The Body Keeps the Score by Bessel Van Der Kolk

Stuck in the Past
When he returned for his appointment, I eagerly asked Tom how the sleeping pills had worked. He told me he hadn’t taken them. 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.”

For real change to take place, the body needs to learn that the danger has passed and to live in the reality of the present.

Without integrating the experience, they continue to be there and didn’t know how to be here, fully alive in the present.

When you can’t be fully here, you go to the places where you did feel alive – even if those places are filled with horror and misery. To heal have to bring those brain structures that deserted them when overwhelmed by trauma back again.

The very event that caused them so much pain had also become their sole source of meaning. They felt fully alive only when they were revisiting their traumatic past.

Sylvia was a gorgeous 19-year-old Boston University student who usually sat alone in the corner of the ward, looking frightened to death and vitually mute, but whose reptuation 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 that our display of “caring” must have felt to her much like a gang rape. If you do something to a patient that you wouldn’t do to your friends, consider whether you are unwittingly replicating a trauma from the patient’s past.

Organizing Your Life
Being traumatized means organizing your life as if the trauma were still going on. The survivor’s energy is focused on suppressing inner chaos, at the expense of spontaneous involvement in their life. Attempts to maintain control over unbearable physiological reactions can result in chronic fatigue, autoimmune disorders, fibromyalgia…

In 1989 I reported on a Vietnam vet who yearly staged an “armed robbery” on the exact anniversary of a boddy’s death. He would put a finger in his pants pocket, claim that it was a pistol, and tell a shopkeeper to empty his cash register – giving him plenty of time to alert the police. This unconscious attempt to commit “suicide by cop” came to an end after a judge referred the veteran to me for treatment. Once we had dealt with his guilt about his friend’s death, there were no further reenactments. (Reenactment as a form of memory.)

As long as a memory is inaccessible, the mind is unable to change it. But as soon as a story starts being told, particularly if it is told repeatedly, it changes – the act of telling itself changes the tale.

If an organism is stuck in survival mode, focused on fighting off unseen enemies, it leaves no room for imagination, other people’s needs, or love.

Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts and sensations related to the trauma take on a life of their own. These fragments intrude into the present, where they are relived.

Learned helplessness in animals. Maier and Seligmann repeatedly administered painful electric shocks to dogs trapped in locked cages. After several courses of shock, the researchers opened the cages and shocked them again. Dogs who had never been shocked before immediately ran away, but dogs who had been subject to “inescapable shock” before, made no attempt to flee. They stayed, whimpering and shitting themselves… Like these dogs, many traumatized people give up, rather than risk experimenting with new options (leaving the cage), they stay stuck in the fear they know.

Addicted to trauma. My patient Julia was brutally raped at gunpoint in a hotel room at age 16. Shortly thereafter she got involved with a violent pimp who prostituted her. He regularly beat her up. She was repeatedly jailed for prostitution, but 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. 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.

1. restoring relationships and community is central to restoring well-being.
2. language gives us the power to change ourselves, to define what we know
3. we can regulate our body via breath, movement, touching
4. we can create environments in which children and adults feel safe and can thrive

Left Brain, Right Brain
Brain scans show that trauma activates the right hemisphere of the brain (intuitive, artistic, memories of sound, touch, smell and emotions they evoke) and de-activates the left (rational, language, facts, ordering experience). Deactivation of the left hemisphere impacts capacity to organize experience into logical sequences and translate into words. When triggered, right brain reacts as if trauma is happening in present. Because left brain isn’t working well, they’re not aware of this, they are just furious, terrified, enraged, ashamed or frozen. After emotional storm passes they may look for what/who to blame.

The imprint of trauma is primarily on the right hemisphere. Up to 90% of human communication occurs in the nonverbal, right-hemisphere realm.

Once triggered, stress hormones are released. Increased adrenaline responsible for dramatic rise in heart rate and blood pressure for traumatized people, takes much longer for these levels to return to normal, and they spike quickly, hypersensitive to mildly stressful stimuli. Can cause memory, attention problems, irritability, sleep disorders.

When a circuit fires repeatedly, it can become a default setting – the response most likely to occur. If you feel safe and loved, your brain becomes specialized in exploration, play and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment.

Talk therapy can simply trigger or restart the trauma. The rational brain is basically impotent to talk the emotional brain out of its own reality. It’s easier to talk about what’s been done to them – to tell a story of victimization and revenge – than to notice, feel and put into words the reality of their internal experience.

In PTSD, the critical balance between the amygdala (smoke detector in reptile brain) and the frontal lobe (MPFC) (watchtower) shifts, making it harder to control emotions and impulses. Overreaction.

Two options for managing emotions: top down or bottom up. Top down: mindfulness, yoga. Bottom up: recalibrating autonomic nervous system. Breath, touch.

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.

Emotion is not opposed to reason. Emotions assign value to experiences. Emotions are the foundation of reason.

Brain scans showed that recalling an emotional event causes them to actually reexperience the bodily sensations felt during the original event.

Inhale activates sympathetic nervous system (arousal, fight/flight), moves blood to muscles for quick action, partly by triggering adrenal glands to squirt our adrenaline which speeds up heart and increases blood pressure. Exhale activates parasympathetic nervous system, slows heart down, relaxes muscles, returns breath to normal.

Our brains are built to help us function as members of a tribe. Most of our energy is devoted to connecting with others. Social support is most powerful protection against being overwhelmed by stress and trauma. Support means: reciprocity. Being heard and seen. For our bodies to calm down and heal, we need a visceral feeling of safety. Human friends. Animal friends.

The brain is a cultural organ – experience shapes the brain.

Traumatized folks get stuck in fight/flight or in chronic shut down. Trauma memory is encoded in viscera, in skeletal/muscular problems, autoimmune disorders. How to deactivate the defenses that once ensured survival?

Marsha, a 40-year-old schoolteacher from a suburb outside Boston. 13 years earlier, she picked up her 5-year-old daughter Melissa from day camp. As they drove off, Marsha heard a persistent beping, indicating that Melissa’s seatbelt was not properly fastened. When Marsha reached over to adjust the belt, she ran a red light. Another car smashed into hers from the right, instantly killing her daughter. In the ambulance on the way to the emergency room, the seven-month-old fetus Marsha was carrying also died. Overnight Marsha changed from a cheerful woman who was the life of the party into a haunted and depressed person filled with self-blame. She moved from classroom teaching into school administration because working directly with children had become intolerable – as for many parents who have lost children, their happy laughter had become a powerful trigger. In a futile attempt to keep her feelings at bay, she worked day and night. After repeatedly rehearsing the details of the trauma with a therapist, her biological responses might become muted, so that she could realize and remember that “that was then and this is now” rather than reliving the experience over and over.

Sherry walked into my office with her shoulders slumped, her chin nearly touching her chest. Even before we spoke a word, her body was telling me that she was afraid to face the world. I also noticed that her long sleeves only partially covered the scabs on her forearms. After sitting down, she told me in a high-pitched monotone that she couldn’t stop herself from picking at the skin on her arms and chest until she bled.

Her mother had run a foster house, her house was often packed with as many as 15 strange, disruptive, frightened and frightening kids. Sherry had grown up taking care of these transient children, feeling there was no room for her and her needs. “I know I wasn’t wanted. My mother would tell me, ‘You know, I don’t think you belong in this family. I think they gave us the wrong baby.’ She’s say it with a smile on her face, but people often pretend to joke when they say something serious.”

Sherry knew that picking her skin was a destructive thing to do, and that it was related to her mother’s neglect, but understanding the source of the impulse made no difference inhelping her control it. She told me she’d started to pick at her skin because it gave her some relief from feeling numb. The physical sensations made her feel more alive but also deeply ashamed.

Traumatized people chronically feel unsafe inside their bodies. The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and in an attempt to control these processes, they often become expert at ignoring gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves.

Sometimes we use our minds not to discover facts but to hide them.

Paul Schilder: To the depersonalized individual the world appears strange, peculiar, foreign, dream-like. Objects appear at time strangely diminished in size, at time flat. Sounds appear to come from a distance. Patients compalin that they are capable of experiencing neither pain nor pleasure. They have become strangers to themselves.

The self can be detached from the body, and live a phantom existence.

This week I tried doing yoga at home and the words came to me ‘Your body has things to say.’ I said to myself, ‘I will try and listen.’

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.

Panic symptoms are maintained cuz of fear of bodily sensations associated with panic attacks. Fear of the sensations keeps them escalating. The price for ignorning or distorting the body’s messages is being unable to detect what is truly dangerous or harmful, and what is safe or nourishing. Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation – drugs, medication.

Out of control, or painfully disorganized people.

Winnicott: The way a mother holds her child underlies “the ability to feel the body as the place where the psyche lives.” This visceral sensation of how our bodies are met lays the foundation for what we experience as “real.”

If a mother can’t meet her baby’s impulses and needs, “the baby learns to become the mother’s idea of what the baby is.” Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. Children who lack physical attunement (with/learned from their mother) are vulnerable to shutting down direct feedback from their bodies, the seat of pleasure, purpose and direction.

Securely attached kids can pick up what others are feeling, can tell games from reality, develop a sense for phony situations or dangerous people, can be pleasant playmates, learning to be in tune they notice subtle changes in voices and faces and adjust behaviour accordingly, living within a shared understanding of the world.

Abused kids are also sensitive to changes in voice or faces, but often respond to them as threats rather than cues for staying in sync. Easily become defensive or scared. Imagine what it’s like trying to figure out who is going to attack you. They may develop a tough front, or lose themselves in TV or drugs.

Jack is a 14-year old kid in Suffolk Jail, arrested for breaking into house of a neighour. The alarm was wailing when the police found him sitting on the couch. They yelled “Oh my God, It’s Jack again, that little motherfucker.” Later Jack said, “You know, that is what makes it worthwhile. Nobody ever pays attention to me.” Kids will go to almost any length to feel seen and connected.

Michael Meaney studied newborn rat pups and their mothers. He discovered that how much a mother rat licks and grooms her pups during the first 12 hours after their birth permanently affects the brain chemicals that respond to stress – and modifies the configuration of over a thousand genes. The rat pups that are intensively licked by their mothers are braver and produce lower levels of stress hormones under stress than rats whose mothers are less attentive. They also recover more quickly – an equanimity that lasts their lives. They develop thicker connections in the hippocampus, a key centre for learning and memory.

Videotape shows young mother playing with her 3-month-old baby. Everything was going well until baby pulled back and turned his head away, signaling that he needed a break. But the mother didn’t pick up on the cue, and intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, feeling terrible. Chronically failing to calm her baby down and establish enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.

A mother’s emotional withdrawal was the most powerful predictor of mental instability in adult children. Infants with seriously disrupted emotional communication patterns with their mothers at 18 months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving and binge eating), inappropriate and intense anger and recurrent suicidal behaviour.

Bowlby: What cannot be communicated to the mother cannot be communicated to the self. (not feeling real)

After World Trade Centre destroyed, many children were treated in hospital for severe burns. The security of their attachment to their mothers predicted the amount of morphine required to control their pain – the more secure the attachment, the less painkiller was required.

Her self criticism escalated to the point that, only a few minutes later, she was taking responsibility for her sexual abuse: “I brought it on myself: I was 7 and I loved my daddy. I wanted him to love me, and I did what he wanted me to do. It was my own fault.” When I intervened to reassure her, saying, “Come on, you were just a little girl – it was your father’s responsibility to maintain boundaries,” Kathy turned towards me. “You know Bessel,” she said, “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusely. After all, I am an incest survivor – I was trained to take care of the needs of grown-up, insecure men. But after two years I trust you enough to tell you that those comments make me feel terrible. Yes, it’s true; I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated – and it confirms the feeling that nobody will ever understand what it feels like to be me.” (I’ve tried since then not to tell my patients that they should not feel the way they do. I have to help them reconstruct their inner map of the world.)

When her father started to touch her, she made herself disappear; she floated up the ceiling, looking down on some other little girl in the bed. She was glad that it was not really her – it was some other little girl who was being molested.

One of the hardest yoga positions for Annie to tolerate is 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. Intense physical sensations unleashed the demons from the past that had been so carefully kept in check by numbing and inattention. Yet as long as Happy Baby (or any posture that resembles it) precipitates intense panic, it is difficult to be intimate.

Terror increases the need for attachment, even if the source of comfort is also the source of terror. I have never met a child below the age of 10 who was tortured at home (and who had broken bones and burnt skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood.

More than a quarter of the US population have been repeatedly physically abused as children. The gravest and most costly public health issue in US: child abuse.

Two guards at a state prison regained the weight they had lost because they felt safer being the biggest guys on the cellblock. Another male patient became obese after this parents divorced and he moved in with his violent alcoholic grandfather. He explained: “It wasn’t that I ate because I was hungry. It was just a place for me to feel safe. All the way from kindergarten I used to get beat up all the tme. When I got the weight on it didn’t happen anymore.” Eating is an adaptation.

Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography.

Listening to accounts of Holocaust experience, we unearth a mosaic of evidence that constantly vanishes into bottomless layers of incompletion.

If you were not there, it’s difficult to describe how it was.

During routine laparoscopic tubal ligation, in which fallopian tubes are cauterized to prevent future pregnancies, she wasn’t given enough anaesthetic, and awakened during the operation. She was unable to alert the OR team because she had been given a standard muscle relaxant to prevent muscle contractions during surgery.

When we went home I was still in a daze. I had trouble sleeping. For days I remained in my own disconnected world. I could not use a hair dryer toaster, stove or anything that warmed up. I could not concentrate on what people were doing or telling me. I was increasingly anxious.

On the fourth night I had memories of the surgery and was deathly afraid of sleep, I lost 23 pounds in 3 weeks, people kept commenting on how good I looked. I began to think about dying. I couldn’t protect my children from my rage. Symbols related to original trauma – a toy, a clothes iron, a curling iron, came to be seen as an instrument of torture. My marriage is falling apart – my husband came to represent the heartless laughing people (the surgical team) who hurt me. I exist in a dual state. A pervasive numbness covers me. Interestingly, I function well at work, and am constantly given positive feedback. Life proceeds with its own sense of falsity.

Maggie, a spunky young psychologist ran a halfway house for sexually abused girls. She did drugs, had dangerous and often violent boyfriends, had frequent altercations with her bosses, and moved from place to place because she could not tolerate her roommates (nor they her). I never understood how she had mobilized enough stability and concentration to earn a PhD in psych from a reputable grad school.

During her second meeting she told us that her father had raped her twice, once when she was five years old and once when she was seven. She was convinced it had been her fault. She loved her daddy, she explained, and she must have been so seductive that he could not control himself. Listening to her I thought “She might not blame her father, but she sure is blaming just about everyone else” – including her previous therapists. Like many trauma survivors she told one story with words and another in her actions, in which she kept replaying various aspects of her trauma.

The challenge of recovery is to reestablish ownership of your body and your mind. This means: being alive to the present, not keeping secrets from yourself about how you have managed to survive.

Marion Woodman (quoted in Stephen Cope the great work of your life): We can hardly bear to look. The shadow may carry the best of the life we have not lived. Go into the basement, the attic, the refuse bin. Find gold there. Find an animal who has not been fed or watered. It is you! This neglected, exiled animal, hungry for attention, is a part of yourself.

Lisa: “I would go into a room and try to memorize every possible way to get out, every detail about a person. I was trying desperately to keep track of everything that could hurt me. Now I know people in a different way. It’s not based on memorizing them out of fea. When you’re not afraid of being hurt, you can know people differently.”

As long as people are hyperaroused or shut down, they cannot learn from experience. Even if they manage to stay in control, they become so uptight (white knuckle sobriety) that they are inflexible, stubborn, and depressed.

Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery.

Traumatized people are often afraid of feeling. Physical sensations are now the enemy. Apprehension about being hijacked by uncomfortable sensations keeps the body frozen and the mind shut. Even though trauma is a thing of the past, the emotional brain keeps generating sensations that make the sufferer feel scared and helpless. It’s not surprising that so many trauma survivors are compulsive eaters and drinkers, fear sex, avoid many social activities. Their sensory world is largely off limits.

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 Annie’s 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 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.

For many children it is safer to hate themselves than to risk their relationship with their caregivers by expressing anger or by running away. As a result, abused children are likely to grow up believing that they are fundamentally unlovable; that was the only way their young minds could explain why they were treated so badly. They survive by denying, ignoring and splitting off large chunks of reality. They forget the abuse; they suppress their rage or despair, they numb their physical sensations. If you were abused as a child, you are likely to have a childlike part living inside you that is frozen in time, holding fast to this kind of self-loathing and denial. Just as we need to revisit traumatic memories in order to integrate them, we need to revisit the parts of ourselves that developed the defensive habits that helped us to survive.

“I used to envy the kids who knew what would happen when their parents got drunk. At least they could predict the havoc. In my home there was no pattern. Anything could set my mother off – eating dinner, watching TV, coming home from school – and I never knew what she was going to do or how she would hurt me. It was so random.”

Her father had abandoned the family when Lisa was three, leaving her at the mercy of her psychotic mother. “Torture” is not too strong a word to describe the abuse she endured. “I lived up in the attic room” she told me “and there was another room up there where I would go and piss on the carpet because I was too scared to go downstairs to the bathroom. I would take all the clothes off my dolls and drive pencils into them and put them up in my window.” When she was 12, Lisa ran away from home and was picked up by police and returned. After she ran away again, child protective services stepped in, and she sent the next 6 years in mental hospitals, shelters, group homes, foseter families and on the street. No placement lasted, because Lisa was so dissociated and self-destructive that she terrified her caretakers. She would attack herself or destroy furniture and afterward she would not remember what she had done, which earned her a reputation as a manipulative liar. In retrospect, Lisa told me, she simply lacked the language to communicate what was going on with her. “I started waking up with cuts, and people at school would know me by different names. I couldn’t have a steady boyfriend because I would date other guys when I was dissociated and then not remember. I was blacking out a lot and opening my eyes into some pretty strange situations.” Like many severely traumatized people, Lisa could not recognize herself in a mirror.

After neurofeedback therapy for several months she stopped dissociating. “I now can actually talk about things like my childhood. For the first time I started being able to do therapy. Up till then I didn’t have enough distance and I couldn’t calm down enough. If you’re still in it, it’s hard to talk about it.” This was a stunning revelation: so many patients are in and out of treatment, unable to meaningfully connect because they are “still in it.” Four years after I met her and recorded our conversations, Lisa graduated near the top of her nursing school class and now works full time as a nurse at a local hospital.

Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized. The role of those relationships is to provide physical and emotional safety, including safety from feeling shamed, admonished or judged, and to bolster the courage to tolerate, face, and process the reality of what has happened. Much of the wiring of our brain is devoted to being in tune with others. Recovery from trauma involved reconnecting with our fellow human beings.

In spring 1997 I attended a group for rape survivors in the courtyard of a clinic in a township outside Johannesburg. We could hear the sound of bullets being fired at a distance while smoke billowed over the walls of the compound and the smell of teargas hung in the air. Later we heard that 40 people had been killed.

The women sat slumped over – sad and frozen – like so many rape therapy groups I had seen in Boston. I felt a familiar sense of helplessness, and surrounded by collapsed people, I felt myself mentally collapse as well. Then one of the women started to hum, while gently swaying back and forth. Slowly a rhythm emerged: bit by bit other women joined in. Soon the whole group was singing, moving, and getting up to dance. It was an astounding transformation: people were coming back to life, faces becoming attuned, vitality returning to bodies.

Learning to become attuned provides parents (and their kids) with the visceral experience of reciprocity.

Just like you can thirst for water, you can thirst for touch.

John Huston doc Let There Be Light – youtube. ww2 vets treated for ptsd by hypnosis.

Fear Patterns
How well we get along with ourselves depends largely on our internal leadership skills – how well we listen to our different parts, make sure they feel taken care of, and keep them from sabotaging one another.

The mind is a kind of society.

Blaming is a universal human trait that helps people feel good while feeling bad.

Harvard psychologist Jerome Kagan: The task of describing most private experiences is like reaching down a deep well to pick up small fragile crystal figures while you are wearing thick leather mittens.

I’m reminded of the distraught woman who once came to our clinic asking for help with her two-month-old because the baby was so “selfish.” Would she have benefited from a fact sheet on child development or an explanation of the concept of altruism? Such information would be unlikely to help her until she gained access to the frightened, abandoned parts of herself – the parts expressed by her terror of dependence.

Sleep plays a major role in mood regulation. The eyes move rapidly back and forth in REM sleep, just as they do in EMDR. Increasing our time in REM sleep reduces depression, while the less REM sleep we get, the more likely we are to become depressed. At Veterans Anonymous my colleagues and I had found that the (Vietnam) veterans with PTSD frequently woke themselves up soon after going into REM sleep

Deep sleep and REM sleep play important roles in how memories change over time. The sleeping brain reshapes memory by increasing the imprint of emotionally relevant information while helping irrelevant material fade away. In a series of elegant studies Stickgold and his colleagues showed that the sleeping brain can even make sense out of information whose relevance is unclear while we are awake and integrate it into the larger memory system. Dreams keep replaying, recombining, and reintegrating pieces of memories for months and even years. They constantly update the subteranean realities that determine what our waking minds pay attention to. And perhaps most relevant to EMDR, in REM sleep we activate more distant associations than in either non-REM sleep or the normal waking state. Stickgold, Hobson, and their colleagues discovered that dreams help forge new relationships between apparently unrelated memories. Seeing novel connections is the cardinal feature of creativity; as we’ve seen, it’s also essential to healing. The inability to recombine experiences is also one of the striking features of PTSD.

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 cut themselves to make the numbing go away, while others try high-risk activities. Any of these methods can give them a false and paradoxical feeling of control.

“That night I had the first orgasm I’d ever had in the presence of another person. And I know it’s because I released something – some tension in my body – that allowed me to be more in the world.”

When people are chronically angry or scared, constant muscle tension ultimately leads to spasms, back pain, migraines, and other forms of chronic pain. Will the doctors they see identify these as symptoms of their attempt to cope with trauma?

“I was afraid all the time. I didn’t like to be touched. I was always jumpy and nervous. I couldn’t close my eyes if another person was around. There was no convincing me that someone wasn’t going to kick me the second I closed my eyes. That makes you feel crazy. You know you’re in a room with someone you trust, you know intellectually that nothing’s going to happen to you, but then there’s the rest of your body and you can’t ever relax. If someone put their arm around me, I would just check out.” She was stuck in a state of inescapable shock.

When fear patterns relax, the brain becomes less susceptible to automatic stress pattterns and better able to focus on ordinary events. After all, stress is not an inherent property of events themselves – it is a function of how we label and react to them.

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 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.”

Internal Family
The core of IFS (Internal Family Systems Therapy) is the notion that the mind of each of us is like a family in which the members have different levels of maturity, excitability, wisdom and pain. The parts form a network or system in which change in any one part will affect all the others. In trauma parts of the self go to war with one another. Self-loathing coexists and fights with grandiosity; loving care with hatred; numbing and passivity with rage and aggression. These extreme parts bear the burden of the trauma. We all have parts that are childlike and fun. When we are abused, these are the parts that are hurt the most, and they become frozen, carrying the pain, terror and betrayal of abuse. This burden makes them toxic – parts of ourselves that we need to deny at all costs. Because they are locked away inside, IFS calls them the exiles.

At this point other parts organize to protect the internal family from the exiles. These protectors keep the toxic parts away, but in so doing they take on some of the energy of the abuser. Critical and perfectionistic managers can make sure we never get close to anyone or drive us to be relentlessly productive. Another group of protectors, which IFS calls firefighters, are emergency responders, acting impulsively whenever an experience triggers an exiled emotion.

Each split off part holds different memories, beliefs, and physical sensations; some hold the shame, others the rage, some the pleasure and excitement, another the intense loneliness or the abject compliance. These are all aspects of the abuse experience. The critical insight is that all these parts have a function: to protect the self from feeling the full terror of annihilation.

Most of the men I evaluated with regard to their childhood molestation by Catholic priests took anabolic steroids and spent an inordinate amount of time in the gym pumping iron. These compulsive bodybuilders lived in a masculine culture of sweat, football and beer, where weakness and fear were carefully concealed. Only after they felt safe with me did I meet the terrified kids inside.

What happens when the self is no longer in charge? IFS calls this blending: a condition in which the Self identifies with a part, as in “I want to kill myself, or “I hate you.”

Beneath the surface of the protective parts of trauma survivors there exists an undamaged essence, a Self that is confident, curious and calm, a Self that has been sheltered from destruction by the various protectors that have emerged in their efforts to ensure survival. Once those protectors trust that it is safe to separate, the Self will spontaneously emerge, and the parts can be enlisted in the healing process. This mindful Self can help reorganize the inner system and communicate with the parts in ways that help those parts trust that there is someone inside who can handle things.

What part of me feels this way? How do you feel toward that (sad, vengeful, terrified) part of you? The protective part is often thanked for its vigilance and assured it can return anytime it is needed.

Joan: Exiles and Firefighters

I asked Joan if she had noticed the part of herself that was critical. She acknowledged that she had, and I asked her how she felt toward that critic. This key question allowed her to begin to separate from that part and to access her Self. Joan responded that she hated the critic, because it reminded her of her mother. When I asked what that critical part might be protecting, her anger subsided, and she became more curious and thoughtful. “I wonder why she finds it necessary to call me some of the same names that my mother used to call me, and worse.” She talked about how scared she had been of her mom growing up and how she felt that she never could do anything right. The critic was obviously a manager. Not only was it protecting Joan from me, but it was trying to preempt her mother’s criticism.

Over the next few weeks Joan told me that she had been sexually molested by her mother’s boyfriend, probably around first or second grade. She thought she’d been “ruined” for intimate relationships. While she was demanding and critical of her husband, for whom she lacked any sexual desire, she was passionate and reckless in her love affairs. But the affairs always ended in a similar way: in the middle of a lovemaking session, she would suddenly become terrified and curl up into a ball, whimpering like a little girl. These scenes left her confused and disgusted, and afterward she could not bear to have anything more to do with her lover.

Joan learned to make herself disappear when she was being molested, floating above the scene as if it were happening to some other girl. Pushing the molestation out of her mind had enabled Joan to have a normal school life of sleepovers, girlfriends, and team sports. The trouble began in adolescence, when she developed her pattern of frigid contempt for boys who treated her well and having casual sex that left her humiliated and ashamed. She told me that bulimia for her was what orgasms must be for other people, and having sex with her husband for her was what vomiting must be for others. While specific memories of her abuse were split off (dissociated), she unwittingly kept reenacting it.

Keeping her exiles hidden and despised was condemning her to a life without intimacy or genuine joy.

As Joan’s treatment progressed, we identified many different parts that were in charge at different times: an aggressive childlike part that threw tantrums, a promiscuous adolescent part, a suicidal part, an obsessive manager, a prissy moralist, and so on. As usual, we met the managers first. Their job was to prevent humiliation and abandonment and to keep her organized and safe. Some managers may be aggressive, like Joan’s critic, while others are perfectionistic or reserved, careful not to draw too much attention to themselves. Internal managers control how much access we have to emotions, so that the self-system doesn’t get overwhelmed. Each part should be approached as an internal protector who maintains an important defensive position. Managers carry huge burdens of responsibility and usually are in over their heads. Some managers are extremely competent. Many of my patients do outstanding professional jobs, and can be superbly attentive parents. While their colleagues may have experienced them as a bit distant or reserved, they would probably have been astonished to discover that their exemplary coworkers engaged in self-mutilation, eating disorders or bizarre sexual practices (??).

The following week Joan missed her appointment. We had triggered her exiles and her firefighters went on a rampage. The evening after we talked about her terror of being put into foster care she went to a bar and picked up a guy. Coming home late, drunk and disheveled, she refused to talk to her husband and fell asleep in the den. The next morning she acted as if nothing had happened.

Firefighters will do anything to make emotional pain go away. Aside from sharing the task of keeping the exiles locked up, they are the opposite of managers. Managers are all about staying in control, while firefightrs will destroy the house in order to extinguish the fire. I’ve met firefighters who shop, drink, play computer games addictively, have impulsive affairs, or exercise compulsively. These can blunt the abused child’s horror and shame, if only for a few hours. The struggle between uptight managers and out-of-control firefighters will continue until the exiles, which carry the burden of the trauma, are allowed to come home and be cared for.

Keeping the exiles locked up stamps out not only memories and emotions but also the parts that hold them – the parts that were hurt the most by the trauma. Schwartz: “Usually those are your most sensitive, creative, intimacy-loving, lively, playful and innocent parts. By exiling them when they get hurt, they suffer a double whammy – the insult of your rejection is added to their original injury.” Keeping the exiles hidden and despised was condemning Joan to a life without intimacy or genuine joy. (Therapy: making Joan feel safe in her body, returning to exiled girl who carried shame of molestation, asking her protectors to step back so she could listen to what her little girl wanted her to know, and finally to rescue the girl. instead of hating this child, she could embrace this part of herself.)

Peter: Judgment
Peter ran an oncology service at a prestigious medical centre, proud of his work, high standards, tough. Internal managers obsessed with power are usually created as a bulwark against feeling helpless. His father was a holocaust survivor who could be brutal and exacting but also had a tender and sentimental side that kept Peter connected with him and inspired him to become a physician. Peter’s wife joined us for the next meeting. She described how he critized her incessantly – her taste in clothes, her child-rearing practices, her reading habits, her intelligence, her friends. He was rarely at home and never emotionally available. Because he had so many important obligations and because he was so explosive, his family always tiptoed around him. She was determined to leave him and start a new life unless he made radical changes. At that point, for the first time, I saw Peter become obviously distressed.

I asked him what would happen if he stopped his ruthless judging. He was silent for perhaps a minute before he whispered “I would get hurt.” I urged him to ask the critic what that meant. Still with his eyes closed Peter replied “If you criticize others, they don’t dare to hurt you. If you are perfect, nobody can criticize you.” I asked him to thank his critic for protecting him against hurt and humiliation, and as he became silent again, I could see his shoulders relax and his breathing become slower and deeper.

He next told me that he was aware that his pomposity was affecting his relationships with his colleagues and students; he felt lonely and despised during staff meetings and uncomfortable at hospital parties. When I asked him if he wanted to change the way that angry part threatened people, he replied that he did. I then asked him where it was located in his body, and he found it in the middle of his chest. Keeping his focus inside, I asked him how he felt toward it. He said it made him feel scared.

Next I asked him to stay focused on it and see how he felt toward it now. He said he was curious to know more about it. I asked how old it was. He said about 7. I asked him to have his critic show him what he protected. He told me he was witnessing a scene from his childhood. His father was beating a little boy, him, and he was standing to one side thinking how stupid that kid was to provoke his dad. When I asked him how he felt about the boy who was getting hurt, he told me that he despised him. He was a weakling and a whiner; after showing even the least bit of defiance to his dad’s high-handed ways, he inevitably capitulated and whimpered that he would be a good little boy. He had no guts, no fire in his belly. I asked the critic if he would be willing to step aside so we could see what was going on with that boy. In response the critic appeared in full force and called him names like ‘wimp’ and ‘sissy.’ I asked Peter again if the critic would step aside and give the boy a chance to speak and he shut down completely.

The next week his wife had filed for divorce. We went inside and identified the part that was terrified of abandonment. His first reaction was again disgust at the boy’s weakness, but after I asked him to get that part to step back, he saw an image of himself as a young boy in his parents’ house, alone in his room, screaming in terror. I asked him if the boy had told him everything he wanted to know. No, there were other scenes, like running to embrace his father at the door and getting slapped for having disobeyed his mother. Then I asked him to show the boy that he cared about him. After some coaxing he put his arms around the boy. I was surprised that this seemingly harsh and callous man knew exactly how to take care of him. Then, after some time, I urged Peter to go back into the scene and take the boy away with him. Peter imagined himself confronting his dad as a grown man, telling him: ‘If you ever mess with that boy again, I’ll kill you.” He then, in his imagination, took the child to a beautiful campground he knew, where the boy could play with ponies while he watched over him. We revisted that isolated boy from time to time, making sure that Peter’s wounded parts were taken care of. This is the stage IFS calls “unburdening”. With each new unburdening Peter’s once-scathing inner critic relaxed, as little by little it became more like a mentor than a judge, and he began to repair his relationships with his family and colleagues. He also stopped suffering from tension headaches.

The more early pain and deprivation we have experienced, the more likely we are to interpret other people’s actions as being directed against us and the less understanding we will be of their struggles, insecurities and concerns. If we can’t appreciate the complexity of their lives, we may see anything they do as a confirmation that we are going to get hurt and disappointed. Trauma and abandonment disconnect people from their body as a source of pleasure and comfort, or even as part of themselves that needs care and nurturance. When we can’t rely on our body to signal safety or warning and instead feel chronically overwhelmed by physical stirrings, we lose the capacity to feel at home in our skin, and in the world. As long as their map of the world is based on trauma, abuse and neglect, people are likely to seek shortcuts to oblivion. Anticipating rejection, ridicule and deprivation, they are reluctant to try out new options, certain that these will lead to failure. This lack of experimentation traps people in a matrix of fear, isolation and scarcity where it is impossible to welcome the very experiences that might change their basic worldview. How to harness the extraordinary power of the imagination to transform the inner narratives that drive and confine our functioning in the world. (imagination – art)

Doerries: Anyone who has come into contact with extreme pain, suffering or death has no trouble understanding Greek drama. It’s all about bearing witness to the stories of (war) veterans.

Pierre Janet (1889): Traumatic stress is an illness of not being able to be fully alive in the present.

In today’s world your ZIP code, more than your genetic code, determines whether you will lead a safe and healthy life. People’s income, family structure, housing, employment and educational opportunities affect not only their risk of developing traumatic stress but also their access to effective help to address it. People who feel safe and meaningfully connected with others have little reason to squander their lives doing drugs or staring numbly at TV, they don’t feel compelled to stuff themselves with carbohydrates or assault their fellow human beings. But if we feel abandoned, worthless or invisible, nothing seems to matter. Fear destroys curiosity and playfulness. In order to have a healthy society we must raise children who can safely play and learn.

Teachers’ perspectives begin to change when they realize that these kids’ disturbing behaviours started out as frustrated attempts to communicate distress and as misguided attempts to survive.

Feeling safe with others defines mental health.