pocket,
claim
that
it
was
a
pistol,
and
tell
a
shopkeeper
to
empty
his
cash
register—giving
him
plenty
of
time
to
alert
the
police.
This
unconscious
attempt
to
commit
“suicide
by
cop”
came
to
an
end
after
a
judge
referred
the
veteran
to
me
for
treatment.
Once
we
had
dealt
with
his
guilt
about
his
friend’s
death,
there
were
no
further
reenactments.
Such
incidents
raise
a
critical
question:
How
can
doctors,
police
officers,
or
social
workers
recognize
that
someone
is
suffering
from
traumatic
stress
as
long
as
he
reenacts
rather
than
remember?
How
can
patients
themselves
identify
the
source
of
their
behavior?
If
their
history
is
not
known,
they
are
likely
to
be
labeled
as
crazy
or
punished
as
criminals
rather
than
helped
to
integrate
the
past.

TRAUMATIC
MEMORY
ON
TRIAL
At
least
two
dozen
men
had
claimed
they
were
molested
by
Paul
Shanley,
and
many
of
them
reached
civil
settlements
with
the
Boston
archdiocese.
Julian
was
the
only
victim
who
was
called
to
testify
in
Shanley’s
trial.
In
February
2005
the
former
priest
was
found
guilty
on
two
counts
of
raping
a
child
and
two
counts
of
assault
and
battery
on
a
child.
He
was
sentenced
to
twelve
to
fifteen
years
in
prison.
In
2007
Shanley’s
attorney,
Robert
F.
Shaw
Jr.,
filed
a
motion
for
a
new
trial,
challenging
Shanley’s
convictions
as
a
miscarriage
of
justice.
Shaw
tried
to
make
the
case
that
“repressed
memories”
were
not
generally
accepted
in
the
scientific
community,
that
the
convictions
were
based
on
“junk
science,”
and
that
there
had
been
insufficient
testimony
about
the
scientific
status
of
repressed
memories
before
the
trial.
The
appeal
was
rejected
by
the
original
trial
judge
but
two
years
later
was
taken
up
by
the
Supreme
Judicial
Court
of
Massachusetts.
Almost
one
hundred
leading
psychiatrists
and
psychologists
from
around
the
United
States
and
eight
foreign
countries
signed
an
amicus
curiae
brief
stating
that
“repressed
memory”
has
never
been
shown
to
exist
and
that
it
should
not
have
been
admitted
as
evidence.
However,
on
January
10,
2010,
the
court
unanimously
upheld
Shanley’s
conviction
with
this
statement:
“In
sum,
the
judge’s
finding
that
the
lack
of
scientific
testing
did
not
make
unreliable
the
theory
that
an
individual
may
experience
dissociative
amnesia
was
supported
in
the
record. . . .
There
was
no
abuse
of
discretion
in
the
admission
of
expert
testimony
on
the
subject
of
dissociative
amnesia.”
In
the
following
chapter
I’ll
talk
more
about
memory
and
forgetting
and
about
how
the
debate
over
repressed
memory,
which
started
with
Freud,
continues
to
be
played
out
today.
 CHAPTER
12

THE
UNBEARABLE
HEAVINESS
OF
REMEMBERING

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

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

THE
NEW
FACE
OF
TRAUMA
The
outbreak
of
World
War
II
prompted
Charles
Samuel
Myers
and
the
American
psychiatrist
Abram
Kardiner
to
publish
the
accounts
of
their
work
with
World
War
I
soldiers
and
veterans.
Shell
Shock
in
France
1914–1918
(1940)11
and
The
Traumatic
Neuroses
of
War
(1941)12
served
as
the
principal
guides
for
psychiatrists
who
were
treating
soldiers
in
the
new
conflict
who
had
“war
neuroses.”
The
U.S.
war
effort
was
prodigious,
and
the
advances
in
frontline
psychiatry
reflected
that
commitment.
Again,
YouTube
offers
a
direct
window
on
the
past:
Hollywood
director
John
Huston’s
documentary
Let
There
Be
Light
(1946)
shows
the
predominant
treatment
for
war
neuroses
at
that
time:
hypnosis.13
In
Huston’s
film,
made
while
he
was
serving
in
the
Army
Signal
Corps,
the
doctors
are
still
patriarchal
and
the
patients
are
still
terrified
young
men.
But
they
manifest
their
trauma
differently:
While
the
World
War
I
soldiers
flail,
have
facial
tics,
and
collapse
with
paralyzed
bodies,
the
following
generation
talks
and
cringes.
Their
bodies
still
keep
the
score:
Their
stomachs
are
upset,
their
hearts
race,
and
they
are
overwhelmed
by
panic.
But
the
trauma
did
not
just
affect
their
bodies.
The
trance
state
induced
by
hypnosis
allowed
them
to
find
words
for
the
things
they
had
been
too
afraid
to
remember:
their
terror,
their
survivor’s
guilt,
and
their
conflicting
loyalties.
It
also
struck
me
that
these
soldiers
seemed
to
keep
a
much
tighter
lid
on
their
anger
and
hostility
than
the
younger
veterans
I’d
worked
with.
Culture
shapes
the
expression
of
traumatic
stress.
 The
feminist
theorist
Germaine
Greer
wrote
about
the
treatment
of
her
father’s
PTSD
after
World
War
II:
“When
[the
medical
officers]
examined
men
exhibiting
severe
disturbances
they
almost
invariably
found
the
root
cause
in
pre-war
experience:
the
sick
men
were
not
first-grade
fighting
material. . . .
The
military
proposition
is
[that
it
is]
not
war
which
makes
men
sick,
but
that
sick
men
can
not
fight
wars.”14
It
seems
unlikely
the
doctors
did
her
father
any
good,
but
Greer’s
efforts
to
come
to
grips
with
his
suffering
undoubtedly
helped
fuel
her
exploration
of
sexual
domination
in
all
its
ugly
manifestations
of
rape,
incest,
and
domestic
violence.
When
I
worked
at
the
VA,
I
was
puzzled
that
the
vast
majority
of
the
patients
we
saw
on
the
psychiatry
service
were
young,
recently
discharged
Vietnam
veterans,
while
the
corridors
and
elevators
that
led
to
the
medical
departments
were
filled
by
old
men.
Curious
about
this
disparity,
I
conducted
a
survey
of
the
World
War
II
veterans
in
the
medical
clinics
in
1983.
The
vast
majority
of
them
scored
positive
for
PTSD
on
the
rating
scales
that
I
administered,
but
their
treatment
focused
on
medical
rather
than
psychiatric
complaints.
These
vets
communicated
their
distress
via
stomach
cramps
and
chest
pains
rather
than
with
nightmares
and
rage,
from
which,
my
research
showed,
they
also
suffered.
Doctors
shape
how
their
patients
communicate
their
distress:
When
a
patient
complains
about
terrifying
nightmares
and
his
doctor
orders
a
chest
X-ray,
the
patient
realizes
that
he’ll
get
better
care
if
he
focuses
on
his
physical
problems.
Like
my
relatives
who
fought
in
or
were
captured
during
World
War
II,
most
of
these
men
were
extremely
reluctant
to
share
their
experiences.
My
sense
was
that
neither
the
doctors
nor
their
patients
wanted
to
revisit
the
war.
However,
military
and
civilian
leaders
came
away
from
World
War
II
with
important
lessons
that
the
previous
generation
had
failed
to
grasp.
After
the
defeat
of
Nazi
Germany
and
imperial
Japan,
the
United
States
helped
rebuild
Europe
by
means
of
the
Marshall
Plan,
which
formed
the
economic
foundation
of
the
next
fifty
years
of
relative
peace.
At
home,
the
GI
Bill
provided
millions
of
veterans
with
educations
and
home
mortgages,
which
promoted
general
economic
well-being
and
created
a
broad-based,
well-educated
middle
class.
The
armed
forces
led
the
nation
in
racial
integration
and
opportunity.
The
Veterans
Administration
built
facilities
nationwide
to
help
combat
veterans
with
their
health
care.
Still,
with
all
this
thoughtful
attention
to
the
returning
veterans,
the
psychological
scars
of
war
went
unrecognized,
and
traumatic
neuroses
disappeared
entirely
from
official
psychiatric
nomenclature.
The
last
scientific
writing
on
combat
trauma
after
World
War
II
appeared
in
1947.15

TRAUMA
REDISCOVERED
As
I
noted
earlier,
when
I
started
to
work
with
Vietnam
veterans,
there
was
not
a
single
book
on
war
trauma
in
the
library
of
the
VA,
but
the
Vietnam
War
inspired
numerous
studies,
the
formation
of
scholarly
organizations,
and
the
inclusion
of
a
trauma
diagnosis,
PTSD,
in
the
professional
literature.
At
the
same
time,
interest
in
trauma
was
exploding
in
the
general
public.
In
1974
Freedman
and
Kaplan’s
Comprehensive
Textbook
of
Psychiatry
stated
that
“incest
is
extremely
rare,
and
does
not
occur
in
more
than
1
out
of
1.1
million
people.”16
As
we
have
seen
in
chapter
2
this
authoritative
textbook
then
went
on
to
extol
the
possible
benefits
of
incest:
“Such
incestuous
activity
diminishes
the
subject’s
chance
of
psychosis
and
allows
for
a
better
adjustment
to
the
external
world. . . .
The
vast
majority
of
them
were
none
the
worse
for
the
experience.”
How
misguided
those
statements
were
became
obvious
when
the
ascendant
feminist
movement,
combined
with
awareness
of
trauma
in
returning
combat
veterans,
emboldened
tens
of
thousands
of
survivors
of
childhood
sexual
abuse,
domestic
abuse,
and
rape
to
come
forward.
Consciousness-raising
groups
and
survivor
groups
were
formed,
and
numerous
popular
books,
including
The
Courage
to
Heal
(1988),
a
best-
selling
self-help
book
for
survivors
of
incest,
and
Judith
Herman’s
book
Trauma
and
Recovery
(1992),
discussed
the
stages
of
treatment
and
recovery
in
great
detail.
Cautioned
by
history,
I
began
to
wonder
if
we
were
headed
toward
another
backlash
like
those
of
1895,
1917,
and
1947
against
acknowledging
the
reality
of
trauma.
That
proved
to
be
the
case,
for
by
the
early
1990s
articles
had
started
to
appear
in
many
leading
newspapers
and
magazines
in
United
States
and
in
Europe
about
a
so-called
False
Memory
Syndrome
in
which
psychiatric
patients
supposedly
manufactured
elaborate
false
memories
of
sexual
abuse,
which
they
then
claimed
had
lain
dormant
for
many
years
before
being
recovered.
 What
was
striking
about
these
articles
was
the
certainty
with
which
they
stated
that
there
was
no
evidence
that
people
remember
trauma
any
differently
than
they
do
ordinary
events.
I
vividly
recall
a
phone
call
from
a
well-known
newsweekly
in
London,
telling
me
that
they
planned
to
publish
an
article
about
traumatic
memory
in
their
next
issue
and
asking
me
whether
I
had
any
comments
on
the
subject.
I
was
quite
enthusiastic
about
their
question
and
told
them
that
memory
loss
for
traumatic
events
had
first
been
studied
in
England
well
over
a
century
earlier.
I
mentioned
John
Eric
Erichsen
and
Frederic
Myers’s
work
on
railway
accidents
in
the
1860s
and
1870s
and
Charles
Samuel
Myers’s
and
W.
H.
R.
Rivers’s
extensive
studies
of
memory
problems
in
combat
soldiers
of
World
War
I.
I
also
suggested
they
look
at
an
article
published
in
The
Lancet
in
1944,
which
described
the
aftermath
of
the
rescue
of
the
entire
British
army
from
the
beaches
of
Dunkirk
in
1940.
More
than
10
percent
of
the
soldiers
who
were
studied
had
suffered
from
major
memory
loss
after
the
evacuation.17
The
following
week,
the
magazine
told
its
readers
that
there
was
no
evidence
whatsoever
that
people
sometimes
lose
some
or
all
memory
for
traumatic
events.
The
issue
of
delayed
recall
of
trauma
was
not
particularly
controversial
when
Myers
and
Kardiner
first
described
this
phenomenon
in
their
books
on
combat
neuroses
in
World
War
I;
when
major
memory
loss
was
observed
after
the
evacuation
from
Dunkirk;
or
when
I
wrote
about
Vietnam
veterans
and
the
survivor
of
the
Cocoanut
Grove
nightclub
fire.
However,
during
the
1980s
and
early
1990s,
as
similar
memory
problems
began
to
be
documented
in
women
and
children
in
the
context
of
domestic
abuse,
the
efforts
of
abuse
victims
to
seek
justice
against
their
alleged
perpetrators
moved
the
issue
from
science
into
politics
and
law.
This,
in
turn,
became
the
context
for
the
pedophile
scandals
in
the
Catholic
Church,
in
which
memory
experts
were
pitted
against
one
another
in
courtrooms
across
the
United
States
and
later
in
Europe
and
Australia.
Experts
testifying
on
behalf
of
the
Church
claimed
that
memories
of
childhood
sexual
abuse
were
unreliable
at
best
and
that
the
claims
being
made
by
alleged
victims
more
likely
resulted
from
false
memories
implanted
in
their
minds
by
therapists
who
were
oversympathetic,
credulous,
or
driven
by
their
own
agendas.
During
this
period
I
examined
more
than
fifty
adults
who,
like
Julian,
remembered
having
been
abused
by
priests.
Their
claims
were
denied
in
about
half
the
cases.
THE
SCIENCE
OF
REPRESSED
MEMORY
There
have
in
fact
been
hundreds
of
scientific
publications
spanning
well
over
a
century
documenting
how
the
memory
of
trauma
can
be
repressed,
only
to
resurface
years
or
decades
later.18
Memory
loss
has
been
reported
in
people
who
have
experienced
natural
disasters,
accidents,
war
trauma,
kidnapping,
torture,
concentration
camps,
and
physical
and
sexual
abuse.
Total
memory
loss
is
most
common
in
childhood
sexual
abuse,
with
incidence
ranging
from
19
percent
to
38
percent.19
This
issue
is
not
particularly
controversial:
As
early
as
1980
the
DSM-III
recognized
the
existence
of
memory
loss
for
traumatic
events
in
the
diagnostic
criteria
for
dissociative
amnesia:
“an
inability
to
recall
important
personal
information,
usually
of
a
traumatic
or
stressful
nature,
that
is
too
extensive
to
be
explained
by
normal
forgetfulness.”
Memory
loss
has
been
part
of
the
criteria
for
PTSD
since
that
diagnosis
was
first
introduced.
One
of
the
most
interesting
studies
of
repressed
memory
was
conducted
by
Dr.
Linda
Meyer
Williams,
which
began
when
she
was
a
graduate
student
in
sociology
at
the
University
of
Pennsylvania
in
the
early
1970s.
Williams
interviewed
206
girls
between
the
ages
of
ten
and
twelve
who
had
been
admitted
to
a
hospital
emergency
room
following
sexual
abuse.
Their
laboratory
tests,
as
well
as
the
interviews
with
the
children
and
their
parents,
were
kept
in
the
hospital’s
medical
records.
Seventeen
years
later
Williams
was
able
to
track
down
136
of
the
children,
now
adults,
with
whom
she
conducted
extensive
follow-up
interviews.20
More
than
a
third
of
the
women
(38
percent)
did
not
recall
the
abuse
that
was
documented
in
their
medical
records,
while
only
fifteen
women
(12
percent)
said
that
they
had
never
been
abused
as
children.
More
than
two-thirds
(68
percent)
reported
other
incidents
of
childhood
sexual
abuse.
Women
who
were
younger
at
the
time
of
the
incident
and
those
who
were
molested
by
someone
they
knew
were
more
likely
to
have
forgotten
their
abuse.
This
study
also
examined
the
reliability
of
recovered
memories.
One
in
ten
women
(16
percent
of
those
who
recalled
the
abuse)
reported
that
they
had
forgotten
it
at
some
time
in
the
past
but
later
remembered
that
it
had
happened.
In
comparison
with
the
women
who
had
always
remembered
their
molestation,
those
with
a
prior
period
of
forgetting
were
younger
at
the
time
of
their
abuse
and
were
less
likely
to
have
received
support
from
their
mothers.
Williams
also
determined
that
the
recovered
memories
were
approximately
as
accurate
as
those
that
had
never
been
lost:
All
the
women’s
memories
were
accurate
for
the
central
facts
of
the
incident,
but
none
of
their
stories
precisely
matched
every
detail
documented
in
their
charts.21
Williams’s
findings
are
supported
by
recent
neuroscience
research
that
shows
that
memories
that
are
retrieved
tend
to
return
to
the
memory
bank
with
modifications.22
As
long
as
a
memory
is
inaccessible,
the
mind
is
unable
to
change
it.
But
as
soon
as
a
story
starts
being
told,
particularly
if
it
is
told
repeatedly,
it
changes—the
act
of
telling
itself
changes
the
tale.
The
mind
cannot
help
but
make
meaning
out
of
what
it
knows,
and
the
meaning
we
make
of
our
lives
changes
how
and
what
we
remember.
Given
the
wealth
of
evidence
that
trauma
can
be
forgotten
and
resurface
years
later,
why
did
nearly
one
hundred
reputable
memory
scientists
from
several
different
countries
throw
the
weight
of
their
reputations
behind
the
appeal
to
overturn
Father
Shanley’s
conviction,
claiming
that
“repressed
memories”
were
based
on
“junk
science”?
Because
memory
loss
and
delayed
recall
of
traumatic
experiences
had
never
been
documented
in
the
laboratory,
some
cognitive
scientists
adamantly
denied
that
these
phenomena
existed23
or
that
retrieved
traumatic
memories
could
be
accurate.24
However,
what
doctors
encounter
in
emergency
rooms,
on
psychiatric
wards,
and
on
the
battlefield
is
necessarily
quite
different
from
what
scientists
observe
in
their
safe
and
well-organized
laboratories.
Consider
what
is
known
as
the
“lost
in
the
mall”
experiment,
for
example.
Academic
researchers
have
shown
that
it
is
relatively
easy
to
implant
memories
of
events
that
never
took
place,
such
as
having
been
lost
in
a
shopping
mall
as
a
child.25
About
25
percent
of
subjects
in
these
studies
later
“recall”
that
they
were
frightened
and
even
fill
in
missing
details.
But
such
recollections
involve
none
of
the
visceral
terror
that
a
lost
child
would
actually
experience.
Another
line
of
research
documented
the
unreliability
of
eyewitness
testimony.
Subjects
might
be
shown
a
video
of
a
car
driving
down
a
street
and
asked
afterward
if
they
saw
a
stop
sign
or
a
traffic
light;
children
might
be
asked
to
recall
what
a
male
visitor
to
their
classroom
had
been
wearing.
Other
eyewitness
experiments
demonstrated
that
the
questions
witnesses
were
asked
could
alter
what
they
claimed
to
remember.
These
studies
were
valuable
in
bringing
many
police
and
courtroom
practices
into
question,
but
they
have
little
relevance
to
traumatic
memory.
 The
fundamental
problem
is
this:
Events
that
take
place
in
the
laboratory
cannot
be
considered
equivalent
to
the
conditions
under
which
traumatic
memories
are
created.
The
terror
and
helplessness
associated
with
PTSD
simply
can’t
be
induced
de
novo
in
such
a
setting.
We
can
study
the
effects
of
existing
traumas
in
the
lab,
as
in
our
script-driven
imaging
studies
of
flashbacks,
but
the
original
imprint
of
trauma
cannot
be
laid
down
there.
Dr.
Roger
Pitman
conducted
a
study
at
Harvard
in
which
he
showed
college
students
a
film
called
Faces
of
Death,
which
contained
newsreel
footage
of
violent
deaths
and
executions.
This
movie,
now
widely
banned,
is
as
extreme
as
any
institutional
review
board
would
allow,
but
it
did
not
cause
Pitman’s
normal
volunteers
to
develop
symptoms
of
PTSD.
If
you
want
to
study
traumatic
memory,
you
have
to
study
the
memories
of
people
who
have
actually
been
traumatized.
Interestingly,
once
the
excitement
and
profitability
of
courtroom
testimony
diminished,
the
“scientific”
controversy
disappeared
as
well,
and
clinicians
were
left
to
deal
with
the
wreckage
of
traumatic
memory.

NORMAL
VERSUS
TRAUMATIC
MEMORY
In
1994
I
and
my
colleagues
at
Massachusetts
General
Hospital
decided
to
undertake
a
systematic
study
comparing
how
people
recall
benign
experiences
and
horrific
ones.
We
placed
advertisements
in
local
newspapers,
in
laundromats,
and
on
student
union
bulletin
boards
that
said:
“Has
something
terrible
happened
to
you
that
you
cannot
get
out
of
your
mind?
Call
727-5500;
we
will
pay
you
$10.00
for
participating
in
this
study.”
In
response
to
our
first
ad
seventy-six
volunteers
showed
up.26
After
we
introduced
ourselves,
we
started
off
by
asking
each
participant:
“Can
you
tell
us
about
an
event
in
your
life
that
you
think
you
will
always
remember
but
that
is
not
traumatic?”
One
participant
lit
up
and
said,
“The
day
that
my
daughter
was
born”;
others
mentioned
their
wedding
day,
playing
on
a
winning
sports
team,
or
being
valedictorian
at
their
high
school
graduation.
Then
we
asked
them
to
focus
on
specific
sensory
details
of
those
events,
such
as:
“Are
you
ever
somewhere
and
suddenly
have
a
vivid
image
of
what
your
husband
looked
like
on
your
wedding
day?”
The
answers
were
always
negative.
“How
about
what
your
husband’s
body
felt
like
on
your
wedding
night?”
(We
got
some
odd
looks
on
that
one.)
We
continued:
“Do
you
ever
have
a
vivid,
precise
recollection
of
the
speech
you
gave
as
a
valedictorian?”
“Do
you
ever
have
intense
sensations
recalling
the
birth
of
your
first
child?”
The
replies
were
all
in
the
negative.
Then
we
asked
them
about
the
traumas
that
had
brought
them
into
the
study—many
of
them
rapes.
“Do
you
ever
suddenly
remember
how
your
rapist
smelled?”
we
asked,
and,
“Do
you
ever
experience
the
same
physical
sensations
you
had
when
you
were
raped?”
Such
questions
precipitated
powerful
emotional
responses:
“That
is
why
I
cannot
go
to
parties
anymore,
because
the
smell
of
alcohol
on
somebody’s
breath
makes
me
feel
like
I
am
being
raped
all
over
again”
or
“I
can
no
longer
make
love
to
my
husband,
because
when
he
touches
me
in
a
particular
way
I
feel
like
I
am
being
raped
again.”
There
were
two
major
differences
between
how
people
talked
about
memories
of
positive
versus
traumatic
experiences:
(1)
how
the
memories
were
organized,
and
(2)
their
physical
reactions
to
them.
Weddings,
births,
and
graduations
were
recalled
as
events
from
the
past,
stories
with
a
beginning,
a
middle,
and
an
end.
Nobody
said
that
there
were
periods
when
they’d
completely
forgotten
any
of
these
events.
In
contrast,
the
traumatic
memories
were
disorganized.
Our
subjects
remembered
some
details
all
too
clearly
(the
smell
of
the
rapist,
the
gash
in
the
forehead
of
a
dead
child)
but
could
not
recall
the
sequence
of
events
or
other
vital
details
(the
first
person
who
arrived
to
help,
whether
an
ambulance
or
a
police
car
took
them
to
the
hospital).
We
also
asked
the
participants
how
they
recalled
their
trauma
at
three
points
in
time:
right
after
it
happened;
when
they
were
most
troubled
by
their
symptoms;
and
during
the
week
before
the
study.
All
of
our
traumatized
participants
said
that
they
had
not
been
able
to
tell
anybody
precisely
what
had
happened
immediately
following
the
event.
(This
will
not
surprise
anyone
who
has
worked
in
an
emergency
room
or
ambulance
service:
People
brought
in
after
a
car
accident
in
which
a
child
or
a
friend
has
been
killed
sit
in
stunned
silence,
dumbfounded
by
terror.)
Almost
all
had
repeated
flashbacks:
They
felt
overwhelmed
by
images,
sounds,
sensations,
and
emotions.
As
time
went
on,
even
more
sensory
details
and
feelings
were
activated,
but
most
participants
also
started
to
be
able
to
make
some
sense
out
of
them.
They
began
to
“know”
what
had
happened
and
to
be
able
to
tell
the
story
to
other
people,
a
story
that
we
call
“the
memory
of
the
trauma.”
 Gradually
the
images
and
flashbacks
decreased
in
frequency,
but
the
greatest
improvement
was
in
the
participants’
ability
to
piece
together
the
details
and
sequence
of
the
event.
By
the
time
of
our
study,
85
percent
of
them
were
able
to
tell
a
coherent
story,
with
a
beginning,
a
middle,
and
an
end.
Only
a
few
were
missing
significant
details.
We
noted
that
the
five
who
said
they
had
been
abused
as
children
had
the
most
fragmented
narratives—
their
memories
still
arrived
as
images,
physical
sensations,
and
intense
emotions.
In
essence,
our
study
confirmed
the
dual
memory
system
that
Janet
and
his
colleagues
at
the
Salpêtrière
had
described
more
than
a
hundred
years
earlier:
Traumatic
memories
are
fundamentally
different
from
the
stories
we
tell
about
the
past.
They
are
dissociated:
The
different
sensations
that
entered
the
brain
at
the
time
of
the
trauma
are
not
properly
assembled
into
a
story,
a
piece
of
autobiography.
Perhaps
the
most
important
finding
in
our
study
was
that
remembering
the
trauma
with
all
its
associated
affects,
does
not,
as
Breuer
and
Freud
claimed
back
in
1893,
necessarily
resolve
it.
Our
research
did
not
support
the
idea
that
language
can
substitute
for
action.
Most
of
our
study
participants
could
tell
a
coherent
story
and
also
experience
the
pain
associated
with
those
stories,
but
they
kept
being
haunted
by
unbearable
images
and
physical
sensations.
Research
in
contemporary
exposure
treatment,
a
staple
of
cognitive
behavioral
therapy,
has
similarly
disappointing
results:
The
majority
of
patients
treated
with
that
method
continue
to
have
serious
PTSD
symptoms
three
months
after
the
end
of
treatment.27
As
we
will
see,
finding
words
to
describe
what
has
happened
to
you
can
be
transformative,
but
it
does
not
always
abolish
flashbacks
or
improve
concentration,
stimulate
vital
involvement
in
your
life
or
reduce
hypersensitivity
to
disappointments
and
perceived
injuries.

LISTENING
TO
SURVIVORS
Nobody
wants
to
remember
trauma.
In
that
regard
society
is
no
different
from
the
victims
themselves.
We
all
want
to
live
in
a
world
that
is
safe,
manageable,
and
predictable,
and
victims
remind
us
that
this
is
not
always
the
case.
In
order
to
understand
trauma,
we
have
to
overcome
our
natural
reluctance
to
confront
that
reality
and
cultivate
the
courage
to
listen
to
the
testimonies
of
survivors.
In
his
book
Holocaust
Testimonies:
The
Ruins
of
Memory
(1991),
Lawrence
Langer
writes
about
his
work
in
the
Fortunoff
Video
Archive
at
Yale
University:
“Listening
to
accounts
of
Holocaust
experience,
we
unearth
a
mosaic
of
evidence
that
constantly
vanishes
into
bottomless
layers
of
incompletion.28
We
wrestle
with
the
beginnings
of
a
permanently
unfinished
tale,
full
of
incomplete
intervals,
faced
by
the
spectacle
of
a
faltering
witness
often
reduced
to
a
distressed
silence
by
the
overwhelming
solicitations
of
deep
memory.”
As
one
of
his
witnesses
says:
“If
you
were
not
there,
it’s
difficult
to
describe
and
say
how
it
was.
How
men
function
under
such
stress
is
one
thing,
and
then
how
you
communicate
and
express
that
to
somebody
who
never
knew
that
such
a
degree
of
brutality
exists
seems
like
a
fantasy.”
Another
survivor,
Charlotte
Delbo,
describes
her
dual
existence
after
Auschwitz:
“[T]he
‘self’
who
was
in
the
camp
isn’t
me,
isn’t
the
person
who
is
here,
opposite
you.
No,
it’s
too
unbelievable.
And
everything
that
happened
to
this
other
‘self,’
the
one
from
Auschwitz,
doesn’t
touch
me
now,
me,
doesn’t
concern
me,
so
distinct
are
deep
memory
and
common
memory. . . .
Without
this
split,
I
wouldn’t
have
been
able
to
come
back
to
life.”29
She
comments
that
even
words
have
a
dual
meaning:
“Otherwise,
someone
[in
the
camps]
who
has
been
tormented
by
thirst
for
weeks
would
never
again
be
able
to
say:
‘I’m
thirsty.
Let’s
make
a
cup
of
tea.’
Thirst
[after
the
war]
has
once
more
become
a
currently
used
term.
On
the
other
hand,
if
I
dream
of
the
thirst
I
felt
in
Birkenau
[the
extermination
facilities
in
Auschwitz],
I
see
myself
as
I
was
then,
haggard,
bereft
of
reason,
tottering.”30
Langer
hauntingly
concludes,
“Who
can
find
a
proper
grave
for
such
damaged
mosaics
of
the
mind,
where
they
may
rest
in
pieces?
Life
goes
on,
but
in
two
temporal
directions
at
once,
the
future
unable
to
escape
the
grip
of
a
memory
laden
with
grief.”31
The
essence
of
trauma
is
that
it
is
overwhelming,
unbelievable,
and
unbearable.
Each
patient
demands
that
we
suspend
our
sense
of
what
is
normal
and
accept
that
we
are
dealing
with
a
dual
reality:
the
reality
of
a
relatively
secure
and
predictable
present
that
lives
side
by
side
with
a
ruinous,
ever-present
past.
NANCY’S
STORY
Few
patients
have
put
that
duality
into
words
as
vividly
as
Nancy,
the
director
of
nursing
in
a
Midwestern
hospital
who
came
to
Boston
several
times
to
consult
with
me.
Shortly
after
the
birth
of
her
third
child,
Nancy
underwent
what
is
usually
routine
outpatient
surgery,
a
laparoscopic
tubal
ligation
in
which
the
fallopian
tubes
are
cauterized
to
prevent
future
pregnancies.
However,
because
she
was
given
insufficient
anesthesia,
she
awakened
after
the
operation
began
and
remained
aware
nearly
to
the
end,
at
times
falling
into
what
she
called
“a
light
sleep”
or
“dream,”
at
times
experiencing
the
full
horror
of
her
situation.
She
was
unable
to
alert
the
OR
team
by
moving
or
crying
out
because
she
had
been
given
a
standard
muscle
relaxant
to
prevent
muscle
contractions
during
surgery.
Some
degree
of
“anesthesia
awareness”
is
now
estimated
to
occur
in
approximately
thirty
thousand
surgical
patients
in
the
United
States
every
year,32
and
I
had
previously
testified
on
behalf
of
several
people
who
were
traumatized
by
the
experience.
Nancy,
however,
did
not
want
to
sue
her
surgeon
or
anesthetist.
Her
entire
focus
was
on
bringing
the
reality
of
her
trauma
to
consciousness
so
that
she
could
free
herself
from
its
intrusions
into
her
everyday
life.
I’d
like
to
end
this
chapter
by
sharing
several
passages
from
a
remarkable
series
of
e-mails
in
which
she
described
her
grueling
journey
to
recovery.
Initially
Nancy
did
not
know
what
had
happened
to
her.
“When
we
went
home
I
was
still
in
a
daze,
doing
the
typical
things
of
running
a
household,
yet
not
really
feeling
that
I
was
alive
or
that
I
was
real.
I
had
trouble
sleeping
that
night.
For
days,
I
remained
in
my
own
little
disconnected
world.
I
could
not
use
a
hair
dryer,
toaster,
stove
or
anything
that
warmed
up.
I
could
not
concentrate
on
what
people
were
doing
or
telling
me.
I
just
didn’t
care.
I
was
increasingly
anxious.
I
slept
less
and
less.
I
knew
I
was
behaving
strangely
and
kept
trying
to
understand
what
was
frightening
me
so.
“On
the
fourth
night
after
the
surgery,
around
3
AM,
I
started
to
realize
that
the
dream
I
had
been
living
all
this
time
related
to
conversations
I
had
heard
in
the
operating
room.
I
was
suddenly
transported
back
into
the
OR
and
could
feel
my
paralyzed
body
being
burned.
I
was
engulfed
in
a
world
of
terror
and
horror.”
From
then
on,
Nancy
says,
memories
and
flashbacks
erupted
into
her
life.
 “It
was
as
if
the
door
was
pushed
open
slightly,
allowing
the
intrusion.
There
was
a
mixture
of
curiosity
and
avoidance.
I
continued
to
have
irrational
fears.
I
was
deathly
afraid
of
sleep;
I
experienced
a
sense
of
terror
when
seeing
the
color
blue.
My
husband,
unfortunately,
was
bearing
the
brunt
of
my
illness.
I
would
lash
out
at
him
when
I
truly
did
not
intend
to.
I
was
sleeping
at
most
2
to
3
hours,
and
my
daytime
was
filled
with
hours
of
flashbacks.
I
remained
chronically
hyperalert,
feeling
threatened
by
my
own
thoughts
and
wanting
to
escape
them.
I
lost
23
pounds
in
3
weeks.
People
kept
commenting
on
how
great
I
looked.
“I
began
to
think
about
dying.
I
developed
a
very
distorted
view
of
my
life
in
which
all
my
successes
diminished
and
old
failures
were
amplified.
I
was
hurting
my
husband
and
found
that
I
could
not
protect
my
children
from
my
rage.
“Three
weeks
after
the
surgery
I
went
back
to
work
at
the
hospital.
The
first
time
I
saw
somebody
in
a
surgical
scrubsuit
was
in
the
elevator.
I
wanted
to
get
out
immediately,
but
of
course
I
could
not.
I
then
had
this
irrational
urge
to
clobber
him,
which
I
contained
with
considerable
effort.
This
episode
triggered
increasing
flashbacks,
terror
and
dissociation.
I
cried
all
the
way
home
from
work.
After
that,
I
became
adept
at
avoidance.
I
never
set
foot
in
an
elevator,
I
never
went
to
the
cafeteria,
I
avoided
the
surgical
floors.”
Gradually
Nancy
was
able
to
piece
together
her
flashbacks
and
create
an
understandable,
if
horrifying,
memory
of
her
surgery.
She
recalled
the
reassurances
of
the
OR
nurses
and
a
brief
period
of
sleep
after
the
anesthesia
was
started.
Then
she
remembered
how
she
began
to
awaken.
“The
entire
team
was
laughing
about
an
affair
one
of
the
nurses
was
having.
This
coincided
with
the
first
surgical
incision.
I
felt
the
stab
of
the
scalpel,
then
the
cutting,
then
the
warm
blood
flowing
over
my
skin.
I
tried
desperately
to
move,
to
speak,
but
my
body
didn’t
work.
I
couldn’t
understand
this.
I
felt
a
deeper
pain
as
the
layers
of
muscle
pulled
apart
under
their
own
tension.
I
knew
I
wasn’t
supposed
to
feel
this.”
Nancy
next
recalls
someone
“rummaging
around”
in
her
belly
and
identified
this
as
the
laparoscopic
instruments
being
placed.
She
felt
her
left
tube
being
clamped.
“Then
suddenly
there
was
an
intense
searing,
burning
pain.
I
tried
to
escape,
but
the
cautery
tip
pursued
me,
relentlessly
burning
through.
There
simply
are
no
words
to
describe
the
terror
of
this
experience.
This
pain
was
not
in
the
same
realm
as
other
pain
I
had
known
and
conquered,
like
a
broken
bone
or
natural
childbirth.
It
begins
as
extreme
pain,
then
continues
relentlessly
as
it
slowly
burns
through
the
tube.
The
pain
of
being
cut
with
the
scalpel
pales
beside
this
giant.”
“Then,
abruptly,
the
right
tube
felt
the
initial
impact
of
the
burning
tip.
When
I
heard
them
laugh,
I
briefly
lost
track
of
where
I
was.
I
believed
I
was
in
a
torture
chamber,
and
I
could
not
understand
why
they
were
torturing
me
without
even
asking
for
information. . . .
My
world
narrowed
to
a
small
sphere
around
the
operating
table.
There
was
no
sense
of
time,
no
past,
and
no
future.
There
was
only
pain,
terror,
and
horror.
I
felt
isolated
from
all
humanity,
profoundly
alone
in
spite
of
the
people
surrounding
me.
The
sphere
was
closing
in
on
me.
“In
my
agony,
I
must
have
made
some
movement.
I
heard
the
nurse
anesthetist
tell
the
anesthesiologist
that
I
was
‘light.’
He
ordered
more
meds
and
then
quietly
said,
‘There
is
no
need
to
put
any
of
this
in
the
chart.’
That
is
the
last
memory
I
recalled.”
In
her
later
e-mails
to
me,
Nancy
struggled
to
capture
the
existential
reality
of
trauma.
“I
want
to
tell
you
what
a
flashback
is
like.
It
is
as
if
time
is
folded
or
warped,
so
that
the
past
and
present
merge,
as
if
I
were
physically
transported
into
the
past.
Symbols
related
to
the
original
trauma,
however
benign
in
reality,
are
thoroughly
contaminated
and
so
become
objects
to
be
hated,
feared,
destroyed
if
possible,
avoided
if
not.
For
example,
an
iron
in
any
form—a
toy,
a
clothes
iron,
a
curling
iron,
came
to
be
seen
as
an
instrument
of
torture.
Each
encounter
with
a
scrub
suit
left
me
disassociated,
confused,
physically
ill
and
at
times
consciously
angry.
“My
marriage
is
slowly
falling
apart—my
husband
came
to
represent
the
heartless
laughing
people
[the
surgical
team]
who
hurt
me.
I
exist
in
a
dual
state.
A
pervasive
numbness
covers
me
with
a
blanket;
and
yet
the
touch
of
a
small
child
pulls
me
back
to
the
world.
For
a
moment,
I
am
present
and
a
part
of
life,
not
just
an
observer.
“Interestingly,
I
function
very
well
at
work,
and
I
am
constantly
given
positive
feedback.
Life
proceeds
with
its
own
sense
of
falsity.
“There
is
a
strangeness,
bizarreness
to
this
dual
existence.
I
tire
of
it.
Yet
I
cannot
give
up
on
life,
and
I
cannot
delude
myself
into
believing
that
if
I
ignore
the
beast
it
will
go
away.
I’ve
thought
many
times
that
I
had
recalled
all
the
events
around
the
surgery,
only
to
find
a
new
one.
 “There
are
so
many
pieces
of
that
45
minutes
of
my
life
that
remain
unknown.
My
memories
are
still
incomplete
and
fragmented,
but
I
no
longer
think
that
I
need
to
know
everything
in
order
to
understand
what
happened.
“When
the
fear
subsides
I
realize
I
can
handle
it,
but
a
part
of
me
doubts
that
I
can.
The
pull
to
the
past
is
strong;
it
is
the
dark
side
of
my
life;
and
I
must
dwell
there
from
time
to
time.
The
struggle
may
also
be
a
way
to
know
that
I
survive—a
re-playing
of
the
fight
to
survive—which
apparently
I
won,
but
cannot
own.”
An
early
sign
of
recovery
came
when
Nancy
needed
another,
more
extensive
operation.
She
chose
a
Boston
hospital
for
the
surgery,
asked
for
a
preoperative
meeting
with
the
surgeons
and
the
anesthesiologist
specifically
to
discuss
her
prior
experience,
and
requested
that
I
be
allowed
to
join
them
in
the
operating
room.
For
the
first
time
in
many
years
I
put
on
a
surgical
scrub
suit
and
accompanied
her
into
the
OR
while
the
anesthesia
was
induced.
This
time
she
woke
up
to
a
feeling
of
safety.
Two
years
later
I
wrote
Nancy
asking
her
permission
to
use
her
account
of
anesthesia
awareness
in
this
chapter.
In
her
reply
she
updated
me
on
the
progress
of
her
recovery:
“I
wish
I
could
say
that
the
surgery
to
which
you
were
so
kind
to
accompany
me
ended
my
suffering.
That
sadly
was
not
the
case.
After
about
six
more
months
I
made
two
choices
that
proved
provident.
I
left
my
CBT
therapist
to
work
with
a
psychodynamic
psychiatrist
and
I
joined
a
Pilates
class.
“In
our
last
month
of
therapy,
I
asked
my
psychiatrist
why
he
did
not
try
to
fix
me
as
all
other
therapists
had
attempted,
yet
had
failed.
He
told
me
that
he
assumed,
given
what
I
had
be
able
to
accomplish
with
my
children
and
career,
that
I
had
sufficient
resiliency
to
heal
myself,
if
he
created
a
holding
environment
for
me
to
do
so.
This
was
an
hour
each
week
that
became
a
refuge
where
I
could
unravel
the
mystery
of
how
I
had
become
so
damaged
and
then
re-construct
a
sense
of
myself
that
was
whole,
not
fragmented,
peaceful,
not
tormented.
Through
Pilates,
I
found
a
stronger
physical
core,
as
well
as
a
community
of
women
who
willingly
gave
acceptance
and
social
support
that
had
been
distant
in
my
life
since
the
trauma.
This
combination
of
core
strengthening—psychological,
social,
and
physical—created
a
sense
of
personal
safety
and
mastery,
relegating
my
memories
to
the
distant
past,
allowing
the
present
and
future
to
emerge.”
PART
FIVE
PATHS
TO
RECOVERY
 CHAPTER
13

HEALING
FROM
TRAUMA:
OWNING
YOUR
SELF

I
don’t
go
to
therapy
to
find
out
if
I’m
a
freak
I
go
and
I
find
the
one
and
only
answer
every
week
And
when
I
talk
about
therapy,
I
know
what
people
think
That
it
only
makes
you
selfish
and
in
love
with
your
shrink
But,
oh
how
I
loved
everybody
else
When
I
finally
got
to
talk
so
much
about
myself
—Dar
Williams,
What
Do
You
Hear
in
These
Sounds

N obody
can
“treat”
a
war,
or
abuse,
rape,
molestation,
or
any
other
horrendous
event,
for
that
matter;
what
has
happened
cannot
be
undone.
But
what
can
be
dealt
with
are
the
imprints
of
the
trauma
on
body,
mind,
and
soul:
the
crushing
sensations
in
your
chest
that
you
may
label
as
anxiety
or
depression;
the
fear
of
losing
control;
always
being
on
alert
for
danger
or
rejection;
the
self-loathing;
the
nightmares
and
flashbacks;
the
fog
that
keeps
you
from
staying
on
task
and
from
engaging
fully
in
what
you
are
doing;
being
unable
to
fully
open
your
heart
to
another
human
being.
Trauma
robs
you
of
the
feeling
that
you
are
in
charge
of
yourself,
of
what
I
will
call
self-leadership
in
the
chapters
to
come.1
The
challenge
of
recovery
is
to
reestablish
ownership
of
your
body
and
your
mind—of
your
self.
This
means
feeling
free
to
know
what
you
know
and
to
feel
what
you
feel
without
becoming
overwhelmed,
enraged,
ashamed,
or
collapsed.
For
most
people
this
involves
(1)
finding
a
way
to
become
calm
and
focused,
(2)
learning
to
maintain
that
calm
in
response
to
images,
thoughts,
sounds,
or
physical
sensations
that
remind
you
of
the
past,
(3)
finding
a
way
to
be
fully
alive
in
the
present
and
engaged
with
the
people
around
you,
(4)
not
having
to
keep
secrets
from
yourself,
including
secrets
about
the
ways
that
you
have
managed
to
survive.
These
goals
are
not
steps
to
be
achieved,
one
by
one,
in
some
fixed
sequence.
They
overlap,
and
some
may
be
more
difficult
than
others,
depending
on
individual
circumstances.
In
each
of
the
chapters
that
follow,
I’ll
talk
about
specific
methods
or
approaches
to
accomplish
them.
I
have
tried
to
make
these
chapters
useful
both
to
trauma
survivors
and
to
the
therapists
who
are
treating
them.
People
under
temporary
stress
may
also
find
them
useful.
I’ve
used
every
one
of
these
methods
extensively
to
treat
my
patients,
and
I
have
also
experienced
them
myself.
Some
people
get
better
using
just
one
of
these
methods,
but
most
are
helped
by
different
approaches
at
different
stages
of
their
recovery.
I
have
done
scientific
studies
of
many
of
the
treatments
I
describe
here
and
have
published
the
research
findings
in
peer-reviewed
scientific
journals.2
My
aim
in
this
chapter
is
to
provide
an
overview
of
underlying
principles,
a
preview
of
what’s
to
come,
and
some
brief
comments
on
methods
I
don’t
cover
in
depth
later
on.

A
NEW
FOCUS
FOR
RECOVERY
When
we
talk
about
trauma,
we
often
start
with
a
story
or
a
question:
“What
happened
during
the
war?”
“Were
you
ever
molested?”
“Let
me
tell
you
about
that
accident
or
that
rape,”
or
“Was
anybody
in
your
family
a
problem
drinker?”
However,
trauma
is
much
more
than
a
story
about
something
that
happened
long
ago.
The
emotions
and
physical
sensations
that
were
imprinted
during
the
trauma
are
experienced
not
as
memories
but
as
disruptive
physical
reactions
in
the
present.
In
order
to
regain
control
over
your
self,
you
need
to
revisit
the
trauma:
Sooner
or
later
you
need
to
confront
what
has
happened
to
you,
but
only
after
you
feel
safe
and
will
not
be
retraumatized
by
it.
The
first
order
of
business
is
to
find
ways
to
cope
with
feeling
overwhelmed
by
the
sensations
and
emotions
associated
with
the
past.
 As
the
previous
parts
of
this
book
have
shown,
the
engines
of
posttraumatic
reactions
are
located
in
the
emotional
brain.
In
contrast
with
the
rational
brain,
which
expresses
itself
in
thoughts,
the
emotional
brain
manifests
itself
in
physical
reactions:
gut-wrenching
sensations,
heart
pounding,
breathing
becoming
fast
and
shallow,
feelings
of
heartbreak,
speaking
with
an
uptight
and
reedy
voice,
and
the
characteristic
body
movements
that
signify
collapse,
rigidity,
rage,
or
defensiveness.
Why
can’t
we
just
be
reasonable?
And
can
understanding
help?
The
rational,
executive
brain
is
good
at
helping
us
understand
where
feelings
come
from
(as
in:
“I
get
scared
when
I
get
close
to
a
guy
because
my
father
molested
me”
or
“I
have
trouble
expressing
my
love
toward
my
son
because
I
feel
guilty
about
having
killed
a
child
in
Iraq”).
However,
the
rational
brain
cannot
abolish
emotions,
sensations,
or
thoughts
(such
as
living
with
a
low-level
sense
of
threat
or
feeling
that
you
are
fundamentally
a
terrible
person,
even
though
you
rationally
know
that
you
are
not
to
blame
for
having
been
raped).
Understanding
why
you
feel
a
certain
way
does
not
change
how
you
feel.
But
it
can
keep
you
from
surrendering
to
intense
reactions
(for
example,
assaulting
a
boss
who
reminds
you
of
a
perpetrator,
breaking
up
with
a
lover
at
your
first
disagreement,
or
jumping
into
the
arms
of
a
stranger).
However,
the
more
frazzled
we
are,
the
more
our
rational
brains
take
a
backseat
to
our
emotions.3

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

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

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

BEFRIENDING
THE
EMOTIONAL
BRAIN
1.
DEALING
WITH
HYPERAROUSAL

Over
the
past
few
decades
mainstream
psychiatry
has
focused
on
using
drugs
to
change
the
way
we
feel,
and
this
has
become
the
accepted
way
to
deal
with
hyper-
and
hypoarousal.
I
will
discuss
drugs
later
in
this
chapter,
but
first
I
need
to
stress
the
fact
that
we
have
a
host
of
inbuilt
skills
to
keep
us
on
an
even
keel.
In
chapter
5
we
saw
how
emotions
are
registered
in
the
body.
Some
80
percent
of
the
fibers
of
the
vagus
nerve
(which
connects
the
brain
with
many
internal
organs)
are
afferent;
that
is,
they
run
from
the
body
into
the
brain.6
This
means
that
we
can
directly
train
our
arousal
system
by
the
way
we
breathe,
chant,
and
move,
a
principle
that
has
been
utilized
since
time
immemorial
in
places
like
China
and
India,
and
in
every
religious
practice
that
I
know
of,
but
that
is
suspiciously
eyed
as
“alternative”
in
mainstream
culture.
In
research
supported
by
the
National
Institutes
of
Health,
my
colleagues
and
I
have
shown
that
ten
weeks
of
yoga
practice
markedly
reduced
the
PTSD
symptoms
of
patients
who
had
failed
to
respond
to
any
medication
or
to
any
other
treatment.7
(I
will
discuss
yoga
in
chapter
16.)
Neurofeedback,
the
topic
of
chapter
19,
also
can
be
particularly
effective
for
children
and
adults
who
are
so
hyperaroused
or
shut
down
that
they
have
trouble
focusing
and
prioritizing.8
Learning
how
to
breathe
calmly
and
remaining
in
a
state
of
relative
physical
relaxation,
even
while
accessing
painful
and
horrifying
memories,
is
an
essential
tool
for
recovery.9
When
you
deliberately
take
a
few
slow,
deep
breaths,
you
will
notice
the
effects
of
the
parasympathetic
brake
on
your
arousal
(as
explained
in
chapter
5).
The
more
you
stay
focused
on
your
breathing,
the
more
you
will
benefit,
particularly
if
you
pay
attention
until
the
very
end
of
the
out
breath
and
then
wait
a
moment
before
you
inhale
again.
As
you
continue
to
breathe
and
notice
the
air
moving
in
and
out
of
your
lungs
you
may
think
about
the
role
that
oxygen
plays
in
nourishing
your
body
and
bathing
your
tissues
with
the
energy
you
need
to
feel
alive
and
engaged.
Chapter
16
documents
the
full-body
effects
of
this
simple
practice.
Since
emotional
regulation
is
the
critical
issue
in
managing
the
effects
of
trauma
and
neglect,
it
would
make
an
enormous
difference
if
teachers,
army
sergeants,
foster
parents,
and
mental
health
professionals
were
thoroughly
schooled
in
emotional-regulation
techniques.
Right
now
this
still
is
mainly
the
domain
of
preschool
and
kindergarten
teachers,
who
deal
with
immature
brains
and
impulsive
behavior
on
a
daily
basis
and
who
are
often
very
adept
at
managing
them.10
Mainstream
Western
psychiatric
and
psychological
healing
traditions
have
paid
scant
attention
to
self-management.
In
contrast
to
the
Western
reliance
on
drugs
and
verbal
therapies,
other
traditions
from
around
the
world
rely
on
mindfulness,
movement,
rhythms,
and
action.
Yoga
in
India,
tai
chi
and
qigong
in
China,
and
rhythmical
drumming
throughout
Africa
are
just
a
few
examples.
The
cultures
of
Japan
and
the
Korean
peninsula
have
spawned
martial
arts,
which
focus
on
the
cultivation
of
purposeful
movement
and
being
centered
in
the
present,
abilities
that
are
damaged
in
traumatized
individuals.
Aikido,
judo,
tae
kwon
do,
kendo,
and
jujitsu,
as
well
as
capoeira
from
Brazil,
are
examples.
These
techniques
all
involve
physical
movement,
breathing,
and
meditation.
Aside
from
yoga,
few
of
these
popular
non-Western
healing
traditions
have
been
systematically
studied
for
the
treatment
of
PTSD.

2.
NO
MIND
WITHOUT
MINDFULNESS

At
the
core
of
recovery
is
self-awareness.
The
most
important
phrases
in
trauma
therapy
are
“Notice
that”
and
“What
happens
next?”
Traumatized
people
live
with
seemingly
unbearable
sensations:
They
feel
heartbroken
and
suffer
from
intolerable
sensations
in
the
pit
of
their
stomach
or
tightness
in
their
chest.
Yet
avoiding
feeling
these
sensations
in
our
bodies
increases
our
vulnerability
to
being
overwhelmed
by
them.
Body
awareness
puts
us
in
touch
with
our
inner
world,
the
landscape
of
our
organism.
Simply
noticing
our
annoyance,
nervousness,
or
anxiety
immediately
helps
us
shift
our
perspective
and
opens
up
new
options
other
than
our
automatic,
habitual
reactions.
Mindfulness
puts
us
in
touch
with
the
transitory
nature
of
our
feelings
and
perceptions.
When
we
pay
focused
attention
to
our
bodily
sensations,
we
can
recognize
the
ebb
and
flow
of
our
emotions
and,
with
that,
increase
our
control
over
them.
Traumatized
people
are
often
afraid
of
feeling.
It
is
not
so
much
the
perpetrators
(who,
hopefully,
are
no
longer
around
to
hurt
them)
but
their
own
physical
sensations
that
now
are
the
enemy.
Apprehension
about
being
hijacked
by
uncomfortable
sensations
keeps
the
body
frozen
and
the
mind
shut.
Even
though
the
trauma
is
a
thing
of
the
past,
the
emotional
brain
keeps
generating
sensations
that
make
the
sufferer
feel
scared
and
helpless.
It’s
not
surprising
that
so
many
trauma
survivors
are
compulsive
eaters
and
drinkers,
fear
making
love,
and
avoid
many
social
activities:
Their
sensory
world
is
largely
off
limits.
In
order
to
change
you
need
to
open
yourself
to
your
inner
experience.
The
first
step
is
to
allow
your
mind
to
focus
on
your
sensations
and
notice
how,
in
contrast
to
the
timeless,
ever-present
experience
of
trauma,
physical
sensations
are
transient
and
respond
to
slight
shifts
in
body
position,
changes
in
breathing,
and
shifts
in
thinking.
Once
you
pay
attention
to
your
physical
sensations,
the
next
step
is
to
label
them,
as
in
“When
I
feel
anxious,
I
feel
a
crushing
sensation
in
my
chest.”
I
may
then
say
to
a
patient:
“Focus
on
that
sensation
and
see
how
it
changes
when
you
take
a
deep
breath
out,
or
when
you
tap
your
chest
just
below
your
collarbone,
or
when
you
allow
yourself
to
cry.”
Practicing
mindfulness
calms
down
the
sympathetic
nervous
system,
so
that
you
are
less
likely
to
be
thrown
into
fight-or-flight.11
Learning
to
observe
and
tolerate
your
physical
reactions
is
a
prerequisite
for
safely
revisiting
the
past.
If
you
cannot
tolerate
what
you
are
feeling
right
now,
opening
up
the
past
will
only
compound
the
misery
and
retraumatize
you
further.12
We
can
tolerate
a
great
deal
discomfort
as
long
as
we
stay
conscious
of
the
fact
that
the
body’s
commotions
constantly
shift.
One
moment
your
chest
tightens,
but
after
you
take
a
deep
breath
and
exhale,
that
feeling
softens
and
you
may
observe
something
else,
perhaps
a
tension
in
your
shoulder.
Now
you
can
start
exploring
what
happens
when
you
take
a
deeper
breath
and
notice
how
your
rib
cage
expands.13
Once
you
feel
calmer
and
more
curious,
you
can
go
back
to
that
sensation
in
your
shoulder.
You
should
not
be
surprised
if
a
memory
spontaneously
arises
in
which
that
shoulder
was
somehow
involved.
A
further
step
is
to
observe
the
interplay
between
your
thoughts
and
your
physical
sensations.
How
are
particular
thoughts
registered
in
your
body?
(Do
thoughts
like
“My
father
loves
me”
or
“my
girlfriend
dumped
me”
produce
different
sensations?)
Becoming
aware
of
how
your
body
organizes
particular
emotions
or
memories
opens
up
the
possibility
of
releasing
sensations
and
impulses
you
once
blocked
in
order
to
survive.14
In
chapter
20,
on
the
benefits
of
theater,
I’ll
describe
in
more
detail
how
this
works.
Jon
Kabat-Zinn,
one
of
the
pioneers
in
mind-body
medicine,
founded
the
Mindfulness-Based
Stress
Reduction
(MBSR)
program
at
the
University
of
Massachusetts
Medical
Center
in
1979,
and
his
method
has
been
thoroughly
studied
for
more
than
three
decades.
As
he
describes
mindfulness,
“One
way
to
think
of
this
process
of
transformation
is
to
think
of
mindfulness
as
a
lens,
taking
the
scattered
and
reactive
energies
of
your
mind
and
focusing
them
into
a
coherent
source
of
energy
for
living,
for
problem
solving,
for
healing.”15
Mindfulness
has
been
shown
to
have
a
positive
effect
on
numerous
psychiatric,
psychosomatic,
and
stress-related
symptoms,
including
depression
and
chronic
pain.16
It
has
broad
effects
on
physical
health,
including
improvements
in
immune
response,
blood
pressure,
and
cortisol
levels.17
It
has
also
been
shown
to
activate
the
brain
regions
involved
in
emotional
regulation18
and
to
lead
to
changes
in
the
regions
related
to
body
awareness
and
fear.19
Research
by
my
Harvard
colleagues
Britta
Hölzel
and
Sara
Lazar
has
shown
that
practicing
mindfulness
even
decreases
the
activity
of
the
brain’s
smoke
detector,
the
amygdala,
and
thus
decreases
reactivity
to
potential
triggers.20

3.
RELATIONSHIPS

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

Choosing
a
Professional
Therapist

The
training
of
competent
trauma
therapists
involves
learning
about
the
impact
of
trauma,
abuse,
and
neglect
and
mastering
a
variety
of
techniques
that
can
help
to
(1)
stabilize
and
calm
patients
down,
(2)
help
to
lay
traumatic
memories
and
reenactments
to
rest,
and
(3)
reconnect
patients
with
their
fellow
men
and
women.
Ideally
the
therapist
will
also
have
been
on
the
receiving
end
of
whatever
therapy
he
or
she
practices.
While
it’s
inappropriate
and
unethical
for
therapists
to
tell
you
the
details
of
their
personal
struggles,
it
is
perfectly
reasonable
to
ask
what
particular
forms
of
therapy
they
have
been
trained
in,
where
they
learned
their
skills,
and
whether
they’ve
personally
benefited
from
the
therapy
they
propose
for
you.
There
is
no
one
“treatment
of
choice”
for
trauma,
and
any
therapist
who
believes
that
his
or
her
particular
method
is
the
only
answer
to
your
problems
is
suspect
of
being
an
ideologue
rather
than
somebody
who
is
interested
in
making
sure
that
you
get
well.
No
therapist
can
possibly
be
familiar
with
every
effective
treatment,
and
he
or
she
must
be
open
to
your
exploring
options
other
than
the
ones
he
or
she
offers.
He
or
she
also
must
be
open
to
learning
from
you.
Gender,
race,
and
personal
background
are
relevant
only
if
they
interfere
with
helping
the
patient
feel
safe
and
understood.
Do
you
feel
basically
comfortable
with
this
therapist?
Does
he
or
she
seem
to
feel
comfortable
in
his
or
her
own
skin
and
with
you
as
a
fellow
human
being?
Feeling
safe
is
a
necessary
condition
for
you
to
confront
your
fears
and
anxieties.
Someone
who
is
stern,
judgmental,
agitated,
or
harsh
is
likely
to
leave
you
feeling
scared,
abandoned,
and
humiliated,
and
that
won’t
help
you
resolve
your
traumatic
stress.
There
may
be
times
as
old
feelings
from
the
past
are
stirred
up,
when
you
become
suspicious
that
the
therapist
resembles
someone
who
once
hurt
or
abused
you.
Hopefully,
this
is
something
you
can
work
through
together,
because
in
my
experience
patients
get
better
only
if
they
develop
deep
positive
feelings
for
their
therapists.
I
also
don’t
think
that
you
can
grow
and
change
unless
you
feel
that
you
have
some
impact
on
the
person
who
is
treating
you.
The
critical
question
is
this:
Do
you
feel
that
your
therapist
is
curious
to
find
out
who
you
are
and
what
you,
not
some
generic
“PTSD
patient,”
need?
Are
you
just
a
list
of
symptoms
on
some
diagnostic
questionnaire,
or
does
your
therapist
take
the
time
to
find
out
why
you
do
what
you
do
and
think
what
you
think?
Therapy
is
a
collaborative
process—a
mutual
exploration
of
your
self.
Patients
who
have
been
brutalized
by
their
caregivers
as
children
often
do
not
feel
safe
with
anyone.
I
often
ask
my
patients
if
they
can
think
of
any
person
they
felt
safe
with
while
they
were
growing
up.
Many
of
them
hold
tight
to
the
memory
of
that
one
teacher,
neighbor,
shopkeeper,
coach,
or
minister
who
showed
that
he
or
she
cared,
and
that
memory
is
often
the
seed
of
learning
to
reengage.
We
are
a
hopeful
species.
Working
with
trauma
is
as
much
about
remembering
how
we
survived
as
it
is
about
what
is
broken.
I
also
ask
my
patients
to
imagine
what
they
were
like
as
newborns—
whether
they
were
lovable
and
filled
with
spunk.
All
of
them
believe
they
were
and
have
some
image
of
what
they
must
have
been
like
before
they
were
hurt.
Some
people
don’t
remember
anybody
they
felt
safe
with.
For
them,
engaging
with
horses
or
dogs
may
be
much
safer
than
dealing
with
human
beings.
This
principle
is
currently
being
applied
in
many
therapeutic
settings
to
great
effect,
including
in
jails,
residential
treatment
programs,
and
veterans’
rehabilitation.
Jennifer,
a
member
of
the
first
graduating
class
of
the
Van
der
Kolk
Center,23
who
had
come
to
the
program
as
an
out-of-
control,
mute
fourteen-year-old,
said
during
her
graduation
ceremony
that
having
been
entrusted
with
the
responsibility
of
caring
for
a
horse
was
the
critical
first
step
for
her.
Her
growing
bond
with
her
horse
helped
her
feel
safe
enough
to
begin
to
relate
to
the
staff
of
the
center
and
then
to
focus
on
her
classes,
take
her
SATs,
and
be
accepted
to
college.24

4.
COMMUNAL
RHYTHMS
AND
SYNCHRONY

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

5.
GETTING
IN
TOUCH

Mainstream
trauma
treatment
has
paid
scant
attention
to
helping
terrified
people
to
safely
experience
their
sensations
and
emotions.
Medications
such
as
serotonin
reuptake
blockers,
Respiridol
and
Seroquel
increasingly
have
taken
the
place
of
helping
people
to
deal
with
their
sensory
world.28
However,
the
most
natural
way
that
we
humans
calm
down
our
distress
is
by
being
touched,
hugged,
and
rocked.
This
helps
with
excessive
arousal
and
makes
us
feel
intact,
safe,
protected,
and
in
charge.
 Rembrandt
van
Rijn:
Christ
Healing
the
Sick.
Gestures
of
comfort
are
universally
recognizable
and
reflect
the
healing
power
of
attuned
touch.

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