메인 The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma
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29 November 2019 (15:58)
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16 March 2020 (02:48)
This is an incredible book for anyone recovering from childhood trauma. I spend 15 minutes reading and 15 minutes reviewing my childhood, my life falls into context and I understand myself better. Along with the 12 steps these kind of texts are really creating a sense of self esteem and self understanding for my life.
14 July 2020 (15:33)
[image: ] VIKING Published by the Penguin Group Penguin Group (USA) LLC 375 Hudson Street New York, New York 10014 [image: 131224.jpg] USA | Canada | UK | Ireland | Australia | New Zealand | India | South Africa | China penguin.com A Penguin Random House Company First published by Viking Penguin, a member of Penguin Group (USA) LLC, 2014 Copyright © 2014 by Bessel van der Kolk Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA [Van der Kolk, Bessel A., 1943- author. The body keeps the score : brain, mind, and body in the healing of trauma / Bessel A. van der Kolk. p. ; cm. Includes bibliographical references and index. eBook ISBN 978-1-101-60830-2 I. Title. [DNLM: 1. Stress Disorders, Post-Traumatic—physiopathology. 2. Stress Disorders, Post-Traumatic—therapy. WM 172.5] RC552.P67 616.85'21206—dc23 2014021365 Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book. Version_1 CHAPTER 16 LEARNING TO INHABIT YOUR BODY: YOGA As we begin to re-experience a visceral reconnection with the n; eeds of our bodies, there is a brand new capacity to warmly love the self. We experience a new quality of authenticity in our caring, which redirects our attention to our health, our diets, our energy, our time management. This enhanced care for the self arises spontaneously and naturally, not as a response to a “should.” We are able to experience an immediate and intrinsic pleasure in self-care. —Stephen Cope, Yoga and the Quest for the True Self The first time I saw Annie she was slumped over in a chair in my waiting room, wearing faded jeans and a purple Jimmy Cliff T-shirt. Her legs were visibly shaking, and she kept staring at the floor even after I invited her in. I had very little information about her, other than that she was forty-seven years old and taught special-needs children. Her body communicated clearly that she was too terrified to engage in conversation—or even to provide routine information about her address or insurance plan. People who are this scared can’t think straight, and any demand to perform will only make them shut down further. If you insist, they’ll run away and you’ll never see them again. Annie shuffled into my office and remained standing, barely breathing, looking like a frozen bird. I knew we couldn’t do anything until I could help her quiet down. Moving to within six feet of her and making sure she had unobstructed access to the door, I encouraged her to take slightly deeper breaths. I breathed with her and asked her to follow my example, gently raising my arms from my sides as she inhaled and lowering them as I exhaled, a qigong technique that one of my Chinese students had taught me. She stealthily followed my movements, her eyes still fixed on the floor. We spent about half an hour this way. From time to time I quietly asked her to notice how her feet felt against the floor and how her chest expanded and contracted with each breath. Her breath gradually became slower and deeper, her face softened, her spine straightened a bit, and her eyes lifted to about the level of my Adam’s apple. I began to sense the person behind that overwhelming terror. Finally she looked more relaxed and showed me the glimmer of a smile, a recognition that we both were in the room. I suggested that we stop there for now—I’d made enough demands on her—and asked whether she would like to come back a week later. She nodded and muttered, “You sure are weird.” As I got to know Annie, I inferred from the notes she wrote and the drawings she gave me that she had been dreadfully abused by both her father and her mother as a very young child. The full story was only gradually revealed, as she slowly learned to call up some of the things that had happened to her without her body being hijacked into uncontrollable anxiety. I learned that Annie was extraordinarily skilled and caring in her work with special-needs kids. (I tried out quite a few of the techniques she told me about with the children in our own clinic and found them extremely helpful). She would talk freely about the children she taught but would clam up immediately if we verged on her relationships with adults. I knew she was married, but she barely mentioned her husband. She often coped with disagreements and confrontations by making her mind disappear. When she felt overwhelmed she’d cut her arms and breasts with a razor blade. She had spent years in various forms of therapy and had tried many different medications, which had done little to help her deal with the imprints of her horrendous past. She had also been admitted to several psychiatric hospitals to manage her self-destructive behaviors, again without much apparent benefit. In our early therapy sessions, because Annie could only hint at what she was feeling and thinking before she would shut down and freeze, we focused on calming the physiological chaos within. We used every technique that I had learned over the years, like breathing with a focus on the out breath, which activates the relaxing parasympathetic nervous system. I also taught her to use her fingers to tap a sequence of acupressure points on various parts of her body, a practice often taught under the name EFT (Emotional Freedom Technique), which has been shown to help patients stay within the window of tolerance and often has positive effects on PTSD symptoms.1 THE LEGACY OF INESCAPABLE SHOCK Because we can now identify the brain circuits involved in the alarm system, we know, more or less, what was happening in Annie’s brain as she sat that first day in my waiting room: Her smoke detector, her amygdala, had been rewired to interpret certain situations as harbingers of life-threatening danger, and it was sending urgent signals to her survival brain to fight, freeze, or flee. Annie had all these reactions simultaneously—she was visibly agitated and mentally shut down. As we’ve seen, broken alarm systems can manifest in various ways, and if your smoke detector malfunctions, you cannot trust the accuracy of your perceptions. For example, when Annie started to like me she began to look forward to our meetings, but she would arrive at my office in an intense panic. One day she had a flashback of feeling excited that her father was coming home soon—but later that evening he molested her. For the first time, she realized that her mind automatically associated excitement about seeing someone she loved with the terror of being molested. Small children are particularly adept at compartmentalizing experience, so that Annie’s natural love for her father and her dread of his assaults were held in separate states of consciousness. As an adult Annie blamed herself for her abuse, because she believed that the loving, excited little girl she once was had led her father on—that she had brought the molestation upon herself. Her rational mind told her this was nonsense, but this belief emanated from deep within her emotional, survival brain, from the basic wiring of her limbic system. It would not change until she felt safe enough within her body to mindfully go back into that experience and truly know how that little girl had felt and acted during the abuse. THE NUMBING WITHIN One of the ways the memory of helplessness is stored is as muscle tension or feelings of disintegration in the affected body areas: head, back, and limbs in accident victims, vagina and rectum in victims of sexual abuse. The lives of many trauma survivors come to revolve around bracing against and neutralizing unwanted sensory experiences, and most people I see in my practice have become experts in such self-numbing. They may become serially obese or anorexic or addicted to exercise or work. At least half of all traumatized people try to dull their intolerable inner world with drugs or alcohol. The flip side of numbing is sensation seeking. Many people cut themselves to make the numbing go away, while others try bungee jumping or high-risk activities like prostitution and gambling. Any of these methods can give them a false and paradoxical feeling of control. When people are chronically angry or scared, constant muscle tension ultimately leads to spasms, back pain, migraine headaches, fibromyalgia, and other forms of chronic pain. They may visit multiple specialists, undergo extensive diagnostic tests, and be prescribed multiple medications, some of which may provide temporary relief but all of which fail to address the underlying issues. Their diagnosis will come to define their reality without ever being identified as a symptom of their attempt to cope with trauma. The first two years of my therapy with Annie focused on helping her learn to tolerate her physical sensations for what they were—just sensations in the present, with a beginning, a middle, and an end. We worked on helping her stay calm enough to notice what she felt without judgment, so she could observe these unbidden images and feelings as residues of a terrible past and not as unending threats to her life today. Patients like Annie continuously challenge us to find new ways of helping people regulate their arousal and control their own physiology. That is how my Trauma Center colleagues and I stumbled upon yoga. FINDING OUR WAY TO YOGA: BOTTOM-UP REGULATION Our involvement with yoga started in 1998 when Jim Hopper and I first heard about a new biological marker, heart rate variability (HRV), that had recently been discovered to be a good measure of how well the autonomic nervous system is working. As you’ll recall from chapter 5, the autonomic nervous system is our brain’s most elementary survival system, its two branches regulating arousal throughout the body. Roughly speaking, the sympathetic nervous system (SNS) uses chemicals like adrenaline to fuel the body and brain to take action, while the parasympathetic nervous system (PNS) uses acetylcholine to help regulate basic body functions like digestion, wound healing, and sleep and dream cycles. When we’re at our best, these two systems work closely together to keep us in an optimal state of engagement with our environment and with ourselves. Heart rate variability measures the relative balance between the sympathetic and the parasympathetic systems. When we inhale, we stimulate the SNS, which results in an increase in heart rate. Exhalations stimulate the PNS, which decreases how fast the heart beats. In healthy individuals inhalations and exhalations produce steady, rhythmical fluctuations in heart rate: Good heart rate variability is a measure of basic well-being. Why is HRV important? When our autonomic nervous system is well balanced, we have a reasonable degree of control over our response to minor frustrations and disappointments, enabling us to calmly assess what is going on when we feel insulted or left out. Effective arousal modulation gives us control over our impulses and emotions: As long as we manage to stay calm, we can choose how we want to respond. Individuals with poorly modulated autonomic nervous systems are easily thrown off balance, both mentally and physically. Since the autonomic nervous system organizes arousal in both body and brain, poor HRV—that is, a lack of fluctuation in heart rate in response to breathing—not only has negative effects on thinking and feeling but also on how the body responds to stress. Lack of coherence between breathing and heart rate makes people vulnerable to a variety of physical illnesses, such as heart disease and cancer, in addition to mental problems such as depression and PTSD.2 In order to study this issue further, we acquired a machine to measure HRV and started to put bands around the chests of research subjects with and without PTSD to record the depth and rhythm of their breathing while little monitors attached to their earlobes picked up their pulse. After we’d tested about sixty subjects, it became clear that people with PTSD have unusually low HRV. In other words, in PTSD the sympathetic and parasympathetic nervous systems are out of sync.3 This added a new twist to the complicated trauma story: We confirmed that yet another brain regulatory system was not functioning as it should.4 Failure to keep this system in balance is one explanation why traumatized people like Annie are so vulnerable to overrespond to relatively minor stresses: The biological systems that are meant to help us cope with the vagaries of life fail to meet the challenge. Our next scientific question was: Is there a way for people to improve their HRV? I had a personal incentive to explore this question, as I had discovered that my own HRV was not nearly robust enough to guarantee long-term physical health. An Internet search turned up studies showing that marathon running markedly increased HRV. Sadly, that was of little use, since neither I nor our patients were good candidates for the Boston Marathon. Google also listed seventeen thousand yoga sites claiming that that yoga improved HRV, but we were unable to find any supporting studies. Yogis may have developed a wonderful method to help people find internal balance and health, but back in 1998 not much work had been done on evaluating their claims with the tools of the Western medical tradition. [image: Art_29_1P.psd] Heart rate variability (HRV) in a well-regulated person. The rising and falling black lines represent breathing, in this case slow and regular inhalations and exhalations. The gray area shows fluctuations in heart rate. Whenever this individual inhales, his heart rate goes up; during exhalations the heart slows down. This pattern of heart rate variability reflects excellent physiological health. [image: Art_30_1P.psd] Responding to upset. When someone remembers an upsetting experience, breathing speeds up and becomes irregular, as does heart rate. Heart and breath no longer stay perfectly in sync. This is a normal response. [image: Art_31_1P.psd] HRV in PTSD. Breathing is rapid and shallow. Heart rate is slow and out of synch with the breath. This is a typical pattern of a shut-down person with chronic PTSD. [image: Art_32_1P.psd] A person with chronic PTSD reliving a trauma memory. Breathing initially is labored and deep, typical of a panic reaction. The heart races out of synch with the breath. This is followed by rapid, shallow breathing and slow heart rate, signs that the person is shutting down. Since then, however, scientific methods have confirmed that changing the way one breathes can improve problems with anger, depression, and anxiety5 and that yoga can positively affect such wide-ranging medical problems as high blood pressure, elevated stress hormone secretion,6 asthma, and low-back pain.7 However, no psychiatric journal had published a scientific study of yoga for PTSD until our own work appeared in 2014.8 As it happened, a few days after our Internet search a lanky yoga teacher named David Emerson walked through the front door of the Trauma Center. He told us that he’d developed a modified form of hatha yoga to deal with PTSD and that he’d been holding classes for veterans at a local vet center and for women in the Boston Area Rape Crisis Center. Would we be interested in working with him? Dave’s visit eventually grew into a very active yoga program, and in due course we received the first grant from the National Institutes of Health to study the effects of yoga on PTSD. Dave’s work also contributed to my developing my own regular yoga practice and becoming a frequent teacher at Kripalu, a yoga center in the Berkshire Mountains in western Massachusetts. (Along the way, my own HRV pattern improved as well.) In choosing to explore yoga to improve HRV we were taking an expansive approach to the problem. We could simply have used any of a number of reasonably priced handheld devices that train people to slow their breathing and synchronize it with their heart rate, resulting in a state of “cardiac coherence” like the pattern shown in the first illustration above.9 Today there are a variety of apps that can help improve HRV with the aid of a smartphone.10 In our clinic we have workstations where patients can train their HRV, and I urge all my patients who, for one reason or another, cannot practice yoga, martial arts, or qigong to train themselves at home. (See Resources for more information.) EXPLORING YOGA Our decision to study yoga led us deeper into trauma’s impact on the body. Our first experimental yoga classes met in a room generously donated by a nearby studio. David Emerson and his colleagues Dana Moore and Jodi Carey volunteered as instructors, and my research team figured out how we could best measure yoga’s effects on psychological functioning. We put flyers in neighborhood supermarkets and laundromats to advertise our classes and interviewed dozens of people who called in response. Ultimately we selected thirty-seven women who had severe trauma histories and who had already received many years of therapy without much benefit. Half the volunteers were selected at random for the yoga group, while the others would receive a well-established mental health treatment, dialectical behavior therapy (DBT), which teaches people how to apply mindfulness to stay calm and in control. Finally, we commissioned an engineer at MIT to build us a complicated computer that could measure HRV simultaneously in eight different people. (In each study group there were multiple classes, each with no more than eight participants.) While yoga significantly improved arousal problems in PTSD and dramatically improved our subjects’ relationships to their bodies (“I now take care of my body”; “I listen to what my body needs”), eight weeks of DBT did not affect their arousal levels or PTSD symptoms. Thus, our interest in yoga gradually evolved from a focus on learning whether yoga can change HRV (which it can)11 to helping traumatized people learn to comfortably inhabit their tortured bodies. Over time we also started a yoga program for marines at Camp Lejeune and have worked successfully with various other programs to implement yoga programs for veterans with PTSD. Even though we have no formal research data on the veterans, it looks as if yoga is at least as effective for them as it has been for the women in our studies. All yoga programs consist of a combination of breath practices (pranayama), stretches or postures (asanas), and meditation. Different schools of yoga emphasize variations in intensity and focus within these core components. For example, variations in the speed and depth of breathing and use of the mouth, nostrils, and throat all produce different results, and some techniques have powerful effects on energy.12 In our classes we keep the approach simple. Many of our patients are barely aware of their breath, so learning to focus on the in and out breath, to notice whether the breath was fast or slow, and to count breaths in some poses can be a significant accomplishment.13 We gradually introduce a limited number of classic postures. The emphasis is not on getting the poses “right” but on helping the participants notice which muscles are active at different times. The sequences are designed to create a rhythm between tension and relaxation—something we hope they will begin to perceive in their day-to-day lives. We do not teach meditation as such, but we do foster mindfulness by encouraging students to observe what is happening in different parts of the body from pose to pose. In our studies we keep seeing how difficult it is for traumatized people to feel completely relaxed and physically safe in their bodies. We measure our subjects’ HRV by placing tiny monitors on their arms during shavasana, the pose at the end of most classes during which practitioners lie face up, palms up, arms and legs relaxed. Instead of relaxation we picked up too much muscle activity to get a clear signal. Rather than going into a state of quiet repose, our students’ muscles often continue to prepare them to fight unseen enemies. A major challenge in recovering from trauma remains being able to achieve a state of total relaxation and safe surrender. LEARNING SELF-REGULATION After seeing the success of our pilot studies, we established a therapeutic yoga program at the Trauma Center. I thought that this might be an opportunity for Annie to develop a more caring relationship with her body, and I urged her to try it. The first class was difficult. Merely being given an adjustment by the instructor was so terrifying that she went home and slashed herself—her malfunctioning alarm system interpreted even a gentle touch on her back as an assault. At the same time Annie realized that yoga might offer her a way to liberate herself from the constant sense of danger that she felt in her body. With my encouragement she returned the following week. Annie had always found it easier to write about her experiences than to talk about them. After her second yoga class she wrote to me: “I don’t know all of the reasons that yoga terrifies me so much, but I do know that it will be an incredible source of healing for me and that is why I am working on myself to try it. Yoga is about looking inward instead of outward and listening to my body, and a lot of my survival has been geared around never doing those things. Going to the class today my heart was racing and part of me really wanted to turn around, but then I just kept putting one foot in front of the other until I got to the door and went in. After the class I came home and slept for four hours. This week I tried doing yoga at home and the words came to me ‘Your body has things to say.’ I said back to myself, ‘I will try and listen.’” A few days later Annie wrote: “Some thoughts during and after yoga today. It occurred to me how disconnected I must be from my body when I cut it. When I was doing the poses I noticed that my jaw and the whole area from where my legs end to my bellybutton is where I am tight, tense and holding the pain and memories. Sometimes you have asked me where I feel things and I can’t even begin to locate them, but today I felt those places very clearly and it made me want to cry in a gentle kind of way.” The following month both of us went on vacation and, invited to stay in touch, Annie wrote to me again: “I’ve been doing yoga on my own in a room that overlooks the lake. I’m continuing to read the book you lent me [Stephen Cope’s wonderful Yoga and the Quest for the True Self]. It’s really interesting to think about how much I have been refusing to listen to my body, which is such an important part of who I am. Yesterday when I did yoga I thought about letting my body tell me the story it wants to tell and in the hip opening poses there was a lot of pain and sadness. I don’t think my mind is going to let really vivid images come up as long as I am away from home, which is good. I think now about how unbalanced I have been and about how hard I have tried to deny the past, which is a part of my true self. There is so much I can learn if I am open to it and then I won’t have to fight myself every minute of every day.” One of the hardest yoga positions for Annie to tolerate was one that’s often called Happy Baby, in which you lie on your back with your knees deeply bent and the soles of your feet pointing to the ceiling, while holding your toes with your hands. This rotates the pelvis into a wide-open position. It’s easy to understand why this would make a rape victim feel extremely vulnerable. Yet, as long as Happy Baby (or any posture that resembles it) precipitates intense panic, it is difficult to be intimate. Learning how to comfortably assume Happy Baby is a challenge for many patients in our yoga classes. GETTING TO KNOW ME: CULTIVATING INTEROCEPTION One of the clearest lessons from contemporary neuroscience is that our sense of ourselves is anchored in a vital connection with our bodies.14 We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.15 While numbing (or compensatory sensation seeking) may make life tolerable, the price you pay is that you lose awareness of what is going on inside your body and, with that, the sense of being fully, sensually alive. In chapter 6 I discussed alexithymia, the technical term for not being able to identify what is going on inside oneself.16 People who suffer from alexithymia tend to feel physically uncomfortable but cannot describe exactly what the problem is. As a result they often have multiple vague and distressing physical complaints that doctors can’t diagnose. In addition, they can’t figure out for themselves what they’re really feeling about any given situation or what makes them feel better or worse. This is the result of numbing, which keeps them from anticipating and responding to the ordinary demands of their bodies in quiet, mindful ways. At the same time, it muffles the everyday sensory delights of experiences like music, touch, and light, which imbue life with value. Yoga turned out to be a terrific way to (re)gain a relationship with the interior world and with it a caring, loving, sensual relationship to the self. If you are not aware of what your body needs, you can’t take care of it. If you don’t feel hunger, you can’t nourish yourself. If you mistake anxiety for hunger, you may eat too much. And if you can’t feel when you’re satiated, you’ll keep eating. This is why cultivating sensory awareness is such a critical aspect of trauma recovery. Most traditional therapies downplay or ignore the moment-to-moment shifts in our inner sensory world. But these shifts carry the essence of the organism’s responses: the emotional states that are imprinted in the body’s chemical profile, in the viscera, in the contraction of the striated muscles of the face, throat, trunk, and limbs.17 Traumatized people need to learn that they can tolerate their sensations, befriend their inner experiences, and cultivate new action patterns. In yoga you focus your attention on your breathing and on your sensations moment to moment. You begin to notice the connection between your emotions and your body—perhaps how anxiety about doing a pose actually throws you off balance. You begin to experiment with changing the way you feel. Will taking a deep breath relieve that tension in your shoulder? Will focusing on your exhalations produce a sense of calm?18 Simply noticing what you feel fosters emotional regulation, and it helps you to stop trying to ignore what is going on inside you. As I often tell my students, the two most important phrases in therapy, as in yoga, are “Notice that” and “What happens next?” Once you start approaching your body with curiosity rather than with fear, everything shifts. Body awareness also changes your sense of time. Trauma makes you feel as if you are stuck forever in a helpless state of horror. In yoga you learn that sensations rise to a peak and then fall. For example, if an instructor invites you to enter a particularly challenging position, you may at first feel a sense of defeat or resistance, anticipating that you won’t be able to tolerate the feelings brought up by this particular position. A good yoga teacher will encourage you to just notice any tension while timing what you feel with the flow of your breath: “We’ll be holding this position for ten breaths.” This helps you anticipate the end of discomfort and strengthens your capacity to deal with physical and emotional distress. Awareness that all experience is transitory changes your perspective on yourself. This is not to say that regaining interoception isn’t potentially upsetting. What happens when a newly accessed feeling in your chest is experienced as rage, or fear, or anxiety? In our first yoga study we had a 50 percent dropout rate, the highest of any study we’d ever done. When we interviewed the patients who’d left, we learned that they had found the program too intense: Any posture that involved the pelvis could precipitate intense panic or even flashbacks to sexual assaults. Intense physical sensations unleashed the demons from the past that had been so carefully kept in check by numbing and inattention. This taught us to go slow, often at a snail’s pace. That approach paid off: In our most recent study only one out of thirty-four participants did not finish. [image: 127460.jpg] Effects of a weekly yoga class. After twenty weeks, chronically traumatized women developed increased activation of critical brain structures involved in self-regulation: the insula and the medial prefrontal cortex. YOGA AND THE NEUROSCIENCE OF SELF-AWARENESS During the past few years brain researchers such as my colleagues Sara Lazar and Britta Hölzel at Harvard have shown that intensive meditation has a positive effect on exactly those brain areas that are critical for physiological self-regulation.19 In our latest yoga study, with six women with histories of profound early trauma, we also found the first indications that twenty weeks of yoga practice increased activation of the basic self-system, the insula and the medial prefrontal cortex (see chapter 6). This research needs much more work, but it opens up new perspectives on how actions that involve noticing and befriending the sensations in our bodies can produce profound changes in both mind and brain that can lead to healing from trauma. After each of our yoga studies, we asked the participants what effect the classes had had on them. We never mentioned the insula or interoception; in fact, we kept the discussion and explanation to a minimum so that they could focus inward. Here is a sample of their responses: “My emotions feel more powerful. Maybe it’s just that I can recognize them now.” “I can express my feelings more because I can recognize them more. I feel them in my body, recognize them, and address them.” “I now see choices, multiple paths. I can decide and I can choose my life, it doesn’t have to be repeated or be experienced like a child.” “I was able to move my body and be in my body in a safe place and without hurting myself/getting hurt.” LEARNING TO COMMUNICATE People who feel safe in their bodies can begin to translate the memories that previously overwhelmed them into language. After Annie had been practicing yoga three times a week for about a year, she noticed that she was able to talk much more freely to me about what had happened to her. She thought this almost miraculous. One day, when she knocked over a glass of water, I got up from my chair and approached her with a Kleenex box, saying, “Let me clean that up.” This precipitated a brief, intense panic reaction. She was quickly able to contain herself, though, and explained why those particular words were so upsetting to her—they were what her father would say after he’d raped her. Annie wrote to me after that session: “Did you notice that I have been able to say the words out loud? I didn’t have to write them down to tell you what was happening. I didn’t lose trust in you because you said words that triggered me. I understood that the words were a trigger and not terrible words that no one should say.” Annie continues to practice yoga and to write to me about her experiences: “Today I went to a morning yoga class at my new yoga studio. The teacher talked about breathing to the edge of where we can and then noticing that edge. She said that if we notice our breath we are in the present because we can’t breathe in the future or the past. It felt so amazing to me to be practicing breathing in that way after we had just talked about it, like I had been given a gift. Some of the poses can be triggering for me. Two of them were today, one where your legs are up frog like and one where you are doing really deep breathing into your pelvis. I felt the beginning of panic, especially in the breathing pose, like oh no that’s not a part of my body I want to feel. But then I was able to stop myself and just say, notice that this part of your body is holding experiences and then just let it go. You don’t have to stay there but you don’t have to leave either, just use it as information. I don’t know that I have ever been able to do that in such a conscious way before. It made me think that if I notice without being so afraid, it will be easier for me to believe myself.” In another message, Annie reflected on the changes in her life: “I slowly learned to just have my feelings, without being hijacked by them. Life is more manageable: I am more attuned to my day and more present in the moment. I am more tolerant of physical touch. My husband and I are enjoying watching movies cuddled together in bed . . . a huge step. All this helped me finally feel intimate with my husband.” FURTHER READING DEALING WITH TRAUMATIZED CHILDREN Blaustein, Margaret, and Kristine Kinniburgh. Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience through Attachment, Self-Regulation, and Competency. New York: Guilford, 2012.. Hughes, Daniel. Building the Bonds of Attachment. New York: Jason Aronson, 2006. Perry, Bruce, and Maia Szalavitz. The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook. New York: Basic Books, 2006. Terr, Lenore. Too Scared to Cry: Psychic Trauma in Childhood. Basic Books, 2008. Terr, Lenore C. Working with Children to Heal Interpersonal Trauma: The Power of Play. Ed., Eliana Gil. New York: Guilford Press, 2011. Saxe, Glenn, Heidi Ellis, and Julie Kaplow. Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach. New York: Guilford Press, 2006. Lieberman, Alicia, and Patricia van Horn. Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment. New York: Guilford Press, 2011. PSYCHOTHERAPY Siegel, Daniel J. Mindsight: The New Science of Personal Transformation. New York: Norton, 2010. Fosha D., M. Solomon, and D. J. Siegel. The Healing Power of Emotion: Affective Neuroscience, Development and Clinical Practice (Norton Series on Interpersonal Neurobiology). New York: Norton, 2009. Siegel, D., and M. Solomon: Healing Trauma: Attachment, Mind, Body and Brain (Norton Series on Interpersonal Neurobiology). New York: Norton, 2003. Courtois, Christine, and Julian Ford. Treating Complex Traumatic Stress Disorders (Adults): Scientific Foundations and Therapeutic Models. New York: Guilford, 2013. Herman, Judith. Trauma and Recovery: The Aftermath of Violence—from Domestic Abuse to Political Terror. New York: Basic Books, 1992. NEUROSCIENCE OF TRAUMA Panksepp, Jaak, and Lucy Biven. The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions (Norton Series on Interpersonal Neurobiology). New York: Norton, 2012. Davidson, Richard, and Sharon Begley. The Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You Think, Feel, and Live—and How You Can Change Them. New York: Hachette, 2012. Porges, Stephen. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation (Norton Series on Interpersonal Neurobiology). New York: Norton, 2011. Fogel, Alan. Body Sense: The Science and Practice of Embodied Self-Awareness (Norton Series on Interpersonal Neurobiology). New York: Norton, 2009. Shore, Allan N. Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. New York: Psychology Press, 1994. Damasio, Antonio R. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. Houghton Mifflin Harcourt, 2000. BODY-ORIENTED APPROACHES Cozzolino, Louis. The Neuroscience of Psychotherapy: Healing the Social Brain, second edition (Norton Series on Interpersonal Neurobiology). New York: Norton, 2010. Ogden, Pat, and Kekuni Minton. Trauma and the Body: A Sensorimotor Approach to Psychotherapy (Norton Series on Interpersonal Neurobiology). New York: Norton, 2008. Levine, Peter A. In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness. Berkeley: North Atlantic, 2010. Levine, Peter A., and Ann Frederic. Waking the Tiger: Healing Trauma. Berkeley: North Atlantic, 2012 Curran, Linda. 101 Trauma-Informed Interventions: Activities, Exercises and Assignments to Move the Client and Therapy Forward. PESI, 2013. EMDR Parnell, Laura. Attachment-Focused EMDR: Healing Relational Trauma. New York: Norton, 2013. Shapiro, Francine. Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. Emmaus, PA: Rodale, 2012. Shapiro, Francine, and Margot Silk Forrest. EMDR: The Breakthrough “Eye Movement” Therapy for Overcoming Anxiety, Stress, and Trauma. New York: Basic Books, 2004. WORKING WITH DISSOCIATION Schwartz, Richard C. Internal Family Systems Therapy (The Guilford Family Therapy Series). New York: Guilford, 1997. O. van der Hart, E. R. Nijenhuis, and F. Steele. The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. New York: Norton, 2006. COUPLES Gottman, John. The Science of Trust: Emotional Attunement for Couples. New York: Norton, 2011. YOGA Emerson, David, and Elizabeth Hopper. Overcoming Trauma through Yoga: Reclaiming Your Body. Berkeley: North Atlantic, 2012. Cope, Stephen. Yoga and the Quest for the True Self. New York: Bantam Books, 1999. NEUROFEEDBACK Fisher, Sebern. Neurofeedback in the Treatment of Developmental Trauma: Calming the Fear-Driven Brain. New York: Norton, 2014. Demos, John N. Getting Started with Neurofeedback. New York: Norton, 2005. Evans, James R. Handbook of Neurofeedback: Dynamics and Clinical Applications. CRC Press, 2013. PHYSICAL EFFECTS OF TRAUMA Mate, Gabor When the Body Says No: Understanding the Stress-Disease Connection. New York: Random House, 2011. Sapolsky, Robert. Why Zebras Don’t Get Ulcers: The Acclaimed Guide to Stress, Stress-Related Diseases, and Coping. New York: Macmillan 2004. MEDITATION AND MINDFULNESS Zinn, Jon Kabat and Thich Nat Hanh. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, revised edition. New York: Random House, 2009. Kornfield, Jack. A Path with Heart: A Guide Through The Perils and Promises of Spiritual Life. New York: Random House, 2009. Goldstein, Joseph, and Jack Kornfield. Seeking the Heart of Wisdom: The Path of Insight Meditation. Shambhala Publications, 2001. PSYCHOMOTOR THERAPY Pesso, Albert, and John S. Crandell. Moving Psychotherapy: Theory and Application of Pesso System-Psychomotor Therapy. Brookline Books, 1991. Pesso, Albert. Experience In Action: A Psychomotor Psychology, New York: New York University Press, 1969. CHAPTER 2 REVOLUTIONS IN UNDERSTANDING MIND AND BRAIN The greater the doubt, the greater the awakening; the smaller the doubt, the smaller the awakening. No doubt, no awakening. —C.-C. Chang, The Practice of Zen You live through that little piece of time that is yours, but that piece of time is not only your own life, it is the summing-up of all the other lives that are simultaneous with yours. . . . What you are is an expression of History. —Robert Penn Warren, World Enough and Time In the late 1960s, during a year off between my first and second years of medical school, I became an accidental witness to a profound transition in the medical approach to mental suffering. I had landed a plum job as an attendant on a research ward at the Massachusetts Mental Health Center, where I was in charge of organizing recreational activities for the patients. MMHC had long been considered one of the finest psychiatric hospitals in the country, a jewel in the crown of the Harvard Medical School teaching empire. The goal of the research on my ward was to determine whether psychotherapy or medication was the best way to treat young people who had suffered a first mental breakdown diagnosed as schizophrenia. The talking cure, an offshoot of Freudian psychoanalysis, was still the primary treatment for mental illness at MMHC. However, in the early 1950s a group of French scientists had discovered a new compound, chlorpromazine (sold under the brand name Thorazine), that could “tranquilize” patients and make them less agitated and delusional. That inspired hope that drugs could be developed to treat serious mental problems such as depression, panic, anxiety, and mania, as well as to manage some of the most disturbing symptoms of schizophrenia. As an attendant I had nothing to do with the research aspect of the ward and was never told what treatment any of the patients was receiving. They were all close to my age—college students from Harvard, MIT, and Boston University. Some had tried to kill themselves; others cut themselves with knives or razor blades; several had attacked their roommates or had otherwise terrified their parents or friends with their unpredictable, irrational behavior. My job was to keep them involved in normal activities for college students, such as eating at the local pizza parlor, camping in a nearby state forest, attending Red Sox games, and sailing on the Charles River. Totally new to the field, I sat in rapt attention during ward meetings, trying to decipher the patients’ complicated speech and logic. I also had to learn to deal with their irrational outbursts and terrified withdrawal. One morning I found a patient standing like a statue in her bedroom with one arm raised in a defensive gesture, her face frozen in fear. She remained there, immobile, for at least twelve hours. The doctors gave me the name for her condition, catatonia, but even the textbooks I consulted didn’t tell me what could be done about it. We just let it run its course. TRAUMA BEFORE DAWN I spent many nights and weekends on the unit, which exposed me to things the doctors never saw during their brief visits. When patients could not sleep, they often wandered in their tightly wrapped bathrobes into the darkened nursing station to talk. The quiet of the night seemed to help them open up, and they told me stories about having been hit, assaulted, or molested, often by their own parents, sometimes by relatives, classmates, or neighbors. They shared memories of lying in bed at night, helpless and terrified, hearing their mother being beaten by their father or a boyfriend, hearing their parents yell horrible threats at each other, hearing the sounds of furniture breaking. Others told me about fathers who came home drunk—hearing their footsteps on the landing and how they waited for them to come in, pull them out of bed, and punish them for some imagined offense. Several of the women recalled lying awake, motionless, waiting for the inevitable—a brother or father coming in to molest them. During morning rounds the young doctors presented their cases to their supervisors, a ritual that the ward attendants were allowed to observe in silence. They rarely mentioned stories like the ones I’d heard. However, many later studies have confirmed the relevance of those midnight confessions: We now know that more than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or even raped as children, or have witnessed violence in their families.1 But such experiences seemed to be off the table during rounds. I was often surprised by the dispassionate way patients’ symptoms were discussed and by how much time was spent on trying to manage their suicidal thoughts and self-destructive behaviors, rather than on understanding the possible causes of their despair and helplessness. I was also struck by how little attention was paid to their accomplishments and aspirations; whom they cared for, loved, or hated; what motivated and engaged them, what kept them stuck, and what made them feel at peace—the ecology of their lives. A few years later, as a young doctor, I was confronted with an especially stark example of the medical model in action. I was then moonlighting at a Catholic hospital, doing physical examinations on women who’d been admitted to receive electroshock treatment for depression. Being my curious immigrant self, I’d look up from their charts to ask them about their lives. Many of them spilled out stories about painful marriages, difficult children, and guilt over abortions. As they spoke, they visibly brightened and often thanked me effusively for listening to them. Some of them wondered if they really still needed electroshock after having gotten so much off their chests. I always felt sad at the end of these meetings, knowing that the treatments that would be administered the following morning would erase all memory of our conversation. I did not last long in that job. On my days off from the ward at MMHC, I often went to the Countway Library of Medicine to learn more about the patients I was supposed to help. One Saturday afternoon I came across a treatise that is still revered today: Eugen Bleuler’s 1911 textbook Dementia Praecox. Bleuler’s observations were fascinating: Among schizophrenic body hallucinations, the sexual ones are by far the most frequent and the most important. All the raptures and joys of normal and abnormal sexual satisfaction are experienced by these patients, but even more frequently every obscene and disgusting practice which the most extravagant fantasy can conjure up. Male patients have their semen drawn off; painful erections are stimulated. The women patients are raped and injured in the most devilish ways. . . . In spite of the symbolic meaning of many such hallucinations, the majority of them correspond to real sensations.2 This made me wonder: Our patients had hallucinations—the doctors routinely asked about them and noted them as signs of how disturbed the patients were. But if the stories I’d heard in the wee hours were true, could it be that these “hallucinations” were in fact the fragmented memories of real experiences? Were hallucinations just the concoctions of sick brains? Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes. There was no question that many patients on the ward engaged in violent, bizarre, and self-destructive behaviors, particularly when they felt frustrated, thwarted, or misunderstood. They threw temper tantrums, hurled plates, smashed windows, and cut themselves with shards of glass. At that time I had no idea why someone might react to a simple request (“Let me clean that goop out of your hair”) with rage or terror. I usually followed the lead of the experienced nurses, who signaled when to back off or, if that did not work, to restrain a patient. I was surprised and alarmed by the satisfaction I sometimes felt after I’d wrestled a patient to the floor so a nurse could give an injection, and I gradually realized how much of our professional training was geared to helping us stay in control in the face of terrifying and confusing realities. Sylvia was a gorgeous nineteen-year-old Boston University student who usually sat alone in the corner of the ward, looking frightened to death and virtually mute, but whose reputation as the girlfriend of an important Boston mafioso gave her an aura of mystery. After she refused to eat for more than a week and rapidly started to lose weight, the doctors decided to force-feed her. It took three of us to hold her down, another to push the rubber feeding tube down her throat, and a nurse to pour the liquid nutrients into her stomach. Later, during a midnight confession, Sylvia spoke timidly and hesitantly about her childhood sexual abuse by her brother and uncle. I realized then our display of “caring” must have felt to her much like a gang rape. This experience, and others like it, helped me formulate this rule for my students: If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past. In my role as recreation leader I noticed other things: As a group the patients were strikingly clumsy and physically uncoordinated. When we went camping, most of them stood helplessly by as I pitched the tents. We almost capsized once in a squall on the Charles River because they huddled rigidly in the lee, unable to grasp that they needed to shift position to balance the boat. In volleyball games the staff members invariably were much better coordinated than the patients. Another characteristic they shared was that even their most relaxed conversations seemed stilted, lacking the natural flow of gestures and facial expressions that are typical among friends. The relevance of these observations became clear only after I’d met the body-based therapists Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about how trauma is held in people’s bodies. MAKING SENSE OF SUFFERING After my year on the research ward I resumed medical school and then, as a newly minted MD, returned to MMHC to be trained as a psychiatrist, a program to which I was thrilled to be accepted. Many famous psychiatrists had trained there, including Eric Kandel, who later won the Nobel Prize in Physiology and Medicine. Allan Hobson discovered the brain cells responsible for the generation of dreams in a lab in the hospital basement while I trained there, and the first studies on the chemical underpinnings of depression were also conducted at MMHC. But for many of us residents, the greatest draw was the patients. We spent six hours each day with them and then met as a group with senior psychiatrists to share our observations, pose our questions, and compete to make the wittiest remarks. Our great teacher, Elvin Semrad, actively discouraged us from reading psychiatry textbooks during our first year. (This intellectual starvation diet may account for the fact that most of us later became voracious readers and prolific writers.) Semrad did not want our perceptions of reality to become obscured by the pseudocertainties of psychiatric diagnoses. I remember asking him once: “What would you call this patient—schizophrenic or schizoaffective?” He paused and stroked his chin, apparently in deep thought. “I think I’d call him Michael McIntyre,” he replied. Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people “acknowledge, experience, and bear” the reality of life—with all its pleasures and heartbreak. “The greatest sources of our suffering are the lies we tell ourselves,” he’d say, urging us to be honest with ourselves about every facet of our experience. He often said that people can never get better without knowing what they know and feeling what they feel. I remember being surprised to hear this distinguished old Harvard professor confess how comforted he was to feel his wife’s bum against him as he fell asleep at night. By disclosing such simple human needs in himself he helped us recognize how basic they were to our lives. Failure to attend to them results in a stunted existence, no matter how lofty our thoughts and worldly accomplishments. Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions. Our profession, however, was moving in a different direction. In 1968 the American Journal of Psychiatry had published the results of the study from the ward where I’d been an attendant. They showed unequivocally that schizophrenic patients who received drugs alone had a better outcome than those who talked three times a week with the best therapists in Boston.3 This study was one of many milestones on a road that gradually changed how medicine and psychiatry approached psychological problems: from infinitely variable expressions of intolerable feelings and relationships to a brain-disease model of discrete “disorders.” The way medicine approaches human suffering has always been determined by the technology available at any given time. Before the Enlightenment aberrations in behavior were ascribed to God, sin, magic, witches, and evil spirits. It was only in the nineteenth century that scientists in France and Germany began to investigate behavior as an adaptation to the complexities of the world. Now a new paradigm was emerging: Anger, lust, pride, greed, avarice, and sloth—as well as all the other problems we humans have always struggled to manage—were recast as “disorders” that could be fixed by the administration of appropriate chemicals.4 Many psychiatrists were relieved and delighted to become “real scientists,” just like their med school classmates who had laboratories, animal experiments, expensive equipment, and complicated diagnostic tests, and set aside the wooly-headed theories of philosophers like Freud and Jung. A major textbook of psychiatry went so far as to state: “The cause of mental illness is now considered an aberration of the brain, a chemical imbalance.”5 Like my colleagues, I eagerly embraced the pharmacological revolution. In 1973 I became the first chief resident in psychopharmacology at MMHC. I may also have been the first psychiatrist in Boston to administer lithium to a manic-depressive patient. (I’d read about John Cade’s work with lithium in Australia, and I received permission from a hospital committee to try it.) On lithium a woman who had been manic every May for the past thirty-five years, and suicidally depressed every November, stopped cycling and remained stable for the three years she was under my care. I was also part of the first U.S. research team to test the antipsychotic Clozaril on chronic patients who were warehoused in the back wards of the old insane asylums.6 Some of their responses were miraculous: People who had spent much of their lives locked in their own separate, terrifying realities were now able to return to their families and communities; patients mired in darkness and despair started to respond to the beauty of human contact and the pleasures of work and play. These amazing results made us optimistic that we could finally conquer human misery. Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals in the United States, from over 500,000 in 1955 to fewer than 100,000 in 1996.7 For people today who did not know the world before the advent of these treatments, the change is almost unimaginable. As a first-year medical student I visited Kankakee State Hospital in Illinois and saw a burly ward attendant hose down dozens of filthy, naked, incoherent patients in an unfurnished dayroom supplied with gutters for the runoff water. This memory now seems more like a nightmare than like something I witnessed with my own eyes. My first job after finishing my residency in 1974 was as the second-to-last director of a once-venerable institution, the Boston State Hospital, which had formerly housed thousands of patients and been spread over hundreds of acres with dozens of buildings, including greenhouses, gardens, and workshops—most of them by then in ruins. During my time there patients were gradually dispersed into “the community,” the blanket term for the anonymous shelters and nursing homes where most of them ended up. (Ironically, the hospital was started as an “asylum,” a word meaning “sanctuary” that gradually took on a sinister connotation. It actually did offer a sheltered community where everybody knew the patients’ names and idiosyncrasies.) In 1979, shortly after I went to work at the VA, the Boston State Hospital’s gates were permanently locked, and it became a ghost town. During my time at Boston State I continued to work in the MMHC psychopharmacology lab, which was now focusing on another direction for research. In the 1960s scientists at the National Institutes of Health had begun to develop techniques for isolating and measuring hormones and neurotransmitters in blood and the brain. Neurotransmitters are chemical messengers that carry information from neuron to neuron, enabling us to engage effectively with the world. Now that scientists were finding evidence that abnormal levels of norepinephrine were associated with depression, and of dopamine with schizophrenia, there was hope that we could develop drugs that target specific brain abnormalities. That hope was never fully realized, but our efforts to measure how drugs could affect mental symptoms led to another profound change in the profession. Researchers’ need for a precise and systematic way to communicate their findings resulted in the development of the so-called Research Diagnostic Criteria, to which I contributed as a lowly research assistant. These eventually became the basis for the first systematic system to diagnose psychiatric problems, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which is commonly referred to as the “bible of psychiatry.” The foreword to the landmark 1980 DSM-III was appropriately modest and acknowledged that this diagnostic system was imprecise—so imprecise that it never should be used for forensic or insurance purposes.8 As we will see, that modesty was tragically short-lived. INESCAPABLE SHOCK Preoccupied with so many lingering questions about traumatic stress, I became intrigued with the idea that the nascent field of neuroscience could provide some answers and started to attend the meetings of the American College of Neuropsychopharmacology (ACNP). In 1984 the ACNP offered many fascinating lectures about drug development, but it was not until a few hours before my scheduled flight back to Boston that I heard a presentation by Steven Maier of the University of Colorado, who had collaborated with Martin Seligman of the University of Pennsylvania. His topic was learned helplessness in animals. Maier and Seligman had repeatedly administered painful electric shocks to dogs who were trapped in locked cages. They called this condition “inescapable shock.”9 Being a dog lover, I realized that I could never have done such research myself, but I was curious about how this cruelty would affect the animals. After administering several courses of electric shock, the researchers opened the doors of the cages and then shocked the dogs again. A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open—they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom. Like Maier and Seligman’s dogs, many traumatized people simply give up. Rather than risk experimenting with new options they stay stuck in the fear they know. I was riveted by Maier’s account. What they had done to these poor dogs was exactly what had happened to my traumatized human patients. They, too, had been exposed to somebody (or something) who had inflicted terrible harm on them—harm they had no way of escaping. I made a rapid mental review of the patients I had treated. Almost all had in some way been trapped or immobilized, unable to take action to stave off the inevitable. Their fight/flight response had been thwarted, and the result was either extreme agitation or collapse. Maier and Seligman also found that traumatized dogs secreted much larger amounts of stress hormones than was normal. This supported what we were beginning to learn about the biological underpinnings of traumatic stress. A group of young researchers, among them Steve Southwick and John Krystal at Yale, Arieh Shalev at Hadassah Medical School in Jerusalem, Frank Putnam at the National Institute of Mental Health (NIMH), and Roger Pitman, later at Harvard, were all finding that traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount Sinai in New York confronted us with her seemingly paradoxical findings that the levels of the stress hormone cortisol are low in PTSD. Her discoveries only started to make sense when her research clarified that cortisol puts an end to the stress response by sending an all-safe signal, and that, in PTSD, the body’s stress hormones do, in fact, not return to baseline after the threat has passed. Ideally our stress hormone system should provide a lightning-fast response to threat, but then quickly return us to equilibrium. In PTSD patients, however, the stress hormone system fails at this balancing act. Fight/flight/freeze signals continue after the danger is over, and, as in the case of the dogs, do not return to normal. Instead, the continued secretion of stress hormones is expressed as agitation and panic and, in the long term, wreaks havoc with their health. I missed my plane that day because I had to talk with Steve Maier. His workshop offered clues not only about the underlying problems of my patients but also potential keys to their resolution. For example, he and Seligman had found that the only way to teach the traumatized dogs to get off the electric grids when the doors were open was to repeatedly drag them out of their cages so they could physically experience how they could get away. I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control? What if they could be taught to physically move to escape a potentially threatening situation that was similar to the trauma in which they had been trapped and immobilized? As I will discuss in the treatment part 5 of this book, that was one of the conclusions I eventually reached. Further animal studies involving mice, rats, cats, monkeys, and elephants brought more intriguing data.10 For example, when researchers played a loud, intrusive sound, mice that had been raised in a warm nest with plenty of food scurried home immediately. But another group, raised in a noisy nest with scarce food supplies, also ran for home, even after spending time in more pleasant surroundings.11 Scared animals return home, regardless of whether home is safe or frightening. I thought about my patients with abusive families who kept going back to be hurt again. Are traumatized people condemned to seek refuge in what is familiar? If so, why, and is it possible to help them become attached to places and activities that are safe and pleasurable?12 ADDICTED TO TRAUMA: THE PAIN OF PLEASURE AND THE PLEASURE OF PAIN One of the things that struck my colleague Mark Greenberg and me when we ran therapy groups for Vietnam combat veterans was how, despite their feelings of horror and grief, many of them seemed to come to life when they talked about their helicopter crashes and their dying comrades. (Former New York Times correspondent Chris Hedges, who covered a number of brutal conflicts, entitled his book War Is a Force That Gives Us Meaning.13) Many traumatized people seem to seek out experiences that would repel most of us,14 and patients often complain about a vague sense of emptiness and boredom when they are not angry, under duress, or involved in some dangerous activity. My patient Julia was brutally raped at gunpoint in a hotel room at age sixteen. Shortly thereafter she got involved with a violent pimp who prostituted her. He regularly beat her up. She was repeatedly jailed for prostitution, but she always went back to her pimp. Finally her grandparents intervened and paid for an intense rehab program. After she successfully completed inpatient treatment, she started working as a receptionist and taking courses at a local college. In her sociology class she wrote a term paper about the liberating possibilities of prostitution, for which she read the memoirs of several famous prostitutes. She gradually dropped all her other courses. A brief relationship with a classmate quickly went sour—he bored her to tears, she said, and she was repelled by his boxer shorts. She then picked up an addict on the subway who first beat her up and then started to stalk her. She finally became motivated to return to treatment when she was once again severely beaten. Freud had a term for such traumatic reenactments: “the compulsion to repeat.” He and many of his followers believed that reenactments were an unconscious attempt to get control over a painful situation and that they eventually could lead to mastery and resolution. There is no evidence for that theory—repetition leads only to further pain and self-hatred. In fact, even reliving the trauma repeatedly in therapy may reinforce preoccupation and fixation. Mark Greenberg and I decided to learn more about attractors—the things that draw us, motivate us, and make us feel alive. Normally attractors are meant to make us feel better. So, why are so many people attracted to dangerous or painful situations? We eventually found a study that explained how activities that cause fear or pain can later become thrilling experiences.15 In the 1970s Richard Solomon of the University of Pennsylvania had shown that the body learns to adjust to all sorts of stimuli. We may get hooked on recreational drugs because they right away make us feel so good, but activities like sauna bathing, marathon running, or parachute jumping, which initially cause discomfort and even terror, can ultimately become very enjoyable. This gradual adjustment signals that a new chemical balance has been established within the body, so that marathon runners, say, get a sense of well-being and exhilaration from pushing their bodies to the limit. At this point, just as with drug addiction, we start to crave the activity and experience withdrawal when it’s not available. In the long run people become more preoccupied with the pain of withdrawal than the activity itself. This theory could explain why some people hire someone to beat them, or burn themselves with cigarettes. or why they are only attracted to people who hurt them. Fear and aversion, in some perverse way, can be transformed into pleasure. Solomon hypothesized that endorphins—the morphinelike chemicals that the brain secretes in response to stress—play a role in the paradoxical addictions he described. I thought of his theory again when my library habit led me to a paper titled “Pain in Men Wounded in Battle,” published in 1946. Having observed that 75 percent of severely wounded soldiers on the Italian front did not request morphine, a surgeon by the name of Henry K. Beecher speculated that “strong emotions can block pain.”16 Were Beecher’s observations relevant to people with PTSD? Mark Greenberg, Roger Pitman, Scott Orr, and I decided to ask eight Vietnam combat veterans if they would be willing to take a standard pain test while they watched scenes from a number of movies. The first clip we showed was from Oliver Stone’s graphically violent Platoon (1986), and while it ran we measured how long the veterans could keep their right hands in a bucket of ice water. We then repeated this process with a peaceful (and long-forgotten) movie clip. Seven of the eight veterans kept their hands in the painfully cold water 30 percent longer during Platoon. We then calculated that the amount of analgesia produced by watching fifteen minutes of a combat movie was equivalent to that produced by being injected with eight milligrams of morphine, about the same dose a person would receive in an emergency room for crushing chest pain. We concluded that Beecher’s speculation that “strong emotions can block pain” was the result of the release of morphinelike substances manufactured in the brain. This suggested that for many traumatized people, reexposure to stress might provide a similar relief from anxiety.17 It was an interesting experiment, but it did not fully explain why Julia kept going back to her violent pimp. SOOTHING THE BRAIN The 1985 ACNP meeting was, if possible, even more thought provoking than the previous year’s session. Kings College professor Jeffrey Gray gave a talk about the amygdala, a cluster of brain cells that determines whether a sound, image, or body sensation is perceived as a threat. Gray’s data showed that the sensitivity of the amygdala depended, at least in part, on the amount of the neurotransmitter serotonin in that part of the brain. Animals with low serotonin levels were hyperreactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.18 That struck me as an important finding: My patients were always blowing up in response to small provocations and felt devastated by the slightest rejection. I became fascinated by the possible role of serotonin in PTSD. Other researchers had shown that dominant male monkeys had much higher levels of brain serotonin than lower-ranking animals but that their serotonin levels dropped when they were prevented from maintaining eye contact with the monkeys they had once lorded over. In contrast, low-ranking monkeys who were given serotonin supplements emerged from the pack to assume leadership.19 The social environment interacts with brain chemistry. Manipulating a monkey into a lower position in the dominance hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the rank of former subordinates. The implications for traumatized people were obvious. Like Gray’s low-serotonin animals, they were hyperreactive, and their ability to cope socially was often compromised. If we could find ways to increase brain serotonin levels, perhaps we could address both problems simultaneously. At that same 1985 meeting I learned that drug companies were developing two new products to do precisely that, but since neither was yet available, I experimented briefly with the health-food-store supplement L-tryptophan, which is a chemical precursor of serotonin in the body. (The results were disappointing.) One of the drugs under investigation never made it to the market. The other was fluoxetine, which, under the brand name Prozac, became one of the most successful psychoactive drugs ever created. On Monday, February 8, 1988, Prozac was released by the drug company Eli Lilly. The first patient I saw that day was a young woman with a horrendous history of childhood abuse who was now struggling with bulimia—she basically spent much of her life bingeing and purging. I gave her a prescription for this brand-new drug, and when she returned on Thursday she said, “I’ve had a very different last few days: I ate when I was hungry, and the rest of the time I did my schoolwork.” This was one of the most dramatic statements I had ever heard in my office. On Friday I saw another patient to whom I’d given Prozac the previous Monday. She was a chronically depressed mother of two school-aged children, preoccupied with her failures as a mother and wife and overwhelmed by demands from the parents who had badly mistreated her as a child. After four days on Prozac she asked me if she could skip her appointment the following Monday, which was Presidents’ Day. “After all,” she explained, “I’ve never taken my kids skiing—my husband always does—and they are off that day. It would really be nice for them to have some good memories of us having fun together.” This was a patient who had always struggled merely to get through the day. After her appointment I called someone I knew at Eli Lilly and said, “You have a drug that helps people to be in the present, instead of being locked in the past.” Lilly later gave me a small grant to study the effects of Prozac on PTSD in sixty-four people—twenty-two women and forty-two men—the first study of the effects of this new class of drugs on PTSD. Our Trauma Clinic team enrolled thirty-three nonveterans and my collaborators, former colleagues at the VA, enrolled thirty-one combat veterans. For eight weeks half of each group received Prozac and the other half a placebo. The study was blinded: Neither we nor the patients knew which substance they were taking, so that our preconceptions could not skew our assessments. Everyone in the study—even those who had received the placebo—improved, at least to some degree. Most treatment studies of PTSD find a significant placebo effect. People who screw up their courage to participate in a study for which they aren’t paid, in which they’re repeatedly poked with needles, and in which they have only a fifty-fifty chance of getting an active drug are intrinsically motivated to solve their problem. Maybe their reward is only the attention paid to them, the opportunity to respond to questions about how they feel and think. But maybe the mother’s kisses that soothe her child’s scrapes are “just” a placebo as well. Prozac worked significantly better than the placebo for the patients from the Trauma Clinic. They slept more soundly; they had more control over their emotions and were less preoccupied with the past than those who received a sugar pill.20 Surprisingly, however, the Prozac had no effect at all on the combat veterans at the VA—their PTSD symptoms were unchanged. These results have held true for most subsequent pharmacological studies on veterans: While a few have shown modest improvements, most have not benefited at all. I have never been able to explain this, and I cannot accept the most common explanation: that receiving a pension or disability benefits prevents people from getting better. After all, the amygdala knows nothing of pensions—it just detects threats. Nonetheless, medications such as Prozac and related drugs like Zoloft, Celexa, Cymbalta, and Paxil, have made a substantial contribution to the treatment of trauma-related disorders. In our Prozac study we used the Rorschach test to measure how traumatized people perceive their surroundings. These data gave us an important clue to how this class of drugs (formally known as selective serotonin reuptake inhibitors, or SSRIs) might work. Before taking Prozac these patients’ emotions controlled their reactions. I think of a Dutch patient, for example (not in the Prozac study) who came to see me for treatment for a childhood rape and who was convinced that I would rape her as soon as she heard my Dutch accent. Prozac made a radical difference: It gave PTSD patients a sense of perspective21 and helped them to gain considerable control over their impulses. Jeffrey Gray must have been right: When their serotonin levels rose, many of my patients became less reactive. THE TRIUMPH OF PHARMACOLOGY It did not take long for pharmacology to revolutionize psychiatry. Drugs gave doctors a greater sense of efficacy and provided a tool beyond talk therapy. Drugs also produced income and profits. Grants from the pharmaceutical industry provided us with laboratories filled with energetic graduate students and sophisticated instruments. Psychiatry departments, which had always been located in the basements of hospitals, started to move up, both in terms of location and prestige. One symbol of this change occurred at MMHC, where in the early 1990s the hospital’s swimming pool was paved over to make space for a laboratory, and the indoor basketball court was carved up into cubicles for the new medication clinic. For decades doctors and patients had democratically shared the pleasures of splashing in the pool and passing balls down the court. I’d spent hours in the gym with patients back when I was a ward attendant. It was the one place where we all could restore a sense of physical well-being, an island in the midst of the misery we faced every day. Now it had become a place for patients to “get fixed.” The drug revolution that started out with so much promise may in the end have done as much harm as good. The theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs has become broadly accepted, by the media and the public as well as by the medical profession.22 In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues. Antidepressants can make all the difference in the world in helping with day-to-day functioning, and if it comes to a choice between taking a sleeping pill and drinking yourself into a stupor every night to get a few hours of sleep, there is no question which is preferable. For people who are exhausted from trying to make it on their own through yoga classes, workout routines, or simply toughing it out, medications often can bring life-saving relief. The SSRIs can be very helpful in making traumatized people less enslaved by their emotions, but they should only be considered adjuncts in their overall treatment.23 After conducting numerous studies of medications for PTSD, I have come to realize that psychiatric medications have a serious downside, as they may deflect attention from dealing with the underlying issues. The brain-disease model takes control over people’s fate out of their own hands and puts doctors and insurance companies in charge of fixing their problems. Over the past three decades psychiatric medications have become a mainstay in our culture, with dubious consequences. Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants.24 The new generation of antipsychotics, such as Abilify, Risperdal, Zyprexa, and Seroquel, are the top-selling drugs in the United States. In 2012 the public spent $1,526,228,000 on Abilify, more than on any other medication. Number three was Cymbalta, an antidepressant that sold well over a billion dollars’ worth of pills,25 even though it has never been shown to be superior to older antidepressants like Prozac, for which much cheaper generics are available. Medicaid, the government health program for the poor, spends more on antipsychotics than on any other class of drugs.26 In 2008, the most recent year for which complete data are available, it funded $3.6 billion for antipsychotic medications, up from $1.65 billion in 1999. The number of people under the age of twenty receiving Medicaid-funded prescriptions for antipsychotic drugs tripled between 1999 and 2008. On November 4, 2013, Johnson & Johnson agreed to pay more than $2.2 billion in criminal and civil fines to settle accusations that it had improperly promoted the antipsychotic drug Risperdal to older adults, children, and people with developmental disabilities.27 But nobody is holding the doctors who prescribed them accountable. Half a million children in the United States currently take antipsychotic drugs. Children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines. These medications often are used to make abused and neglected children more tractable. In 2008 19,045 children age five and under were prescribed antipsychotics through Medicaid.28 One study, based on Medicaid data in thirteen states, found that 12.4 percent of children in foster care received antipsychotics, compared with 1.4 percent of Medicaid-eligible children in general.29 These medications make children more manageable and less aggressive, but they also interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society. Children who take them are also at risk of becoming morbidly obese and developing diabetes. Meanwhile, drug overdoses involving a combination of psychiatric and pain medications continue to rise.30 Because drugs have become so profitable, major medical journals rarely publish studies on nondrug treatments of mental health problems.31 Practitioners who explore treatments are typically marginalized as “alternative.” Studies of nondrug treatments are rarely funded unless they involve so-called manualized protocols, where patients and therapists go through narrowly prescribed sequences that allow little fine-tuning to individual patients’ needs. Mainstream medicine is firmly committed to a better life through chemistry, and the fact that we can actually change our own physiology and inner equilibrium by means other than drugs is rarely considered. ADAPTATION OR DISEASE? The brain-disease model overlooks four fundamental truths: (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive. When we ignore these quintessential dimensions of humanity, we deprive people of ways to heal from trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self. Given the limitations of drugs, I started to wonder if we could find more natural ways to help people deal with their post-traumatic responses. ACKNOWLEDGMENTS This book is the fruit of thirty years of trying to understand how people deal with, survive, and heal from traumatic experiences. Thirty years of clinical work with traumatized men, women and children; innumerable discussions with colleagues and students, and participation in the evolving science about how mind, brain, and body deal with, and recover from, overwhelming experiences. Let me start with the people who helped me organize, and eventually publish, this book. Toni Burbank, my editor, with whom I communicated many times each week over a two-year period about the scope, organization, and specific contents of the book. Toni truly understood what this book is about, and that understanding has been critical in defining its form and substance. My agent, Brettne Bloom, understood the importance of this work, found a home for it with Viking, and provided critical support at critical moments. Rick Kot, my editor at Viking, supplied invaluable feedback and editorial guidance. My colleagues and students at the Trauma Center have provided the feeding ground, laboratory, and support system for this work. They also have been constant reminders of the sober reality of our work for these three decades. I cannot name them all, but Joseph Spinazzola, Margaret Blaustein, Roslin Moore, Richard Jacobs, Liz Warner, Wendy D’Andrea, Jim Hopper, Fran Grossman, Alex Cook, Marla Zucker, Kevin Becker, David Emerson, Steve Gross, Dana Moore, Robert Macy, Liz Rice-Smith, Patty Levin, Nina Murray, Mark Gapen, Carrie Pekor, Debbie Korn, and Betta de Boer van der Kolk all have been critical collaborators. And of course Andy Pond and Susan Wayne of the Justice Resource Institute. My most important companions and guides in understanding and researching traumatic stress have been Alexander McFarlane, Onno van der Hart, Ruth Lanius and Paul Frewen, Rachel Yehuda, Stephen Porges, Glenn Saxe, Jaak Panksepp, Janet Osterman, Julian Ford, Brad Stolback, Frank Putnam, Bruce Perry, Judith Herman, Robert Pynoos, Berthold Gersons, Ellert Nijenhuis, Annette Streeck-Fisher, Marylene Cloitre, Dan Siegel, Eli Newberger, Vincent Felitti, Robert Anda, and Martin Teicher; as well as my colleagues who taught me about attachment: Edward Tronick, Karlen Lyons-Ruth, and Beatrice Beebe. Peter Levine, Pat Ogden, and Al Pesso read my paper on the importance of the body in traumatic stress back in 1994 and then offered to teach me about the body. I am still learning from them, and that learning has since then been expanded by yoga and meditation teachers Stephen Cope, Jon Kabat-Zinn, and Jack Kornfield. Sebern Fisher first taught me about neurofeedback. Ed Hamlin and Larry Hirshberg later expanded that understanding. Richard Schwartz taught me internal family systems (IFS) therapy and assisted in helping to write the chapter on IFS. Kippy Dewey and Cissa Campion introduced me to theater, Tina Packer tried to teach me how to do it, and Andrew Borthwick- Leslie provided critical details. Adam Cummings, Amy Sullivan, and Susan Miller provided indispensible support, without which many projects in this book could never have been accomplished. Licia Sky created the environment that allowed me to concentrate on writing this book; she provided invaluable feedback on each one of the chapters; she donated her artistic gifts to many illustrations; and she contributed to sections on body awareness and clinical case material. My trusty secretary, Angela Lin, took care of multiple crises and kept the ship running at full speed. Ed and Edith Schonberg often provided a shelter from the storm; Barry and Lorrie Goldensohn served as literary critics and inspiration; and my children, Hana and Nicholas, showed me that every new generation lives in a world that is radically different from the previous one, and that each life is unique—a creative act by its owner that defies explanation by genetics, environment, or culture alone. Finally, my patients, to whom I dedicate this book—I wish I could mention you all by name—who taught me almost everything I know—because you were my true textbook—and the affirmation of the life force, which drives us human beings to create a meaningful life, regardless of the obstacles we encounter. CHAPTER 1 LESSONS FROM VIETNAM VETERANS I became what I am today at the age of twelve, on a frigid overcast day in the winter of 1975. . . . That was a long time ago, but it’s wrong what they say about the past. . . . Looking back now, I realize I have been peeking into that deserted alley for the last twenty-six years. —Khaled Hosseini, The Kite Runner Some people’s lives seem to flow in a narrative; mine had many stops and starts. That’s what trauma does. It interrupts the plot. . . . It just happens, and then life goes on. No one prepares you for it. —Jessica Stern, Denial: A Memoir of Terror The Tuesday after the Fourth of July weekend, 1978, was my first day as a staff psychiatrist at the Boston Veterans Administration Clinic. As I was hanging a reproduction of my favorite Breughel painting, “The Blind Leading the Blind,” on the wall of my new office, I heard a commotion in the reception area down the hall. A moment later a large, disheveled man in a stained three-piece suit, carrying a copy of Soldier of Fortune magazine under his arm, burst through my door. He was so agitated and so clearly hungover that I wondered how I could possibly help this hulking man. I asked him to take a seat, and tell me what I could do for him. His name was Tom. Ten years earlier he had been in the Marines, doing his service in Vietnam. He had spent the holiday weekend holed up in his downtown-Boston law office, drinking and looking at old photographs, rather than with his family. He knew from previous years’ experience that the noise, the fireworks, the heat, and the picnic in his sister’s backyard against the backdrop of dense early-summer foliage, all of which reminded him of Vietnam, would drive him crazy. When he got upset he was afraid to be around his family because he behaved like a monster with his wife and two young boys. The noise of his kids made him so agitated that he would storm out of the house to keep himself from hurting them. Only drinking himself into oblivion or riding his Harley-Davidson at dangerously high speeds helped him to calm down. Nighttime offered no relief—his sleep was constantly interrupted by nightmares about an ambush in a rice paddy back in ’Nam, in which all the members of his platoon were killed or wounded. He also had terrifying flashbacks in which he saw dead Vietnamese children. The nightmares were so horrible that he dreaded falling asleep and he often stayed up for most of the night, drinking. In the morning his wife would find him passed out on the living room couch, and she and the boys had to tiptoe around him while she made them breakfast before taking them to school. Filling me in on his background, Tom said that he had graduated from high school in 1965, the valedictorian of his class. In line with his family tradition of military service he enlisted in the Marine Corps immediately after graduation. His father had served in World War II in General Patton’s army, and Tom never questioned his father’s expectations. Athletic, intelligent, and an obvious leader, Tom felt powerful and effective after finishing basic training, a member of a team that was prepared for just about anything. In Vietnam he quickly became a platoon leader, in charge of eight other Marines. Surviving slogging through the mud while being strafed by machine-gun fire can leave people feeling pretty good about themselves—and their comrades. At the end of his tour of duty Tom was honorably discharged, and all he wanted was to put Vietnam behind him. Outwardly that’s exactly what he did. He attended college on the GI Bill, graduated from law school, married his high school sweetheart, and had two sons. Tom was upset by how difficult it was to feel any real affection for his wife, even though her letters had kept him alive in the madness of the jungle. Tom went through the motions of living a normal life, hoping that by faking it he would learn to become his old self again. He now had a thriving law practice and a picture-perfect family, but he sensed he wasn’t normal; he felt dead inside. Although Tom was the first veteran I had ever encountered on a professional basis, many aspects of his story were familiar to me. I grew up in postwar Holland, playing in bombed-out buildings, the son of a man who had been such an outspoken opponent of the Nazis that he had been sent to an internment camp. My father never talked about his war experiences, but he was given to outbursts of explosive rage that stunned me as a little boy. How could the man I heard quietly going down the stairs every morning to pray and read the Bible while the rest of the family slept have such a terrifying temper? How could someone whose life was devoted to the pursuit of social justice be so filled with anger? I witnessed the same puzzling behavior in my uncle, who had been captured by the Japanese in the Dutch East Indies (now Indonesia) and sent as a slave laborer to Burma, where he worked on the famous bridge over the river Kwai. He also rarely mentioned the war, and he, too, often erupted into uncontrollable rages. As I listened to Tom, I wondered if my uncle and my father had had nightmares and flashbacks—if they, too, had felt disconnected from their loved ones and unable to find any real pleasure in their lives. Somewhere in the back of my mind there must also have been my memories of my frightened—and often frightening—mother, whose own childhood trauma was sometimes alluded to and, I now believe, was frequently reenacted. She had the unnerving habit of fainting when I asked her what her life was like as a little girl and then blaming me for making her so upset. Reassured by my obvious interest, Tom settled down to tell me just how scared and confused he was. He was afraid that he was becoming just like his father, who was always angry and rarely talked with his children—except to compare them unfavorably with his comrades who had lost their lives around Christmas 1944, during the Battle of the Bulge. As the session was drawing to a close, I did what doctors typically do: I focused on the one part of Tom’s story that I thought I understood—his nightmares. As a medical student I had worked in a sleep laboratory, observing people’s sleep/dream cycles, and had assisted in writing some articles about nightmares. I had also participated in some early research on the beneficial effects of the psychoactive drugs that were just coming into use in the 1970s. So, while I lacked a true grasp of the scope of Tom’s problems, the nightmares were something I could relate to, and as an enthusiastic believer in better living through chemistry, I prescribed a drug that we had found to be effective in reducing the incidence and severity of nightmares. I scheduled Tom for a follow-up visit two weeks later. When he returned for his appointment, I eagerly asked Tom how the medicines had worked. He told me he hadn’t taken any of the pills. Trying to conceal my irritation, I asked him why. “I realized that if I take the pills and the nightmares go away,” he replied, “I will have abandoned my friends, and their deaths will have been in vain. I need to be a living memorial to my friends who died in Vietnam.” I was stunned: Tom’s loyalty to the dead was keeping him from living his own life, just as his father’s devotion to his friends had kept him from living. Both father’s and son’s experiences on the battlefield had rendered the rest of their lives irrelevant. How had that happened, and what could we do about it? That morning I realized I would probably spend the rest of my professional life trying to unravel the mysteries of trauma. How do horrific experiences cause people to become hopelessly stuck in the past? What happens in people’s minds and brains that keeps them frozen, trapped in a place they desperately wish to escape? Why did this man’s war not come to an end in February 1969, when his parents embraced him at Boston’s Logan International Airport after his long flight back from Da Nang? Tom’s need to live out his life as a memorial to his comrades taught me that he was suffering from a condition much more complex than simply having bad memories or damaged brain chemistry—or altered fear circuits in the brain. Before the ambush in the rice paddy, Tom had been a devoted and loyal friend, someone who enjoyed life, with many interests and pleasures. In one terrifying moment, trauma had transformed everything. During my time at the VA I got to know many men who responded similarly. Faced with even minor frustrations, our veterans often flew instantly into extreme rages. The public areas of the clinic were pockmarked with the impacts of their fists on the drywall, and security was kept constantly busy protecting claims agents and receptionists from enraged veterans. Of course, their behavior scared us, but I also was intrigued. At home my wife and I were coping with similar problems in our toddlers, who regularly threw temper tantrums when told to eat their spinach or to put on warm socks. Why was it, then, that I was utterly unconcerned about my kids’ immature behavior but deeply worried by what was going on with the vets (aside from their size, of course, which gave them the potential to inflict much more harm than my two-footers at home)? The reason was that I felt perfectly confident that, with proper care, my kids would gradually learn to deal with frustrations and disappointments, but I was skeptical that I would be able to help my veterans reacquire the skills of self-control and self-regulation that they had lost in the war. Unfortunately, nothing in my psychiatric training had prepared me to deal with any of the challenges that Tom and his fellow veterans presented. I went down to the medical library to look for books on war neurosis, shell shock, battle fatigue, or any other term or diagnosis I could think of that might shed light on my patients. To my surprise the library at the VA didn’t have a single book about any of these conditions. Five years after the last American soldier left Vietnam, the issue of wartime trauma was still not on anybody’s agenda. Finally, in the Countway Library at Harvard Medical School, I discovered The Traumatic Neuroses of War, which had been published in 1941 by a psychiatrist named Abram Kardiner. It described Kardiner’s observations of World War I veterans and had been released in anticipation of the flood of shell-shocked soldiers expected to be casualties of World War II.1 Kardiner reported the same phenomena I was seeing: After the war his patients were overtaken by a sense of futility; they became withdrawn and detached, even if they had functioned well before. What Kardiner called “traumatic neuroses,” today we call posttraumatic stress disorder—PTSD. Kardiner noted that sufferers from traumatic neuroses develop a chronic vigilance for and sensitivity to threat. His summation especially caught my eye: “The nucleus of the neurosis is a physioneurosis.”2 In other words, posttraumatic stress isn’t “all in one’s head,” as some people supposed, but has a physiological basis. Kardiner understood even then that the symptoms have their origin in the entire body’s response to the original trauma. Kardiner’s description corroborated my own observations, which was reassuring, but it provided me with little guidance on how to help the veterans. The lack of literature on the topic was a handicap, but my great teacher, Elvin Semrad, had taught us to be skeptical about textbooks. We had only one real textbook, he said: our patients. We should trust only what we could learn from them—and from our own experience. This sounds so simple, but even as Semrad pushed us to rely upon self-knowledge, he also warned us how difficult that process really is, since human beings are experts in wishful thinking and obscuring the truth. I remember him saying: “The greatest sources of our suffering are the lies we tell ourselves.” Working at the VA I soon discovered how excruciating it can be to face reality. This was true both for my patients and for myself. We don’t really want to know what soldiers go through in combat. We do not really want to know how many children are being molested and abused in our own society or how many couples—almost a third, as it turns out—engage in violence at some point during their relationship. We want to think of families as safe havens in a heartless world and of our own country as populated by enlightened, civilized people. We prefer to believe that cruelty occurs only in faraway places like Darfur or the Congo. It is hard enough for observers to bear witness to pain. Is it any wonder, then, that the traumatized individuals themselves cannot tolerate remembering it and that they often resort to using drugs, alcohol, or self-mutilation to block out their unbearable knowledge? Tom and his fellow veterans became my first teachers in my quest to understand how lives are shattered by overwhelming experiences, and in figuring out how to enable them to feel fully alive again. TRAUMA AND THE LOSS OF SELF The first study I did at the VA started with systematically asking veterans what had happened to them in Vietnam. I wanted to know what had pushed them over the brink, and why some had broken down as a result of that experience while others had been able to go on with their lives.3 Most of the men I interviewed had gone to war feeling well prepared, drawn close by the rigors of basic training and the shared danger. They exchanged pictures of their families and girlfriends; they put up with one another’s flaws. And they were prepared to risk their lives for their friends. Most of them confided their dark secrets to a buddy, and some went so far as to share each other’s shirts and socks. Many of the me