This poses a real challenge for recovery. Once you recognize that posttraumatic reactions started off as efforts to save your life, you may gather the courage to face your inner music (or cacophony), but you will need help to do so. You have to find someone you can trust enough to accompany you, someone who can safely hold your feelings and help you listen to the painful messages from your emotional brain. You need a guide who is not afraid of your terror and who can contain your darkest rage, someone who can safeguard the wholeness of you while you explore the fragmented experiences that you had to keep secret from yourself for so long. Most traumatized individuals need an anchor and a great deal of coaching to do this work.
Choosing a Professional Therapist
The training of competent trauma therapists involves learning about the impact of trauma, abuse, and neglect and mastering a variety of techniques that can help to (1) stabilize and calm patients down, (2) help to lay traumatic memories and reenactments to rest, and (3) reconnect patients with their fellow men and women. Ideally the therapist will also have been on the receiving end of whatever therapy he or she practices.
While it’s inappropriate and unethical for therapists to tell you the details of their personal struggles, it is perfectly reasonable to ask what particular forms of therapy they have been trained in, where they learned their skills, and whether they’ve personally benefited from the therapy they propose for you.
There is no one “treatment of choice” for trauma, and any therapist who believes that his or her particular method is the only answer to your problems is suspect of being an ideologue rather than somebody who is interested in making sure that you get well. No therapist can possibly be familiar with every effective treatment, and he or she must be open to your exploring options other than the ones he or she offers. He or she also must be open to learning from you. Gender, race, and personal background are relevant only if they interfere with helping the patient feel safe and understood.
Do you feel basically comfortable with this therapist? Does he or she seem to feel comfortable in his or her own skin and with you as a fellow human being? Feeling safe is a necessary condition for you to confront your fears and anxieties. Someone who is stern, judgmental, agitated, or harsh is likely to leave you feeling scared, abandoned, and humiliated, and that won’t help you resolve your traumatic stress. There may be times as old feelings from the past are stirred up, when you become suspicious that the therapist resembles someone who once hurt or abused you. Hopefully, this is something you can work through together, because in my experience patients get better only if they develop deep positive feelings for their therapists. I also don’t think that you can grow and change unless you feel that you have some impact on the person who is treating you.
The critical question is this: Do you feel that your therapist is curious to find out who you are and what you, not some generic “PTSD patient,” need? Are you just a list of symptoms on some diagnostic questionnaire, or does your therapist take the time to find out why you do what you do and think what you think? Therapy is a collaborative process—a mutual exploration of your self.
Patients who have been brutalized by their caregivers as children often do not feel safe with anyone. I often ask my patients if they can think of any person they felt safe with while they were growing up. Many of them hold tight to the memory of that one teacher, neighbor, shopkeeper, coach, or minister who showed that he or she cared, and that memory is often the seed of learning to reengage. We are a hopeful species. Working with trauma is as much about remembering how we survived as it is about what is broken.
I also ask my patients to imagine what they were like as newborns—whether they were lovable and filled with spunk. All of them believe they were and have some image of what they must have been like before they were hurt.
Some people don’t remember anybody they felt safe with. For them, engaging with horses or dogs may be much safer than dealing with human beings. This principle is currently being applied in many therapeutic settings to great effect, including in jails, residential treatment programs, and veterans’ rehabilitation. Jennifer, a member of the first graduating class of the Van der Kolk Center,23 who had come to the program as an out-of-control, mute fourteen-year-old, said during her graduation ceremony that having been entrusted with the responsibility of caring for a horse was the critical first step for her. Her growing bond with her horse helped her feel safe enough to begin to relate to the staff of the center and then to focus on her classes, take her SATs, and be accepted to college.24
4. COMMUNAL RHYTHMS AND SYNCHRONY
From the moment of our birth, our relationships are embodied in responsive faces, gestures, and touch. As we saw in chapter 7, these are the foundations of attachment. Trauma results in a breakdown of attuned physical synchrony: When you enter the waiting room of a PTSD clinic, you can immediately tell the patients from the staff by their frozen faces and collapsed (but simultaneously agitated) bodies. Unfortunately, many therapists ignore those physical communications and focus only on the words with which their patients communicate.
The healing power of community as expressed in music and rhythms was brought home for me in the spring of 1997, when I was following the work of the Truth and Reconciliation Commission in South Africa. In some places we visited, terrible violence continued. One day I attended a group for rape survivors in the courtyard of a clinic in a township outside Johannesburg. We could hear the sound of bullets being fired at a distance while smoke billowed over the walls of the compound and the smell of teargas hung in the air. Later we heard that forty people had been killed.
Yet, while the surroundings were foreign and terrifying, I recognized this group all too well: The women sat slumped over—sad and frozen—like so many rape therapy groups I had seen in Boston. I felt a familiar sense of helplessness, and, surrounded by collapsed people, I felt myself mentally collapse as well. Then one of the women started to hum, while gently swaying back and forth. Slowly a rhythm emerged; bit by bit other women joined in. Soon the whole group was singing, moving, and getting up to dance. It was an astounding transformation: people coming back to life, faces becoming attuned, vitality returning to bodies. I made a vow to apply what I was seeing there and to study how rhythm, chanting, and movement can help to heal trauma.
We will see more of this in chapter 20, on theater, where I show how groups of young people—among them juvenile offenders and at-risk foster kids—gradually learn to work together and to depend on one another, whether as partners in Shakespearean swordplay or as the writers and performers of full-length musicals. Different patients have told me how much choral singing, aikido, tango dancing, and kickboxing have helped them, and I am delighted to pass their recommendations on to other people I treat.
I learned another powerful lesson about rhythm and healing when clinicians at the Trauma Center were asked to treat a five-year-old mute girl, Ying Mee, who had been adopted from an orphanage in China. After months of failed attempts to make contact with her, my colleagues Deborah Rozelle and Liz Warner realized that her rhythmical engagement system didn’t work—she could not resonate with the voices and faces of the people around her. That led them to sensorimotor therapy.25
The sensory integration clinic in Watertown, Massachusetts, is a wondrous indoor playground filled with swings, tubs full of multicolored rubber balls so deep that you can make yourself disappear, balance beams, crawl spaces fashioned from plastic tubing, and ladders that lead to platforms from which you can dive onto foam-filled mats. The staff bathed Ying Mee in the tub with plastic balls; that helped her feel sensations on her skin. They helped her sway on swings and crawl under weighted blankets. After six weeks something shifted—and she started to talk.26
Ying Mee’s dramatic improvement inspired us to start a sensory integration clinic at the Trauma Center, which we now also use in our residential treatment programs. We have not yet explored how well sensory integration wor
ks for traumatized adults, but I regularly incorporate sensory integration experiences and dance in my seminars.
Learning to become attuned provides parents (and their kids) with the visceral experience of reciprocity. Parent-child interaction therapy (PCIT) is an interactive therapy that fosters this, as is SMART (sensory motor arousal regulation treatment), developed by my colleagues at the Trauma Center.27
When we play together, we feel physically attuned and experience a sense of connection and joy. Improvisation exercises (such as those found at http://learnimprov.com/) also are a marvelous way to help people connect in joy and exploration. The moment you see a group of grim-faced people break out in a giggle, you know that the spell of misery has broken.
5. GETTING IN TOUCH
Mainstream trauma treatment has paid scant attention to helping terrified people to safely experience their sensations and emotions. Medications such as serotonin reuptake blockers, Respiridol and Seroquel increasingly have taken the place of helping people to deal with their sensory world.28 However, the most natural way that we humans calm down our distress is by being touched, hugged, and rocked. This helps with excessive arousal and makes us feel intact, safe, protected, and in charge.
Rembrandt van Rijn: Christ Healing the Sick. Gestures of comfort are universally recognizable and reflect the healing power of attuned touch.
Touch, the most elementary tool that we have to calm down, is proscribed from most therapeutic practices. Yet you can’t fully recover if you don’t feel safe in your skin. Therefore, I encourage all my patients to engage in some sort of bodywork, be it therapeutic massage, Feldenkrais, or craniosacral therapy.
I asked my favorite bodywork practitioner, Licia Sky, about her practice with traumatized individuals. Here is some of what she told me: “I never begin a bodywork session without establishing a personal connection. I’m not taking a history; I’m not finding out how traumatized a person is or what happened to them. I check in where they are in their body right now. I ask them if there is anything they want me to pay attention to. All the while, I’m assessing their posture; whether they look me in the eye; how tense or relaxed they seem; are they connecting with me or not.
“The first decision I make is if they will feel safer face up or face down. If I don’t know them, I usually start face up. I am very careful about draping; very careful to let them feel safe with whatever clothing they want to leave on. These are important boundaries to set up right at the beginning.
“Then, with my first touch, I make firm, safe contact. Nothing forced or sharp. Nothing too fast. The touch is slow, easy for the client to follow, gently rhythmic. It can be as strong as a handshake. The first place I might touch is their hand and forearm, because that’s the safest place to touch anybody, the place where they can touch you back.
“You have to meet their point of resistance—the place that has the most tension—and meet it with an equal amount of energy. That releases the frozen tension. You can’t hesitate; hesitation communicates a lack of trust in yourself. Slow movement, careful attuning to the client is different from hesitation. You have to meet them with tremendous confidence and empathy, let the pressure of your touch meet the tension they are holding in their bodies.”
What does bodywork do for people? Licia’s reply: “Just like you can thirst for water, you can thirst for touch. It is a comfort to be met confidently, deeply, firmly, gently, responsively. Mindful touch and movement grounds people and allows them to discover tensions that they may have held for so long that they are no longer even aware of them. When you are touched, you wake up to the part of your body that is being touched.
“The body is physically restricted when emotions are bound up inside. People’s shoulders tighten; their facial muscles tense. They spend enormous energy on holding back their tears—or any sound or movement that might betray their inner state. When the physical tension is released, the feelings can be released. Movement helps breathing to become deeper, and as the tensions are released, expressive sounds can be discharged. The body becomes freer—breathing freer, being in flow. Touch makes it possible to live in a body that can move in response to being moved.
“People who are terrified need to get a sense of where their bodies are in space and of their boundaries. Firm and reassuring touch lets them know where those boundaries are: what’s outside them, where their bodies end. They discover that they don’t constantly have to wonder who and where they are. They discover that their body is solid and that they don’t have to be constantly on guard. Touch lets them know that they are safe.”
6. TAKING ACTION
The body responds to extreme experiences by secreting stress hormones. These are often blamed for subsequent illness and disease. However, stress hormones are meant to give us the strength and endurance to respond to extraordinary conditions. People who actively do something to deal with a disaster—rescuing loved ones or strangers, transporting people to a hospital, being part of a medical team, pitching tents or cooking meals—utilize their stress hormones for their proper purpose and therefore are at much lower risk of becoming traumatized. (Nonetheless, everyone has his or her breaking point, and even the best-prepared person may become overwhelmed by the magnitude of the challenge.)
Helplessness and immobilization keep people from utilizing their stress hormones to defend themselves. When that happens, their hormones still are being pumped out, but the actions they’re supposed to fuel are thwarted. Eventually, the activation patterns that were meant to promote coping are turned back against the organism and now keep fueling inappropriate fight/flight and freeze responses. In order to return to proper functioning, this persistent emergency response must come to an end. The body needs to be restored to a baseline state of safety and relaxation from which it can mobilize to take action in response to real danger.
My friends and teachers Pat Ogden and Peter Levine have each developed powerful body-based therapies, sensorimotor psychotherapy29 and somatic experiencing30 to deal with this issue. In these treatment approaches the story of what has happened takes a backseat to exploring physical sensations and discovering the location and shape of the imprints of past trauma on the body. Before plunging into a full-fledged exploration of the trauma itself, patients are helped to build up internal resources that foster safe access sensations and emotions that overwhelmed them at the time of the trauma. Peter Levine calls this process pendulation—gently moving in and out of accessing internal sensations and traumatic memories. In this way patients are helped to gradually expand their window of tolerance.
Once patients can tolerate being aware of their trauma-based physical experiences, they are likely to discover powerful physical impulses—like hitting, pushing, or running—that arose during the trauma but were suppressed in order to survive. These impulses manifest themselves in subtle body movements such as twisting, turning, or backing away. Amplifying these movements and experimenting with ways to modify them begins the process of bringing the incomplete, trauma-related “action tendencies” to completion and can eventually lead to resolution of the trauma. Somatic therapies can help patients to relocate themselves in the present by experiencing that it is safe to move. Feeling the pleasure of taking effective action restores a sense of agency and a sense of being able to actively defend and protect themselves.
Back in 1893 Pierre Janet, the first great explorer of trauma, wrote about “the pleasure of completed action,” and I regularly observe that pleasure when I practice sensorimotor psychotherapy and somatic experiencing: When patients can physically experience what it would have felt like to fight back or run away, they relax, smile, and express a sense of completion.
When people are forced to submit to overwhelming power, as is true for most abused children, women trapped in domestic violence, and incarcerated men and women, they often survive with resigned compliance. The best way to overcome ingrained patterns of submission is to restore a physical cap
acity to engage and defend. One of my favorite body-oriented ways to build effective fight/flight responses is our local impact center’s model mugging program, in which women (and increasingly men) are taught to actively fight off a simulated attack.31 The program started in Oakland, California, in 1971 after a woman with a fifth-degree black belt in karate was raped. Wondering how this could have happened to someone who supposedly could kill with her bare hands, her friends concluded that she had become de-skilled by fear. In the terms of this book, her executive functions—her frontal lobes—went off-line, and she froze. The model mugging program teaches women to recondition the freeze response through many repetitions of being placed in the “zero hour” (a military term for the precise moment of an attack) and learning to transform fear into positive fighting energy.
One of my patients, a college student with a history of unrelenting child abuse, took the course. When I first met her, she was collapsed, depressed, and overly compliant. Three months later, during her graduation ceremony, she successfully fought off a gigantic male attacker who ended up lying cringing on the floor (shielded from her blows by a thick protective suit) while she faced him, arms raised in a karate stance, calmly and clearly yelling no.
Not long afterward, she was walking home from the library after midnight when three men jumped out of some bushes, yelling: “Bitch, give us your money.” She later told me that she took that same karate stance and yelled back: “Okay, guys, I’ve been looking forward to this moment. Who wants to take me on first?” They ran away. If you’re hunched over and too afraid to look around, you are easy prey to other people’s sadism, but when you walk around projecting the message “Don’t mess with me,” you’re not likely to be bothered.
The Body Keeps the Score Page 27