These goals are not steps to be achieved, one by one, in some fixed sequence. They overlap, and some may be more difficult than others, depending on individual circumstances. In each of the chapters that follow, I’ll talk about specific methods or approaches to accomplish them. I have tried to make these chapters useful both to trauma survivors and to the therapists who are treating them. People under temporary stress may also find them useful. I’ve used every one of these methods extensively to treat my patients, and I have also experienced them myself. Some people get better using just one of these methods, but most are helped by different approaches at different stages of their recovery.
I have done scientific studies of many of the treatments I describe here and have published the research findings in peer-reviewed scientific journals.2 My aim in this chapter is to provide an overview of underlying principles, a preview of what’s to come, and some brief comments on methods I don’t cover in depth later on.
A NEW FOCUS FOR RECOVERY
When we talk about trauma, we often start with a story or a question: “What happened during the war?” “Were you ever molested?” “Let me tell you about that accident or that rape,” or “Was anybody in your family a problem drinker?” However, trauma is much more than a story about something that happened long ago. The emotions and physical sensations that were imprinted during the trauma are experienced not as memories but as disruptive physical reactions in the present.
In order to regain control over your self, you need to revisit the trauma: Sooner or later you need to confront what has happened to you, but only after you feel safe and will not be retraumatized by it. The first order of business is to find ways to cope with feeling overwhelmed by the sensations and emotions associated with the past.
As the previous parts of this book have shown, the engines of posttraumatic reactions are located in the emotional brain. In contrast with the rational brain, which expresses itself in thoughts, the emotional brain manifests itself in physical reactions: gut-wrenching sensations, heart pounding, breathing becoming fast and shallow, feelings of heartbreak, speaking with an uptight and reedy voice, and the characteristic body movements that signify collapse, rigidity, rage, or defensiveness.
Why can’t we just be reasonable? And can understanding help? The rational, executive brain is good at helping us understand where feelings come from (as in: “I get scared when I get close to a guy because my father molested me” or “I have trouble expressing my love toward my son because I feel guilty about having killed a child in Iraq”). However, the rational brain cannot abolish emotions, sensations, or thoughts (such as living with a low-level sense of threat or feeling that you are fundamentally a terrible person, even though you rationally know that you are not to blame for having been raped). Understanding why you feel a certain way does not change how you feel. But it can keep you from surrendering to intense reactions (for example, assaulting a boss who reminds you of a perpetrator, breaking up with a lover at your first disagreement, or jumping into the arms of a stranger). However, the more frazzled we are, the more our rational brains take a backseat to our emotions.3
LIMBIC SYSTEM THERAPY
The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and emotional brains, so that you can feel in charge of how you respond and how you conduct your life. When we’re triggered into states of hyper- or hypoarousal, we are pushed outside our “window of tolerance”—the range of optimal functioning.4 We become reactive and disorganized; our filters stop working—sounds and lights bother us, unwanted images from the past intrude on our minds, and we panic or fly into rages. If we’re shut down, we feel numb in body and mind; our thinking becomes sluggish and we have trouble getting out of our chairs.
As long as people are either hyperaroused or shut down, they cannot learn from experience. Even if they manage to stay in control, they become so uptight (Alcoholics Anonymous calls this “white-knuckle sobriety”) that they are inflexible, stubborn, and depressed. Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity.
If we want to change posttraumatic reactions, we have to access the emotional brain and do “limbic system therapy”: repairing faulty alarm systems and restoring the emotional brain to its ordinary job of being a quiet background presence that takes care of the housekeeping of the body, ensuring that you eat, sleep, connect with intimate partners, protect your children, and defend against danger.
DRAWING BY LICIA SKY
Accessing the emotional brain. The rational, analyzing part of the brain, centered on the dorsolateral prefrontal cortex, has no direct connections with the emotional brain, where most imprints of trauma reside, but the medial prefrontal cortex, the center of self-awareness, does.
The neuroscientist Joseph LeDoux and his colleagues have shown that the only way we can consciously access the emotional brain is through self-awareness, i.e. by activating the medial prefrontal cortex, the part of the brain that notices what is going on inside us and thus allows us to feel what we’re feeling.5 (The technical term for this is “interoception”—Latin for “looking inside.”) Most of our conscious brain is dedicated to focusing on the outside world: getting along with others and making plans for the future. However, that does not help us manage ourselves. Neuroscience research shows that the only way we can change the way we feel is by becoming aware of our inner experience and learning to befriend what is going inside ourselves.
BEFRIENDING THE EMOTIONAL BRAIN
1. DEALING WITH HYPERAROUSAL
Over the past few decades mainstream psychiatry has focused on using drugs to change the way we feel, and this has become the accepted way to deal with hyper- and hypoarousal. I will discuss drugs later in this chapter, but first I need to stress the fact that we have a host of inbuilt skills to keep us on an even keel. In chapter 5 we saw how emotions are registered in the body. Some 80 percent of the fibers of the vagus nerve (which connects the brain with many internal organs) are afferent; that is, they run from the body into the brain.6 This means that we can directly train our arousal system by the way we breathe, chant, and move, a principle that has been utilized since time immemorial in places like China and India, and in every religious practice that I know of, but that is suspiciously eyed as “alternative” in mainstream culture.
In research supported by the National Institutes of Health, my colleagues and I have shown that ten weeks of yoga practice markedly reduced the PTSD symptoms of patients who had failed to respond to any medication or to any other treatment.7 (I will discuss yoga in chapter 16.) Neurofeedback, the topic of chapter 19, also can be particularly effective for children and adults who are so hyperaroused or shut down that they have trouble focusing and prioritizing.8
Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery.9 When you deliberately take a few slow, deep breaths, you will notice the effects of the parasympathetic brake on your arousal (as explained in chapter 5). The more you stay focused on your breathing, the more you will benefit, particularly if you pay attention until the very end of the out breath and then wait a moment before you inhale again. As you continue to breathe and notice the air moving in and out of your lungs you may think about the role that oxygen plays in nourishing your body and bathing your tissues with the energy you need to feel alive and engaged. Chapter 16 documents the full-body effects of this simple practice.
Since emotional regulation is the critical issue in managing the effects of trauma and neglect, it would make an enormous difference if teachers, army sergeants, foster parents, and mental health professionals were thoroughly schooled in emotional-regulation techniques. Right now this still is mainly the domain of preschool and kindergarten teachers, who deal with immature brains and impulsive b
ehavior on a daily basis and who are often very adept at managing them.10
Mainstream Western psychiatric and psychological healing traditions have paid scant attention to self-management. In contrast to the Western reliance on drugs and verbal therapies, other traditions from around the world rely on mindfulness, movement, rhythms, and action. Yoga in India, tai chi and qigong in China, and rhythmical drumming throughout Africa are just a few examples. The cultures of Japan and the Korean peninsula have spawned martial arts, which focus on the cultivation of purposeful movement and being centered in the present, abilities that are damaged in traumatized individuals. Aikido, judo, tae kwon do, kendo, and jujitsu, as well as capoeira from Brazil, are examples. These techniques all involve physical movement, breathing, and meditation. Aside from yoga, few of these popular non-Western healing traditions have been systematically studied for the treatment of PTSD.
2. NO MIND WITHOUT MINDFULNESS
At the core of recovery is self-awareness. The most important phrases in trauma therapy are “Notice that” and “What happens next?” Traumatized people live with seemingly unbearable sensations: They feel heartbroken and suffer from intolerable sensations in the pit of their stomach or tightness in their chest. Yet avoiding feeling these sensations in our bodies increases our vulnerability to being overwhelmed by them.
Body awareness puts us in touch with our inner world, the landscape of our organism. Simply noticing our annoyance, nervousness, or anxiety immediately helps us shift our perspective and opens up new options other than our automatic, habitual reactions. Mindfulness puts us in touch with the transitory nature of our feelings and perceptions. When we pay focused attention to our bodily sensations, we can recognize the ebb and flow of our emotions and, with that, increase our control over them.
Traumatized people are often afraid of feeling. It is not so much the perpetrators (who, hopefully, are no longer around to hurt them) but their own physical sensations that now are the enemy. Apprehension about being hijacked by uncomfortable sensations keeps the body frozen and the mind shut. Even though the trauma is a thing of the past, the emotional brain keeps generating sensations that make the sufferer feel scared and helpless. It’s not surprising that so many trauma survivors are compulsive eaters and drinkers, fear making love, and avoid many social activities: Their sensory world is largely off limits.
In order to change you need to open yourself to your inner experience. The first step is to allow your mind to focus on your sensations and notice how, in contrast to the timeless, ever-present experience of trauma, physical sensations are transient and respond to slight shifts in body position, changes in breathing, and shifts in thinking. Once you pay attention to your physical sensations, the next step is to label them, as in “When I feel anxious, I feel a crushing sensation in my chest.” I may then say to a patient: “Focus on that sensation and see how it changes when you take a deep breath out, or when you tap your chest just below your collarbone, or when you allow yourself to cry.” Practicing mindfulness calms down the sympathetic nervous system, so that you are less likely to be thrown into fight-or-flight.11 Learning to observe and tolerate your physical reactions is a prerequisite for safely revisiting the past. If you cannot tolerate what you are feeling right now, opening up the past will only compound the misery and retraumatize you further.12
We can tolerate a great deal discomfort as long as we stay conscious of the fact that the body’s commotions constantly shift. One moment your chest tightens, but after you take a deep breath and exhale, that feeling softens and you may observe something else, perhaps a tension in your shoulder. Now you can start exploring what happens when you take a deeper breath and notice how your rib cage expands.13 Once you feel calmer and more curious, you can go back to that sensation in your shoulder. You should not be surprised if a memory spontaneously arises in which that shoulder was somehow involved.
A further step is to observe the interplay between your thoughts and your physical sensations. How are particular thoughts registered in your body? (Do thoughts like “My father loves me” or “my girlfriend dumped me” produce different sensations?) Becoming aware of how your body organizes particular emotions or memories opens up the possibility of releasing sensations and impulses you once blocked in order to survive.14 In chapter 20, on the benefits of theater, I’ll describe in more detail how this works.
Jon Kabat-Zinn, one of the pioneers in mind-body medicine, founded the Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center in 1979, and his method has been thoroughly studied for more than three decades. As he describes mindfulness, “One way to think of this process of transformation is to think of mindfulness as a lens, taking the scattered and reactive energies of your mind and focusing them into a coherent source of energy for living, for problem solving, for healing.”15
Mindfulness has been shown to have a positive effect on numerous psychiatric, psychosomatic, and stress-related symptoms, including depression and chronic pain.16 It has broad effects on physical health, including improvements in immune response, blood pressure, and cortisol levels.17 It has also been shown to activate the brain regions involved in emotional regulation18 and to lead to changes in the regions related to body awareness and fear.19 Research by my Harvard colleagues Britta Hölzel and Sara Lazar has shown that practicing mindfulness even decreases the activity of the brain’s smoke detector, the amygdala, and thus decreases reactivity to potential triggers.20
3. RELATIONSHIPS
Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized. Safety and terror are incompatible. When we are terrified, nothing calms us down like the reassuring voice or the firm embrace of someone we trust. Frightened adults respond to the same comforts as terrified children: gentle holding and rocking and the assurance that somebody bigger and stronger is taking care of things, so you can safely go to sleep. In order to recover, mind, body, and brain need to be convinced that it is safe to let go. That happens only when you feel safe at a visceral level and allow yourself to connect that sense of safety with memories of past helplessness.
After an acute trauma, like an assault, accident, or natural disaster, survivors require the presence of familiar people, faces, and voices; physical contact; food; shelter and a safe place; and time to sleep. It is critical to communicate with loved ones close and far and to reunite as soon as possible with family and friends in a place that feels safe. Our attachment bonds are our greatest protection against threat. For example, children who are separated from their parents after a traumatic event are likely to suffer serious negative long-term effects. Studies conducted during World War II in England showed that children who lived in London during the Blitz and were sent away to the countryside for protection against German bombing raids fared much worse than children who remained with their parents and endured nights in bomb shelters and frightening images of destroyed buildings and dead people.21
Traumatized human beings recover in the context of relationships: with families, loved ones, AA meetings, veterans’ organizations, religious communities, or professional therapists. The role of those relationships is to provide physical and emotional safety, including safety from feeling shamed, admonished, or judged, and to bolster the courage to tolerate, face, and process the reality of what has happened.
As we have seen, much the wiring of our brain circuits is devoted to being in tune with others. Recovery from trauma involves (re)connecting with our fellow human beings. This is why trauma that has occurred within relationships is generally more difficult to treat than trauma resulting from traffic accidents or natural disasters. In our society the most common traumas in women and children occur at the hands of their parents or intimate partners. Child abuse, molestation, and domestic violence all are inflicted by people who are supposed to love you. That knocks out the most important protection against being traumatized:
being sheltered by the people you love.
If the people whom you naturally turn to for care and protection terrify or reject you, you learn to shut down and to ignore what you feel.22 As we saw in part 3, when your caregivers turn on you, you have to find alternative ways to deal with feeling scared, angry, or frustrated. Managing your terror all by yourself gives rise to another set of problems: dissociation, despair, addictions, a chronic sense of panic, and relationships that are marked by alienation, disconnection, and explosions. Patients with these histories rarely make the connection between what happened to them long ago and how they currently feel and behave. Everything just seems unmanageable.
Relief does not come until they are able to acknowledge what has happened and recognize the invisible demons they’re struggling with. Recall, for example, the men I described in chapter 11 who had been abused by pedophile priests. They visited the gym regularly, took anabolic steroids, and were strong as oxen. However, in our interviews they often acted like scared kids; the hurt boys deep inside still felt helpless.
While human contact and attunement are the wellspring of physiological self-regulation, the promise of closeness often evokes fear of getting hurt, betrayed, and abandoned. Shame plays an important role in this: “You will find out how rotten and disgusting I am and dump me as soon as you really get to know me.” Unresolved trauma can take a terrible toll on relationships. If your heart is still broken because you were assaulted by someone you loved, you are likely to be preoccupied with not getting hurt again and fear opening up to someone new. In fact, you may unwittingly try to hurt them before they have a chance to hurt you.
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