The images kept coming: “I have pictures of a bulldozer flattening the house I grew up in. It’s over!” Then Kathy started on a different track: “I am thinking about how much I like Jeffrey [a boy in one of her classes]. Thinking that he might not want to hang out with me. Thinking I can’t handle it. I have never been someone’s girlfriend before and I don’t know how.” I asked her what she thought she needed to know and began the next sequence. “Now, there is a person who just wants to be with me—it is too simple. I don’t know how to just be myself around men. I am petrified.”
As she tracked my finger, Kathy started to sob. When I stopped, she told me: “I had an image of Jeffrey and me sitting in the coffeehouse. My father comes in the door. He starts screaming at the top of his lungs and he is wielding an ax; he says, ‘I told you that you belong to me.’ He puts me on top of the table—then he rapes me, and then he rapes Jeffrey.” She was crying hard now. “How can you be open with somebody when you have visions of your dad raping you and then raping us both?” I wanted to comfort her, but I knew it was more important to keep her associations moving. I asked her to focus on what she felt in her body: “I feel it in my forearms, in my shoulders, and my right chest. I just want to be held.” We continued the EMDR and when we stopped, Kathy looked relaxed. “I heard Jeffrey say it’s okay, that he was sent here to take care of me. And that it was not anything that I did and that he just wants to be with me for my sake.” Again I asked what she felt in her body. “I feel really peaceful. A little bit shaky—like when you’re using new muscles. Some relief. Jeffrey knows all this already. I feel like I’m alive and that it is all over. But I am afraid that my father has another little girl, and that makes me very, very sad. I want to save her.”
But as we continued the trauma returned, together with other thoughts and images: “I need to throw up. . . . I have intrusions of lots of smells—bad cologne, alcohol, vomit.” A few minutes later Kathy was crying profusely: “I really feel my mom here now. It feels like she wants me to forgive her. I have the sense that the same thing happened to her—she is apologizing to me over and over. She’s telling me that this happened to her—that it was my grandfather. She’s also telling me that my grandmother is really sorry for not being there to protect me.” I kept asking her to take deep breaths and stay with whatever was coming up.
At the end of the next sequence Kathy said: “I feel like it’s over. I felt my grandmother holding me at my current age—telling me that she is so sorry she married my grandfather. That she and my mom are making sure that it stops here.” After one final EMDR sequence Kathy was smiling: “I have an image of pushing my father out of the coffeehouse and Jeffrey locking the door behind him. He stands outside. You can see him through the glass—everybody’s making fun of him.”
With the help of EMDR Kathy was able to integrate the memories of her trauma and call on her imagination to help her lay them to rest, arriving at a sense of completion and control. She did so with minimal input from me and without any discussion of the particulars of her experiences. (I never felt a reason to question their accuracy; her experiences were real to her, and my job was to help her deal with them in the present.) The process freed something in her mind/brain to activate new images, feelings, and thoughts; it was as if her life force emerged to create new possibilities for her future.5
As we’ve seen, traumatic memories persist as split-off, unmodified images, sensations, and feelings. To my mind the most remarkable feature of EMDR is its apparent capacity to activate a series of unsought and seemingly unrelated sensations, emotions, images, and thoughts in conjunction with the original memory. This way of reassembling old information into new packages may be just the way we integrate ordinary, nontraumatic day-to-day experiences.
EXPLORING THE SLEEP CONNECTION
Shortly after learning about EMDR I was asked to speak about my work at the sleep laboratory headed by Allan Hobson at the Massachusetts Mental Health Center. Hobson (together with his teacher, Michel Jouvet)6 was famous for discovering where dreams are generated in the brain, and one of his research assistants, Robert Stickgold, was just then beginning to explore the function of dreams. I showed the group a videotape of a patient who had suffered from severe PTSD for thirteen years after a terrible car accident and who, in only two sessions of EMDR, had transformed from a helpless panicked victim into a confident, assertive woman. Bob was fascinated.
A few weeks later a friend of Stickgold’s family became so depressed after the death of her cat that she had to be hospitalized. The attending psychiatrist concluded that the cat’s death had triggered unresolved memories of the death of the woman’s mother when she was twelve, and he connected her with Roger Solomon, a well-known EMDR trainer, who treated her successfully. Afterward she called Stickgold and said, “Bob, you have to study this. It’s really strange—it has to do with your brain, not your mind.”
Soon afterward an article appeared in the journal Dreaming suggesting that EMDR was related to rapid eye movement (REM) sleep—the phase of sleep in which dreaming occurs.7 Research had already shown that sleep, and dream sleep in particular, plays a major role in mood regulation. As the article in Dreaming pointed out, 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.8
Of course, PTSD is notoriously associated with disturbed sleep, and self-medication with alcohol or drugs further disrupts REM sleep. During my time at the VA my colleagues and I had found that the veterans with PTSD frequently woke themselves up soon after going into REM sleep9—probably because they had activated a trauma fragment during a dream.10 Other researchers have also noticed this phenomenon, but thought that it was irrelevant to understanding PTSD.11
Today we know that both 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.12 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.13
Dreams keep replaying, recombining, and reintegrating pieces of old memories for months and even years.14 They constantly update the subterranean 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. For example, when subjects are wakened from non-REM sleep and given a word-association test, they give standard responses: hot/cold, hard/soft, etc. Wakened from REM sleep, they make less conventional connections, such as thief/wrong.15 They also solve simple anagrams more easily after REM sleep. This shift toward activation of distant associations could explain why dreams are so bizarre.16
Stickgold, Hobson, and their colleagues thus discovered that dreams help to forge new relationships between apparently unrelated memories.17 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. While Noam in chapter 4 could imagine a trampoline to save future victims of terrorism, traumatized people are trapped in frozen associations: Anybody who wears a turban will try to kill me; any man who finds me attractive wants to rape me.
Finally, Stickgold suggests a clear link between EMDR and memory processing in dreams: “If the bilateral stimulation of EMDR can alter brain states in a manner similar to that seen during REM sleep then there is now good evidence that EMDR should be able to take advantage of sleep-dependent processes, which may be blocked or ineffective in PTSD sufferers, to allow effective memory processing and trauma resolution.”18 The basic EMDR instruction, “Hold that image in your mind and just watch my fingers moving back and forth,” ma
y very well reproduce what happens in the dreaming brain. As this book is going to press Ruth Lanius and I are studying how the brain reacts, both while remembering a traumatic event and an ordinary experience, to saccadic eye movements as subjects lie in an fMRI scanner. Stay tuned.
ASSOCIATION AND INTEGRATION
Unlike conventional exposure treatment, EMDR spends very little time revisiting the original trauma. The trauma itself is certainly the starting point, but the focus is on stimulating and opening up the associative process. As our Prozac/EMDR study showed, drugs can blunt the images and sensations of terror, but they remain embedded in the mind and body. In contrast with the subjects who improved on Prozac—whose memories were merely blunted, not integrated as an event that happened in the past, and still caused considerable anxiety—those who received EMDR no longer experienced the distinct imprints of the trauma: It had become a story of a terrible event that had happened a long time ago. As one of my patients said, making a dismissive hand gesture: “It’s over.”
While we don’t yet know precisely how EMDR works, the same is true of Prozac. Prozac has an effect on serotonin, but whether its levels go up or down, and in which brain cells, and why that makes people feel less afraid, is still unclear. We likewise don’t know precisely why talking to a trusted friend gives such profound relief, and I am surprised how few people seem eager to explore that question.19
Clinicians have only one obligation: to do whatever they can to help their patients get better. Because of this, clinical practice has always been a hotbed for experimentation. Some experiments fail, some succeed, and some, like EMDR, dialectical behavior therapy, and internal family systems therapy, go on to change the way therapy is practiced. Validating all these treatments takes decades and is hampered by the fact that research support generally goes to methods that have already been proven to work. I am much comforted by considering the history of penicillin: Almost four decades passed between the discovery of its antibiotic properties by Alexander Fleming in 1928 and the final elucidation of its mechanisms in 1965.
CHAPTER 16
LEARNING TO INHABIT YOUR BODY: YOGA
As we begin to re-experience a visceral reconnection with the needs 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 st
ored 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 Body Keeps the Score Page 33