Summary of Bessel van der Kolk's The Body Keeps the Score

This summary was made with Ollama eBook Summary.

Trauma is a fact of life. Veterans and their families deal with the painful aftermath of combat; one in five Americans has been molested; one in four grew up with alcoholics; one in three couples have engaged in physical violence. Dr. Bessel van der Kolk, one of the world’s foremost experts on trauma, has spent over three decades working with survivors. In The Body Keeps the Score, he uses recent scientific advances to show how trauma literally reshapes both body and brain, compromising sufferers’ capacities for pleasure, engagement, self-control, and trust. He explores innovative treatments—from neurofeedback and meditation to sports, drama, and yoga—that offer new paths to recovery by activating the brain’s natural neuroplasticity. Based on Dr. van der Kolk’s own research and that of other leading specialists, The Body Keeps the Score exposes the tremendous power of our relationships both to hurt and to heal—and offers new hope for reclaiming lives. - The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

PROLOGUE

FACING TRAUMA

Trauma

One in five Americans were sexually molested as a child
One in four experienced physical violence from parents
Trauma leaves traces on individuals and families
Affects capacity for joy, intimacy, and biology
Can lead to hypervigilance, emotional distress, and impulsive actions
Survivors may fear being damaged beyond redemption

Impact of Trauma

Physical recalibration of the brain's alarm system, increased stress hormone activity, altered filtering system
Compromises brain area responsible for feeling alive
Explains hypervigilance and difficulty engaging in daily life
Causes repetition of problems and trouble learning from experience

Understanding Trauma

Three new branches of science:
- neuroscience
- developmental psychopathology
- interpersonal neurobiology
Revealed trauma produces physiological changes
Opened up possibilities to palliate or reverse damage

Healing from Trauma

Top down: talking, connecting with others, processing memories
Middle: medicines, technologies that change brain organization
Bottom up: allowing body to have experiences contradicting trauma
Combination of approaches needed for individual survivors
Talking, understanding, and human connections help
Drugs can dampen hyperactive alarm systems
Physical experiences can regain self-mastery

Author's Background

Drawn to study medicine at a young age
Founded Trauma Center 30 years ago to treat traumatized individuals and conduct research
Received grants from various organizations for trauma research and treatment development
Practices all forms of treatment discussed in the book

PART ONE. THE REDISCOVERY OF TRAUMA.

CHAPTER 1

LESSONS FROM VIETNAM VETERANS

In 1978, author's first day as a staff psychiatrist at the Boston VA Clinic
Encountered a veteran named Tom, suffering from PTSD due to experiences in Vietnam
Tom experienced nightmares, flashbacks, and intense fear, leading him to isolate himself from family
Tom's background: valedictorian of high school class, enlisted in Marines after graduation, became platoon leader in Vietnam**
After returning home, attended college on GI Bill, graduated from law school, married, and had two sons
Felt disconnected from his wife and dead inside, despite a thriving law practice and picture-perfect family
Tom's story reminded author of her own experiences growing up with parents who had been traumatized during World War II
Author focused on treating Tom's nightmares with medication but he refused to take it
Realized that Tom's loyalty to his fallen comrades was keeping him from living his own life
Recognized the complexity of trauma and its impact on veterans' lives
Struggled to find resources and knowledge to help veterans, leading her to question the lack of research on wartime trauma
Discovered "The Traumatic Neuroses of War" by Abram Kardiner, which described similar symptoms in World War I veterans and coined the term "traumatic neuroses," now known as PTSD.
Kardiner noted that traumatic neuroses have a physiological basis, not just psychological
Author's realization of the importance of facing reality and learning from patients in understanding trauma.

TRAUMA AND THE LOSS OF SELF

Study at VA aimed to understand why some veterans broke down after Vietnam experience
Most veterans went to war well-prepared, formed close bonds with comrades
Tom's story: friend Alex was killed in ambush, left feeling helpless and traumatized**
Flashbacks of ambush recurred, triggered by sounds, smells, or images
Tom's rage led him to commit unspeakable acts of revenge
Trauma makes it difficult to engage in intimate relationships
Shame about actions during trauma is a common experience for veterans and victims

Tom's Experience

Close friendship with Alex before ambush
Helpless during ambush, saw friend's death
Recurring flashbacks of ambush and its aftermath
Rage led to violent acts against civilians
Impossible to go home again due to shame and guilt

Shame and Trauma

Shame about actions during trauma is common
Difficulty confronting own behavior during traumatic episode
Sarah Haley's article on discussing atrocities committed during war experiences
Deep-rooted shame for feelings of terror, dependence, excitement, or rage
Confusion about difference between love and terror, pain and pleasure

Impact of Trauma

Difficulty trusting self or others after trauma
Intimacy becomes a challenge due to shame and guilt
Trauma survivors may feel like part of themselves has been destroyed
Lifeline for traumatized people: trust and courage to remember and confront shame.

NUMBING

Tom's Symptoms:

Emotional numbness
Distant from family and self
Felt like living behind a glass wall
Could not recognize himself
Lack of purpose or direction
Intense involvement in particular cases brought him to life

Effects of Intense Involvement:

Felt fully alive
Nothing else mattered
Relief from aimlessness and demons

Tom's Coping Mechanisms:

Working
Drinking
Drugging
Avoiding confrontation with demons
Fantasizing about becoming a mercenary
Riding his Harley

Case of Defending a Mobster:

Total absorption in the case
Intense strategy devising
Stayed up all night to immerse himself
Felt alive and purposeful
Return of demons and numbness after winning the case
Terrifying to be alone

Tom's Struggles:

Desperately wanted to love family but couldn't feel deep emotions
Lack of recognition of self
Intense involvement in cases brought relief from aimlessness and demons
Coping mechanisms included work, substances, and distractions
Return of demons after intense involvement ended
Fear of being alone with demons.

THE REORGANIZATION OF PERCEPTION

The Reorganization of Perception: Trauma and Imagination

Study on trauma's effect on perception and imagination
Participant: Bill, a former medic who experienced heavy action in Vietnam
Post-traumatic reactions after his wife gave birth to their first child
Diagnosed as psychotic by medical professionals due to auditory and visual hallucinations
Misdiagnosis based on textbooks describing symptoms of paranoid schizophrenia
Bill's symptoms triggered by feelings of displacement in his wife's affections
Researcher, intrigued by diagnosis, asked Bill about his experiences
Bill described traumatic memories and flashbacks
Rorschach test used to observe how people construct mental images from ambiguous stimuli

Bill's Flashback during the Rorschach Test

First time witnessing a veteran's flashback
Bill saw a child being blown up in Vietnam in the inkblot
Panic and physical sensations similar to original trauma
Realized the agony veterans face with unpredictable flashbacks

Impact of Trauma on Imagination

Flashbacks can be worse due to their unpredictability
Rorschach tests revealed traumatized people's altered perception
Sixteen veterans saw wartime trauma in inkblots
Five veterans saw nothing, lacking mental flexibility
Imagination is essential for quality of life and hope for a better future
Trauma affects imagination by limiting mental flexibility

Trauma and Perception: A Fundamental Difference

Normal response to ambiguous stimuli: use imagination to read something into it
Traumatized people have trouble deciphering what's going on around them
Trauma alters perception, making the world appear differently
Importance of understanding trauma's impact on perception and imagination for effective treatment.

STUCK IN TRAUMA

Trauma and Veterans

Clinic saw increase in veterans seeking help due to mental health issues
Shortage of qualified doctors led to long waiting lists
Sharp increase in violent offenses, drunken brawls, and suicides among veterans

Starting a Group for Vietnam Veterans

First session: Veteran refused to discuss war
Long silence followed by intense discussion of traumatic experiences
Renewed sense of comradeship and belonging in the group
Members insisted doctor be part of their unit, gave Marine captain's uniform

Limitations of Group Therapy

Veterans had difficulty discussing daily life issues
Preferred to relive traumatic experiences instead
Trauma became their sole source of meaning and full aliveness
Could not help veterans bridge the gap between past and present
Trauma was their only source of meaning and full aliveness.

DIAGNOSING POSTTRAUMATIC STRESS

Diagnosing Posttraumatic Stress Disorder (PTSD)

In early days at VA, veterans diagnosed with various disorders and ineffective treatments applied
Labeling veterans with diagnoses like alcoholism, depression, etc., failed to help and sometimes worsened their condition
Turning point came in 1980 when PTSD was created as a diagnosis for symptoms common among veterans
Identifying symptoms led to understanding of patient suffering and research on effective treatments

Background: Pre-PTSD Era

VA focused on treating conditions other than PTSD, with limited success
Trauma victims' memories didn't fade or transform into benign stories
Grant proposal for studying biology of traumatic memories rejected
Unwilling to continue working in an organization that disregarded PTSD, resigned and took a position at Massachusetts Mental Health Center

Impact on New Job: Psychopharmacology

Sensitized to trauma impact, listened differently to patients with depression and anxiety
Discovered high prevalence of sexual abuse among female patients
Textbook underestimated incidence and impact of incest
Patients with incest histories had similar symptoms as veterans with PTSD

Prevalence of Trauma

About a quarter of soldiers in war zones develop serious posttraumatic problems
More Americans experience violent crimes than soldiers serving in war zones
12 million women in the US have been raped
3 million children reported as victims of child abuse and neglect each year
For every soldier, ten children are endangered at home

Impact on Children

Difficult for growing children to recover when source of terror is caretakers
High prevalence of trauma among the population, especially children
PTSD not limited to soldiers in war zones

A NEW UNDERSTANDING

A New Understanding of Trauma

Since meeting Tom in the 1990s, significant progress has been made in understanding trauma and its effects.

Impact and Manifestations of Trauma

Brain imaging shows damage inflicted by trauma.
Essential for understanding and repair.
Trauma results in a reorganization of how mind and brain manage perceptions.
Affects sensations and relationship to physical reality.
Not just an event, but an imprint with ongoing consequences.
Trauma is not just an event from the past; it leaves an imprint on mind, brain, and body with ongoing consequences.

Understanding the Healing Process

Helping victims tell their story is important but not enough.
Body needs to learn danger has passed and live in present reality for true healing.
For lasting change, the body needs to learn that danger has passed and live in the present reality.

CHAPTER 2

REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN

In the late 1960s, author witnessed transition in mental health treatment at Massachusetts Mental Health Center (MMHC)
Author worked as an attendant on research ward for young schizophrenia patients
Goal of research: Determine if psychotherapy or medication was best treatment
Talking cure (Freudian psychoanalysis) primary treatment, but chlorpromazine (Thorazine) discovered in 1950s as alternative
Chlorpromazine tranquilized patients, reducing agitation and delusions
Drugs offered hope for treating various mental problems like depression, anxiety, mania, and schizophrenia symptoms
Author had no role in research, focused on organizing activities for patients
Patients were college students with severe mental issues: suicide attempts, self-harm, irrational behavior**

Author's Role and Experiences on the Ward

Author worked as attendant, organizing activities for young schizophrenia patients
Patients had attempted suicide or engaged in self-harm, irrational behavior
Attendants kept patients involved in normal college student activities
Author attended ward meetings to understand patients' speech and logic
Dealt with irrational outbursts and terrified withdrawal
Learned about conditions like catatonia, but no clear solution provided by doctors or textbooks.

TRAUMA BEFORE DAWN

Childhood Trauma

Author spent many nights on psychiatric unit, heard patients' stories of childhood trauma and family violence
Doctors rarely discussed these experiences during rounds
Dispassionate approach to patients' symptoms and lack of attention to their lives and motivations
Studies show over 50% of psychiatric patients have experienced assault, abandonment, or neglect as children
Stories of physical and emotional abuse by parents, relatives, classmates, neighbors

Questions about Hallucinations and Memories

Are hallucinations just concoctions of sick brains?
Can people make up physical sensations they've never experienced?
What is the line between creativity and pathological imagination?
Research shows that abuse survivors may experience sensations with no obvious physical cause, hear voices

Patient Behaviors and Trauma

Patients engaged in violent, bizarre, self-destructive behaviors when frustrated or misunderstood
Author's realization of the impact of force-feeding on Sylvia
Rule for students: Consider if actions towards patients replicate past traumas

Patient Observations

Patients were clumsy and physically uncoordinated
Conversations lacked natural flow of gestures and facial expressions
Relevance of body-based therapies in understanding trauma and its effects on the body.

MAKING SENSE OF SUFFERING

Training at MMHC (1960s)

Famous psychiatrists trained there, including Eric Kandel and Allan Hobson
Focus on patients and their suffering
Elvin Semrad as a great teacher, discouraging textbooks and emphasizing acknowledging reality

Shift in Approach to Human Suffering (1968-1970s)

Study showing schizophrenic patients benefited more from drugs than therapy
Gradual change from viewing human suffering as infinitely variable expressions of feelings and relationships to a brain-disease model
Many psychiatrists embraced the pharmacological revolution, becoming "real scientists"
Major textbook of psychiatry stated cause of mental illness is a chemical imbalance

Pharmacological Revolution (1970s)

First chief resident in psychopharmacology at MMHC
Administered lithium to manic-depressive patient, first in Boston
Part of the first U.S. research team to test antipsychotic Clozaril on chronic patients
Amazing results led to optimism about conquering human misery
Reduction in number of people living in mental hospitals

Development of Research Diagnostic Criteria and DSM-III (1970s-1980)

Scientists developed techniques for measuring hormones and neurotransmitters
Evidence of abnormal levels of norepinephrine associated with depression, dopamine with schizophrenia
Hope of developing drugs targeting specific brain abnormalities
Researchers needed a precise way to communicate findings, leading to the creation of Research Diagnostic Criteria and DSM-III.

INESCAPABLE SHOCK

Traumatic Stress and Neuroscience

Attended American College of Neuropsychopharmacology (ACNP) meetings in 1984
Heard a presentation by Steven Maier and Martin Seligman on learned helplessness in animals
Dogs subjected to "inescapable shock" became immobile and unresponsive when given chance to escape
Similarities between traumatized dogs and human patients
Traumatized people may give up and not take action to escape fear
Maier and Seligman's research on stress hormones in traumatized animals
- Large amounts of stress hormones secreted after danger has passed
- Ideally, stress hormone system should return to equilibrium but fails in PTSD patients
- Continued secretion of stress hormones leads to agitation, panic, and long-term health issues
Maier's research offered potential keys to resolving traumatized patients' issues
Repeatedly dragging traumatized dogs out of cages helped them learn to escape
Question: Can traumatized people benefit from physical experiences to restore a sense of control?**
Animal studies on mice, rats, cats, monkeys, and elephants
- Mice return home regardless of safety
- Traumatized people may seek refuge in what is familiar
- Question: Is it possible to help traumatized people become attached to safe and pleasurable places?

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

Mark Greenberg and author observed trauma survivors seeking out dangerous or painful experiences despite feelings of horror and grief
Traumatized individuals may feel empty or bored without anger, duress, or dangerous activities (Julia's case)
Attractors: things that draw us, motivate us, make us feel alive**
Normally attractors make us feel better, but some people are attracted to dangerous or painful situations
Richard Solomon's study on fear and pain becoming thrilling experiences
Body adjusts to stimuli, leading to enjoyment and craving (marathon running, parachute jumping)
Endorphins play a role in paradoxical addictions
Beecher's observation of soldiers not requesting morphine due to strong emotions possibly explained by release of endorphins
Reexposure to stress might provide relief from anxiety for traumatized individuals

Mark Greenberg and author's observations in therapy groups for Vietnam combat veterans:

Traumatized individuals seem to come alive when talking about traumatic experiences
Many complain of emptiness and boredom without anger or danger

Patient Julia:

Brutally raped at age sixteen, got involved with violent pimp
Repeatedly jailed for prostitution but always went back to her pimp
Completed rehab program but returned to dangerous relationships

Freud's theory of "compulsion to repeat":

Unconscious attempt to gain control and lead to mastery and resolution
No evidence for this theory, repetition leads to further pain and self-hatred

Attractors:

Things that draw us, motivate us, make us feel alive
Normally attractors make us feel better
Some people are attracted to dangerous or painful situations

Richard Solomon's study on fear and pain becoming thrilling experiences:

Body adjusts to stimuli, leading to enjoyment and craving
Endorphins play a role in paradoxical addictions

Beecher's observation of soldiers not requesting morphine:

Strong emotions can block pain
Reexposure to stress might provide relief from anxiety for traumatized individuals.

SOOTHING THE BRAIN

Soothing the Brain

1985 ACNP meeting: Jeffrey Gray's talk about amygdala and serotonin
Amygdala determines threat perception based on serotonin levels
Low serotonin = hyperreactive, high serotonin = less reactive
Social environment interacts with brain chemistry
Monkeys: dominance hierarchy affects serotonin levels
Implications for traumatized people
1985: L-tryptophan experiment (disappointing results)
Prozac, a new drug to increase serotonin levels, released in 1988
Young woman with bulimia: dramatic improvement after taking Prozac
Chronically depressed mother: improved and enjoyed family time
Study on Prozac's effects on PTSD (64 participants)
- Trauma Clinic patients: significant improvement
- Combat veterans at VA: no effect
Most pharmacological studies on veterans have shown limited benefits or no effect
Medications like Prozac, Zoloft, Celexa, Cymbalta, and Paxil contribute to trauma-related disorders treatment
Rorschach test data: SSRIs give PTSD patients a sense of perspective and control over impulses.**

THE TRIUMPH OF PHARMACOLOGY

Impact of Pharmacology on Psychiatry

Revolutionized psychiatry: Offered doctors greater efficacy, income, and prestige.
Brain-disease model: Widely accepted theory that mental illness is caused by chemical imbalances in the brain.
Displacement of therapy: Drugs have allowed patients to suppress problems without addressing underlying issues.
Antidepressants: Can provide relief and help with functioning, but should be considered adjuncts to therapy.
Downside of psychiatric medications: May deflect attention from dealing with underlying issues.
Antipsychotics: Top-selling drugs with questionable effectiveness and serious downsides.
Children and psychiatric medications: At risk of becoming obese, developing diabetes, and being overprescribed antipsychotics.
Funding for nondrug treatments: Rarely funded or published in mainstream medical journals.

Consequences of the Drug Revolution

Increasing use of psychiatric medications has not reduced hospital admissions for depression.
One in ten Americans now take antidepressants, with tripled hospitalizations for depression over two decades.
Antipsychotics are top-selling drugs, with billions spent on them annually.
Medicaid spends more on antipsychotic medications than any other class of drugs.
Children are four times as likely to receive antipsychotics if they're from low-income families.
Drug overdoses involving a combination of psychiatric and pain medications continue to rise.
Mainstream medicine is committed to a better life through chemistry, marginalizing nondrug treatments.

ADAPTATION OR DISEASE?

Adaptation or Disease?

Brain-disease model overlooks four fundamental truths: Capacity to heal:
- Capacity to destroy and heal one another
- Restoring relationships and community essential for restoring well-being Power of language:
- Gives power to change ourselves and others
- Helps define experiences and find common meaning Self-regulation:
- Ability to regulate physiology through basic activities
  - Breathing, moving, touching Changing social conditions:
- Creating safe environments for children and adults to thrive
Ignoring these dimensions of humanity:
- Deprives people of ways to heal from trauma
- Separates suffering people from community
- Alienates them from inner sense of self
Limitations of drugs:
- Natural ways to help people deal with post-traumatic responses explored

Fundamental Truths

Capacity to destroy and heal one another
Restoring relationships and community essential for restoring well-being
Power of language to change ourselves and others
Ability to regulate our own physiology
Changing social conditions to create safe environments

CHAPTER 3

LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION

In the early 1990s, brain-imaging techniques opened up new opportunities to understand brain processing and mapping the circuits of mind and consciousness.
Technologies like Positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) enabled scientists to visualize brain activation during tasks or memories.
Neuroimaging transformed our understanding of trauma by allowing researchers to study brain activity during flashbacks.

Harvard Medical School and the Neuroscience Revolution

In 1994, Scott Rauch was appointed as the first director of the Massachusetts General Hospital Neuroimaging Laboratory.
Researchers aimed to study brain activity during flashbacks using neuroimaging techniques.

Studying Flashbacks with Neuroimaging

Participants were asked to recall traumatic memories and a safe scene for comparison.
Scripts were created to re-create the trauma moment by moment.
Participants listened to the scripts while in an fMRI scanner, which monitored brain activity through changes in oxygen consumption.

Case Study: Marsha's Experience

Marsha, a forty-year-old schoolteacher, experienced a traumatic event thirteen years prior that resulted in the death of her daughter and fetus.
Hearing the script of the traumatic event caused increased heart rate and blood pressure, indicating brain activation similar to the original event.
The neutral script did not cause any physiological response.

Results: Brain Activation during Trauma Recall

Large red spot in the right lower center of the brain (limbic area or emotional brain) showed significant activation.
Activation was primarily in the amygdala, which is known to respond to intense emotions and trigger stress response.
The study demonstrated that traumatized people's amygdalas react with alarm when presented with trauma-related stimuli, even years after the event.

SPEECHLESS HORROR

Significant decrease in Broca's area in left frontal lobe during trauma
Broca's area is a speech center; damage leads to inability to put thoughts and feelings into words
Trauma causes speechlessness, as shown in Macbeth's "horror! horror! horror!" quote
People may scream, call for help, shut down, or struggle to speak after traumatic experiences

Brain Activity During Trauma

Broca's area deactivates during flashbacks
Surprise finding: Brodmann's area 19 (visual cortex) activates long after trauma
Raw images registered in area 19 are usually rapidly diffused to other brain areas for interpretation
Trauma causes unprocessed sense fragments to be registered separately from the story itself
Flashbacks bring back unmodified sensations, including haunting images

SHIFTING TO ONE SIDE OF THE BRAIN

Two distinct halves with different functions: right and left
Differences between the two: intuitive vs. logical, emotional vs. analytical

Right Brain

Intuitive, emotional, visual, spatial, tactual
Stores memories of sound, touch, smell, emotions
Communicates through facial expressions, body language, singing, swearing, crying, dancing, mimicking
Develops first in the womb and handles nonverbal communication between mothers and infants
Processes past experiences as intuitive truth
Stores memories differently than left brain

Left Brain

Linguistic, sequential, analytical
Remembers facts, statistics, vocabulary of events
Enables speaking, understanding language, comparing, and communicating experiences to others
Processes past experiences logically
Deactivated during flashbacks in trauma victims
Controls executive functioning (organizing experience into logical sequences, identifying cause and effect)

Impact of Trauma on Brain Hemispheres

Trauma can deactivate left hemisphere
Loss of executive functioning: difficulty organizing experiences, identifying cause and effect, creating coherent plans for the future
Right brain reacts to past traumatic events as if they were happening in the present
Trauma victims may not be aware they are reexperiencing and reenacting the past
After emotional storm passes, trauma victims may blame others for their behavior

STUCK IN FIGHT OR FLIGHT

Marsha's experience in the scanner: Thirteen years after her daughter's death, sensations from the accident activated her alarm system, causing a physiological response as if the tragedy was happening again.
Fight or flight response: Increased adrenaline led to dramatic heart rate and blood pressure increases. Traumatized people have prolonged stress hormone responses and heightened reactions to mildly stressful stimuli.
Effects of prolonged stress hormones: Memory and attention problems, irritability, sleep disorders, and long-term health issues.
Denial response: Some people ignore the emotional response to a threat but still experience physical effects and increased stress hormones.
Neurochemical imbalance: Marsha may be suffering from a biochemical imbalance that can be treated with drugs or a combination of drugs.
Hypersensitization: Marsha's memories are highly sensitive, and desensitization through therapy could help her realize that "that was then and this is now."
Difficulty conveying trauma experience: People who have experienced trauma find it challenging to put their internal experience into words.
EMDR treatment: Three years after participating in the study, Marsha came to see the author as a patient and was successfully treated with Eye Movement Desensitization and Reprocessing (EMDR).

PART TWO. THIS IS YOUR BRAIN ON TRAUMA.

CHAPTER 4

RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL

Five-year-old Noam Saul witnessed the September 11 attacks from his classroom near the World Trade Center.
He and his family ran to safety -- Noam drew a picture of the disaster with an added "trampoline" for future safety.

Two critical aspects of adaptive response to threat:

Active role in survival: Noam's ability to run away from the disaster allowed him to take control and be an agent in his own rescue.
Integration of new experiences: Once safe, Noam was able to make sense of what happened and imagine a creative solution.

Trauma vs. Adaptive Response:

Traumatized people become stuck, unable to integrate new experiences into their lives.
PTSD: body continues to defend against past threat, affecting the entire organism (body, mind, brain).
Healing from PTSD involves terminating continued stress mobilization and restoring the organism to safety.

Effects of Trauma:

Focus on suppressing inner chaos at the expense of spontaneous involvement in life.
Physical symptoms: fibromyalgia, chronic fatigue, autoimmune diseases.
Critical for trauma treatment to engage the entire organism (body, mind, brain).

ORGANIZED TO SURVIVE

Brain's Alarm System

Triggers preprogrammed physical escape plans in oldest brain parts
Direct connection between brain and body
Old brain takes over, shuts down higher brain (conscious mind)
Propels body to run, hide, fight, or freeze

Fight/Flight/Freeze Response

Ends threat when effective action is taken
Immobilization keeps body in state of shock and learned helplessness
Stress hormones fuel resistance and escape
Brain and body programmed to return to safety

Effects of Trauma

Elevated stress hormone levels can cause ongoing fear, depression, rage, physical disease
Normal response may be blocked in certain situations (war zone, car accident, domestic violence, rape)
Brain continues sending signals to body to escape non-existent threat

Recognition of Trauma

Recognized since 1889 by French psychologist Pierre Janet
Survivors may continue "attempt at action" long after event
Critical factor in determining long-term effects of traumatic experience

Brain's Response to Trauma

Vast network of interconnected parts organized for survival and flourishing
Understanding brain's response essential for resolving traumatic stress

THE BRAIN FROM BOTTOM TO TOP

Brain's primary job: ensuring survival and coordinating group living
Essential functions:
- Generate internal signals for needs (food, rest, protection, etc.)
- Create a map of the world
- Generate energy and actions
- Warn of dangers and opportunities
- Adjust actions based on requirements

Brain Development and Structure

Brain develops level by level in fetus and evolution
Three main parts:
- rational brain
- emotional brain (reptilian and limbic systems)
- body housekeeping functions

Emotional Brain (Reptilian and Limbic Systems)

Oldest part of the brain
Responsible for basic survival functions
Located in brainstem and hypothalamus
Controls energy levels, heart and lungs, endocrine and immune systems
Develops in use-dependent manner (neuroplasticity)
Shapes emotional and perceptual map of the world
Influences small and large decisions
Initiates preprogrammed escape plans (fight or flight responses)

Rational Brain

Youngest part of the brain
Occupies about 30% of the skull
Primarily concerned with understanding the external world
Develops after birth and throughout childhood
Enables language, abstract thought, planning, and reflection
Allows for culture creation and unique human abilities

MIRRORING EACH OTHER: INTERPERSONAL NEUROBIOLOGY

Discovery of Mirror Neurons (1994)

Italian scientists identified specialized cells in monkey's cortex
Fired when monkey watched actions, not just performed them
Explained empathy, imitation, synchrony, language development
"Neural WiFi," pick up others' emotions and intentions

Effects of Mirror Neurons

People tend to mimic each other in body language and voice rhythms
Vulnerable to others' negativity
Trauma often involves lack of being seen, mirrored, or taken into account

Frontal Lobes

Crucial for harmonious relationships with humans
Understanding others' motives and adapting in groups
Flexible, active frontal lobes prevent superficial relationships
Invention, innovation, discovery, and wonder
Stop us from embarrassing or hurting ourselves or others

Challenges with Frontal Lobes

Impulse control: less rational brain capacity with intense emotional input**
Troubles begin on edge between impulse and acceptable behavior

IDENTIFYING DANGER: THE COOK AND THE SMOKE DETECTOR

Identifying Danger: The Role of the Cook (Thalamus) and Smoke Detector (Amygdala) in the Brain

Danger is a normal part of life
Sensory information reaches thalamus, the "cook" within the brain
Thalamus blends sensations into coherent experience

The Low Road: Amygdala's Role in Identifying Danger

Amygdala, brain's smoke detector
Quickly identifies threats to survival
Processes information faster than frontal lobes
Sends message to hypothalamus and brain stem
Triggers stress hormones (cortisol, adrenaline) release
Prepares body for fight or flight response

The High Road: Frontal Lobes' Role in Conscious Awareness

Processes information more slowly than amygdala
Reaches conscious awareness

Threat Detection and Misinterpretation

Amygdala can misinterpret danger
Trauma increases risk of misinterpreting situations
Accurately gauging people's intentions crucial for relationships and work environments
Faulty alarm systems lead to misunderstandings or extreme reactions.

CONTROLLING THE STRESS RESPONSE: THE WATCHTOWER

Amygdala as smoke detector:
- Triggers stress response
- Does not make judgments
Medial Prefrontal Cortex (MPFC) as watchtower:
- Offers objective perspective
- Helps assess situation and inhibit stress response
Balance between amygdala and MPFC:
- Crucial for emotional control
- PTSD: Shifted balance, difficulty controlling emotions
Top-down regulation:
- Strengthening watchtower's monitoring capacity
- Mindfulness meditation and yoga help
Bottom-up regulation:
- Recalibrating autonomic nervous system (ANS)
- Access through breath, movement, or touch
Breathing:
- One of few body functions under conscious and autonomic control
Techniques for increasing top-down and bottom-up regulation will be explored in part 5.

THE RIDER AND THE HORSE

Emotion is not opposed to reason, but foundational for it.
Self-experience is the balance between rational and emotional brains.
Survival situations can cause independent functioning of emotional and rational brains.
Comparison of relationship between rational brain and emotional brain to a rider and an unruly horse.
Emotional brain can take control when survival is at stake or during intense emotions like fear, rage, longing, etc.
Psychological problems often originate from deeper regions in the brain rather than defects in understanding.
When emotional brain perceives a threat, pathways between it and rational brain become tenuous.
Anger management techniques may not work during intense emotions.
Conflict between emotional and rational brains results in physical discomfort and psychological misery.

Brain Scans and Core Features of Traumatic Stress:

Timeless reliving: traumatic memories can be reexperienced as if they are happening in the present.
Reexperiencing images, sounds, and emotions: traumatic memories can trigger strong emotional responses and sensory experiences.
Dissociation: a coping mechanism where an individual disconnects from their thoughts, feelings, or surroundings during traumatic events.

STAN AND UTE’S BRAINS ON TRAUMA

September 1999: Stan and Ute Lawrence, a professional couple, were involved in the worst road disaster in Canadian history near London, Ontario.
Accident: Dense fog caused a massive pileup involving 87 cars, including Stan and Ute's car. They came to a stop just before being hit by an eighteen-wheeler.
Aftermath: Trapped in their car, they witnessed people dying and heard ear-splitting crashes. Eventually, they were freed and taken to the hospital with no major injuries.
Trauma Symptoms: Unable to sleep, irritable, jumpy, on edge, haunted by images and questions related to the accident. Turned to wine for relief.
Seeking Help: Three months after the accident, they sought help from Dr. Ruth Lanius, a psychiatrist at the University of Western Ontario.

fMRI Scan and Treatment

fMRI Scan: Dr. Lanius wanted to use an fMRI scan to visualize Stan and Ute's brains before treatment. This non-invasive method measures neural activity by tracking changes in blood flow.
Flashbacks: During the scan, Stan experienced a flashback, reliving the accident instead of remembering it as something that had happened three months earlier. His heart raced, blood pressure was high, and he sweated.
Treatment: Unspecified treatment followed after the fMRI scan.

DISSOCIATION AND RELIVING

Dissociation: overwhelming trauma experiences split off and fragmented, intruding into present as sensory fragments
Trauma replayed through flashbacks, unaware of connection to past traumatic events
Stress hormones circulating, defensive responses repeated

Characteristics of Flashbacks

Can occur at any time, without warning or end
Exhausting and leaves people fatigued, depressed, weary
Memories engraved deeper with each replay
Difficulty experiencing present fully

Triggered Responses

Intense and irrational reactions outside of control
Shame and hiding the truth central preoccupation
Differences in responses: some may startle, others numb or shut down
Physical reactions detectable through lab tests

Impact on Brain

Amygdala makes no distinction between past and present during flashbacks
Normal stress hormone responses during trauma can become disruptive if overactive

Therapy and Recovery

Therapy helps bring emotions generated by trauma to surface
Gaining mastery over internal sensations and emotions key to recovery
Sensing, naming, and identifying what's going on inside first step to recovery.

THE TIMEKEEPER COLLAPSES

Stan and Ute's prefrontal cortex struggled to maintain control after the accident
Stan's flashback led to a more extreme reaction
Two brain systems relevant for mental processing of trauma: emotional intensity and context

Emotional Intensity

Defined by the amygdala, smoke alarm, and medial prefrontal cortex (MPFC)
Amygdala: responsible for emotional response
Smoke alarm: triggers fear response
MPFC: counterweight to amygdala, regulates emotional response

Context and Meaning

Determined by dorsolateral prefrontal cortex (DLPFC) and hippocampus
DLPFC: timekeeper of the brain, relates present experience to past and future
Hippocampus: forms memories

The Thalamus Shuts Down

Two white holes in lower half of brain are Stan's right and left thalamus
Blanked out during flashback as they were during original trauma
Functions as a "cook" or relay station for sensory information
Breakdown explains why trauma is remembered as isolated sensory imprints
Normally acts as a filter or gatekeeper, compromised by trauma
People with PTSD have their floodgates wide open and are on constant sensory overload
Try to shut down naturally or use drugs/alcohol to block out the world
Price of closing down includes filtering out sources of pleasure and joy.

DEPERSONALIZATION: SPLIT OFF FROM THE SELF

Depersonalization:

Response to trauma where mind goes blank and brain activity decreases
Heart rate and blood pressure don't elevate
Outward manifestation of dissociation created by trauma
Patients may tell horrendous stories without feeling
Conventional talk therapy is virtually useless in such cases

Ute's Experience:

Responded to trauma by going numb
Learned survival strategy in childhood to cope with harsh treatment from mother
Discovered she could blank out her mind when mother yelled at her
Automatically went into same survival mode during car accident
Challenged to become alert and engaged to recapture her life

Approach Towards Blanked-Out Patients:

Conventional talk therapy is ineffective due to decreased brain activity
Bottom-up approach essential to change patient's physiology
Measures include heart rate and breathing patterns, evoking bodily sensations
Rhythmic interactions with others effective (tossing ball, bouncing on Pilates ball, drumming, dancing)

Impact of Depersonalization:

Can be more damaging than explosive flashbacks over time
Particular problem for traumatized children who blank out and are overlooked
Acting-out kids get attention while blanked-out ones don't, leading to loss of future.

LEARNING TO LIVE IN THE PRESENT

Difficulty feeling alive in the present leads to dominance of traumatic memories in PTSD

Misconception about Trauma Treatment:

Many approaches focus on desensitizing patients to past traumas
Expectation is that reexposure will reduce emotional outbursts and flashbacks

Importance of Living Fully in the Present:

Focus on enhancing daily experience instead of just dealing with past traumas
Bring back brain structures that deserted during trauma
Desensitization may make less reactive but unable to find satisfaction in everyday activities
Ordinary experiences like walking, cooking, or playing with kids enrich life and help move past trauma.
Reason for traumatic memories' dominance: difficulty living fully and securely in the present

CHAPTER 5

BODY-BRAIN CONNECTIONS

Charles Darwin's "The Expression of the Emotions in Man and Animals (1872)

Key Points:

Exploration of emotional life, filled with observations and anecdotes
Discusses the physical organization common to all mammals
Emotions are fundamentally rooted in biology
Facial and physical movements communicate mental state and intention
Emotions give shape and direction to actions
Origin of emotions: initiate movement to restore organism to safety and equilibrium
Intense emotions involve gut and heart (body-brain connections)

Darwin's Observations:

Humans share physical signs of animal emotion
Emotions are the source of motivation
Facial and physical expressions communicate mental state and intention
Emotions initiate movement to restore organism to safety and equilibrium
Intense emotions involve gut and heart (body-brain connections)

Body-Brain Connections:

Heart, guts, and brain communicate intimately via the 'pneumogastric' nerve
Mind affects state of viscera under excitement
Visceral sensations unbearable, can lead to mental health problems (drug addiction, self-injurious behavior)
Traditional healing practices in India and China focus on body-brain connections
Transforming our understanding of trauma and recovery today.

A WINDOW INTO THE NERVOUS SYSTEM

Two branches of Autonomic Nervous System (ANS): sympathetic and parasympathetic
Linked to body's energy flow, managing expenditure and conservation

Sympathetic Nervous System (SNS)

Arousal, fight-or-flight response
Roman physician Galen named it "sympathetic" due to its connection with emotions
Prepares body for action: moves blood to muscles, triggers adrenal glands to release adrenaline

Parasympathetic Nervous System (PNS)

Promotes self-preservative functions: digestion, wound healing
Slows down arousal: triggers release of acetylcholine
Important for feeding, shelter, and mating activities

Experiencing SNS and PNS

Deep breaths activate SNS (increases heart rate)
Exhalation activates PNS (slows down heart rate)

Heart Rate Variability (HRV)

Measurement of the flexibility of the arousal system
Good HRV indicates proper functioning and balance of brake and accelerator in arousal system
Can be used to help treat PTSD (as explained in chapter 16)

THE NEURAL LOVE CODE

Polyvagal Theory introduced by Stephen Porges in 1994:

Expanded understanding of safety and danger based on body's visceral experiences and social relationships
Named for the many branches of vagus nerve connecting brain, organs, and social interactions
Explained how kind faces or soothing voices can alter feelings and improve regulation
Clarified importance of being seen and heard in maintaining safety and calming effects of focused attunement
Highlighted role of social relationships in understanding trauma and new approaches to healing

Key Points about Human Beings:

Highly attuned to emotional shifts in others through mirror neurons and facial expressions
Our faces give others clues about our emotions and arousal levels
We function as members of a tribe, with most energy devoted to connecting with others
Mental suffering often involves relationship issues or arousal regulation difficulties

Implications:

Social relationships are crucial for safety, healing, and mental wellbeing
Focus on understanding and addressing relationship problems and arousal regulation can be more effective than searching for specific drugs to treat symptoms."

SAFETY AND RECIPROCITY

Jerome Kagan's observation: every act of cruelty outweighed by hundreds of small acts of kindness and connection
Being able to feel safe with others is crucial for mental health and satisfying lives
Social support is essential protection against stress and trauma
Reciprocity is key: being truly heard and seen by people around us
Physiological healing requires a visceral feeling of safety
No prescription for friendship and love, complex and hard-earned capacities
Focusing on shared trauma may provide solace but promotes further alienation
Well-functioning people accept individual differences and acknowledge humanity of others
Animals like dogs, horses, and dolphins offer less complicated companionship and sense of safety for some trauma patients.

Social Support:

Most powerful protection against stress and trauma
Not just being in the presence of others, but reciprocity: feeling truly heard and seen**
Numerous studies on disaster response around the world

Trauma:

Can lead to isolation and denial of individual differences
Focusing on shared trauma may provide solace but promotes further alienation
Gangs, extremist political parties, religious cults may offer solace but hinder mental flexibility

Animals as Companions:

Offer less complicated companionship and sense of safety for some trauma patients
Extensively used to treat trauma patients with dogs, horses, and dolphins.

THREE LEVELS OF SAFETY

Autonomic Nervous System (ANS) Regulates Three Fundamental Physiological States
- Level of safety determines which state is activated
Three Responses to Threat
1. Social engagement system:
  - Signals danger and calls for help
  - Ventral vagal complex (VVC)
  - Smile, nod, frown, slow heart rate, deep breathing
2. Fight or flight response:
  - Teeth bared, face of rage and terror
  - Sympathetic nervous system (SNS)
  - Fast heart rate, fast breathing, growling dog
3. Collapse or freeze response:
  - Body signals defeat and withdraws
  - Dorsal vagal complex (DVC)
  - Heart rate plunges, can't breathe, gut stops working or empties

Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations and implications for the assessment and treatment of traumatic stress. In D. F. Barlow & J. C. Beck (Eds.), Handbook of anxiety disorders (pp. 273-286). Guilford Press.

FIGHT OR FLIGHT VERSUS COLLAPSE

Mammalian Fight-or-Flight System: protective, keeps us engaged in present
- Characterized by playfulness and huddling in animals
- Activated in response to sudden threat
- Decreases responsiveness to human voice and increases sensitivity to threatening sounds
- Makes people feel energized
Reptilian Brain: produces collapse response
- Characterized by immobilization and unresponsiveness
- Engages when fight or flight does not take care of threat
- Controlled by DVC, an ancient part of parasympathetic nervous system
  - Associated with digestive symptoms like diarrhea and nausea
  - Slows down heart and induces shallow breathing
  - Shuts down awareness and may cause lack of physical pain registration.
Examples of fight or flight: road rage, intense impulse to move and attack
Examples of collapse: shutting down and becoming dead to the world, feeling numb in safe situations
Collapse is a last resort when physically immobilized or no escape from threat.

HOW WE BECOME HUMAN

Vagus Nerve Complex (VVC) evolution in mammals for complex social life
- Mating, nurturing young, defending, coordinating hunting and food acquisition
- Efficiently synchronizes sympathetic and parasympathetic nervous systems

Infant Development

Newborns not very social, at mercy of sympathetic and parasympathetic nervous systems
Parental interactions stimulate growth of synchronicity in VVC
- Helps bring emotional arousal systems into sync with surroundings
- Controls sucking, swallowing, facial expression, larynx sounds
- Creates foundation for social behavior and sense of pleasure and safety

The Brain as a Cultural Organ

Attuned interactions between mother and child continue throughout life
Synchrony in various activities fosters deep sense of pleasure and connection

Trauma and the VVC

Trauma occurs when VVC fails to respond appropriately
- Immobilization leads to DVC takeover
- Heart slows, breathing becomes shallow, dissociation and loss of self-awareness ensue"

DEFEND OR RELAX?

Defensive System and Emotional Connection

Natural state of mammals: somewhat on guard (Steve Porges)
To feel emotionally close: defensive system must temporarily shut down
Brain needs to turn off vigilance for play, mating, nurturing

Effects of Trauma

Hypervigilant or numb: unable to enjoy pleasures or respond to danger
Malfunctioning smoke detectors in the brain
Increased risk of violence and abuse for traumatized individuals (ACE study)

Intimacy and Safety

ACE Study findings:
- Women with early abuse/neglect 7x more likely to be raped
- Witnessing mother's assault increases chance of domestic violence
Deep intimacy requires allowing immobilization without fear
Challenges for traumatized people:
- Discerning safety and activating defenses when necessary
- Restoring sense of physical safety (topic to be covered in later chapters)

NEW APPROACHES TO TREATMENT

Traumatized individuals get stuck in fight/flight or chronic shut-down.
To help them deactivate defensive maneuvers:
- Create small, safe places for social engagement.
- Engage emotional-engagement system before promoting new ways of thinking.

Steve Gross's Approach:

Used brightly colored beach ball to engage traumatized children.
Gradually created back-and-forth interaction, leading to smiles and relaxation.

Importance of Engaging Emotional System:

Humans respond to playful tones with opening up and relaxing.
Yelling can lead to further dysregulation.
Educational system often bypasses emotional engagement.

Polyvagal Theory:

Helped explain why unconventional techniques work in trauma treatment.
Combines top-down (social engagement) with bottom-up (calming body).

Effective Therapeutic Techniques:

Yoga, theater programs, karate, play techniques, sensory stimulation.
Breath exercises, chanting, martial arts, drumming, group singing, and dancing.

Body Keeps the Score:

Trauma memory encoded in viscera and emotions.
Mind/brain/visceral communication is crucial for emotion regulation.
Demands a radical shift in therapeutic assumptions.

CHAPTER 6

LOSING YOUR BODY, LOSING YOUR SELF

Sherry Grew up in a foster home with transient children
Mother emotionally abused her, making her feel unwanted
Graduated from college, worked clerical job, lived alone with cats, no close friends
Experienced kidnapping and rape in college

Effects of Emotional Abuse and Neglect:

Devastating, especially for young children
Can be as damaging as physical or sexual abuse
Leads to disconnection from self and others
May result in maladaptive coping mechanisms

Sherry's Coping Mechanisms:

Picking at skin for relief from numbness and shame
Previously hospitalized involuntarily, questioned about suicidal behavior
Felt disconnected from therapists, unable to form vital connections

Discovering the Relevance of the Body:

Sherry's extreme disconnection from her body
Importance of understanding the living, breathing body as foundation of self
Therapy focusing on insight and understanding had ignored body's role

Help for Sherry:

Suggested seeing a massage therapist, Liz
First session resulted in panic when Sherry lost sense of Liz's presence
Helped Sherry reconnect with her body and self.

LOSING YOUR BODY

McFarlane's Research:

Studied how we recognize objects by touch in Adelaide, Australia.
Requires sensing shape, weight, temperature, texture, and position.
People with PTSD often struggle to integrate these sensory experiences.

William James' Case Study:

Woman reported having "no human sensations."
Could not feel objects she touched or experience enjoyment.
Felt a void in the front of her head and a diminished sensibility over her body.

Implications for PTSD:

Trauma can lead to sensory insensibility and inability to feel secure and complete in one's body.
Important question: How can traumatized people learn to integrate ordinary sensory experiences?

HOW DO WE KNOW WE’RE ALIVE?

Ruth Lanius posed new question: What happens in the brains of trauma survivors when they are not thinking about the past?
Studied "default state network" (DSN) or idling brain
Normal subjects showed activation of midline structures involved in self-awareness:
- Posterior cingulate (internal GPS)
- Medial prefrontal cortex (MPFC, watchtower)
- Insula (relays messages from viscera to emotional centers)
- Parietal lobes (integrates sensory information)
- Anterior cingulate (coordinates emotions and thinking)
Chronic PTSD patients with severe early-life trauma showed no activation of self-sensing areas:
- MPFC, anterior cingulate, parietal cortex, insula
- Deadened capacity to feel fully alive
Implications for loss of sense of purpose and direction, inability to recognize oneself in a mirror
Need to reactivate self-sensing system.

THE SELF-SENSING SYSTEM

Sherry's massage therapy improved her life, making her more relaxed and open
Met Antonio Damasio, who clarified the relationship between body states, emotions, and consciousness
Damasio's work focuses on identifying areas of the brain responsible for self-awareness

The Divide Between Self and Body Sensations

Our sense of self hides inner body states, preventing us from sensing our true selves
Primordial feelings provide direct experience of body states and are the foundation of self-awareness

Pre-Natal and Post-Natal Development of Bodily Sensations

We feel sensations in the womb and after birth that define our relationship to ourselves and surroundings
Physical sensation continues to provide crucial feedback on moment-to-moment condition throughout life

The Role of Consciousness in Maintaining Inner Equilibrium

Our conscious self plays a vital role in registering and acting on physical sensations to keep bodies safe
Subcortical regions of the brain regulate basic functions, but can become overwhelmed by threats
Proto-self refers to housekeeping areas of the brain that create wordless knowledge underlying conscious sense of self

THE SELF UNDER THREAT

In 2000, Damasio et al. published an article in Science about the brain's response to reliving negative emotions

Brain changes during emotional recall:

Significant changes in brain areas receiving nerve signals from muscles, gut, and skin
Distinct patterns for each emotion
Brain stem involved in sadness and anger, but not happiness or fear

Expressions link emotions with body
- "You make me sick"
- "It made my skin crawl"
- "I was all choked up"
- "My heart sank"
- "He makes me bristle

Elementary self system in brain stem and limbic system

Threat of annihilation:

Overwhelming sense of fear and terror
Intense physiological arousal
People reliving trauma are trapped in life-or-death situation

Symptoms:

Startle easily
Frustrated by small irritations
Chronically disturbed sleep
Food loses sensual pleasures
Desperate attempts to shut feelings down

Regaining control when animal brains are in fight or survival mode

Subcortical brain structures:
- Orchestrate body sensations
- Limited control over them?
Shutting down feelings:
- Desperate attempts to freeze and dissociate.

AGENCY: OWNING YOUR LIFE

Agency: feeling in charge of one's life, knowing where one stands, having a say in what happens

Interoception: awareness of subtle body-based feelings; essential for controlling one's life
Mindfulness practice: strengthens the MPFC, helps observe inner experiences and manage them
Trauma: can shut down inner compass, rob imagination to create something better
Neuroscience of selfhood and agency: validates somatic therapies
Sensorimotor approaches: draw out blocked sensory information, help befriend energies released by trauma, complete self-preserving physical actions
Gut feelings: signal what is safe or threatening, help evaluate outer environment
Traumatized people: chronically feel unsafe inside their bodies, ignore or suppress inner warning signs
Fear of fear: develop a fear of bodily sensations associated with panic attacks
Self-regulation: depends on having a friendly relationship with one's body
Somatic symptoms: ubiquitous in traumatized children and adults, no clear physical basis, can include chronic pain, digestive problems, asthma, etc.
Traumatized children: have fifty times the rate of asthma as non-traumatized peers
Somatic symptoms: not aware of having breathing problems before fatal asthma attacks.

ALEXITHYMIA: NO WORDS FOR FEELINGS

Symptoms:

Difficulty identifying feelings
Appearing emotionless or detached
Experiencing physical symptoms instead of emotional responses
Trouble sensing body signals
Lack of nuanced response to frustration
Reluctance to acknowledge and process emotions

Causes:

Trauma history
Suppression of feelings for survival
Disconnection between mind and body

Effects:

Difficulty with intimacy and relationships
High rates of revictimization
Lack of self-protection
Remarkable difficulties feeling pleasure, sensuality, and having a sense of meaning

Brain Scans:

Less activity in self-sensing areas of the brain for those out of touch with feelings
Contributes to lack of nuanced response to frustration and difficulties processing emotions.

DEPERSONALIZATION

Depersonalization: losing sense of self
Illustrated by Ute's brain scan in chapter 4, appearing blank
Common during traumatic experiences
Author's personal experience: mugging, feeling detached and curious
Schilder's description (1928): strange, foreign, dream-like perception of the world
Objects appear altered in size or flat, sounds come from a distance
Emotions altered, unable to feel pain or pleasure
Neuroscientists at University of Geneva induced out-of-body experiences by stimulating temporal parietal junction
Patients reported feeling detached from body, hanging from ceiling or having someone behind them
Confirms patients' reports that self can be detached and live as phantom existence
Lanius and Frewen, University of Groningen: brain scans showed fear centers shut down during recall of traumatic events.

BEFRIENDING THE BODY

Trauma Recovery

Trauma victims cannot recover until they befriend their bodies and become aware of sensations
Fear, anger, and child abuse victims have tense, defensive bodies
Importance of physical self-awareness to release past trauma

Exploring Internal World of Sensations:

Notice and describe physical sensations beneath emotions
Identify sensations associated with relaxation or pleasure
Pay attention to subtle shifts in body during negative events

Dealing with Distressing Physical Reactions:

Noticing sensations for the first time can be distressing, may cause flashbacks
Therapist must help prevent retraumatization
Medications like Abilify, Zyprexa, and Seroquel only blunt sensations

The Power of Touch:

Human beings naturally calm themselves through touch
Trauma victims crave touch but are terrified of it
Mind needs to be reeducated to feel physical sensations
Body needs to be helped to tolerate and enjoy comforts of touch

Emotional Awareness:

Individuals who lack emotional awareness can connect physical sensations to psychological events
Gradually reconnect with oneself

CONNECTING WITH YOURSELF, CONNECTING WITH OTHERS

Study on the cost of losing body connection: what happens in chronically traumatized people during face-to-face contact?
Ruth Lanius' research: brain activation differences between normal controls and survivors of chronic trauma during eye contact
- Expensive device used: video character approaching at direct gaze or averted gaze
- Normal controls: prefrontal cortex (PFC) activated, assessing person and curiosity
- Survivors of PTSD: no PFC activation, intense activation in Periaqueductal Gray, self-protective behaviors
Implications for relationships and therapy
- Ability to experience others as separate individuals with motivations and intentions
- Need to stand up for oneself while recognizing others' agendas
- Trauma can make these abilities hazy and gray.

PART THREE. THE MINDS OF CHILDREN.

CHAPTER 7

GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT

The Children's Clinic at Massachusetts Mental Health Center was filled with disturbed children who were wild, clingy, oppositional, and had difficulty exploring or playing.
Researchers Nina Fish-Murray and Bessel van der Kolk aimed to understand the differences between traumatized and non-traumatized children using projective tests.
They used Thematic Apperception Test (TAT) cards with realistic but ambiguous scenes, asking children to tell stories about what's happening in the photos.
A study was conducted comparing twelve traumatized children from the clinic with a control group of non-traumatized children.
Traumatized children had experienced severe abuse within their families, including physical and sexual abuse.
Control children also lived in poverty and witnessed violence but responded differently to the cards, imagining benign outcomes.
Traumatized children's responses were alarming, revealing intense feelings of danger, aggression, sexual arousal, and terror.
The children's worldview was filled with triggers, making anyone or anything a potential harbinger of catastrophe.
Staff discussions at the clinic focused on diagnostic labels instead of addressing the underlying trauma.
Challenges: Understanding resilience in normal children and helping traumatized children redraw their inner maps with trust and confidence.

MEN WITHOUT MOTHERS

MEN WITHOUT MOTHERS: A study on the importance of the mother-infant relationship initiated by upper-class Englishmen who experienced early separation from their mothers due to boarding schools.

English psychiatrists: John Bowlby, Wilfred Bion, Harry Guntrip, Ronald Fairbairn, and Donald Winnicott
Early experiences shape later connections with others and self-concept
"Me-search" in psychology
Inspired by their own experiences of separation from mothers
Boarding school experiences may have influenced George Orwell's 1984

John Bowlby:

Born into an aristocratic family
Educated at Cambridge University and trained in psychology, medicine, and psychoanalysis
Worked with delinquent boys in London's East End
Observed effects of wartime evacuations, group nurseries, and hospitalization on children
Claimed children's disturbed behavior was due to actual life experiences rather than infantile sexual fantasies
Radical claim led to being ostracized from British psychoanalytic community
Developed attachment theory

Impact of Early Separation:

Inspired research on mother-infant relationship
Shaped these men's perspectives and work in psychology
Orwell's 1984 may have been influenced by their experiences
Children's behavior affected by neglect, brutality, and separation."

A SECURE BASE

Secure Base and Attachment

Humans are profoundly social creatures who learn self-care from early interactions with caregivers
Importance of harmonious early interactions for mastering self-regulation and developing healthy ways of responding to people
Children are captivated by faces and voices, sensitive to nonverbal cues, and form primary attachment bonds with responsive adults
Attachment bond creates a secure base for children to explore the world
Research supports the importance of having a safe haven for promoting self-reliance, empathy, and social skills

Early Interactions and Child Development

Infants are sensitive to facial expressions, posture, tone of voice, physiological changes, tempo of movement, and incipient actions
Children choose one or a few adults for primary attachment bonds
Responsive adults deepen the attachment bond and promote healthy development
Inconsistency in caregiver attention can make children nervous and disrupt their sense of security

Impact of Attachment on Childhood and Beyond

Secure base provides self-awareness, empathy, impulse control, and self-motivation for social interaction
Lack of these qualities was observed in kids at Children's Clinic.

THE DANCE OF ATTUNEMENT

Attachment develops between children and primary caregivers
Secure attachment forms through emotional attunement
Attunement starts at physical levels, giving babies a feeling of being met and understood
Infants learn imitation as a fundamental social skill
Attunement includes emotional synchrony and physical synchrony
Disruptions in attunement can lead to distress and repair
Secure attachment leads to self-regulation, self-soothing, and self-nurture
Parents teach children to manage arousal and regulate emotions
Securely attached children learn agency and difference between controllable and uncontrollable situations
Insecure attachment from abuse or neglect can lead to learned helplessness

Emotional Attunement:

Starts at subtle physical levels
Gives babies a feeling of being met and understood
Develops secure attachment

Attunement and Synchrony:

Infants imitate behavior of parents, teachers, and peers
Physical and emotional synchrony between infant and caregiver

Disruptions and Repair:

Disruptions can lead to distress
Caregivers repair the relationship through soothing actions

Secure Attachment:

Foundation for self-regulation, self-soothing, and self-nurture
Children learn what makes them feel good and bad
Acquire a sense of agency
Learn difference between controllable and uncontrollable situations

Insecure Attachment:

Can lead to learned helplessness
Children learn that their actions have no effect on caregiver's response.

BECOMING REAL

Donald Winnicott and his studies on attunement**:
Focused on the importance of physical interactions between mothers and infants in developing a sense of self and identity
Proposed that "good enough mothering" is essential for healthy development
Physical attunement lays the foundation for feeling the body as the place where the psyche lives
Lack of physical attunement can lead to children perceiving something is wrong with themselves, shutting down feedback from their bodies, and becoming vulnerable to emotional issues
Secure attachment:
- Majority of children are securely attached due to reliable, responsive caregiving
- Helps maintain emotional security throughout life and forms a template for relationships
- Securely attached children pick up on others' feelings, learn to tell reality from games, and develop good interpersonal skills
Impact of abuse or neglect:
- Children may become defensive, scared, and sensitive to threats
- May shut down or lose control of impulses, leading to social isolation and further emotional issues
Need for attachment:
- Humans cannot tolerate disengagement from others for long periods
- People find other ways to bond when unable to connect through work, friendships, or family
Case study:
- Fourteen-year-old boy named Jack, repeatedly arrested for burglaries
- Felt irrelevant and unconnected, seeking attention and recognition even through criminal activities.

LIVING WITH THE PARENTS YOU HAVE

Living with Parents: Children have a biological instinct to attach; coping styles based on attempts to get needs met

Secure Attachment:

Distressed when mother leaves
Delighted when she returns
Settle down and resume play

Avoidant Attachment:

Infants seem unaffected by separation
Chronically increased heart rates
Mothers have trouble showing affection
Infants "deal but don't feel

Anxious or Ambivalent Attachment:

Infants constantly seek attention
Derive little comfort from mother's return
Focused on mother even in other children's presence
Anxious toddlers grow into anxious adults
Avoidant toddlers become out of touch with feelings

Disorganized Attachment:

Unable to engage with caregivers
Caregivers are a source of distress or terror
Children cannot choose between seeking closeness and avoiding parent
"Fright without solution"

Assessment:

Mary Ainsworth's Strange Situation research tool
Securely attached infants return to play contentedly after mother leaves
Insecure attachments have more complex reactions

Consequences:

Persist into adulthood
Anxious adults may become bullies or victims
Disorganized attachment children may trust nobody or be intensely affectionate with strangers.

BECOMING DISORGANIZED WITHIN

Attachment Research:

Conscientious parents may worry about occasional impatience or lapses in attunement affecting their kids
Infants often left to calm themselves, not a problem within limits
"Good enough" caregivers allow for repair of broken connections
Critical issue is feeling viscerally safe with parents or caregivers

Attachment Patterns:

Secure: 62% of infants in normal middle-class environments
Avoidant: 15%
Anxious (ambivalent): 9%
Disorganized: 15%
Gender and temperament have little effect on attachment style
Children from lower socioeconomic groups more likely to be disorganized

Effects of Disorganized Attachment:

Trouble regulating moods and emotional responses as they grow older
Aggressive or disengaged behavior in kindergarten
Range of psychiatric problems
Biological dysregulation may not reset to normal

Causes of Disorganized Attachment:

Parental abuse
Parents preoccupied with their own trauma (domestic abuse, rape, recent death)

Misattunement and Chronic Disconnection:

Misunderstandings and failures in communication are common
Misattunement can lead to chronic disconnection
Mothers who fail to calm baby down may perceive child as difficult and give up on comforting

Intertwined Problems:

Difficult to distinguish problems from disorganized attachment and trauma
Upbringing leaves children with vulnerable physiology, making it hard to regain equilibrium after traumatic experiences

Parental Stress and Child Reactions:

Children's reactions to painful events determined by parents' calmness or stress
Secure attachment predicts less painkiller requirement for hospitalized children
Mothers' PTSD or depression increases child's risk of emotional problems and hyperaggression
Fathers' PTSD affects children indirectly through mothers

Self-Perceptions and Trauma:

Disorganized people may carry self-perceptions that make them more susceptible to trauma
Feeling chronically numbed out or expecting others to treat them poorly increases risk of being traumatized.

THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT

Research by Karlen Lyons-Ruth in the 1980s
Focused on mothers and infants from high-risk families
Two types of disorganized attachment:
- Mothers who were intrusive and hostile
  - Preoccupied with their own issues
  - Inconsistent and unpredictable behavior
  - History of physical abuse or domestic violence
- Mothers who were helpless and fearful
  - Sweet or fragile demeanor
  - Unable to be the adult in the relationship
  - History of sexual abuse or parental loss (but not physical abuse)
Disorganized attachment led to:
- Increasingly frustrating interactions between mother and child
- Mothers viewing children as strangers
- Setting the stage for subsequent abuse
Follow-up study when children were around twenty years old:
- Infants with disrupted emotional communication patterns at eighteen months
  - Unstable sense of self
  - Self-damaging impulsivity (excessive spending, promiscuous sex, substance abuse, reckless driving, binge eating)
  - Inappropriate and intense anger
  - Recurrent suicidal behavior
Surprising findings:
- Emotional withdrawal had the most profound impact on adult children's mental instability
- Emotional distance and role reversal linked to aggressive behavior against self and others.

DISSOCIATION: KNOWING AND NOT KNOWING

Dissociation: feeling lost, overwhelmed, disconnected from the world, unloved, empty, helpless, trapped, and weighed down.

Relationship between Maternal Disengagement and Dissociative Symptoms:

Infants not truly seen and known by mothers at high risk for dissociation in early adulthood (Lyons-Ruth)
Secure relationships: infants communicate needs, emerging selves, receive sympathetic response
Maternal neglect or hostility leads to anticipation of rejection, coping through dissociation

Bowlby's Perspective:

What cannot be communicated to mother cannot be communicated to self
Inability to tolerate what is known or feel feelings leads to denial and dissociation
Lack of feeling real inside makes it impossible to protect oneself, may result in extreme behaviors

Early Learning of Dissociation:

Dissociative symptoms learned early, not solely caused by later abuse or trauma (Karlen's research)
Critical underlying issue: lack of safety and impaired sense of inner reality
Treatment needs to address consequences of not being mirrored, attuned to, and given consistent care and affection.

RESTORING SYNCHRONY

Early attachment patterns shape our relationships throughout life, influencing what we expect and experience in terms of comfort and pleasure

Importance of early experiences:
- e.e. cummings' joyous lines likely influenced by positive early experiences
- Realization of past experiences may not directly lead to healing but can help explore new ways to connect
Attachment maps are implicit, etched into emotional brain and not easily reversible
Damaged attunement systems can be healed through training in rhythmicity and reciprocity (discussed in Part 5)

Being in synch:

Requires integration of body-based senses: vision, hearing, touch, balance
Importance of sensory rhythms: cooking, cleaning, going to bed/waking up
Sharing activities like funny faces, hugs, tossing balls, singing together
Trauma Center programs focus on coaching parents in connection and attunement
Other ways to foster synchronicity: choral singing, ballroom dancing, joining teams, etc.

CHAPTER 8

TRAPPED IN RELATIONSHIPS: THE COST OF ABUSE AND NEGLECT

Marilyn: operating-room nurse in her midthirties, athletic, played tennis with Boston fireman named Michael
Invited him to stay over one evening, felt "uptight and unreal"
Fell asleep together, woke up to Michael touching her, exploded in rage
Attacked Michael, screamed, humiliated and hated herself
Came to therapy for help with terror of men and rage attacks

Therapy Process:

Therapist listens without trying to fix the problem immediately
Inexplicable behaviors common in therapy:
- Attacking a boyfriend
- Feeling terrified when someone looks you in the eye
- Covered with blood after cutting yourself
- Deliberately vomiting up every meal
Takes time and patience for reality behind symptoms to reveal itself

TERROR AND NUMBNESS

Marilyn's Background:

Marilyn, a nursing degree holder, shared her experiences of feeling numb and losing control when spending time alone with men.
She had a violent confrontation with her alcoholic father at age sixteen and ran away from home.
Her childhood memories are vague before the age of twelve.
She's harboring terrible memories but cannot recognize them.
Marilyn has drawn a family portrait revealing a wild and terrified child trapped in a cage, threatened by nightmarish figures and a huge erect penis.

Therapy Approach:

Marilyn joined an established therapy group for support and acceptance before facing her distrust, shame, and rage.
The group's intrusive questions about her love life reminded her of past traumas.
Marilyn was diagnosed with lupus erythematosus of her retina, an autoimmune disease eroding her vision.

Study Findings:

Collaboration between psychiatrist, immunologist, and research team to study incest survivors' immune system response.
Twelve women with incest histories and twelve non-traumatized women participated in the study.
Incest survivors had a larger proportion of RA cells (memory cells) ready to pounce compared to non-traumatized peers.
The oversensitive immune system in incest victims makes it difficult for their bodies to distinguish between danger and safety, with the imprint of past trauma affecting not only their minds but also their core beings.

A TORN MAP OF THE WORLD

Understanding the Impact of Child Abuse and Neglect

People learn about safety, self, and relationships based on childhood experiences
Marilyn's story: Egocentric view of the world shaped by abuse and neglect
- Self-perception marked by contempt and humiliation
- Distrustful of others, especially men and women
- Suspicious of kindness, blames herself for mistreatment

Inner Map of the World

Shaped by earliest caregivers' interactions
- Conveys what is safe and dangerous
- Forms template of self and world perception
Stable across time but can be modified by experience
- Deep love relationships during adolescence or birth of a child
- Adults who were abused or neglected can still learn intimacy and trust
Distorted maps due to adult rape or assault may lead to terror or despair

Recognizing and Changing Inner Maps

People like Marilyn discover their assumptions are not the same as others
- Friends and colleagues may tell them in words, but rarely do
Vulnerability to activating old maps when feeling trapped, enraged, or rejected
Change begins by learning to "own" emotional brains
- Observe and tolerate heartbreaking sensations
- Befriend emotions instead of obliterating them

LEARNING TO REMEMBER

Marilyn's group: members share traumatic experiences for empathy and understanding
- Mary shares experience of rape and abortion at age 13
- Group offers comfort and empathy
Marilyn's revelation of her own trauma
- Trauma involved dissociation, fear system activation, and lack of story
Therapy for dealing with past traumas
- Calming techniques: deep breathing, acupressure points, mindfulness
- Recognizing present from past experiences
Marilyn's memories begin to surface
- Flashbacks of wallpaper in childhood bedroom
- No protection or support from parents during abuse
Child Sexual Abuse Accommodation Syndrome
- Initiation, intimidation, stigmatization, isolation, helplessness, and self-blame
- Adult conspiracy of silence and disbelief
Common reactions to childhood trauma
- Disbelief, shame, self-blame, and denial
- Dissociation: making oneself disappear during traumatic experiences.

HATING YOUR HOME

Children:

No choice in parents or home environment
Cannot understand or talk about abuse due to loyalty and fear
Exhibit enraged, shut down, compliant, or defiant behavior
Cling to abusers despite danger

Effects of Childhood Abuse:

Loneliness, despair, self-hatred, and helplessness
Inability to trust
Difficulty distinguishing reality from imagination (soul murder)
Erasing awareness and cultivating denial for survival.

Adult Survivors:

Struggle with trust and identity
May exhibit similar behaviors as children, such as clinging to abusers or hiding abuse.

REPLAYING THE TRAUMA

Trauma and Childhood Memories

Marilyn's childhood trauma resurfaced in a choking dream
Dream reminded her of war veterans' nightmares with unadulterated images and sensations
During therapy, Marilyn was flooded with fragments of the traumatic experience
- Sitting in kitchen as a four-year-old with injuries and being mocked by family
- Brushing teeth and feeling panicked and unable to breathe
Trauma not stored as a narrative with beginning, middle, and end
Memories return as flashbacks with isolated images, sounds, and body sensations
Marilyn had no way to give voice to the unspeakable during childhood
Survivors of childhood abuse exemplify the power of the life force and will to live
Healing trauma requires acknowledgement and awe for survivors' dedication to survival

CHAPTER 9

WHAT’S LOVE GOT TO DO WITH IT?

Complex mental health issues:

Receive multiple, unrelated diagnoses
Mood swings: bipolar disorder
Despair: major depression
Restlessness and lack of attention: ADHD
Trauma history: PTSD
No diagnosis fully describes patients' experiences or identities

DSM:

First systematic manual of psychiatric diagnoses (1980)
Warned insufficiently precise for forensic settings, insurance purposes
Insurance companies require DSM diagnosis for reimbursement
Academic programs organized around DSM categories
Virtual industry earning APA over $100 million

Consequences of misdiagnosis:

Disastrous effects on treatment
Profound influence on self-perception and identity
Patients seen as out-of-control, needing to be "straightened out"

HOW DO YOU TAKE A TRAUMA HISTORY?

Started collaborating with Judith Herman in 1985
Both interested in trauma's impact on patients diagnosed with Borderline Personality Disorder (BPD)

Trauma History Interview: The Traumatic Antecedents Questionnaire (TAQ)

Designed interview instrument to uncover childhood trauma without asking point-blank questions
Gradual progression from simple to revealing questions
Asked about current relationships and childhood relationships, safety, rules, discipline, and disagreement solutions
Many patients reported traumatic experiences, including abuse, neglect, and violence
Realized that BPD issues may have started as coping mechanisms for overwhelming emotions and inescapable brutality

Findings from the Study

81% of BPD patients at Cambridge Hospital reported severe histories of child abuse and/or neglect
Impact of abuse depends on age at which it begins
Later research supported findings, but some studies still focus on particular horrendous events instead of long-term effects

Implications for Treatment

Understanding the language of trauma and abuse is crucial to understanding BPD
Children's feelings of anger, guilt, fear, and inner conflict are often a result of experiences rather than counterreactions
Chronic distrust, inhibition of curiosity, distrust of senses, and tendency to find everything unreal can be consequences of disowned experiences.

SELF-HARM

Self-Harm

Woman came to hospital three nights in a row with self-inflicted neck injuries
Told the author she felt better after harming herself
Author wondered why some people cope with upsetting situations differently

Study Findings

History of childhood sexual and physical abuse linked to repeated suicide attempts and self-cutting
Suicidal thoughts may start in early childhood
Inflicting harm on oneself could be a desperate attempt for control

Patient Outcomes

After three years of therapy, approximately two-thirds of patients had improved
Patients who remained self-destructive lacked memories of feeling safe as children
Lack of deep memory of feeling loved and safe may result in underdeveloped brain receptors for human kindness

Implications for Therapy

Importance of attuned relationships and feeling safe in therapy for those who lack memories of safety in childhood
Question of how to help people learn to calm themselves down and feel grounded in their bodies (to be explored further in Part 5)

THE POWER OF DIAGNOSIS

The study identified a distinct population of traumatized individuals, different from combat soldiers and accident victims
These individuals, such as Marilyn, Kathy, and children with abuse histories, do not necessarily remember their traumas but continue to behave as if they're in danger
They have trouble concentrating, staying on task, and negotiating relationships, among other symptoms
A field trial was conducted under Robert Spitzer's guidance to compare trauma symptoms in different populations: childhood abuse, domestic violence, and natural disasters
Results showed clear differences between groups, particularly those with childhood abuse histories
Symptoms included trouble concentrating, being on edge, self-loathing, relationship difficulties, memory gaps, self-destructive behaviors, and medical problems
The study suggested creating a new diagnosis for victims of interpersonal trauma: "Disorders of Extreme Stress, Not Otherwise Specified" (DESNOS) or "Complex PTSD"
The diagnosis was not included in the DSM-IV publication despite being overwhelmingly approved by the work group
Lack of diagnosis creates a dilemma for therapists, forcing them to diagnose with conditions that don't fully address the patients' needs
Consequences of caretaker abuse and neglect are more common and complex than natural disasters or accidents but were ignored in the diagnostic system.

THE HIDDEN EPIDEMIC

Discovery of the Connection between Childhood Trauma and Obesity:

Vincent Felitti, chief of Kaiser Permanente's Department of Preventive Medicine in San Diego, discovered that many morbidly obese patients had a history of childhood sexual abuse.
A nurse aide who lost weight through his program regained it due to the attention of a male coworker and her past traumatic experiences.
Felitti presented this finding at a meeting of the North American Association for the Study of Obesity, but faced skepticism from some experts.

The Adverse Childhood Experiences (ACE) Study:

In 1990, Felitti collaborated with Robert Anda and the Centers for Disease Control and Prevention (CDC) to conduct a larger study on adverse childhood experiences.
The study involved interviewing over 25,000 Kaiser patients about their childhood experiences and comparing the results with their medical records.

Findings of the ACE Study:

Prevalence of Adverse Childhood Experiences: More than one-third of respondents reported no adverse experiences, but more than a quarter reported physical abuse, and over 20% reported sexual abuse or neglect.
Impact on Health in Adulthood: People with higher ACE scores (indicating more adverse childhood experiences) had higher rates of chronic depression, workplace absenteeism, financial problems, lower lifetime income, and increased likelihood of substance abuse, suicide attempts, and risky sexual behavior.
Interrelatedness of Adverse Experiences: The study found that incidents of abuse are rarely standalone events; instead, they are interconnected.

Health Consequences of Childhood Trauma:

Mental Health: Chronic depression in adulthood is more common among those with higher ACE scores.
Substance Abuse: People with an ACE score of four were seven times more likely to be alcoholic, and the likelihood of IV drug use increased exponentially for those with higher scores.
Suicide Attempts: The risk of suicide attempts increases exponentially as the ACE score rises.
Violence: Abused or neglected girls are at much higher risk of being raped later in life, and boys who witness domestic violence are more likely to abuse their own partners.
Health Problems: People with an ACE score of six or above had a greater chance of currently suffering from any of the ten leading causes of death in the United States.

Implications:

The ACE study highlights the importance of addressing childhood trauma as a public health issue and its long-term impact on individuals' lives.
Understanding the interconnectedness of adverse experiences can help inform prevention and intervention strategies to mitigate their effects."

WHEN PROBLEMS ARE REALLY SOLUTIONS

Felitti saw a woman who had undergone bariatric surgery but became suicidal after losing weight
Obesity may be a personal solution for some, not a problem to eliminate
Weight can provide protection and safety for individuals:
- Woman felt overlooked as an overweight person
- Guards in prison felt safer being the biggest guy on the cellblock
- Male patient gained weight as a means of feeling safe from violence
Adaptations such as smoking, drinking, drugs, obesity are difficult to give up due to short-term benefits
ACE study group concluded:
- Long-term health risks may be personally beneficial in the short term
- The presenting problem is often a marker for the real problem
- Real problem lies buried in time, concealed by patient shame, secrecy, and sometimes clinician discomfort.

CHILD ABUSE: OUR NATION’S LARGEST PUBLIC HEALTH PROBLEM

Robert Anda's discovery at CDC: child abuse is the most costly public health issue in the US
Costs exceed those of cancer or heart disease
Eradicating child abuse would reduce: depression by more than half, alcoholism by two-thirds, suicide, IV drug use, and domestic violence by three-quarters
Improve workplace performance and decrease incarceration needs

Impact of ACE Study:

Revealed the gravest public health issue in the US
Calculated overall costs exceeded those of cancer or heart disease
Reduction in depression, alcoholism, suicide, drug use, and domestic violence if child abuse is eradicated
Dramatic effect on workplace performance and decreased need for incarceration

Comparison to Smoking and Health Campaign:

Surgeon General's report on smoking and health in 1964 led to decades-long campaign
Number of American smokers fell from 42% to 19% between 1965 and 2010
Prevented nearly 800,000 deaths from lung cancer between 1975 and 2000

Current Reality:

Follow-up studies and papers continue to appear
Day-to-day reality of children in outpatient clinics and residential treatment centers remains the same
High doses of psychotropic agents given instead, impairing emotional and intellectual growth and contributing membership to society.

CHAPTER 10

DEVELOPMENTAL TRAUMA: THE HIDDEN EPIDEMIC.

Hundreds of thousands of children with traumatic backgrounds absorb significant resources without noticeable improvement
Children end up in jails, welfare rolls, and medical clinics as statistics
Professionals and taxpayers fund their care

Anthony's Story:

Referred to Trauma Center at age 2.5 for biting, pushing, refusal to nap, and constant crying
Anxiously clung to mother, hid face, and started head banging when pushed away
Mother had a history of abandonment, abuse, and violent relationships
Diagnosed with various psychiatric disorders: depression, oppositional defiant disorder, anxiety, reactive attachment disorder, ADHD, and PTSD
Felt scared and fought for survival, did not trust mother's help

Maria's Story:

Fifteen-year-old Latina in foster care with a history of abuse and multiple placements
Diagnosed as mute, vengeful, impulsive, reckless, self-harming, with extreme mood swings and explosive temper
Described herself as "garbage, worthless, rejected"
Placed in equine therapy program where she felt safe and formed a connection with her horse
Graduated from high school and accepted into college

Virginia's Story:

Taken away from biological mother due to drug abuse
Moved from foster home to foster home before being adopted again
Described as isolated, controlling, explosive, sexualized, intrusive, vindictive, and narcissistic
Diagnosed with bipolar disorder, intermittent explosive disorder, reactive attachment disorder, ADD, ODD, and substance use disorder
Felt disgusting and wished to be dead

The Challenge:

Correctly define the issues these children face
Find ways to help them lead productive lives
Save taxpayers' money by addressing root causes
Focus on facts instead of developing new drugs or finding a single "gene" responsible for their "disease"

BAD GENES?

Genetics and Mental Illness

Pervasive problems in families lead to belief in "bad genes" as cause of mental illness
Thirty years of research on schizophrenia's genetic causes have failed to yield consistent results
Genes do not produce fixed results, but are influenced by life events and methylation
Epigenetics: life events can change gene behavior, which can be passed on to offspring

Schizophrenia Research

Affects about 1% of population, severe, runs in families
Thirty years of research, millions spent, no consistent genetic patterns found

Genes and Multiple Outcomes

Many genes work together to influence a single outcome
Genes are not fixed; life events can change their behavior through methylation

Epigenetics

Life events can modify gene behavior by attaching methyl groups
Methylation patterns can be passed on to offspring
McGill University research on rat pups and mothers:
- Intensive licking and grooming affects brain chemicals, gene expression, and hippocampus development
- Lasts throughout the rat's life and affects stress response and learning ability

Human Epigenetics

Stressful experiences can affect gene expression in humans
Quebec ice storm study: epigenetic changes in children of mothers trapped in unheated houses
Social class differences associated with distinct epigenetic profiles, but abused children share specific modifications in seventy-three genes.

MONKEYS CLARIFY OLD QUESTIONS ABOUT NATURE VERSUS NURTURE

Stephen Suomi's research on rhesus monkeys (95% human gene similarity) for over 40 years
Two consistent personality types identified:
- uptight, anxious monkeys
- highly aggressive monkeys
Biological differences detected within the first few weeks of life in arousal levels, stress hormones, and brain chemistry metabolism
Social environment significantly influences behavior and biology

Uptight Monkeys:

Lack social support as adults, often neglect or abuse firstborns
Can provide protection under stable social conditions
Peer-raised monkeys become uptight with attachment issues and overreact to stress

Aggressive Monkeys:

Punitive mothers, infants lack peer friendships
No social advantages

Impact of Environment on Genes:

Monkeys with short serotonin transporter alleles (associated with impulsivity, aggression, depression)
Raised by adequate mother: normal behavior and no deficit in serotonin metabolism
Raised with peers: aggressive risk-takers
Human research supports the importance of safe early relationships for children's development
Parents with genetic vulnerabilities can still protect their children with support.

THE NATIONAL CHILD TRAUMATIC STRESS NETWORK

The National Child Traumatic Stress Network (NCTSN)

Established by an act of Congress in 2001
Dedicated to research and treatment of traumatized children
Previously, no comprehensive organization for childhood trauma
Conceived due to interest from Nathan Cummings Foundation
Lack of systematic education on childhood trauma
Affects mental, biological, or moral development
Trauma in children different from adults
Collaborative network of 17 sites grew to over 150 centers
Includes universities, hospitals, tribal agencies, etc.
Over 8,300 affiliated partners

Background and Formation

Call from Adam Cummings, Nathan Cummings Foundation
Discussion on effects of trauma on learning
No forum for implementing discoveries
Convened think tank with representatives from various departments and organizations
Agreed on need for national organization promoting study and education
Bill drafted by Bill Harris and Senator Kennedy's staff
Overwhelming bipartisan support in the Senate

Children and Developmental Trauma Disorder (DTD)

Single traumatic incidents can cause basic PTSD symptoms in children.
Children with histories of abuse and neglect have less obvious traumatic roots for their behaviors.
Many receive pseudoscientific diagnoses like oppositional defiant disorder or disruptive mood dysregulation disorder.
Needed a diagnosis that captured the reality of their experience: Developmental Trauma Disorder (DTD).

Characteristics of DTD

Pervasive pattern of dysregulation
Problems with attention and concentration
Difficulties getting along with themselves and others
Rapidly shifting moods and feelings
Physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound
Self-harming activities (masturbation, rocking, biting, cutting)
Difficulties with language processing and fine-motor coordination
Clinging and needy behavior towards abusers
Sense of defectiveness and worthlessness
Difficulty making friends

Rejection of DTD Proposal

Matthew Friedman, executive director of the National Center for PTSD, believed no new diagnosis was required.
Claimed that clinical intuition about early childhood adverse experiences cannot be backed up by prospective studies.
Several prospective studies were included in the proposal.

HOW RELATIONSHIPS SHAPE DEVELOPMENT

How Relationships Shape Development: Insights from the Minnesota Longitudinal Study

Alan Sroufe and colleagues studied 180 children and families from 1975 to 2004 (Minnesota Longitudinal Study of Risk and Adaptation)
Debate on nature vs. nurture, temperament vs. environment, and trauma were not initial focuses
Recruited Caucasian mothers who qualified for public assistance with various backgrounds and support levels
Assessed children's major aspects of functioning and significant life circumstances from birth to age 28

Questions Addressed:

How do children learn to regulate arousal and impulses?
What supports do they need, and when?
Role of quality of care and biological factors

Findings:

No single factor (mother's personality, infant's neurological anomalies, IQ, or temperament) predicted behavioral problems in adolescence
Parent-child relationship was the key issue
Vulnerable infants with inflexible caregivers led to clingy, uptight kids
Insensitive, pushy, and intrusive parental behavior at six months predicted hyperactivity and attention problems
Caregivers help children develop their own arousal regulation abilities
Consistent caregiving produced well-regulated kids; erratic caregiving led to chronically aroused kids
Early neglect or harsh treatment led to behavior problems in school, lack of empathy for others, and vicious cycle of rejection and punishment

Resilience:

Security established with primary caregiver during first two years crucial for coping with life's disappointments
Highly lovable kids at age 2 predicted resilience in adulthood.

THE LONG-TERM EFFECTS OF INCEST

Frank Putnam and Penelope Trickett's Research (1986)

First longitudinal study on impact of incest on female development
Recruited 84 sexually abused girls, matched with 82 non-abused girls
Assessed six times over 20 years, starting at age 11
Results: Sexually abused girls suffer from various negative effects

Negative Effects:

Cognitive deficits
Depression
Dissociative symptoms
Troubled sexual development
High rates of obesity and self-mutilation
Higher dropout rate from high school
More major illnesses, healthcare utilization
Abnormalities in stress hormone responses
Earlier onset of puberty
Multiple psychiatric diagnoses

Impact on Development:

Lack of friends before and after puberty
Difficulties with trust, self-esteem, and biology
Inability to keep up in social skills development
Isolation and early sexual maturation
Increased levels of testosterone and androstenedione

Consequences:

Numbing: suppressed reactions to distress
Lack of protective action
Difficulties forming healthy relationships
Impulsive behavior, lack of self-protection
Viewing helpers as frightening and intrusive

Implications for Clinicians:

Understanding the world from a traumatized perspective
Moving beyond victim/perpetrator dynamics and labels
Addressing the unique challenges faced by sexually abused girls.

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

Published in May 2013, includes three hundred disorders in its 945 pages
Offers various labels for problems associated with severe early-life trauma, such as Disruptive Mood Regulation Disorder, Non-suicidal Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement Disorder, and Disruptive Impulse Control Disorder
Ignores underlying causes of mental problems, focusing on surface phenomena
Lacks reliability and validity, according to American Journal of Psychiatry study
British Psychological Society criticized for overlooking social causation of many problems
Most striking rejection came from National Institute of Mental Health (NIMH)

NIMH's Reaction:

NIMH could no longer support DSM's "symptom-based diagnosis"
Focused on Research Domain Criteria (RDoC) to study mental illness as brain disorders
Funding exploration of brain circuits and neurobiological measures underlying mental problems
First step towards precision medicine for mental health

Limitations:

Ignores social causes of mental problems, focusing solely on brain disorders
Overlooks the importance of relationships and social conditions in mental development

Reactions to DSM-5:

Thousands of clinicians supported study of Developmental Trauma Disorder (DTD) through donations
First results from field trials have been published, more to come as book goes to print.

WHAT DIFFERENCE WOULD DTD MAKE?

Focus on central principles of chronically traumatized children and adults:
- Pervasive biological and emotional dysregulation
- Failed or disrupted attachment
- Problems staying focused and on track
- Deficient sense of coherent personal identity and competence

Lessons from Neuroplasticity:

Apply neuroplasticity to rewire brains and reorganize minds of traumatized individuals
Social support is a biological necessity for prevention and treatment

Early Childhood Programs:

Quality programs that involve parents and promote basic skills in disadvantaged children
Improve outcomes, save costs on welfare, healthcare, substance abuse, and incarceration
Examples: Home-visitation programs, day care, preschool

European Approach to Public Health:

Universal health care, guaranteed minimum wage, paid parental leave, high-quality childcare for all working mothers
Lower incarceration rates and crime rates
Fewer foster children in prison systems
Investment in helping parents raise children in safe surroundings

Implications:

Recognize profound effects of trauma and deprivation on child development
Parents need help to nurture their kids, not blame
Industrialized nations with strong support systems have better outcomes and lower costs

PART FOUR. THE IMPRINT OF TRAUMA.

CHAPTER 11

UNCOVERING SECRETS: THE PROBLEM OF TRAUMATIC MEMORY

In spring 2002, a young man named Julian claimed to have been sexually abused by Catholic priest Paul Shanley.
He had forgotten the abuse until he heard about the investigation against the priest.
Question: Were his memories credible for testimony in court?

Historical Context: Controversies over Traumatic Memory

Debate on credibility of traumatic memories dates back to late 19th century.
Psychiatrists first described unusual nature of traumatic memories.
Passions surrounding this issue have been intense.

Impact of Trauma on Memory

Traumatic experiences can lead to repressed or delayed memories.
Memories may be fragmented, incomplete, or distorted.
The recall process can be influenced by various factors, including emotional state and context.

FLOODED BY SENSATIONS AND IMAGES

Julian's Experience with Childhood Abuse

February 11, 2001: Julian recalls conversation with girlfriend about Father Shanley's suspected molestation
Panic and flood of memories; initial denial of abuse
Overwhelming emotions and physical symptoms (panic attacks, seizures, self-harm)
Childhood experiences with Father Shanley
- Age 6: First encounter in CCD class
- Fondling and sexual acts
- Fragmented memories
- Self-blame and shame

Impact of Abuse on Julian's Life

Popular athlete in high school, but poor student and heavy drug use
Homeless after graduation
Enlisted to regain control of life
Struggles with self-image and emotional regulation
Triggers and reenactments of abuse during sexual experiences

Therapeutic Approach

Focus on tolerating emotions and reactions, not determining exact details
Addressing self-blame and accepting trauma was not their fault

Legal Considerations

Determination of culpability in legal cases
Daubert hearing to set standards for expert testimony
Previous research on traumatic memory and its effects on recall

NORMAL VERSUS TRAUMATIC MEMORY

Autobiographical memories are not precise reflections of reality, but personal stories.
The Grant Study of Adult Development illustrates how memories change over time.
Wartime memories evolve with time for most participants, except those with PTSD.
Memories depend on personal significance and emotional arousal.
Ordinary experiences quickly fade from memory.
Incidents that deviate from the established pattern are more likely to be remembered.
Adrenaline plays a role in memory formation; higher adrenaline leads to more precise memories.
Traumatic experiences can overwhelm the memory system, leading to fragmented sensory and emotional traces.

Normal Memory

Autobiographical memories are not exact reflections of reality.
Memories depend on personal significance and emotional arousal.
Ordinary experiences quickly fade from memory.
Incidents that deviate from the established pattern are more likely to be remembered.
Adrenaline plays a role in memory formation; higher adrenaline leads to more precise memories up to a point.

Traumatic Memory

Memories of traumatic experiences are preserved essentially intact over long periods.
Trauma leads to fragmented sensory and emotional traces instead of coherent narratives.
High arousal disrupts collaboration between rational and emotional memory systems.
Trauma disconnects other brain areas necessary for proper storage and integration of information, such as the hippocampus and thalamus.
Emotional brain takes over during traumatic experiences, expressing altered activation through changes in emotional arousal, body physiology, and muscular action."

UNCOVERING THE SECRETS OF TRAUMA

Late 19th century: Mental problems, including traumatic memory, under study
Central topics: "Railway spine" (psychological aftermath of railroad accidents), hysteria
Hysteria: Emotional outbursts, susceptibility to suggestion, muscle contractions/paralysis
Early researchers: Charcot, Janet, Freud
Trauma as root cause of hysteria, particularly childhood sexual abuse
Traumatic memories: "Pathogenic secrets" or "mental parasites"
Hysteria investigation linked to French politics (struggle between monarchists and advocates of the French Republic)

Jean-Martin Charcot

Father of neurology, studied hysteria as scientific explanation for supernatural phenomena
Believed women would influence struggle between old order and secular democracy
Studied hysteria as scientific explanation for supernatural phenomena
Meticulous studies of physiological and neurological correlates

Pierre Janet

Helped establish research lab at Salpêtrière
Published first book-length scientific account of traumatic stress (1889)
Root cause: Vehement emotions or intense emotional arousal
Automatic repetition of trauma-related actions, emotions, sensations
Primary interest in understanding patients' minds and treating them

Significant Findings

Trauma as root cause of mental disorders (hysteria)
Traumatic memories as "pathogenic secrets" or "mental parasites"
Importance of emotional arousal in traumatic stress
Need for understanding patients' minds and treating them
Early studies on physiological and neurological correlates of trauma

AMNESIA, DISSOCIATION, AND REENACTMENT

Janet's work on traumatic memory vs. narrative memory
Irène's case: amnesia for mother's death & compulsive reenactment
Traumatized people remember too little and too much
Automatism: involuntary, unconscious actions
Differences between ordinary and traumatic memory
- Triggers precipitate traumatic memories
- Traumatic memory is not condensed
- No social function for traumatic memory
- Reenactments are frozen, lonely experiences
Janet's term "dissociation": splitting off and isolation of traumatic memories
Cost of dissociation: inability to integrate new experiences and decline in functioning
PTSD: unable to put trauma behind and integrate into autobiographical memory
Goal of treatment for PTSD: association, integrating cut-off elements into ongoing narrative of life."

THE ORIGINS OF THE “TALKING CURE”

Psychoanalysis origins at Salpêtrière, Paris (1885) under Charcot's influence
Freud and Breuer's 1893 paper on hysteria: traumatic memories persist, not at patient's disposal
- Memories lost due to impossible reaction or severely paralyzing affects
- Belief in seduction of children by adults (later retracted)
Freud's shift from seduction theory to unconscious wishes and fantasies
Trauma and lack of verbal memory: reproduced as action, not remembered
"Talking Cure" origin: recollection with affect disappears symptoms, language as substitute for action
CBT assumption: detailed trauma story helps in leaving it behind
Case studies: reenactment instead of remembering (cigarette girl, Vietnam veteran)
Recognition challenge: how to identify traumatic stress when no memory is present?
Patients risk being labeled as crazy or punished as criminals without known history.

TRAUMATIC MEMORY ON TRIAL

Traumatic Memory on Trial

Paul Shanley, a former priest, was found guilty of raping a child and assaulting a child in 2005.
He was sentenced to 12-15 years in prison.
In 2007, his attorney filed for a new trial based on the invalidity of "repressed memory" evidence.
The appeal was rejected by the original trial judge but taken up by the Supreme Judicial Court of Massachusetts in 2009.
Over 100 psychiatrists and psychologists signed an amicus curiae brief stating that "repressed memory" does not exist.
The court unanimously upheld Shanley's conviction in January 2010, allowing the use of dissociative amnesia theory as evidence.

Court Decision

The court found that the lack of scientific testing did not make unreliable the theory of dissociative amnesia.
There was no abuse of discretion in the admission of expert testimony on the subject of dissociative amnesia.

CHAPTER 12

THE UNBEARABLE HEAVINESS OF REMEMBERING

Scientific interest in trauma: Fluctuated over the past 150 years, with Charcot's death and Freud's shift leading to neglect until World War I.
Effect of World War I on scientific interest in trauma: Hundreds of thousands of soldiers with bizarre symptoms and memory loss led to renewed interest.
Shell shock vs. neurasthenia: British diagnosis of shell shock entitled veterans to treatment and a pension, while neurasthenia did not.
British General Staff's response: Issued General Routine Order Number 2384 in 1917, denying the existence of shell shock and labeling all soldiers with psychiatric problems as "NYDN."
German treatment of shell shock: Treated as a character defect, punitive methods used.
British government's response: Issued Southborough Report in 1922 to prevent diagnosis of shell shock in future wars and undermine compensation claims.
Fate of US veterans: Welcomed as national heroes but denied pensions until 1945, leading to encampment on the Mall in Washington DC in 1932.
Denial of trauma consequences: Played a role in the rise of fascism and militarism around the world in the 1930s.
Impact of World War I on literature and art: All Quiet on the Western Front by Erich Maria Remarque became an international best seller but was later burned by the Nazis for its awareness of trauma's effects.
Consequences of denying trauma: Can lead to social fabric damage, humiliation of the powerless, and moral justification for vanquishing the inferior, ultimately contributing to the ensuing war.

THE NEW FACE OF TRAUMA

World War II and the Study of Trauma
Charles Samuel Myers and Abram Kardiner's work with WWI soldiers and veterans published in Shell Shock in France 1914–1918 (1940) and The Traumatic Neuroses of War (1941)
Hypnosis as the predominant treatment for war neuroses, shown in John Huston's documentary "Let There Be Light" (1946)
Differences in trauma expression between WWI and WWII soldiers: physical symptoms like stomach upsets and heart races, but also verbalization of traumatic experiences
Culture shapes the expression of traumatic stress: doctors focused on medical complaints instead of psychiatric ones
Germaine Greer's account of her father's PTSD after WWII and its impact on her work
Disparity between young Vietnam veterans and older WWII veterans in VA treatment: older vets communicated distress through physical symptoms, not nightmares or rage
Doctors influenced how patients communicated their distress: focusing on physical problems for better care
Important lessons from WWII: Marshall Plan, GI Bill, racial integration, and VA facilities
Psychological scars of war went unrecognized, leading to disappearance of traumatic neuroses from official psychiatric nomenclature
Last scientific writing on combat trauma after WWII in 1947.

TRAUMA REDISCOVERED

Trauma and Vietnam War:
- No books on war trauma in VA library (1960s)
- Numerous studies, scholarly organizations, PTSD diagnosis (1970s)
- Public interest in trauma growing
Misconceptions about Incest:
- Freedman and Kaplan's Comprehensive Textbook of Psychiatry (1974)
  - Claimed incest rare, beneficial
  - Incorrect and misguided
Survivors Speak Out:
- Feminist movement and awareness of trauma
- Consciousness-raising groups, survivor groups
- Popular books on recovery from trauma (The Courage to Heal, Trauma and Recovery)
False Memory Syndrome Backlash:
- Articles denying existence of traumatic memory loss
- Claimed no evidence for memory loss in traumatic events
- Contradicts historical evidence (John Eric Erichsen, Frederic Myers, Charles Samuel Myers, W.H.R. Rivers)
Memory Loss in Trauma:
- Not controversial before 1980s and early 1990s
- Observed in combat soldiers, Dunkirk evacuees, Vietnam veterans, survivors of domestic abuse
Pedophile Scandals and False Memories:
- Memory problems moved from science to politics and law
- Church experts claimed memories unreliable or implanted by therapists
- Over fifty adults with claims of priest abuse denied in about half the cases

THE SCIENCE OF REPRESSED MEMORY

Hundreds of scientific publications documenting repressed trauma memories over a century
Memory loss reported in people experiencing natural disasters, accidents, war trauma, kidnapping, torture, concentration camps, and physical/sexual abuse
Total memory loss most common in childhood sexual abuse (19%-38%)
DSM-III recognized memory loss for traumatic events in dissociative amnesia since 1980
PTSD diagnosis includes memory loss since its introduction

Study by Dr. Linda Meyer Williams:

Began as a graduate student interviewing 206 girls (ages 10-12) admitted to hospital following sexual abuse
Interviewed 136 women (now adults) 17 years later
38% did not recall documented abuse, while only 12% said they had never been abused
68% reported other incidents of childhood sexual abuse
Women who were younger and knew the abuser were more likely to forget
16% of those who recalled abuse forgot it at some point but later remembered
Recovered memories were approximately as accurate as those that had never been lost

Neuroscience Research:

Memories change when retrieved, especially if told repeatedly
Memories are less likely to be changed while inaccessible

Controversy over Repressed Memories:

Some cognitive scientists denied existence or accuracy of repressed memories due to lack of laboratory documentation
Studies on implanted memories and eyewitness testimony have little relevance to traumatic memory
Trauma cannot be induced de novo in a lab setting, so studying original imprint of trauma is necessary

Dr. Roger Pitman's Study:

Showed college students a violent movie (Faces of Death) but did not cause PTSD symptoms in normal volunteers
To study traumatic memory, one must study the memories of people who have been traumatized

Conclusion:

Controversy over repressed memories disappeared once courtroom testimony became less profitable for scientists
Clinicians are left to deal with the complexities of traumatic memory.

NORMAL VERSUS TRAUMATIC MEMORY

Study Comparing Benign and Traumatic Memories

In 1994, researchers at Massachusetts General Hospital studied memory recall of benign and traumatic experiences.
Advertisements were placed in local newspapers, laundromats, and student union bulletin boards for volunteers.
Participants recalled non-traumatic events with a beginning, middle, and end; no vivid sensory recollections.
Traumatic memories were disorganized, with some clear details but missing sequence or vital information.
Trauma participants could not recall details immediately after the event.
Flashbacks were common, with increasing sensory details and feelings over time.
Gradual improvement: ability to piece together details and tell a coherent story.
Five participants abused as children had the most fragmented narratives.
Traumatic memories are dissociated: not properly assembled into a story or autobiography.
Language cannot substitute for action in resolving trauma.
Contemporary exposure treatment (CBT) has disappointing results, with persistent PTSD symptoms.

LISTENING TO SURVIVORS

Trauma is difficult to confront due to natural reluctance for its unpredictability and overwhelming nature.
Lawrence Langer's work in the Fortunoff Video Archive at Yale University:
- Listening to Holocaust testimonies reveals an incomplete, unfinished tale.
- Witnesses struggle to communicate their experiences to those who didn't live through it.
Survivors describe a dual existence:
- The 'self' in the trauma is not the same as the present self.
- Deep memory and common memory are distinct.
Trauma affects language:
- Words have different meanings before and after traumatic experiences.
Essence of trauma:
- Overwhelming, unbelievable, and unbearable.
- Demands suspension of normalcy for dealing with a dual reality.
Langer's conclusion:
- Damaged mosaics of the mind need a proper grave to rest in peace.
- Life goes on in two temporal directions at once.

NANCY’S STORY

Nancy, a director of nursing, underwent laparoscopic tubal ligation but received insufficient anesthesia.
She became aware during the surgery and remained paralyzed, unable to alert the team.
After the surgery, she experienced trauma symptoms including flashbacks, anxiety, fear, and avoidance.
Flashbacks included memories of conversations in the OR and feelings of burning and terror.
Nancy's marriage suffered, and she felt isolated and alone.
She struggled with existential reality of trauma and dual existence.
Recovery began when she chose a Boston hospital for another surgery, requested preoperative meeting, and asked for my presence in the OR.
Woke up feeling safe and began working with a psychodynamic psychiatrist and joining a Pilates class.
Found psychological, social, and physical core strengthening through therapy and Pilates.

Trauma Experience:

Awake during laparoscopic tubal ligation surgery due to insufficient anesthesia.
Paralyzed and unable to alert team or move.
Experienced memories and flashbacks of the surgery, including conversations in the OR.
Felt burning sensations and terror during flashbacks.
Avoided triggers such as scrub suits and elevators.
Struggled with existential reality of trauma and dual existence.
Marriage suffered due to trauma symptoms.

Recovery:

Chose Boston hospital for another surgery, requested preoperative meeting, and asked for my presence in the OR.
Found psychological safety through therapy with a psychodynamic psychiatrist.
Found social support and physical core strengthening through Pilates class.
Relegated memories to the distant past, allowing present and future to emerge.

PART FIVE. PATHS TO RECOVERY.

CHAPTER 13

HEALING FROM TRAUMA: OWNING YOUR SELF.

Trauma cannot be undone, but its imprints can be addressed
Goal is to reestablish ownership of body and mind

Reclaiming Self-Leadership

Calm and focused:
- Techniques for managing anxiety and depression
- Mindfulness practices
Maintaining calm in response to triggers:
- Exposure therapy
- Cognitive restructuring
Engaging with the present and people around you:
- Building healthy relationships
- Expressing emotions effectively
No longer keeping secrets from yourself:
- Acceptance and commitment therapy
- Narrative therapy

Overview of Recovery Principles

Calm and focused: Regain control over body and mind
Overlapping goals, not a fixed sequence
Specific methods covered in following chapters

Additional Methods Not Covered In Depth

Eye Movement Desensitization and Reprocessing (EMDR)
Somatic Experiencing
Sensorimotor Psychotherapy
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

A NEW FOCUS FOR RECOVERY

Trauma is More Than a Story

Trauma involves disruptive physical reactions in the present
Emotions and sensations imprinted during trauma
Need to confront past, but only after feeling safe

Coping with Overwhelming Sensations and Emotions

Find ways to manage feelings of being overwhelmed
Engines of post-traumatic reactions in emotional brain

Role of Rational Brain

Understanding emotions and origins
Cannot abolish emotions, sensations, or thoughts
Helps explain why we feel a certain way

Limitations of Understanding

Does not change how we feel
Rational brain takes a backseat when frazzled

LIMBIC SYSTEM THERAPY

Goal: Restore balance between rational and emotional brains
Trauma pushes individuals outside "window of tolerance"
- Hyperaroused: reactive, disorganized, filters stop working
- Hypoaroused: numb, sluggish thinking, difficulty moving
Cannot learn from experience in hyperaroused or shut down states
Recovery involves restoring executive functioning and self-confidence
Necessary to access emotional brain for change through "limbic system therapy"
- Repair faulty alarm systems
- Restore emotional brain to quiet background presence

Emotional Brain:

Affects body functions: eating, sleeping, connecting, protecting
Accessed through self-awareness and interoception (looking inside)
Most conscious brain focused on outside world, not self-management

Self-Awareness:

Activates medial prefrontal cortex
Allows feeling of inner experience
Essential for changing emotions and managing self

BEFRIENDING THE EMOTIONAL BRAIN.

1. DEALING WITH HYPERAROUSAL

Mainstream psychiatry focus on drugs for dealing with hyper- and hypoarousal
Inbuilt skills to regulate arousal system: breathing, chanting, movement
Vagus nerve connection between brain and organs allows direct training
Yoga effective in reducing PTSD symptoms (chapter 16)
Neurofeedback helpful for hyperaroused individuals (chapter 19)
Parasympathetic nervous system effects through deep breathing
Oxygen's role in nourishing the body and promoting engagement
Western traditions neglect self-management, focusing on drugs and verbal therapies
Non-Western healing traditions rely on mindfulness, movement, rhythms, and action
Examples: yoga (India), tai chi and qigong (China), martial arts (Japan, Korea, Brazil)
Few of these practices systematically studied for PTSD treatment.

2. NO MIND WITHOUT MINDFULNESS

Mindfulness and Self-Awareness in Trauma Recovery

Core of recovery: self-awareness
Importance of mindfulness: noticing sensations, shifting perspective, opening up new options
Traumatized people avoid uncomfortable sensations due to fear
Body awareness puts us in touch with inner world and transient nature of feelings
Mindfulness calms down sympathetic nervous system, allowing for exploration of past experiences

Barriers to Inner Experience

Fear of physical sensations
Compulsive behaviors (eating, drinking, avoiding social activities) as coping mechanisms
Emotional brain generates sensations that keep sufferer feeling scared and helpless

Practicing Mindfulness

Focus on physical sensations and notice how they shift
Label sensations to increase control
Observe interplay between thoughts and physical sensations
Mindfulness decreases reactivity to potential triggers (decreases amygdala activity)

Benefits of Mindfulness

Positive effects on psychiatric, psychosomatic, and stress-related symptoms
Improvements in immune response, blood pressure, cortisol levels
Activates brain regions involved in emotional regulation and body awareness
Broad effects on physical health

Mindfulness as a Lens

Mindfulness transforms scattered and reactive energies of the mind into coherent source of energy for living, problem solving, healing.
Positively impacts depression, chronic pain, immune response, blood pressure, cortisol levels, emotional regulation, body awareness, fear, reactivity to potential triggers.

3. RELATIONSHIPS

Relationships and Trauma

Having a good support network is crucial in protecting against trauma.
Safety and terror are incompatible, and trusted people provide comfort and reassurance.
Recovery from trauma requires physical and emotional safety, familiar faces, food, shelter, time to sleep, and communication with loved ones.
Trauma survivors benefit from relationships with families, friends, support groups, or professional therapists.
Relationships help provide safety, reduce shame, and bolster courage to face reality of trauma.
Humans are wired for attachment and connection; recovery involves reconnecting with others.
Trauma within relationships is more challenging to treat due to the breach of trust.
Child abuse, molestation, and domestic violence can knock out the primary protection against being traumatized.
Unresolved trauma can lead to dissociation, despair, addictions, chronic panic, and unhealthy relationships.
Shame plays a role in fearing rejection and abandonment.
Unacknowledged trauma can negatively impact current feelings and behaviors.
Trusted individuals are needed to help face inner emotions and process past experiences.

CHOOSING A PROFESSIONAL THERAPIST

Gender, race, and background irrelevant if not interfering with safety and understanding
Engaging with animals can help some patients feel safer (e.g., horses, dogs)
Therapeutic settings applying this principle effectively (jails, residential programs, veterans' rehabilitation)

Trauma Therapist Training:

Mastering techniques for stabilizing, calming, and reconnecting patients
Ideally, therapists have personal experience with therapy
No one treatment of choice for trauma
Open to exploring different options and learning from patient

Selecting a Therapist:

Important that patient feels comfortable and safe
Collaborative process: therapist curious about patient's unique needs

Impact of Childhood Abuse:

Survivors may have difficulty feeling safe with humans
Engaging with animals can help some patients feel safer

Effective Therapeutic Settings:

Applying principle of engaging with animals effectively (jails, residential programs, veterans' rehabilitation)

4. COMMUNAL RHYTHMS AND SYNCHRONY

Communal rhythms and synchrony:
- From birth, relationships are based on physical synchrony (facial expressions, gestures, touch)
- Trauma results in breakdown of attuned physical synchrony
- Patients with PTSD exhibit frozen faces and collapsed bodies
- Many therapists focus only on words and ignore physical communications
Healing power of community through music, rhythms, and movement:
- Witnessed transformation of rape survivors in South Africa through communal singing and dancing
- Various activities like choral singing, aikido, tango dancing, and kickboxing have helped traumatized individuals
- Sensorimotor therapy used to help mute girl Ying Mee after failed attempts with traditional methods
- Sensory integration therapy involves engaging senses to promote connection and communication
Parent-child interaction therapy (PCIT) and SMART:
- Interactive therapies that foster physical attunement between parents and children
Improvisation exercises:
- Help people connect through joy and exploration
- Break the spell of misery when groups start giggling.

5. GETTING IN TOUCH

Getting in Touch

Mainstream trauma treatment overlooks the importance of helping individuals safely experience sensations and emotions
Humans naturally calm down through touch, hugging, and rocking
Touch is underutilized in therapeutic practices
Recovery impossible without feeling safe in one's skin

Benefits of Bodywork

Establishing personal connection before session
Careful assessment of client's comfort and safety
Meeting resistance with equal energy to release tension
Touch provides comfort, grounds people, and releases physical and emotional tensions
Allows discovery of unaware tensions
Releases feelings and deepens breathing
Helps individuals understand their body boundaries and feel safe

Bodywork Practitioner's Approach

Establishing personal connection before session
Careful assessment of client's comfort and safety
Meeting resistance with equal energy to release tension
Firm, safe contact with slow, easy touch
Touch can start at hand and forearm
Meeting point of resistance with confidence and empathy

Effects of Bodywork

Releases physical and emotional tensions
Allows deeper breathing and expressive sounds
Helps individuals live in a body that moves freely
Provides sense of safety and understanding of body boundaries

6. TAKING ACTION

Taking Action

Stress hormones are meant to help us respond to extraordinary conditions
Utilizing stress hormones through action reduces risk of trauma
Helplessness and immobilization prevent proper use of stress hormones
Trauma imprints on body, causing persistent emergency response

Somatic Therapies

Sensorimotor psychotherapy, somatic experiencing
Explore physical sensations and discover trauma imprints on body
Build internal resources for safe access to emotions
Gradually expand window of tolerance through pendulation
Bring incomplete trauma-related "action tendencies" to completion
Restore a sense of agency and ability to defend oneself.

Impact of Trauma

Stress hormones meant to give strength and endurance
Helplessness and immobilization prevent proper use, leading to persistent emergency response
Body needs to be restored to baseline state for proper functioning.

INTEGRATING TRAUMATIC MEMORIES

Integrating Traumatic Memories

Ordinary memories do not involve reliving sensory or emotional elements.
Traumatic memories are experienced as fragments of sensations, images, and emotions.
Brain structures necessary for engagement in the present must be online for trauma integration.

Traditional Psychotherapy and Trauma

Focuses on constructing narratives to explain feelings.
Telling the story does not guarantee resolution of traumatic memories.

Brain Function and Trauma

Key brain areas go blank during traumatic memory recall.
Eye Movement Desensitization and Reprocessing (EMDR) keeps necessary brain structures online for trauma integration.
Dissociation shuts down necessary brain functions, complicating recovery.

Historical Treatment of Trauma

Hypnosis was widely used to treat trauma from late 1800s to after World War II.
Fell out of favor in the 1990s but may make a comeback due to its potential for trauma integration.
Induces a calm state, allowing observation of traumatic experiences without being overwhelmed.

COGNITIVE BEHAVIORAL THERAPY (CBT)

Most psychologists are trained in CBT
Developed to treat irrational fears through exposure techniques: imaginal, in vivo, or virtual
Patients gradually desensitized by repeated exposure without bad consequences
Helps patients deal with avoidance tendencies

CBT for PTSD:

Not as effective as for irrational fears
One in three participants with PTSD show improvement after finishing studies
Fewer symptoms but not complete recovery for most
High dropout rates and adverse reactions
Ineffective for dealing with guilt and complex emotions

Exposure Techniques:

Prolonged exposure or "flooding"
- Focus on traumatic material without distraction
- Up to 100 minutes required for decreases in anxiety
- Not effective for all PTSD symptoms

Virtual Reality Therapy:

Limited benefit compared to real-world therapy
Traumatized patients need help feeling alive in the present

Challenges with CBT for PTSD:

Overwhelming trauma can prevent resolution
Mental defeat and lack of motivation are common issues
Brain changes from trauma affect focus on everyday life

Real World Therapy:

Helps patients feel alive in the present
Important for dealing with complex emotions and symptoms

Study of Vietnam Veterans:

Repeatedly talking about experiences led to panic and increased symptoms for some veterans
Some dropped out, others became more depressed, violent, and fearful
Increased alcohol consumption led to further problems.

DESENSITIZATION

Desensitization vs. Integration

Prevailing treatment for psychology students: systematic desensitization
Goal of desensitization: helping patients become less reactive to certain emotions and sensations
Alternative perspective: integration of traumatic events into overall life arc

Child's Example

Boy unfazed by father's yelling
Author's reaction: heart racing, impulse to intervene
Question: what price for child's indifference?

Desensitization and Emotional Sensitivity

Desensitization leads to blunting of emotional sensitivity (Jean Decety)
Medical students learn to stay analytical during treatment of severe burns
Desensitization to pain can lead to overall emotional numbness

Effectiveness of Exposure Treatment

2010 report on veterans with PTSD: fewer than one out of ten completed recommended treatment
Exposure treatment rarely works for veterans (Pitman's research)
Horrendous experiences must not overwhelm to be processed effectively

Necessity of Other Approaches

Other approaches necessary for processing traumatic experiences
Desensitization alone may not be sufficient.

DRUGS TO SAFELY ACCESS TRAUMA?

Drugs for Trauma Treatment:

In the 1960s, professor Jan Bastiaans in Netherlands used LSD for Holocaust survivor treatment with questionable results (few data)
Research on mind-altering substances for trauma treatment neglected until 2000
MDMA (ecstasy), a controlled substance since 1985, studied for trauma treatment due to hormonal effects and decreased fear/defensiveness
MDMA increases oxytocin, vasopressin, cortisol, prolactin, self-awareness, compassion, clarity, confidence, creativity, and connectedness
Enhances psychotherapy effectiveness by enabling patients to revisit traumatic memories without overwhelming arousal

MDMA Studies:

Initial pilot studies with positive results: combat veterans, firefighters, police officers with PTSD
Study on unresponsive assault victims: 83% of MDMA group vs. 25% placebo group considered cured, no adverse effects
Long-term gains maintained after more than a year
Difference lies in association and integration rather than desensitization

Cautions:

Powerful agents with troubled history
Careless administration and poor therapeutic boundaries can lead to misuse
MDMA not another "magic cure"

WHAT ABOUT MEDICATIONS?

Medications for Traumatic Stress

People have used drugs to cope with traumatic stress throughout history
Mainstream psychiatry spends over $4.5 billion on psychotropic drugs for military personnel
20% of active-duty troops surveyed were taking some form of psychotropic drug
Drugs cannot cure trauma, only dampen symptoms
SSRIs (Prozac, Zoloft, etc.) can make feelings less intense and help with therapy engagement
Autonomic nervous system medications (propranolol, clonidine) reduce hyperarousal and reactivity
Benzodiazepines (Klonopin, Valium, Xanax) calm patients but have high addiction potential and interfere with trauma processing
Anticonvulsants and mood stabilizers (lithium, valproate) have mildly positive effects
Second-generation antipsychotics (Risperdal, Seroquel) can be helpful in extreme cases but interfere with emotional experience and cause side effects
No studies on the effects of psychotropic medications on developing brains
Combat veterans and civilians respond differently to medications
VA and DoD spend billions on medications for soldiers and veterans without providing other forms of therapy

SSRIs

Most thoroughly studied psychotropic agents for PTSD
Can make feelings less intense and improve engagement in therapy
Patients may feel calmer or blunted
Prozac, Zoloft, Effexor, Paxil

Autonomic Nervous System Medications

Decrease hyperarousal and reactivity to stress
Block physical effects of adrenaline
Reduce nightmares, insomnia, and trauma triggers
Propranolol, clonidine

Benzodiazepines

Calm patients and keep them from worrying
Weaken inhibitions against hurtful behavior
High addiction potential
Interfere with trauma processing
Patients may experience withdrawal reactions when stopping use

Anticonvulsants and Mood Stabilizers

Mildly positive effects on hyperarousal and panic
Lithium, valproate

Second-Generation Antipsychotics

Calm down combat veterans and women with PTSD related to childhood abuse
Block dopamine system, interfering with emotional experience and pleasure
Risperdal, Abilify, Seroquel
Significant side effects including weight gain, diabetes, inertia, and interference with learning and developing friendships

Differences between Combat Veterans and Civilians

Traumatized civilians tend to respond better to medications than combat veterans
Discrepancies found in studies since Prozac study in chapter 2
VA and DoD prescribe enormous quantities of medications to soldiers and veterans without providing other forms of therapy
No studies on the effects of psychotropic medications on developing brains
Risperdal and Seroquel spent $1.5 billion by VA, $90 million by Defense between 2001-2011 (ineffective for PTSD)
Benzodiazepines spent $72.1 million by VA, $44.1 million by Defense between 2001-2012 (generally avoided for civilians with PTSD due to addiction potential and lack of effectiveness)

THE ROAD OF RECOVERY IS THE ROAD OF LIFE

The Road of Recovery is the Road of Life

Introduced patient Bill, met at VA in the 1980s
Served as medic in Vietnam (1967–71)
Tried nursing but experienced nightmares and insomnia
Diagnosis of PTSD did not exist during that time
Enrolled in seminary to become a minister
Flashbacks triggered by his son's crying
Treated for PTSD after seeking help in 1978
Gradually opened up about Vietnam experiences
Improved and became a pastor with his own parish

First Treatment (1978–1980)

Flashbacks, nightmares, feelings of losing control
Worked together to deal with specific memories of Vietnam
Integrated memories using EMDR
Dealt with childhood traumas and guilt
Organized support group for fellow clergy

Second Treatment (1993)

Developed neurological illness at age 53
Diagnosed with no specific lesions or cure
Encouraged to befriend distressing feelings in body
Consulted body worker and started practicing Feldenkrais
Gained sense of control and pleasure through yoga

Third Treatment (1998–present)

Became certified as a yoga instructor
Taught yoga to returning combat veterans at local armory
Continues to cope with physical limitations
Teaches yoga to over 1,300 veterans
Flashbacks and weakness in limbs are part of life's ongoing story.

CHAPTER 14

LANGUAGE: MIRACLE AND TYRANNY

September 2001, post-9/11:

Several organizations organized expert panels to recommend best treatments for traumatized people.
Opportunity to compare different approaches.

Recommendations:

Psychoanalytically oriented therapy (Freudian psychoanalysis) due to local practitioners.
Cognitive Behavioral Therapy (CBT) due to academic researchers.

Surprising Results:

Few survivors showed up for "traditional" therapies.

Dr. Spencer Eth's Survey, 2002:

Survivors credited acupuncture, massage, yoga, and EMDR as most helpful.
Rescue workers preferred massages.

Disparity between Survivors' Experience and Experts' Recommendations:

Question: What is the value of talking about trauma?
Unknown how many survivors sought traditional therapies later.

THE UNSPEAKABLE TRUTH

The belief in talk as a solution for trauma
- Dates back to Freud and Breuer's work in 1893
- Trauma "disappears" when memory is brought to light and affect is expressed
Limitations of putting traumatic events into words
- Impossible for most people, including those without PTSD
- Initial reactions to September 11 were images, not stories
- Trauma creates "pitch-sharp" emotions that mind and memory can't fully register
The importance of narrative in processing trauma
- Narrative helps share experiences with others
- Giuliani and media helped create a shared narrative after September 11
The path to revealing the whole story
- Paved with carefully assembled words, piece by piece
- Helps make traumatic experiences less overwhelming and more manageable.

BREAKING THE SILENCE

Silence and Trauma: Silence about trauma can lead to isolation and prevent healing. Naming and acknowledging traumatic experiences are crucial for starting the healing process.
Power of Naming: Giving a name to our experiences allows us to control them, recognize emotions, and begin the healing process. It also changes our physiology and creates an "aha moment."
Impact of Silence: Hiding from ourselves traumatic experiences can lead to irrational behaviors, stress hormones, and health problems. Suppressing information leaves us at war with ourselves and vulnerable to triggers.
Importance of Speaking Out: Talking about traumatic experiences with someone who listens and understands can help us feel heard and understood, leading to improved mental and physical health.
Impact of Trauma on Identity: Trauma can lead to a sense of being dead inside, feeling disconnected from ourselves, and questioning our identity. Allowing ourselves to know what we know is essential for healing.
Case Study: Vietnam Veterans - Karl Marlantes' experience of returning from war with a split personality and the need to tell the truth about his experiences to begin the healing process.
Healing through Sharing: Forming groups where soldiers can share their experiences can help reestablish a sense of being part of the human race and open hearts to loved ones.

THE MIRACLE OF SELF-DISCOVERY

Helen Keller's Journey into Language

At 19 months old, Helen lost her sight and hearing due to a viral infection.
Five years later, Anne Sullivan, a partially blind teacher, was invited to be Helen's tutor.
Anne taught Helen the manual alphabet but faced challenges connecting with her wild and isolated child.

Breakthrough: The Power of Words

The turning point came when Anne spelled the word "water" into Helen's hand while she was holding it under a water pump.
This experience awakened Helen's soul and enabled her to understand the names of things.
Learning language allowed Helen to create an inner representation of reality and discover herself.

The Impact of Language on Selfhood

Six months after this breakthrough, Helen started using the first-person "I."
Before learning language, Helen felt bewildered and self-centered, calling herself "Phantom."
Acquiring language allowed Helen to join a community and communicate with others.

The Therapeutic Power of Language

The therapeutic relationship is characterized by finding words where they were absent before.
Sharing deep pain and feelings with another human being is a profound experience.
Communicating fully is the opposite of being traumatized.

KNOWING YOURSELF OR TELLING YOUR STORY? OUR DUAL AWARENESS SYSTEM

Limitation of Language in Talk Therapy:
- Difficulty in feeling feelings deeply while reporting them to someone else
- Choice between reliving old scenes and telling a logical, coherent story
- Easy to lose touch with self and focus on analyst's opinion

Two Distinct Forms of Self-Awareness:

Autobiographical Self:
- Creates connections among experiences
- Assembles them into a coherent story
- Rooted in language
- Changes with telling and perspective
Moment-to-moment Self-Awareness:
- Based on physical sensations
- Registers the self in the present moment
- Primarily localized in medial prefrontal cortex
- Can change emotional brain

Interplay of Two Systems:

Soldiers radiated pride and belonging while telling horrible tales
Patients told stories of happy families with anxious bodies
Public story may not contain the whole truth
Second system registers deep, inner experience

Case Study:

Young woman with temporal lobe epilepsy
Standard questions did not explain her suicide attempt
Asked about how it felt for the five-year-old girl to be diagnosed and left alone
Fierce defense of coping mechanism
Allowed abandoned, frightened girl to tell her story
Public story and inner experience met

THE BODY IS THE BRIDGE

Importance of Trauma Stories:

Lessen isolation
Provide explanations
Allow diagnoses
Offer targets for blame

Obscuring the Real Issue:

Trauma radically changes people
Difficult to describe feeling of no longer being oneself
Language evolved primarily for sharing "things out there"
Most private experiences hard to describe

Getting Past Slippery Words:

Engage self-observing, body-based self system
Speaks through sensations, tone of voice, and body tensions
Foundation of emotional awareness

Exploring Inner Feelings:

Patient's description of father deserting the family
Stop and ask for self-check: What happens inside?
Activate gut feelings and listen to heartbreak
Follow interoceptive pathways to innermost recesses
Things begin to change.

WRITING TO YOURSELF

Effective way to access inner world of feelings
Can make you feel better even if not sent
Free from judgment as it's for yourself
Helps discover surprising truths
Allows free flow of thoughts without worrying about reception
Can be used in trance state, with pen or keyboard acting as an outlet
Can lead to memories and associations unique to you
Used in therapy sessions as a tool for self-exploration

Writing Techniques:

Free writing: write whatever comes to mind without stopping, rereading or crossing out
Use any object as a trigger for stream of associations
Writing about traumas can help process hidden parts of self

Pennebaker's Studies:

Divided students into three groups: writing about current life, trauma details, and facts & feelings about trauma
Students took study seriously, revealing deep secrets and crying during writing sessions
Those who wrote about traumas had fewer doctor visits and improved health
Writing about emotions and feelings led to increased self-understanding

Physiological Changes:

Writing about traumas led to significant physiological changes: increased heart rate, blood pressure, muscle tension, and hand temperature
Long-term drop in blood pressure and improved immune function

Switching:

Patients who write about intimate or difficult issues often show distinct emotional and physiological states (switching)
Changes can manifest as different vocal patterns, facial expressions, body movements, and handwriting
Failure to appreciate these different states can lead to mute patients who transmit help in other ways (suicide attempts, depression, rage attacks)

ART, MUSIC, AND DANCE

Art, music, and dance therapies used for treating traumatized individuals (abused children, soldiers, victims of incest, refugees, torture survivors)
Thousands of practitioners, but little research on how they work or specific aspects of trauma addressed
Expressive therapies may help circumvent speechlessness caused by terror
Study by Pennebaker and Krantz compared expressive body movements with writing
- Group 1: Expressive movement + writing for ten minutes/day for three days
- Group 2: Expressive movement only
- Group 3: Routine exercise program
- All groups reported feeling happier and healthier after three months
- Only group 1 (expressive movement + writing) showed objective evidence of improved physical health and better grade-point average
Conclusion: Expression of trauma is not enough, translating experiences into language is essential for healing
Writing studies on PTSD symptoms have been disappointing
Pennebaker cautions that most writing studies were done in group settings where participants were expected to share stories
Objective of writing is to write for yourself, to let yourself know what you've been avoiding.

THE LIMITS OF LANGUAGE

Paul Fussell's "The Great War in Modern Memory" discusses the challenge of describing traumatic experiences using available language

Language and Trauma:

Trauma overwhelms speakers and listeners
English language rich in terms to describe trauma but societal norms limit use
Soldiers fall silent due to lack of interest from listeners

Challenges of Expressing Trauma:

Families, friends, and organizations may reject those who air dirty laundry
Survivor groups and professional therapists provide safe spaces for expressing pain
Therapists need emotional preparation to listen to traumatic stories

Speechless or Confused Trauma Victims:

Some victims become speechless or confused when testifying about their experiences
Their testimony can be dismissed as chaotic and unreliable
Legal cases may be dismissed due to incoherent accounts of trauma reasons for fleeing

Therapy Techniques:

Establishing "islands of safety" within the body
Focusing on hands, breath, lifting arms, tapping acupressure points, and feeling body weight
Pendulating between states of exploration and safety is essential for trauma resolution.

DEALING WITH REALITY

People with PTSD have difficulties with focused attention and learning new information (McFarlane's study)
- Normal subjects averaged fifteen words in one minute, PTSD subjects averaged three or four
- PTSD patients react hesitantly to ordinary words under threat
Daily life challenges for people with PTSD
- Expend more energy on living than non-traumatized individuals
- Making real contributions in various fields and raising children
Illusion of easily correcting "dysfunctional thinking" in cognitive behavioral therapy (CBT)
- Top-down approach to change: challenging or reframing negative cognitions
- Irrational thoughts in traumatized people: blame, fear of being a man, should have known better
Treat irrational thoughts as cognitive flashbacks
- Don't argue with them; they are residues of traumatic incidents
A better way to treat irrational thoughts is with EMDR (Eye Movement Desensitization and Reprocessing)

BECOMING SOME BODY

Trauma causes long-term effects on the brain, acting like a foreign object that continues to affect the individual (Freud's notion of psychical trauma)
Modern neuroscience supports Freud's idea that conscious thoughts are rationalizations for unconscious processes
Trauma affects brain areas responsible for managing and interpreting experiences
A healthy sense of self depends on proper functioning of these areas
Trauma often causes abnormal activation of the insula, leading to alexithymia (inability to sense and communicate bodily sensations) and dissociation
Alexithymia results in feeling disconnected from one's body or like no body at all
Language is essential for organizing memories into a coherent whole, requiring proper connections between conscious brain and body systems
Overcoming trauma involves getting back in touch with the body and repairing damaged structures to regain a sense of self.

CHAPTER 15

LETTING GO OF THE PAST: EMDR

David, a contractor in his middle age, sought therapy due to violent rage attacks
Triggered by an assault at age 23, when he was a lifeguard and lost his eye in a beer bottle attack
Suffered from nightmares, flashbacks, criticized son mercilessly, unable to show affection towards wife
Felt permission to abuse others due to past trauma, but hated the person he had become
Chronically tense, fear of losing control made love and friendship impossible

First Session:

Introduced Eye Movement Desensitization and Reprocessing (EMDR)
Asked David to recall details of assault, bring back images, sounds, thoughts
Used finger movements to facilitate processing
Cascades of rage and terror surfaced, followed by deep breaths and focusing on new memories

Second Session:

Dealt with the aftermath of trauma: use of drugs and alcohol to cope with rage
More memories arose: wanting to hurt assailants, barroom brawls
Encouraged David to notice and stay with each memory
Realization of turning away from revenge was liberating

Third Session:

Recognized treating son the same way he felt towards attackers
Asked for family therapy session to ask for forgiveness

Fifth and Final Session:

Reported improved sleep, inner peace, closer relationship with wife, more laughter, pleasure in gardening and woodworking

EMDR Process:

Go back to details of traumatic event
Bring back images, sounds, thoughts
Follow therapist's finger movements
Notice and stay with new memories as they emerge
Take deep breaths and focus on current memory
Encouragement from therapist during processing
Repeat process until intensity of trauma lessens.

LEARNING ABOUT EMDR

Eye Movement Desensitization and Reprocessing

Introduced to EMDR through Maggie, a sexually abused woman in therapy group
Previously had a troubled past with multiple issues: drug use, violent relationships, instability
Revealed her father raped her twice as a child, believed it was her fault
Attended EMDR training and shared remarkable experience

EMDR Session Experience

Vividly remembered father's rape from inside child's body
Felt physically small and smelled father's alcohol breath
Observed incident from the perspective of her adult self
Burst into tears, realized it wasn't her fault, trauma was over

Impact of EMDR on Maggie

Less angry but kept sardonic sense of humor
Involved with a different kind of man
Left group, believing she had resolved her trauma

Personal Experience and Curiosity

Astounded by Maggie's experience
Sought a way to help people revisit traumatic past without being retraumatized
Decided to get trained in EMDR after witnessing its effectiveness.

EMDR: FIRST EXPOSURES

EMDR (Eye Movement Desensitization and Reprocessing)

Originated from psychologist Francine Shapiro's observation of the relief from distress after rapid eye movements in 1987
Developed into a standardized procedure through years of experimentation and research

Personal Experience with EMDR

Attended first training session in need of trauma processing due to professional setbacks
Experienced vivid, floating memories during session without discussing specific traumatic event
Felt resigned and able to move on after session

Observing EMDR with Another Client

Client unwilling to discuss traumatic experiences
Appeared distressed during session but reported resolution afterwards
Gerry Puk, trainer, advised Bessel to respect client's privacy during sessions

Key Insights from EMDR

Loosens up something in the mind/brain for rapid access to past memories and images
May allow healing without verbal discussion of traumatic experiences
Effective even with a non-trusting relationship between patient and therapist
Does not require patients to speak about intolerable experiences or explain feelings to therapist
Can be effective with language barriers using a translator for process explanation

STUDYING EMDR

EMDR and The Trauma Clinic

Manager at Massachusetts Department of Mental Health asked team to organize community trauma response team for Boston area
Discovered power of EMDR in treating previously unresponsive PTSD patients
Weekly improvements observed through videotapes and standard PTSD rating scale
Neuroimaging specialist scanned 12 patients before and after treatment
Eight of twelve showed significant decrease in PTSD scores and brain activity changes

Secured funding from NIMH for comparison study with Prozac or placebo

Placebo group had greatest improvement (42%)
Prozac group slightly better than placebo but not statistically significant
EMDR group showed substantial improvement: 1 in 4 completely cured after eight sessions, 60% completely cured eight months later
Adults with childhood trauma responded differently: 73% adult-onset group cured eight months later vs. 25% child abuse group
Child abuse group had small but consistent responses to Prozac
Study demonstrated EMDR's effectiveness compared to medication for PTSD treatment

Additional Findings

Chronic childhood abuse causes different mental and biological adaptations than discrete adult traumas
EMDR not necessarily resolves effects of betrayal and abandonment in childhood trauma
Eight weeks of therapy rarely sufficient to resolve long-standing trauma
First solid scientific study using EMDR in combat veterans with PTSD (EMDR more effective than biofeedback-assisted relaxation therapy)
EMDR now sanctioned by Department of Veterans Affairs for PTSD treatment.

IS EMDR A FORM OF EXPOSURE THERAPY?

EMDR (Eye Movement Desensitization and Reprocessing) is related to exposure therapy, but it integrates traumatic material instead of just desensitizing it

Memory Processing:

Memories undergo integration and reinterpretation after being laid down
In PTSD, this process fails and memories remain raw and undigested
Few psychologists are taught about memory processing in their training
Exposure Therapy:
- Patients relive traumatic experiences to reduce reactions
- Initial response includes increased heart rate, blood pressure, and stress hormones
- Prolonged exposure can lead to less reactivity and lower PTSD ratings
- Does not integrate memories into overall context of a person's life
EMDR and Other Therapies:
- Focus on regulating intense memories and restoring agency, engagement, and commitment
- Treatments include internal family systems, yoga, neurofeedback, psychomotor therapy, and theater.

PROCESSING TRAUMA WITH EMDR

Kathy was a 21-year-old student with a history of severe childhood abuse
Had been in psychotherapy for three years without progress
Able to focus on studies but struggled with relationships
Recovered from trauma after eight EMDR sessions

EMDR Session Details

Kathy sat facing therapist at a 45-degree angle
Therapist asked her to recall a painful memory and rate its intensity
Asked Kathy to follow therapist's moving finger with her eyes
After each eye movement sequence, Kathy reported associations

Associations during First Eye Movement Sequence

Recalled physical scars from abuse
Described instances of being raped and doused in gasoline
Looked stunned but surprisingly calm

Associations during First Eye Movement Sequence

Recalled physical scars from abuse
Described instances of rape and dousing in gasoline
Looked stunned but surprisingly calm

Subsequent Sequences

Saw herself as a karate fighter standing up to her abusers
Realized the brutalization of the little girl within her
Imagined herself holding her "little me" and feeling safe
Had images of bulldozing down old house and starting anew
Felt fear about being open with Jeffrey, a classmate
Experienced intrusive memories of smells and father's presence
Felt her mother apologizing for not protecting her
Imagined her grandmother holding her and expressing regret for marrying abuser

Outcome

Kathy integrated traumatic memories through EMDR, creating new associations and feelings
Arrived at a sense of completion and control over her past experiences
Minimal input from therapist required
New images, emotions, and thoughts emerged, allowing for personal growth.

Remarkable Feature of EMDR

Activates unsought and seemingly unrelated sensations, emotions, images, and thoughts in conjunction with the original memory
May be how we integrate ordinary experiences as well.

EXPLORING THE SLEEP CONNECTION

EMDR at Sleep Laboratory: Speaker shares success story of PTSD patient treated with EMDR (Eye Movement Desensitization and Reprocessing)
Connection to Dreams: Researcher Robert Stickgold becomes interested in EMDR after witnessing its effectiveness
Role of Dreams in Mood Regulation: Article suggests EMDR is related to REM sleep, where dreams occur
Importance of REM Sleep: Increased REM sleep reduces depression; PTSD associated with disturbed sleep and disrupted REM sleep
Memory Processing during Sleep: Deep sleep and REM sleep play roles in memory change; sleeping brain integrates unclear information
Dreams as Memory Recombination: Dreams update subterranean realities, activate distant associations, and forge new relationships between memories
Creativity and Healing: Ability to recombine experiences is essential to creativity and healing; PTSD patients are trapped in frozen associations
Link between EMDR and Sleep-Dependent Processes: Stickgold suggests EMDR may take advantage of sleep-dependent processes for effective memory processing and trauma resolution
Study on Eye Movements during Trauma Recall: Ruth Lanius and speaker studying brain reactions to saccadic eye movements in fMRI scanner while recalling traumatic events and ordinary experiences.

ASSOCIATION AND INTEGRATION

EMDR (Eye Movement Desensitization and Reprocessing) vs Conventional Exposure Treatment:

EMDR spends little time revisiting original trauma
Focuses on stimulating associative process
Drugs like Prozac can blunt trauma images and sensations but not integrate them as past events
EMDR patients no longer experience distinct imprints of trauma, considering it a story of the past
How EMDR works is unclear, same goes for Prozac

Clinical Practice and Experimentation:

Clinicians' primary obligation: help patients get better
History of experimentation in clinical practice
Some treatments fail, some succeed, some change therapy practice (EMDR, DBT, IFS)
Research support for new treatments takes decades and is often hampered

History of Penicillin:

Discovered antibiotic properties by Alexander Fleming in 1928
Mechanisms elucidated in 1965 (almost 40 years later)

CHAPTER 16

LEARNING TO INHABIT YOUR BODY: YOGA

Annie's Story

Annie, a special-needs teacher, appeared terrified and unable to engage during first session
Fear prevented her from thinking or providing basic information
Couldn't demand too much or she would shut down and leave
Used qigong technique (breathing exercises) to help calm her down
Gradually, Annie began to relax and show signs of improvement

Background Information on Annie

Abused as a child by both parents
Skilled and caring in her work with special-needs children
Closed off about relationships with adults
Married but rarely mentioned husband
Coping mechanisms included self-harm and disappearing mentally during disagreements or confrontations
Previous therapy and medication attempts unsuccessful
Multiple psychiatric hospitalizations

Early Therapy Sessions Focus

First Session with Annie

Slumped in chair, shaking legs, fixed gaze on floor
Invited her into office but made no demands
Encouraged deeper breathing using qigong technique
Spent 30 minutes calming her physiological response
Asked if she'd return for another session

Annie's Background

Dreadful childhood abuse by both parents
Skilled and caring teacher of special-needs children
Closed off about relationships with adults
Coped with disagreements and confrontations by disappearing mentally
Self-destructive behaviors: cutting herself
Previous therapy, medications, and hospitalizations had little effect

Early Therapy Sessions

Focused on calming physiological chaos within
Used various techniques to help Annie stay within her window of tolerance
Breathing exercises with a focus on out breath
Taught acupressure points tapping (Emotional Freedom Technique)

EFT (Emotional Freedom Technique): A practice that has been shown to help patients manage symptoms of PTSD.

THE LEGACY OF INESCAPABLE SHOCK

Broken Alarm Systems: Malfunctioning amygdala can cause misinterpretation of situations as life-threatening

Annie's Case:

Smoke detector (amygdala) rewired to perceive certain situations as dangerous
Simultaneously experienced agitation and mental shutdown
Past experiences led to fear response towards loved ones
Manifests in Various Ways:
- Compartmentalization of experiences in childhood
- Love and dread held in separate states of consciousness
Impact on Annie:
- Blamed herself for abuse
- Belief rooted in emotional, survival brain
- Could not change belief without feeling safe in her body
Childhood Compartmentalization:
- Children can separate experiences easily
- Annie's love and dread towards father were distinct
Impact of Abuse:
- Belief that she led father on and brought molestation upon herself
- Rational mind knew it was nonsense but belief came from emotional brain
- Could not change until she felt safe enough to revisit the experience.

THE NUMBING WITHIN

The Numbing Within

Trauma survivors store memories as muscle tension or feelings of disintegration in affected body areas
Survivors may engage in self-numbing behaviors to cope with unwanted sensory experiences.
Self-numbing strategies:
- obesity
- anorexia
- addiction to exercise or work
- drugs
- alcohol
- cutting
- sensation seeking
- high-risk activities
Numbing can lead to chronic pain, spasms, back pain, migraines, fibromyalgia, etc.
People may visit multiple specialists, undergo extensive tests, and be prescribed medications for symptoms without addressing underlying trauma.
First two years of therapy focused on helping survivors tolerate physical sensations
Helped Annie learn to observe unbidden images and feelings as residues of past trauma without judgment
Challenging to help patients regulate arousal and control physiology

New Approaches: Yoga for Trauma Survivors

Stumbled upon yoga as a new way to help patients regulate their arousal and control their own physiology.

FINDING OUR WAY TO YOGA: BOTTOM-UP REGULATION

Understanding the Importance of Heart Rate Variability (HRV) and its Connection to Yoga

Background:

Discovery of HRV as a measure of autonomic nervous system (ANS) balance in 1998
ANS regulates arousal, with sympathetic (SNS) and parasympathetic (PNS) branches
Good HRV indicates optimal state of engagement with environment and self

Importance of HRV:

Measures basic well-being and control over response to stressors
Affects thinking, feeling, and body's response to stress
Low HRV linked to physical illnesses (heart disease, cancer) and mental problems (depression, PTSD)

Findings on HRV in PTSD:

Individuals with PTSD have unusually low HRV
SNS and PNS are out of sync
Explains vulnerability to overrespond to stressors

Questions and Discoveries:

Is it possible to improve HRV?
Personal incentive for exploration due to own poor HRV
Initial research: marathon running increases HRV, but not feasible for everyone
Internet search revealed conflicting claims about yoga's effect on HRV
Scientific evidence lacking in 1998

Later Discoveries:

Changing breathing patterns can improve problems with anger, depression, and anxiety
Yoga positively affects medical conditions (high blood pressure, asthma, low-back pain)
No psychiatric journal had published a study on yoga for PTSD until 2014

Meeting David Emerson:

Yoga teacher with experience working with veterans and rape crisis center clients
Developed modified form of hatha yoga to deal with PTSD
Collaboration led to active yoga program and first NIH grant for studying the effects of yoga on PTSD

Alternative Approaches:

Using handheld devices or apps to train HRV through breathing exercises
Encouraging patients to practice at home if unable to attend yoga classes or other practices (qigong, martial arts)

EXPLORING YOGA

Decision to study yoga led to exploration of trauma's impact on the body
First experimental classes held with donated studio space and volunteer instructors
Selected 37 women with severe trauma histories for study, half in yoga group, other half in DBT group
Measured Heart Rate Variability (HRV) to assess effects of yoga and DBT on psychological functioning
Yoga significantly improved arousal problems in PTSD and body relationship, DBT had no effect on arousal or symptoms
Interest shifted from HRV to helping traumatized people inhabit their bodies
Successful implementation of yoga programs for veterans with PTSD, despite lack of formal research data

Components of Yoga:

Combination of breath practices (pranayama), stretches or postures (asanas), and meditation
Variations in intensity and focus within core components
Simple approach in classes, focusing on breath awareness and body observation
Gradual introduction to classic postures, emphasis on tension-relaxation rhythm
Encouragement of mindfulness through observing bodily sensations

Challenges with Trauma Recovery:

Difficulty achieving total relaxation and safe surrender in bodies
Muscles remain prepared for fight or flight response during shavasana (final relaxation pose)

LEARNING SELF-REGULATION

Establishing a Therapeutic Yoga Program at the Trauma Center

Success of pilot studies led to program establishment
Opportunity for Annie to develop caring relationship with body
Difficulties and progress in yoga practice

First Class Experience

Terrifying experience due to alarm system response
Fear of being touched
Realization of potential healing benefits

Second Class and Beyond

Writing about experiences instead of talking
Overcoming fear and attending classes regularly
Discovering connection between mind and body
Noticing physical tension and pain
Reading "Yoga and the Quest for the True Self"
Reflecting on disconnection from body and past denial
Learning to listen to body's story

Challenges in Yoga Practice

Difficulty with vulnerable poses (e.g., Happy Baby)
Intense panic and vulnerability
Importance of learning to comfortably assume challenging poses for intimacy and healing.

GETTING TO KNOW ME: CULTIVATING INTEROCEPTION

Interoception:

Anchors our sense of self
Essential for navigating life
Numbing or compensatory sensation seeking can lead to loss of body awareness

Alexithymia:

Inability to identify inner feelings
Leads to multiple vague physical complaints and difficulty responding to situations

Benefits of Yoga:

Re-establishes relationship with interior world
Cultivates sensory awareness
Helps with emotional regulation
Strengthens capacity to deal with discomfort
Approaches body with curiosity instead of fear

Effects of Trauma:

Makes individuals feel stuck in a helpless state
Yoga helps individuals understand that experience is transitory

Challenges of Practicing Yoga with Trauma:

Intense physical sensations can unleash past traumas
Important to go slow and be patient.

YOGA AND THE NEUROSCIENCE OF SELF-AWARENESS

Yoga and meditation have positive effects on brain areas critical for self-regulation (insula, medial prefrontal cortex) according to research by Sara Lazar and Britta Hölzel at Harvard.
Intensive meditation shown to increase activation of self-system in the brain.
Study with six women with trauma history found increased activation after 20 weeks of yoga practice.
Participants reported:
- Recognizing emotions more powerfully.
- Expressing feelings more effectively.
- Seeing choices and deciding on life paths.
- Feeling safe in their bodies during yoga practice.
Research needs further exploration, but suggests that noticing and befriending bodily sensations can lead to healing from trauma.

LEARNING TO COMMUNICATE

Communicating Past Trauma

People who feel safe in their bodies can express repressed memories into language.

Annie practiced yoga three times a week for about a year.
Noticed ability to talk freely about past experiences.
Panic reaction to words that triggered traumatic memories.
Wrote to therapist about being able to say the triggering words out loud.
Attended morning yoga class and noticed the present moment through breathing exercises.
Experienced panic in certain poses but was able to use them as information instead of being overwhelmed.

Impact of Yoga on Annie's Life

Annie learned to manage her feelings instead of being hijacked by them.
Increased self-awareness led to improved relationships, including becoming intimate with her husband.
Regular yoga practice helped Annie feel more present in the moment and tolerant of physical touch.

CHAPTER 17

PUTTING THE PIECES TOGETHER: SELF-LEADERSHIP

Early in author's career, met Mary with history of abuse
Three months into therapy, Mary appeared as "Jane"
Dressed provocatively, warned therapist not to believe Mary's lies
Met different identities: Jane, hurt little girl, angry male adolescent
First encounter with Dissociative Identity Disorder (DID)
Extreme end of mental life spectrum, but common for traumatized people
Internal splitting and emergence of distinct identities
Important component of healing: exploring and befriending those parts.

Dissociative Identity Disorder (DID)

Extreme form of mental life, but internal splitting common to all
Survival mechanism for traumatized people
Characterized by warring impulses or parts
Exploring and befriending those parts is crucial for healing.

DESPERATE TIMES REQUIRE DESPERATE MEASURES

Trauma leads to self-protection strategies: humiliation, revenge, becoming powerful, etc.
- Many psychiatric problems started as adaptations to trauma.
- Trauma survivors are resilient but may pay a high price for coping.
Self-Protective Behaviors:
- repressing feelings
- plotting revenge
- becoming powerful
- denying reality
- suppressing emotions
- numbing sensations
Childhood Abuse: children may hate themselves to protect relationship with caregivers, leading to self-loathing and denial in adulthood.
Short-term Adaptation, Long-term Consequences: pushing away intense feelings can help in the short run but leads to isolation and unawareness of triggered parts later.
Parts of Self: traumatized parts may trigger extreme beliefs and behaviors, requiring therapy to help them give up these beliefs.
Challenges of Recovery: revisiting past memories and reconfiguring brain/mind system that was constructed to cope with trauma.

THE MIND IS A MOSAIC

Internal Leadership Skills:

Our ability to get along with ourselves depends on how well we listen to our different parts and take care of them
Parts often come across as absolutes but represent only one aspect of our complex inner world

Psychological Theories:

William James: consciousness can be split into parts that coexist but ignore each other
Carl Jung: psyche is a self-regulating system with opposing components and the need for reconciliation
Michael Gazzaniga: mind is composed of semiautonomous functioning modules or "selves"
Marvin Minsky: there exists a society of different minds within our brains

Therapeutic Approaches:

Structural Dissociation Model: developed by Onno van der Hart, Ellert Nijenhuis, and Kathy Steel for treating complex trauma
Internal Family Systems Therapy (IFS): developed by Richard Schwartz to help individuals understand and work with their inner parts or "subpersonalities

Parts and Trauma:

Trauma can result in polarized parts that go to war with one another, each carrying the burden of the trauma
Extreme parts include self-loathing, grandiosity, loving care, hatred, numbing, rage, and aggression
These parts are not just passing emotional states or thought patterns but distinct mental systems with their own history, abilities, needs, and worldview
Trauma injects parts with beliefs and emotions that hijack them out of their naturally valuable state, leading to exiles (parts that hold pain, terror, betrayal) and protectors (parts that protect the self from the exiles)

Understanding and Working with Parts:

IFS offers a framework for understanding and talking about parts in a nonpathologizing way
Recognizing each part's function in the overall system makes it feel less threatening or overwhelming
Collaborating with the internal system rather than teaching, confronting, or filling holes is essential for healing from trauma.

SELF-LEADERSHIP

Self-Leadership and IFS

Cultivating mindful self-leadership essential for healing from trauma
Mindfulness allows compassionate and curious survey of internal landscape
Effective leadership necessary for all systems, including internal system
Internal leader distributes resources, provides vision for whole self

Differences in Internal Systems

Absence of effective leadership in abuse victim's internal system
Parts operate under extreme rules and outdated assumptions
Fear of revealing childhood secrets

Blending vs. Separation

Blending: Self identifies with a part
"I want to kill myself" vs. "A part of me wishes that I were dead"
Schwartz's assertions about mindful Self
- Undamaged essence exists beneath protective parts
- Confident, curious, and calm
- Spontaneously emerges when protectors trust it's safe
- Active leadership role in reorganizing inner system
- Increases control over emotional brain through mindfulness
Neuroscience research supports active role of mindful Self
- Increases medial prefrontal cortex activation
- Decreases amygdala activation
Inner relationship between Self and protective parts in IFS model
Self acts as orchestra conductor, helping parts function harmoniously

GETTING TO KNOW THE INTERNAL LANDSCAPE

Therapist's role is to help patients identify and separate protective parts from the Self.

Identifying Protective Parts:

Patients ask each emerging part to "stand back" for self-observation.
Unblending parts makes them less intimidating and overwhelming.
Identify the part involved in current problem (e.g., feeling worthless, abandoned, or vengeful).
Describe the part with an image (e.g., abandoned child, combat marine).

Mindful Self-Observation:

Patients ask how they feel toward the protective part.
Extreme responses indicate another protective part blended with Self.
Thank and assure protective parts of their importance.
Ask how patients feel toward the previously rejected part.
Encourage getting to know the part better (e.g., age, origin).

Dialogue with Protective Parts:

Patients engage in constructive inner dialogues from a stable Self perspective.
Identify and address the protective parts interfering.
Empathic comments or questions to facilitate self-reflection.
Continuous self-detection question: "How do you feel toward the part now?"

A LIFE IN PARTS

Joan's Issues: Uncontrollable temper tantrums, guilt about affairs, defensiveness, vulnerability, anger, fear, and sorrow.
First Session: Joan critiqued therapist's office, prepared for disappointment, needed to test therapist's ability to handle her emotions.
Therapist's Approach: Showing interest in Joan's life, unwavering support, accepting shameful parts.
Identifying Critical Part: Joan acknowledged the critical part and hated it due to its resemblance to her mother.
Protective Role of Critic: Protecting Joan from criticism, preempting her mother's criticism.
Childhood Trauma: Sexual molestation by mother's boyfriend around first or second grade.
Patterns in Adulthood: Demanding and critical of husband, passionate and reckless in affairs, fearful and ashamed after sex.
Dissociation: Specific memories of abuse were split off, reenacting the trauma unintentionally.
Therapy Approach: Focus on Joan's relationship with her parts, not on therapist, pendulation, recruiting inner resources, self-healing.
Limitations of Therapist: Cannot fill holes of early deprivation, wrong person, time, and place.

MEETING THE MANAGERS

Identified various parts in charge of Joan's behavior: aggressive childlike, promiscuous adolescent, suicidal, obsessive manager, prissy moralist, etc.
Met managers first to understand their roles and responsibilities.
Managers prevent humiliation and abandonment, keep organized and safe.
Can be aggressive, perfectionistic, reserved, or deny reality.
Control access to emotions and maintain defensive positions.
Huge burden of responsibility, often incompetent but can be highly skilled.

Characteristics of Managers

Prevent humiliation and abandonment.
Keep organized and safe.
Can be aggressive, perfectionistic, reserved, or deny reality.
Control access to emotions.
Maintain defensive positions.

Impact of Managers on Joan's Life

Simultaneous experience of conflicting feelings and thoughts is normal.
Realized that only a part of her felt consumed by hate.
After negative evaluation, went into a tailspin, feeling powerless and worthless.
Resisted acknowledging weak, powerless parts.
Criticized herself, felt embarrassed and contemptuous.
Felt suicidal and bulimic.

Interaction with the Critic Manager

Wanted to ignore all noise and increase medications.
Believed people would hate her and be alone if parts stepped back.
Memory of mother's threat of adoption triggered fear and sadness.

Impact of Managers on Joan's Healing Process

Unintentionally doing harm in their desire to protect injured parts.
Asked managers what would happen if they stepped back.
Felt bad for the scared girl inside, Self returned.
Session was too much too soon, calmed system down but not enough.

PUTTING OUT THE FLAMES

Joan missed appointment due to exile being triggered
Firefighters went on rampage: drinking, picking up strangers, refusing to talk to husband
Firefighters vs Managers:
- Managers: stay in control
- Firefighters: destroy house to put out fire
Struggle between managers and firefighters continues until exiles are cared for
Anyone dealing with survivors will encounter firefighters
Firefighters protect system from emotional pain
Firefighter behaviors: shopping, drinking, addictive activities, impulsive affairs, self-harm
Firefighters believe stopping their job would cause entire self-system to crash
Firefighters oblivious to better ways for physical and emotional safety
Cycles end when Self takes charge and system feels safe

THE BURDEN OF TOXICITY: Exiles

Toxic Waste Dump: Exiles are the part of the psyche that holds traumatic memories, sensations, beliefs, and emotions.
Hazardous to Release: Releasing exiles is dangerous due to their association with trauma, terror, collapse, and accommodation.
Forms of Exiles: Crushing physical sensations or extreme numbing.
Impact on Managers: Overwhelms managers, leading to loss of reasonableness.
Impact on Firefighters: Offends the bravado of firefighters who want to suppress emotions.
Hated and Despised: Exiles are often hated and despised by survivors, particularly the parts that responded to abuse or were abandoned.
Being Overwhelmed: When exiles overwhelm managers, the Self becomes "blended" with them, eclipsing all alternatives for life.
Loss of Sensitivity and Creativity: Keeping exiles locked up stamps out not only memories and emotions but also the parts that hold them, leading to a life without intimacy or genuine joy.
Double Whammy: The parts that hold the exiles are hurt twice**: by the original trauma and by being rejected and exiled.
Impact on Sensitive Parts: These parts are often the most sensitive, creative, intimate, lively, playful, and innocent parts of a person.

UNLOCKING THE PAST

Unlocking the Past with Internal Family Systems (IFS)

Joan's treatment involved accessing the exiled girl carrying feelings from her molestation
Girl had developed enough trust and self-awareness to observe herself as a child
Important for Joan to keep girl in state of calm observation, prevent her from pulling away
Encouraged Joan to take an active role in liberating her inner child
Trauma resolution through accessing imagination and reworking frozen scenes

IFS Helps Family Members "Mentor" Each Other

Witnessed this with Joan and her husband, Brian
Initially proud of putting up with Joan's behavior, felt pressured by her desire for change
Revealed panicked part that feared being overwhelmed by pain
Grew up in an alcoholic family where dysfunctional behaviors were common
Fearful of women and determined to never let himself be vulnerable
Strong caretaker part gave him self-worth, purpose, and a way to deal with terror

Brian's Exile: The Scared, Essentially Motherless Child

Ready to meet his exile after dealing with other parts
New possibilities opened up for both Joan and Brian
IFS helped them hear each other from an objective, compassionate perspective
No longer locked in the past.

THE POWER OF SELF-COMPASSION: IFS IN THE TREATMENT OF RHEUMATOID ARTHRITIS

Nancy Shadick is a rheumatologist at Boston's Brigham and Women's Hospital with an interest in patients' personal experience of rheumatoid arthritis (RA)

RA is an autoimmune disease causing chronic pain, disability, and impaired quality of life; no cure, only medication for symptom relief
IFS (Internal Family Systems) therapy introduced to help patients accept and understand their emotions, taught in a nine-month study
Group sessions: teach patients to recognize and approach internal states with interest and compassion
Patients were alexithymic, denying pain and emotions due to stoic parts
IFS helped patients identify and communicate with managers, exiles, and firefighters
Individual therapy applied IFS language to daily issues, improving self-compassion and self-efficacy
Study results: IFS group showed improvements in self-assessed pain, physical function, self-compassion, depression, and overall pain relative to control group at 9 months
Improvements sustained for one year, although medical tests could no longer detect measurable improvements
Conclusion: IFS's focus on self-compassion key factor in improved ability to live with disease
Previous studies showed psychological interventions (CBT, mindfulness) had positive impact on RA patients but didn't address immune system function.

LIBERATING THE EXILED CHILD

Peter ran an oncology service at a prestigious medical center
Arrogant and callous behavior towards his wife
Contempt for psychiatrists and therapy
Determined not to be a victim or feel helpless

Family Background

Father: Holocaust survivor, brutal and exacting but tender and sentimental
Mother: Substituted rigorous housekeeping for genuine care

Marital Issues

Criticized wife incessantly
Rarely at home and emotionally unavailable
Wife determined to leave unless he made changes

Therapy Sessions

First Session
- Peter expressed contempt for psychiatrists and therapy
- Described himself as brutally honest, high standards, no need for love just respect
- Denied any issues with his past or parents
Second Session (with wife present)
- Wife described Peter's criticizing behavior
- Peter became distressed for the first time
Subsequent Sessions
- Identified critical part and its fear of hurt and humiliation
- Discovered fear of abandonment and childhood traumas
- Unburdening process: nursing wounded parts back to health

Outcome

Peter's inner critic relaxed, became more like a mentor
Repaired relationships with family and colleagues
No longer suffered from tension headaches
Realized he had spent his adulthood trying to let go of his past by getting closer to it.

CHAPTER 18

FILLING IN THE HOLES: CREATING STRUCTURES

Trauma survivors face inner voids or "holes in the soul" due to lack of love, validation, and feeling unwanted or ignored during childhood.
Conventional psychotherapy may not be effective for those who did not feel safe or cared for as children.
Attended US Association for Body Psychotherapy conference in 1994 and met Albert Pesso, who claimed to have a way of changing people's relationship with their core selves.
Pesso's PBSP psychomotor therapy involves:
- Witnessing and validating the protagonist's experiences
- Creating tableaus or structures in three-dimensional space
  - Significant people from the past are represented by group members
  - Ideal parents provide support, love, and protection
- Protagonists direct their own plays
Benefits:
- Instills imprints of safety and comfort alongside those of trauma
- Communication primarily occurs in nonverbal realm (right hemisphere)
- Contact person's presence helps protagonist tolerate painful experiences
Visited Pesso at his farmhouse for a structure session.
- Chose objects to represent significant people in my life
- Revealed implicit map of the world: two large, threatening objects representing parents and small objects representing family and friends
- Felt deep release when Al interposed himself between me and the threatening objects.

RESTRUCTURING INNER MAPS

Projecting inner world into 3D structures for clearer perspective on reactions
Position placeholders for important people in life, eliciting memories, thoughts, emotions
No explanation or interpretation of past, allows re-experiencing and visualization
Can rewrite crucial scenes, direct role-players to do things left undone
Safety of group allows exploration of hidden, shameful experiences
Placing shame on rightful figures, saying suppressed words
Active participation and taking charge of representation
Witness reflects changes in posture, facial expression, tone of voice
Physically re-experiencing past in present, creating new supplemental memories
Structures do not erase bad memories but offer fresh options for fulfilling needs and longings.

REVISING THE PAST

Maria's Trauma Healing Experience

Maria, a Filipina woman in her mid-40s, appeared scared during a trauma exploration workshop
She reported feeling numb and having a blank mind

Witness Figure:

Validates protagonist's emotions
Encourages focus on breath and body feelings
Reflects emotional state and context
Creates a safe environment for exploration

Maria's Childhood:

Grew up with fear of her father
Never felt cared for by him
Mother was loving but unable to protect her from father's abuse
Felt trapped and incapable of protecting herself

Ideal Parents:

Represented by group members (Ellen as mother, Danny as father)
Enacted roles of caring, protective parents
Allowed Maria to express desires for a different upbringing
Created a sense of joy and safety for Maria

Impact on Group:

Several group members wept silently during the exercise
The possibility of growing up safe and happy resonated with their own longings.

RESCRIPTING YOUR LIFE

Growing up with ideal circumstances is rare
Defects in childhood upbringing can lead to:
- Lack of self-respect
- Difficulty standing up for oneself
- Smoldering rage
- Interpreting others' actions as threats
- Inability to appreciate others' complexities
Trauma and neglect disconnect people from their bodies
People trapped in a matrix of fear, isolation, and scarcity:
- Anticipate rejection and hurt
- Reluctant to try new options
Value of structured experiences like psychomotor therapy:
- Safe exploration of inner reality
- Concrete "aha moments"
- Transformation of inner narratives
Structures harness the power of imagination:
- Disclosure of hidden secrets
- Transformation of feared and forbidden into concrete reality
Importance of accurate mirroring:
- Permission to feel and know
- Essential foundation of recovery
Trauma causes people to remain stuck in the past
Structures represent the structure of inner world:
- Internal map and hidden rules.

DARING TO TELL THE TRUTH

Mark, a 26-year-old man, overheard his father having an affair with his aunt at age 13
Tried to discuss it with his father but was met with rage and denial
Felt confused, embarrassed, hurt, betrayed, and isolated
Father's hypocrisy contaminated family life, gave him a sense of distrust
Spent adolescence feeling disconnected from others
Mother died when he was 21, father married the aunt, Mark was not invited to funeral or wedding
Secrets became inner toxins, affecting every aspect of his life

Group Therapy Session:

Mark stood out for emotional distance, acknowledged feeling separated by a fog
Invited to talk about family, initially shut down
Created a tableau to represent his family members and their roles in his life
Confronted his father (Joe) and expressed long-held anger and accusations
Ideal father figure (Richard) validated his feelings and offered support
Confronted his aunt (Amanda), unleashed abuse and anger
Created ideal versions of his aunt and mother to replace the betrayers
Ended session quietly, feeling content with new perspective

Outcome:

Mark became an open and valuable group member
Three months later, sent email saying therapy changed his life
Moved in with first girlfriend, able to disagree and stand up for himself without fear or rage
Asked for referral to a therapist for further help.

ANTIDOTES TO PAINFUL MEMORIES

Psychomotor therapy offers the possibility of forming virtual memories that contradict painful realities of the past
People need to become viscerally familiar with sensations rooted in safety, mastery, delight, and connection
Dreaming creates associations that reweave the past, psychomotor structures do the same but are subject to laws of physics
Healing tableaus of structures offer an experience of being welcomed, protected, met needs, and feeling at home

Benefits of Psychomotor Therapy

Forms virtual memories that live side by side with painful realities
Provides sensory experiences contradicting static feelings of trauma
Offers intense and real emotional scenarios to defuse old ones
Creates a world where people delight, protect, meet needs, and make feel at home

Functions of Psychomotor Therapy

Replaces frustrating events with sensations rooted in safety and connection
Contradicts painful memories with new emotional experiences
Offers an experience of being welcomed and protected

Limitations of Psychomotor Therapy

Cannot undo past events, but can create new emotional scenarios to defuse old ones.

CHAPTER 19

REWIRING THE BRAIN: NEUROFEEDBACK

Working at Hartmann's Sleep Laboratory
- Part-time research assistant
- Prepared and monitored participants
- Analyzed EEG tracings
- Documented dreams
- Used intercom to wake participants during REM sleep cycles
- Pored over EEGs, recorded baseball scores, filled out questionnaires
Contributions to Understanding Sleep Processes
- Documented REM sleep and dreaming
- Contributed to basic understanding of sleep processes
- Led to crucial discoveries (Chapter 15)
Unrealized Hope for EEG in Understanding Psychiatric Problems
- Long-standing hope that EEG would help understand psychiatric problems
- Realization largely unachieved

MAPPING THE ELECTRICAL CIRCUITS OF THE BRAIN

Before pharmacological revolution, both chemical and electrical signals important for brain activity
Hans Berger: first recording of brain's electrical activity in 1924 using electroencephalography (EEG)
Initially met with skepticism but became essential tool for diagnosing seizure activity in epilepsy patients

Different brain-wave patterns reflect different mental activities

Berger hoped to correlate psychiatric problems with specific EEG irregularities
Early 1930s: EEG findings in "behavior problem children" with slow frontal lobe electrical activity linked to ADHD
Mid-late 1980s: Sent patients for EEGs to determine emotional instability, but results were ambiguous and unhelpful
2000: McFarlane et al. study documented differences in information processing between traumatized subjects and "normal" individuals using the oddball paradigm
- Traumatized brains had loosely coordinated brain waves, failing to generate coherent patterns for filtering, focus, and analysis
- Lack of N200 wave: difficulty paying attention on task at hand by filtering out irrelevant information
- Poorly defined core information-processing configuration (P300)
Implications for understanding day-to-day information processing in traumatized individuals

McFarlane's study reminded author of Pierre Janet's statement:

Traumatic stress is an illness of not being able to be fully alive in the present

The Hurt Locker movie illustrates the focus and attention problems in PTSD veterans
2007: Met Sebern Fisher, who used neurofeedback for treating severely disturbed adolescents with dramatic results
Neurofeedback: non-invasive treatment that trains individuals to control their brain waves
Author's firsthand experience of neurofeedback demonstration and its dramatic impact on mental functioning.

SEEING THE SYMPHONY OF THE BRAIN

Neurofeedback: a brain training technique using real-time information about brain activity to "train" the brain to function optimally.

Equipment: desktop computers, amplifier, electrodes
Principle: provides mirror of brain function, nudges brain to make more of certain frequencies and less of others
Process:
- Electrodes placed on head to detect brain waves
- Computer displays brain wave patterns as feedback (e.g., spaceships)
- User adjusts mental state to influence feedback
- Goal: develop new, complex, self-regulating brain patterns
Benefits:
- Enhances natural complexity and self-regulation
- Frees up stuck oscillatory properties
- Allows new ones to develop
Similarities with conversation:
- User responds based on feedback (smiles, nods)
- Inhibition is neutral instead of negative
Additional feature: tracks circuitry in specific brain areas
- Rewards specific frequencies in different regions
- Affects mental and physical sensations

Neurofeedback and Trauma:

Goal: intervene in fear and shame circuits, reduce automatic stress reactions
Benefits:
- Relaxes fear patterns
- Increases resiliency
- Allows for more choices in response to events
Neurofeedback as treatment:
- Changes habitual brain patterns created by trauma
- Stabilizes the brain and increases focus on ordinary events
- Reduces susceptibility to stress reactions.

THE BIRTH OF NEUROFEEDBACK

Neurofeedback not new in 2007, with roots dating back to late 1950s
University of Chicago professor Joe Kamiya discovered people could learn to produce alpha waves associated with relaxation (1950s)
- Reached 100% accuracy in identifying alpha waves within 4 days
- Could voluntarily enter alpha state in response to sound cue
Alpha training for stress relief became widely known after Psychology Today article (1968)

Early Scientific Research on Neurofeedback

Barry Sterman at UCLA: studied effects of rocket fuel monomethylhydrazine (MMH) on cats (1970s)
- Ordinary lab cats developed seizures after MMH exposure
- Cats with neurofeedback training did not develop seizures
- Neurofeedback stabilized their brains
First human study: Mary Fairbanks, epileptic patient, became virtually seizure-free after 3 months of training (1971)
Impressive results published in Epilepsia (1978)

Decline and Revival of Neurofeedback

Optimism about human mind's potential waned in the mid-1970s
Psychiatry and brain science adopted chemical model of mind and brain
Neurofeedback field grew slowly, with much research done outside US
Limited commercial potential and insurance coverage hinder widespread acceptance
- Expensive for consumers
- Prevents practitioners from conducting large-scale studies

FROM A HOMELESS SHELTER TO THE NURSING STATION

Lisa's Journey

Lisa, a 27-year-old nursing student, shared her remarkable story with the author
Lisa possessed great resilience and was an engaging, curious, intelligent person
Grew up in an abusive household with an unpredictable mother
Father abandoned family when she was three years old
Endured physical and emotional abuse, spent years in mental hospitals, group homes, foster families, and on the street
Lack of language to communicate her experiences led to a reputation as manipulative liar
Could not remember self-inflicted injuries or recognize herself in a mirror
Suffered from dissociative identity disorder (DID) and inescapable shock

Neurofeedback Treatment

Invited by Sebern for neurofeedback sessions
Impossible to do talk therapy
Frequent panic attacks and memory loss when discussing past experiences
Stuck in a state of inescapable shock
First dissociative patient for neurofeedback treatment
Rewarded more coherent brain patterns in right temporal lobe (fear center)
Noticed improvement in social anxiety and fear of basements
Stopped dissociating after half a year of neurofeedback sessions
Developed a more continuous sense of self
Able to talk about past experiences for the first time
No longer feared attachment or memorizing people out of fear

Impact of Neurofeedback

Clearer and able to focus
Able to meaningfully connect with others
Stunning potential for neurofeedback treatment in trauma recovery

GETTING STARTED IN NEUROFEEDBACK

Training Session Experience

Michael reported feeling safe and open after session
Placed electrode over sensorimotor strip on right side of head
Rewarded frequency of 11-14 Hz
Michael shared remarkable experience with group
Emerged from low profile, became valuable contributor to neurofeedback program

Study with 17 Patients

Targeted right temporal area of brain due to excessive activation during traumatic stress
Twenty neurofeedback sessions over ten weeks
Difficult to get self-reports from patients due to alexithymia
Objective changes in behavior better indicators of treatment success
Significant improvements in PTSD scores, interpersonal comfort, emotional balance, and self-awareness

First Patient's Experience

Professional man with compulsive homosexual behavior
Previous therapy unsuccessful
Neurofeedback training led to new behaviors, such as fishing instead of cruising
Brain may have derived comfort from fishing due to changed connectivity patterns

Neurofeedback Effects on the Brain

Neurofeedback changes brain connectivity patterns
Mind follows by creating new patterns of engagement

BRAIN-WAVE BASICS FROM SLOW TO FAST

Brain waves range from slow to fast: Delta, Theta, Alpha, Beta

Delta Waves (2-5 Hz)

Slowest brain waves, most common during sleep
Brain is in idling state, mind turned inward
Excessive delta activity during wakefulness leads to foggy thinking and poor judgment
Linked to ADHD and PTSD

Theta Waves (5-8 Hz)

Predominate at edge of sleep and in hypnotic trance states
Create unconstrained frame of mind for novel connections and associations
Used in alpha/theta training for PTSD treatment
Occur during out-of-it or depressed states

Alpha Waves (8-12 Hz)

Accompanied by sense of peace and calm
Familiar to mindfulness meditation practitioners
Used to help people achieve focused relaxation
Walter Reed National Military Medical Center uses alpha training for PTSD treatment

Beta Waves (13-20 Hz)

Fastest brain waves, brain oriented to outside world
Enable focused attention during tasks
High beta (over 20 Hz) associated with agitation, anxiety, and body tenseness.

HELPING THE BRAIN TO FOCUS

Neurofeedback Training:

Improves creativity, athletic control, inner awareness (even for highly accomplished individuals)
Studied more thoroughly for performance enhancement than psychiatric problems

Sports Medicine:

Boston University's only department familiar with neurofeedback
Len Zaichkowsky, sports psychologist, used neurofeedback to train Vancouver Canucks

Performance Enhancement:

Neurofeedback studied extensively for performance enhancement
AC Milan soccer club used it to help players remain focused and relaxed
Increased mental and physiological control led to wins in 2006 World Cup and European championship (AC Milan)
Included in Canada's $117 million, five-year plan for 2010 Winter Olympics

Musical Performance:

Neurofeedback benefits focus, attention, and concentration
Students who received neurofeedback training had a 10% improvement in music performance (Britain’s Royal College of Music study)

Attention-Deficit/Hyperactivity Disorder (ADHD):

At least thirty-six studies show neurofeedback is an effective and time-limited treatment for ADHD
As effective as conventional drugs
No further treatment necessary once brain has been trained to produce different patterns of electrical communication

WHERE IS THE PROBLEM IN MY BRAIN?

qEEG Analysis:

Sophisticated computerized EEG analysis (quantitative EEG or qEEG)
Traces brain-wave activity millisecond by millisecond
Converts activity into a color map of frequency levels in key brain areas
Shows communication between brain regions
Large databases available for comparison with other individuals
Relatively inexpensive and portable compared to fMRI scans

qEEG and DSM Diagnostic Categories:

qEEG evidence shows arbitrary boundaries of current mental illness labels (DSM)
Mental states common to multiple diagnoses, such as confusion or agitation, have specific qEEG patterns
More problems a patient has, the more abnormalities in the qEEG

Benefits of qEEG for Patients:

Helps patients understand localized electrical activity in their brains
Explains difficulty focusing and lack of emotional control
Shifts focus from self-blame to learning new processing methods
Empowering experience of changing brain activity with the mind

Interpreting qEEG Results:

Training to increase presentness: patients can see progress in real time
Benefits accumulate when feedback is related to specific behaviors or actions.

HOW DOES TRAUMA CHANGE BRAIN WAVES?

Trauma and Brain Waves

Traumatized individuals show various qEEG patterns in neurofeedback lab
- Hyperaroused emotional brains dominate mental life: excessive right temporal lobe activity, frontal slow-wave activity
- Calming fear center decreases trauma-based problems, improves executive functioning
- Other patients panic when closing eyes, train to produce more relaxed brain patterns
- Overreact to sounds and light, focus on changing communication patterns at the back of the brain

Alexander McFarlane's Research

Studying how combat changes previously normal brains
Australian Department of Defence asked for mental and biological functioning study
Measured qEEG in 179 combat troops before and after each deployment to Middle East
Decrease in alpha power at the back of the brain with more months in combat
- Area monitors body state, regulates sleep and hunger
- Decrease reflects persistent agitation
Brain waves at front of brain show progressive slowing with each deployment
- Soldiers develop frontal-lobe activity resembling ADHD
- Interferes with executive functioning and focused attention
Arousal no longer helps soldiers focus on ordinary tasks, only makes them agitated and restless
Unknown if any soldiers will develop PTSD or degree to which brains will readjust to civilian life

NEUROFEEDBACK AND LEARNING DISABILITIES

Childhood trauma interferes with proper wiring of sensory-integration systems
Result: Learning disabilities, affecting auditory-word processing and hand-eye coordination
Behavioral problems often mask learning difficulties
Trauma disrupts basic processing functions (e.g., getting lost, auditory delay)

Impact on Learning:

Difficulty following instructions
Inability to concentrate
Disorganization in time and space management
Lack of attention and focus

Neurofeedback as a Solution:

Helps reverse learning disabilities
Improves ability to keep track of things (maps, schedules)
Enhances organization skills
Potential for activating neuroplasticity after critical periods

Challenges in Brain and Mind Science:

Assisting individuals in organizing time and space if early trauma has interfered with their development
Limited success with drugs or conventional therapy in addressing these issues
Urgent need to study the potential of neurofeedback as an alternative intervention.

ALPHA-THETA TRAINING

Alpha-Theta Training

Neurofeedback procedure to induce hypnagogic states
Predomination of theta waves leads to focus on internal world
Alpha brain waves act as bridge between external and internal worlds
Frequencies alternately rewarded in alpha-theta training

PTSD and Alpha-Theta Training

Open mind to new possibilities, loosen conditioned connections
Twilight states foster safe reexperiencing of traumatic events
New associations created, potential for fresh perspective

Study on Alpha-Theta Training and PTSD

29 Vietnam veterans with chronic combat-related PTSD
15 assigned to EEG alpha-theta training, 14 to control group
Neurofeedback facilitated twilight states by rewarding alpha and theta waves
Participants guided into deep relaxation, asked to use positive mental imagery
Outcomes:
- Neurofeedback group had significant decrease in PTSD symptoms, physical complaints, depression, anxiety, paranoia
- Only three neurofeedback-treated veterans reported disturbing flashbacks and nightmares
- Fourteen out of fifteen used significantly less medication
Comparison group experienced increase in PTSD symptoms, hospitalizations, and medication use
Study replicated by other researchers but received little attention outside neurofeedback community.

NEUROFEEDBACK, PTSD, AND ADDICTION

Approximately one-third to one-half of severely traumatized people develop substance abuse problems (Trauma and Substance Abuse)
- Soldiers have used alcohol to cope with trauma since ancient times
- Motor vehicle accident victims have a high risk of developing drug or alcohol problems

PTSD and Substance Abuse are linked (Circular Relationship)

Drugs and alcohol provide temporary relief from trauma symptoms
Withdrawal increases hyperarousal, intensifying PTSD symptoms
Two ways to break the cycle: Resolve PTSD symptoms or treat hyperarousal
- EMDR is one method for resolving PTSD symptoms
- Naltrexone is sometimes used to reduce hyperarousal but not effective in all cases

Case Study: Neurofeedback and Cocaine Addiction

Woman with history of childhood sexual abuse, addiction to cocaine (Severe Trauma and Drug Abuse)
Quick recovery after two neurofeedback sessions (Recovery from Drug Abuse)
Few studies on neurofeedback for addiction in recent years (Limited Research)

Study: Neurofeedback and PTSD with Alcoholism

Study by Peniston and Kulkosky on veterans with dual diagnoses of alcoholism and PTSD (Dual Diagnosis)
Fifteen veterans received alpha-theta training, control group received standard treatment without neurofeedback
Follow-up for three years: Eight members of neurofeedback group stopped drinking completely, one relapsed but didn't drink again, most were less depressed (Effective Results)
Control group was readmitted to the hospital within eighteen months (Ineffective Results)

Conclusion

Neurofeedback shows promise in treating addiction and PTSD
More research is needed to establish potential and limitations

THE FUTURE OF NEUROFEEDBACK

Neurofeedback and its applications:

Used for developmental trauma, tension headaches, traumatic brain injury, anxiety, panic attacks, meditation, autism, seizure control, mood disorders, etc.
Used in military and VA facilities to treat PTSD.
Wide spectrum of efficacy, according to research.
Neurofeedback plays a major therapeutic role (Frank Duffy).
Questions remain about treatment protocols.

Shift in scientific paradigm:

Thomas Insel's call for understanding mind and brain in terms of electrical communication.
NIMH re-orienting research towards "disorders of the human connectome."
Mapping the connectome to decipher electrical signals.

Lisa's experience with Neurofeedback:

Calmed down, stopped dissociation.
Emotions have meaning, not always anxious or in fight-or-flight mode.
Lowered blood pressure, freed up to live life.
Graduated top of nursing school class and works full time as a nurse.

CHAPTER 20

FINDING YOUR VOICE: COMMUNAL RHYTHMS AND THEATER

Finding Your Voice: author's personal experience with son's recovery from chronic fatigue syndrome through theater

Background:

Son, Nick, experienced health issues leading to isolation and self-hate
Desperate parents sought help through improvisational theater

Theater as Therapy:

Nick responded positively to evening class
Landed first role as "Action" in West Side Story
Developed physical sense of pleasure, confidence
Cast as "Fonz" in Happy Days, experienced adoration and power

Importance of Embodiment:

Our sense of agency defined by relationship with body and its rhythms
Waking, sleeping, eating, sitting, walking shape our days
Finding your voice requires being in your body
Opposite of dissociation or depression

Acting as a Tool for Embodiment:

Acting is an experience of using your body to take your place in life
Provides opportunity to deeply and physically experience different identities
Valuable contribution to a group leads to visceral sense of power and competence
Sets the foundation for personal growth and development into creative, loving adult.

THE THEATER OF WAR

Theater as a Form of Therapy for Veterans

Witnessed veterans' transformation through theater in 1988
Three veterans involved in production raised funds for homeless veteran shelter
Greek theater may have served as ritual reintegration for combat veterans

Ancient Greek Theater and Military Connection

Originated from religious rites and reenacting mythical stories
Central role in civic life, with audience seeing each other's reactions
Audiences likely composed of combat veterans and active-duty soldiers
Performers were citizen-soldiers (e.g., Sophocles)

Modern Application: Theater of War

Bryan Doerries arranges readings of Greek plays for military personnel
Inspired by personal loss and classical texts
Funded by U.S. Department of Defense
Performances followed by town hall discussions
Over 200 performances since 2008 to address combat veterans' plight

Impact of Theater of War

Provides a platform for veterans to share experiences and emotions
Fosters dialogue and understanding among families, friends, and community
Electric atmosphere with audience members connecting and sharing stories
Validation and recognition of veterans' experiences through ancient texts.

KEEPING TOGETHER IN TIME

Collective movement and music create a larger context for our lives and instill hope and courage

Religious rituals:

Involve rhythmic movements and music
Examples:
- Jewish davening
- Catholic Mass
- Buddhist meditation
- Muslim prayer rituals

Civil rights movement in the US:

Marchers linked arms and sang "We Shall Overcome"
Music bound people together and made them powerful advocates

Archbishop Desmond Tutu and Truth and Reconciliation Commission:

Used collective singing and dancing to help witnesses testify about atrocities
Prevented potential orgy of revenge

Historical role of dance and military drill:

Creating "muscular bonding" (William H. McNeill)
Roman legions' invincibility attributed to marching in step with music
Prince Maurice of Orange introduced close-order drill in Dutch army
- Provided sense of purpose and solidarity
- Made it possible to execute complicated maneuvers
Spread of close-order drill across Europe and US military

Estonia's "Singing Revolution":

Thousands gathered to sing patriotic songs in defiance of Soviet occupation
Continued protests led to independence and protection of radio and TV stations from Soviet tanks.

TREATING TRAUMA THROUGH THEATER

Three programs for treating trauma through theater: Urban Improv (Boston), The Possibility Project (New York City), and Shakespeare & Company (Lenox, MA)
Common foundation: confrontation of painful realities and symbolic transformation through communal action
Confronting emotions and embodying them in theater helps traumatized people connect with their feelings and others
Theater provides a safe space to explore inner and interpersonal conflicts
Trauma survivors can find common humanity and understanding through theater
Theater encourages expressing deep truths and finding ways to tell the truth

Benefits of Theater for Trauma Survivors

Confrontation of painful realities and emotions
Symbolic transformation through communal action
Connection with others through shared humanity
Exploration of inner and interpersonal conflicts
Expression of deep truths

Challenges Faced by Traumatized People

Afraid to feel deeply or experience emotions due to fear of loss of control
Cut off from human race, feeling godforsaken
Terrified of conflict and potential for losing control
Tendency to hide or forget traumatic experiences

Theater as a Resource for Recovery

Theater is widely available resource for trauma recovery
Confronts themes of love, hate, aggression, surrender, loyalty, betrayal, etc.
Encourages embodying emotions and expressing them to others
Provides opportunities for collective confrontation with human condition
Helps traumatized people connect with their feelings and others
Offers a safe space to explore conflicts and find ways to tell the truth

MAKING IT SAFE TO ENGAGE

Making it Safe for Traumatized Individuals in Theater Programs

Theater programs for traumatized individuals: angry, frightened teenagers, withdrawn veterans, etc.
Initial challenge: getting participants to be more present in the room

Engaging Participants

Start with simple physical activities
Gradually increase complexity
Incremental approach to avoid overwhelming participants

Creating a Safe Space

Get participants moving around the room
Create balance and awareness of others
Use prompts to encourage interaction
Encourage eye contact gradually

Mirroring Exercises

Help participants get in tune with one another
Loosen preoccupation with what others think
Attune viscerally, not cognitively
Indicates safety when exercises result in giggles

Building Trust

Blindfolded leading exercise
Terrifying for both leader and follower
Gradually increase duration
Emotionally overwhelming, some participants need time alone afterwards

Theater as a Healing Tool

Access full range of emotions and physical sensations
Put participants in touch with their bodies
Explore alternative ways of engaging with life

URBAN IMPROV

Urban Improv (UI) and Their Violence Prevention Program

UI is a Boston arts institution that runs a theater group for students
My son was involved with UI through high school and volunteered during college
UI's violence prevention program received a research grant to assess its efficacy
I joined the team as they visited schools with their multicultural ensemble

UI Program Structure

Scripted skits depicting everyday problems for students
Students experiment with various solutions in role-play scenarios
Discussion groups after each presentation

Fourth-Grade Study Results

Significant positive response on standardized rating scales
Fewer fights, angry outbursts, and more cooperation and self-control
Increased attentiveness and engagement in the classroom

Eighth-Grade Study Results

High levels of trauma exposure among eighth graders
Significantly more aggressive behavior than fourth graders
Program made no significant difference in their behavior

Longer, Intensive Program Development

Collaboration between Trauma Center team and UI actors
Focus on team building and emotion-regulation exercises
Scripts dealing directly with violence experiences

Testing the Longer Program

Chaotic environment with students from high-crime neighborhoods
Students sided with aggressors in scenes involving danger
Gradual progress in getting students to experiment with new roles

Bureaucratic Resistance

Attempt to make Trauma Drama a regular part of eighth-grade curriculum unsuccessful
Continues as an integral part of residential treatment programs at Justice Resource Institute
Music, theater, art, and sports disappearing from schools.

THE POSSIBILITY PROJECT

Paul Griffin's New York City program for creating a full-length musical by actors who write their own scripts over nine months
Actors meet three hours a week, perform for several hundred people
Recent graduates lead production teams, acting as role models

Foster Care Program

Difficult population: 60% convicted of a crime, 75% on public assistance, only 6% completed community college degree after aging out
Understanding foster care is like learning about a foreign country
Foster children create their own security and love
Life is upside down for foster-care youth: abandonment makes it hard to trust
Multiple people in charge leads to political savvy and playing people
Permanency and independence: best form of permanency is steady group of friends, interdependence is key
Natural actors: express emotions and create reality from pain and hurt
Collaboration helps kids become important people in one another's lives

Program Phases

Phase One: Group Building
- Establish basic agreements
- Singing and moving together
Phase Two: Sharing Life Stories
- Discover shared experiences
- Create their own show
- Focus shifts to becoming the best actor, singer, dancer, etc.
- Competence is the best defense against trauma

Importance of Theater Programs

Teaches cause and effect
Gives foster kids a sense of control by giving them power over their destiny in production
Heals trauma without mentioning the word

SENTENCED TO SHAKESPEARE

Program for adjudicated teenage offenders sentenced to intensive acting study
Six weeks, four afternoons a week
Focus on Shakespeare plays and performances

Challenges for Participants

Convicted of fighting, drinking, stealing, and property crimes
Angry, suspicious, and in shock
Struggle with language and communication
Familiar with violence as means of expression

Benefits of the Program

Opportunity to practice contained aggression through swordplay
Learning richness and potential of language
Discovering character and emotional depth
Life-changing experience for some participants

Process of the Program

Investigate Shakespeare's words line by line
Emphasis on understanding meaning and reactions
Gradual internalization of lines
Focus on emotional experiences instead of judgments

Impact on Participants

Learning to experience and tolerate deep emotions
Improved communication skills
Increased self-confidence
Reduced vulnerability and increased trust in themselves

Larry's Story

Fifty-nine-year-old Vietnam veteran with twenty-seven detox hospitalizations
Volunteered to play Brutus in Julius Caesar
Struggled with lines, fearful of judgment
Gradually allowed himself to feel every word and own the lines
Started first job in seven years and still working six months later

THERAPY AND THEATER

Tina Packer: therapy and theater are based on intuition and deep resonance, opposed to objective research (Edward, a Shakespeare & Company teacher, shared an experience)

Experience of Edward:

Morning exercise: Releasing torso muscles for natural breath
Feeling wave of sadness when rolling through certain ribs
No injury reported
Afternoon class: Prepared speech from Richard II about giving up crown
Recalled mother's broken ribs during discussion
Anger and frustration towards Tina's questions about early life experiences
Memories resurfaced: Incubator, hospital stays, oxygen tent, uncle driving through red lights
Intense emotional response: Screaming, trembling, shaking
Tina's guidance: Becoming mother reassuring self and newborn
New intention for speech: Expressing deep emotions as mother
Release of tension: First orgasm with another person

Impact of Tina's Approach:

Allowed Edward to connect with deep emotions and release tension
Changed the story by reassuring him that it was safe to express pain
Led to a more profound understanding of his experiences and increased connection to the world.

EPILOGUE

CHOICES TO BE MADE

We are on the brink of becoming a trauma-conscious society.

Advances in neuroscience provide a better understanding of how trauma affects brain development, self-regulation, and attention.

Importance of a Healthy Society and Safe Childhood

Feeling abandoned, worthless, or invisible leads to fear, destruction of curiosity and playfulness
Healthy society requires children who can safely play and learn
Growth requires curiosity and adaptability through exploration
Over 50% of Head Start children have experienced three or more adverse childhood experiences (ACE study)
Safe and meaningfully connected individuals less likely to engage in destructive behaviors
Child abuse and neglect is preventable cause of mental illness, drug/alcohol abuse, and leading causes of death

Impact of Trauma on Children and Adolescents

Trauma can lead to feelings of helplessness, susceptibility to harmful influences
Trauma is the single most preventable cause of mental illness, drug/alcohol abuse, and significant contributors to various health issues
Focus of work: children and adolescents
National Child Traumatic Stress Network (NCTSN) established in 2001 with over 150 centers nationwide
Comprehensive programs for traumatized, abused, and neglected children

Transforming Schools into Safe Havens

Teachers' initial response: "I came here to be a teacher, not a social worker"
Trauma-focused interventions can transform school culture
Recognizing and understanding trauma effects on children
Fostering safety, predictability, and being known and seen
Greeting children by name, face-to-face contact, check-ins, modeling new ways of communication
Acknowledging and addressing the cause of disturbing behaviors instead of punishment
Predictability, clarity of expectations, consistency
Translating brain science into everyday practice: calming down, safe areas, sensory awareness.

Self-Regulation and Emotional Intelligence for Children:

Kids as young as three can learn self-regulation through practices like blowing soap bubbles and focusing on breath.
Older children need help "befriending" their bodies to deal with disruptive physical sensations and emotional reactions.
Self-awareness, self-regulation, and communication are essential skills for children alongside academic subjects.
Mirroring exercises help kids identify emotions and learn interpersonal communication.
Reciprocity and safe interpersonal communication promote relaxation and focus.
Simple activities like playing games or keeping a beach ball in the air can improve focus and cohesion.
Engaging in communal efforts, such as sports, music, or theater, promotes agency and community.

Interventions for Children:

Mirroring exercises to identify emotions and learn interpersonal communication.
Computer games to help focus and improve heart rate variability.
Athletics, music, dance, and theatrical performances promote agency and community.
Intense communal efforts force kids to collaborate, compromise, and stay focused on tasks.

Success Stories:

Children become less anxious, emotionally reactive, aggressive, or withdrawn.
Improved school performance and attention deficit issues.
Parents report better sleep and increased ability to seek help.
Interventions draw on natural wellsprings of cooperation, safety, reciprocity, and imagination.

The Importance of Trauma:

Trauma reveals our fragility and man's inhumanity but also our resilience.
Visionaries and societies have made profound advances from dealing with trauma.
Trauma is now the most urgent public health issue, and we have the knowledge to respond effectively.

APPENDIX

CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER

Consensus Proposed Criteria for Developmental Trauma Disorder

Goal: Capture clinical presentations of children exposed to chronic interpersonal trauma
Current diagnostic system limitations: No diagnosis, multiple diagnoses, emphasis on behavior control, lack of safety in etiology, and neglect of developmental disruptions
Proposed Criteria Development Team: Bessel A. van der Kolk, MD & Robert S. Pynoos, MD (leaders) with participation from Dante Cicchetti, PhD, Marylene Cloitre, PhD, Wendy D’Andrea, PhD, Julian D. Ford, PhD, Alicia F. Lieberman, PhD, Frank W. Putnam, MD, Glenn Saxe, MD, Joseph Spinazzola, PhD, Bradley C. Stolbach, PhD, and Martin Teicher, MD, PhD
Basis: Extensive literature review, expert clinical wisdom, NCTSN clinician surveys, and preliminary data analysis from various settings (NCTSN treatment centers, child welfare systems, inpatient psychiatric settings, juvenile detention centers)
Validity, prevalence, symptom thresholds, or clinical utility not yet examined through prospective data collection or analysis
Intended to describe symptoms exhibited by many children and adolescents following complex trauma
Guided Developmental Trauma Disorder field trials since 2009.

Clinical Significance of Developmental Trauma Disorder

Captures reality of clinical presentations of children exposed to chronic interpersonal trauma
Helps clinicians develop effective interventions and study neurobiology and transmission of chronic interpersonal violence
Addresses limitations in current diagnostic system for children with complex trauma backgrounds.

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Summary of Bessel van der Kolk's The Body Keeps the Score

Contents

PROLOGUE

FACING TRAUMA

PART ONE. THE REDISCOVERY OF TRAUMA.

CHAPTER 1

LESSONS FROM VIETNAM VETERANS

TRAUMA AND THE LOSS OF SELF

NUMBING

THE REORGANIZATION OF PERCEPTION

STUCK IN TRAUMA

DIAGNOSING POSTTRAUMATIC STRESS

A NEW UNDERSTANDING

CHAPTER 2

REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN

TRAUMA BEFORE DAWN

MAKING SENSE OF SUFFERING

INESCAPABLE SHOCK

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

SOOTHING THE BRAIN

THE TRIUMPH OF PHARMACOLOGY

ADAPTATION OR DISEASE?

CHAPTER 3

LOOKING INTO THE BRAIN: THE NEUROSCIENCE REVOLUTION

SPEECHLESS HORROR

SHIFTING TO ONE SIDE OF THE BRAIN

STUCK IN FIGHT OR FLIGHT

PART TWO. THIS IS YOUR BRAIN ON TRAUMA.

CHAPTER 4

RUNNING FOR YOUR LIFE: THE ANATOMY OF SURVIVAL

ORGANIZED TO SURVIVE

THE BRAIN FROM BOTTOM TO TOP

MIRRORING EACH OTHER: INTERPERSONAL NEUROBIOLOGY

IDENTIFYING DANGER: THE COOK AND THE SMOKE DETECTOR

CONTROLLING THE STRESS RESPONSE: THE WATCHTOWER

THE RIDER AND THE HORSE

STAN AND UTE’S BRAINS ON TRAUMA

DISSOCIATION AND RELIVING

THE TIMEKEEPER COLLAPSES

DEPERSONALIZATION: SPLIT OFF FROM THE SELF

LEARNING TO LIVE IN THE PRESENT

CHAPTER 5

BODY-BRAIN CONNECTIONS

A WINDOW INTO THE NERVOUS SYSTEM

THE NEURAL LOVE CODE

SAFETY AND RECIPROCITY

THREE LEVELS OF SAFETY

FIGHT OR FLIGHT VERSUS COLLAPSE

HOW WE BECOME HUMAN

DEFEND OR RELAX?

NEW APPROACHES TO TREATMENT

CHAPTER 6

LOSING YOUR BODY, LOSING YOUR SELF

LOSING YOUR BODY

HOW DO WE KNOW WE’RE ALIVE?

THE SELF-SENSING SYSTEM

THE SELF UNDER THREAT

AGENCY: OWNING YOUR LIFE

ALEXITHYMIA: NO WORDS FOR FEELINGS

DEPERSONALIZATION

BEFRIENDING THE BODY

CONNECTING WITH YOURSELF, CONNECTING WITH OTHERS

PART THREE. THE MINDS OF CHILDREN.

CHAPTER 7

GETTING ON THE SAME WAVELENGTH: ATTACHMENT AND ATTUNEMENT

MEN WITHOUT MOTHERS

A SECURE BASE

THE DANCE OF ATTUNEMENT

BECOMING REAL

LIVING WITH THE PARENTS YOU HAVE

BECOMING DISORGANIZED WITHIN

THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT

DISSOCIATION: KNOWING AND NOT KNOWING

RESTORING SYNCHRONY