All the notes were taken directly from the source mentioned.

– – –

Refugee camp in Syria or the Congo to encounter trauma.

Long after a traumatic experience is over, it may be reactivated at the slightest hint of danger and mobilize disturbed brain circuits and secrete massive amounts of stress hormones.

Those new disciplines are neuroscience, the study of how the brain supports mental processes; developmental psychopathology, the study of the impact of adverse experiences on the development of mind and brain; and interpersonal neurobiology, the study of how our behavior influences the emotions, biology, and mindsets of those around us.

Trauma produces actual physiological changes, including a recalibration of the brain’s alarm system, an increase in stress hormone activity, and alterations in the system that filters relevant information from irrelevant.

There are fundamentally three avenues: 1) top down, by talking, (re-) connecting with others, and allowing ourselves to know and understand what is going on with us, while processing the memories of the trauma; 2) by taking medicines that shut down inappropriate alarm reactions, or by utilizing other technologies that change the way the brain organizes information, and 3) bottom up: by allowing the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.

How do horrific experiences cause people to become hopelessly stuck in the past? What happens in people’s minds and brains that keeps them frozen, trapped in a place they desperately wish to escape?

My great teacher, Elvin Semrad.

The greatest sources of our suffering are the lies we tell ourselves.

It’s hard enough to face the suffering that has been inflicted by others, but deep down many traumatized people are even more haunted by the shame they feel about what they themselves did or did not do under the circumstances.

In that very moment in my office, Bill was obviously seeing the same images, smelling the same smells, and feeling the same physical sensations he had felt during the original event.

Rorschach test

We learned from these Rorschach tests that traumatized people have a tendency to superimpose their trauma on everything around them and have trouble deciphering whatever is going on around them.

When people are compulsively and constantly pulled back into the past, to the last time they felt intense involvement and deep emotions, they suffer from a failure of imagination, a loss of the mental flexibility.

After trauma the world becomes sharply divided between those who know and those who don’t. People who have not shared the traumatic experience cannot be trusted, because they can’t understand it.

In other words, for every soldier who serves in a war zone abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children to recover when the source of terror and pain is not enemy combatants but their own caretakers.

We have learned that trauma is not just an event that took place sometime in the past; it is also the imprint left by that experience on mind, brain, and body.

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.

I was often surprised by the dispassionate way patients’ symptoms were discussed and by how much time was spent on trying to manage their suicidal thoughts and self-destructive behaviors, rather than on understanding the possible causes of their despair and helplessness. I was also struck by how little attention was paid to their accomplishments and aspirations; whom they cared for, loved, or hated; what motivated and engaged them, what kept them stuck, and what made them feel at peace the ecology of their lives.

Was then moonlighting at a Catholic hospital, doing physical examinations on women who’d been admitted to receive electroshock treatment for depression.

Could people make up physical sensations they had never experienced? Was there a clear line between creativity and pathological imagination? Between memory and imagination? These questions remain unanswered to this day, but research has shown that people who’ve been abused as children often feel sensations (such as abdominal pain) that have no obvious physical cause; they hear voices warning of danger or accusing them of heinous crimes.

If you do something to a patient that you would not do to your friends or children, consider whether you are unwittingly replicating a trauma from the patient’s past.

Another characteristic they shared was that even their most relaxed conversations seemed stilted, lacking the natural flow of gestures and facial expressions that are typical among friends. The relevance of these observations became clear only after I’d met the body-based therapists Peter Levine and Pat Ogden; in the later chapters I’ll have a lot to say about how trauma is held in people’s bodies.

Semrad taught us that most human suffering is related to love and loss and that the job of therapists is to help people acknowledge, experience, and bear the reality of life with all its pleasures and heartbreak. The greatest sources of our suffering are the lies we tell ourselves, he’d say, urging us to be honest with ourselves about every facet of our experience.

Healing, he told us, depends on experiential knowledge: You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions.

Antipsychotic drugs were a major factor in reducing the number of people living in mental hospitals in the United States, from over 500,000 in 1955 to fewer than 100,000 in 1996.7 For people today who did not know the world before the advent of these treatments, the change is almost unimaginable.

Neurotransmitters are chemical messengers that carry information from neuron to neuron, enabling us to engage effectively with the world.

Martin Seligman of the University of Pennsylvania.

A group of control dogs who had never been shocked before immediately ran away, but the dogs who had earlier been subjected to inescapable shock made no attempt to flee, even when the door was wide open they just lay there, whimpering and defecating. The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom. Like Maier and Seligman’s dogs, many traumatized people simply give up. Rather than risk experimenting with new options they stay stuck in the fear they know.

All finding that traumatized people keep secreting large amounts of stress hormones long after the actual danger has passed, and Rachel Yehuda at Mount Sinai in New York confronted us with her seemingly paradoxical findings that the levels of the stress hormone cortisol are low in PTSD.

Ideally our stress hormone system should provide a lightning-fast response to threat, but then quickly return us to equilibrium.

For example, he and Seligman had found that the only way to teach the traumatized dogs to get off the electric grids when the doors were open was to repeatedly drag them out of their cages so they could physically experience how they could get away. I wondered if we also could help my patients with their fundamental orientation that there was nothing they could do to defend themselves? Did my patients also need to have physical experiences to restore a visceral sense of control?

Scared animals return home, regardless of whether home is safe or frightening. I thought about my patients with abusive families who kept going back to be hurt again. Are traumatized people condemned to seek refuge in what is familiar? If so, why, and is it possible to help them become attached to places and activities that are safe and pleasurable?

Normally attractors are meant to make us feel better. So, why are so many people attracted to dangerous or painful situations?

At this point, just as with drug addiction, we start to crave the activity and experience withdrawal when it’s not available. In the long run people become more preoccupied with the pain of withdrawal than the activity itself.

We concluded that Beecher’s speculation that strong emotions can block pain was the result of the release of morphine like substances manufactured in the brain. This suggested that for many traumatized people, re-exposure to stress might provide a similar relief from anxiety.

Animals with low serotonin levels were hyper-reactive to stressful stimuli (like loud sounds), while higher levels of serotonin dampened their fear system, making them less likely to become aggressive or frozen in response to potential threats.

The social environment interacts with brain chemistry. Manipulating a monkey into a lower position in the dominance hierarchy made his serotonin drop, while chemically enhancing serotonin elevated the rank of former subordinates.

Prozac made a radical difference: It gave PTSD patients a sense of perspective21 and helped them to gain considerable control over their impulses.

In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues.

For people who are exhausted from trying to make it on their own through yoga classes, workout routines, or simply toughing it out, medications often can bring life-saving relief.

Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and one in ten Americans now take antidepressants.

These medications make children more manageable and less aggressive, but they also interfere with motivation, play, and curiosity, which are indispensable for maturing into a well-functioning and contributing member of society.

Because drugs have become so profitable, major medical journals rarely publish studies on non-drug treatments of mental health problems.

The brain-disease model overlooks four fundamental truths: (1) our capacity to destroy one another is matched by our capacity to heal one another. Restoring relationships and community is central to restoring well-being; (2) language gives us the power to change ourselves and others by communicating our experiences, helping us to define what we know, and finding a common sense of meaning; (3) we have the ability to regulate our own physiology, including some of the so-called involuntary functions of the body and brain, through such basic activities as breathing, moving, and touching; and (4) we can change social conditions to create environments in which children and adults can feel safe and where they can thrive.

Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self.

New technology could answer and reading some articles I had written, Scott asked me whether I thought we could study what happens in the brains of people who have flashbacks. I had just finished a study on how trauma is remembered (to be discussed in chapter 12), in

In the early 1990s novel brain-imaging techniques opened up undreamed-of capacities to gain a sophisticated understanding about the way the brain processes information.

Positron emission tomography (PET) and, later, functional magnetic resonance imaging (fMRI) enabled scientists to visualize how different parts of the brain are activated when people are engaged in certain tasks or when they remember events from the past. For the first time we could watch the brain as it processed memories, sensations, and emotions and begin to map the circuits of mind and consciousness.

It was already well known that intense emotions activate the limbic system, in particular an area within it called the amygdala.

Even years later traumatized people often have enormous difficulty telling other people what has happened to them. Their bodies re-experience terror, rage, and helplessness, as well as the impulse to fight or flee, but these feelings are almost impossible to articulate.

Sooner or later most survivors, like the veterans in chapter 1, come up with what many of them call their cover story that offers some explanation for their symptoms and behavior for public consumption. These stories, however, rarely capture the inner truth of the experience.

We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical.

While the left half of the brain does all the talking, the right half

We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical. While the left half of the brain does all the talking, the right half of the brain carries the music of experience. It communicates through facial expressions and body language and by making the sounds of love and sorrow: by singing, swearing, crying, dancing, or mimicking. The right brain is the first to develop in the womb, and it carries the nonverbal communication between mothers and infants. We know the left hemisphere has come online when children start to understand language and learn how to speak. This enables them to name things, compare them, understand their interrelations, and begin to communicate their own unique, subjective experiences to others.

The left brain remembers facts, statistics, and the vocabulary of events. We call on it to explain our experiences and put them in order. The right brain stores memories of sound, touch, smell, and the emotions they evoke. It reacts automatically to voices, facial features, and gestures and places experienced in the past.

Deactivation of the left hemisphere has a direct impact on the capacity to organize experience into logical sequences and to translate our shifting feelings and perceptions into words.

Without sequencing we can’t identify cause and effect, grasp the long-term effects of our actions, or create coherent plans for the future.

When something reminds traumatized people of the past, their right brain reacts as if the traumatic event were happening in the present.

Adrenaline is one of the hormones that are critical to help us fight back or flee in the face of danger. Increased adrenaline was responsible for our participants’ dramatic rise in heart rate and blood pressure while listening to their trauma narrative. Under normal conditions people react to a threat with a temporary increase in their stress hormones. As soon as the threat is over, the hormones dissipate and the body returns to normal. The stress hormones of traumatized people, in contrast, take much longer to return to baseline and spike quickly and disproportionately in response to mildly stressful stimuli. The insidious effects of constantly elevated stress hormones include memory and attention problems, irritability, and sleep disorders. They also contribute to many long-term health issues, depending on which body system is most vulnerable in a particular individual.

We can also make a strong case that Marsha is hyper-sensitized to her memories of the past and that the best treatment would be some form of desensitization.4 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.

No matter how much insight and understanding we develop, the rational brain is basically impotent to talk the emotional brain out of its own reality.

It is so much easier for them to talk about what has 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.

Witnessed had come to an end. During disasters young children usually take their cues from their parents. As long as their caregivers remain calm and responsive to their needs, they often survive terrible incidents without serious psychological scars.

Traumatized people become stuck, stopped in their growth because they can’t integrate new experiences into their lives.

Being traumatized means continuing to organize your life as if the trauma were still going on unchanged and immutable as every new encounter or event is contaminated by the past.

After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives. These attempts to maintain control over unbearable physiological reactions can result in a whole range of physical symptoms, including fibromyalgia, chronic fatigue, and other autoimmune diseases.

Brain keeps secreting stress chemicals, and the brain’s electrical circuits continue to fire in vain.2 Long after the actual event has passed, the brain may keep sending signals to the body to escape a threat that no longer exists.

The most important job of the brain is to ensure our survival, even under the most miserable conditions. Everything else is secondary. In order to do that, brains need to: (1) generate internal signals that register what our bodies need, such as food, rest, protection, sex, and shelter; (2) create a map of the world to point us where to go to satisfy those needs; (3) generate the necessary energy and actions to get us there; (4) warn us of dangers and opportunities along the way; and (5) adjust our actions based on the requirements of the moment.4 And since we human beings are mammals, creatures that can only survive and thrive in groups, all of these imperatives require coordination and collaboration.

Psychological problems occur when our internal signals don’t work, when our maps don’t lead us where we need to go, when we are too paralyzed to move, when our actions do not correspond to our needs, or when our relationships break down.

Our rational, cognitive brain is actually the youngest part of the brain and occupies only about 30 percent of the area inside our skull. The rational brain is primarily concerned with the world outside us: understanding how things and people work and figuring out how to accomplish our goals, manage our time, and sequence our actions.

Beneath the rational brain lie two evolutionarily older, and to some degree separate, brains, which are in charge of everything else: the moment-by-moment registration and management of our body’s physiology and the identification of comfort, safety, threat, hunger, fatigue, desire, longing, excitement, pleasure, and pain.

The most primitive part, the part that is already online when we are born, is the ancient animal brain, often called the reptilian brain. It is located in the brain stem, just above the place where our spinal cord enters the skull. The reptilian brain is responsible for all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating. The brain stem and the hypothalamus (which sits directly above it) together control the energy levels of the body. They coordinate the functioning of the heart and lungs and also the endocrine and immune systems, ensuring that these basic life-sustaining systems are maintained within the relatively stable internal balance known as homeostasis.

Development of this part of the brain truly takes off after a baby is born. It is the seat of the emotions, the monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is or is not important for survival purposes.

The limbic system is shaped in response to experience, in partnership with the infant’s own genetic makeup and inborn temperament.

Neuroplasticity, the relatively recent discovery that neurons that fire together, wire together. 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.

Taken together the reptilian brain and limbic system make up what I’ll call the emotional brain throughout this book.

Finally we reach the top layer of the brain, the neocortex. We share this outer layer with other mammals, but it is much thicker in us humans. In the second year of life the frontal lobes, which make up the bulk of our neocortex, begin to develop at a rapid pace. The ancient philosophers called seven years the age of reason. For us first grade is the prelude of things to come, a life organized around frontal-lobe capacities: sitting still; keeping sphincters in check; being able to use words rather than acting out; understanding abstract and symbolic ideas; planning for tomorrow; and being in tune with teachers and classmates.

The frontal lobes are responsible for the qualities that make us unique within the animal kingdom.7 They enable us to use language and abstract thought. They give us our ability to absorb and integrate vast amounts of information and attach meaning to it.

The frontal lobes allow us to plan and reflect, to imagine and play out future scenarios. They help us to predict what will happen if we take one action (like applying for a new job) or neglect another (not paying the rent).

Numerous other experiments followed around the world, and it soon became clear that mirror neurons explained many previously unexplainable aspects of the mind, such as empathy, imitation, synchrony, and even the development of language.

Crucial for understanding trauma, the frontal lobes are also the seat of empathy our ability to feel into someone else.

We pick up not only another person’s movement but her emotional state and intentions as well.

trauma almost invariably involves not being seen, not being mirrored, and not being taken into account. Treatment needs to reactivate the capacity to safely mirror, and be mirrored, by others, but also to resist being hijacked by others’ negative emotions.

The more intense the visceral, sensory input from the emotional brain, the less capacity the rational brain has to put a damper on

The neuroscientist Joseph LeDoux calls the pathway to the amygdala the low road, which is extremely fast, and that to the frontal cortex the high road, which takes several milliseconds longer in the midst of an overwhelmingly threatening experience.

The central function of the amygdala, which I call the brain’s smoke detector, is to identify whether incoming input is relevant for our survival.

Because the amygdala processes the information it receives from the thalamus faster than the frontal lobes do, it decides whether incoming information is a threat to our survival even before we are consciously aware of the danger.

Sensory Information about the environment and body state received by the eyes, ears, touch, kinesthetic sense, etc., converges on the thalamus, where it is processed, and then passed on to the amygdala to interpret its emotional significance. This occurs with lightning speed. If a threat is detected the amygdala sends messages to the hypothalamus to secrete stress hormones to defend against that threat.

While the smoke detector is usually pretty good at picking up danger clues, trauma increases the risk of misinterpreting whether a particular situation is dangerous or safe.

Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations.

Bottom-up regulation involves recalibrating the autonomic nervous system,

A traumatic event has a beginning and an end at some point it is over. But for people with PTSD a flashback can occur at any time, whether they are awake or asleep. There is no way of knowing when it’s going to occur again or how long it will last.

Sensing, naming, and identifying what is going on inside is the first step to recovery.

Visiting the past in therapy should be done while people are, biologically speaking, firmly rooted in the present and feeling as calm, safe, and grounded as possible.

Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past.

Breakdown of the thalamus explains why trauma is primarily remembered not as a story, a narrative with a beginning middle and end, but as isolated sensory imprints: images, sounds, and physical sensations that are accompanied by intense emotions, usually terror and helplessness.

The medical term for Ute’s response is depersonalization.18 Anyone who deals with traumatized men, women, or children is sooner or later confronted with blank stares and absent minds, the outward manifestation of the biological freeze reaction.

Depersonalization is one symptom of the massive dissociation created by trauma.

With nearly every part of their brains tuned out, they obviously cannot think, feel deeply, remember, or make sense out of what is going on. Conventional talk therapy, in those circumstances, is virtually useless.

This is where a bottom-up approach to therapy becomes essential. The aim is actually to change the patient’s physiology, his or her relationship to bodily sensations.

Rhythmic interactions with other people are also effective tossing a beach ball back and forth, bouncing on a Pilates ball, drumming, or dancing to music.

1872, Charles Darwin published The Expression of the Emotions in Man and Animals.

The Expression of the Emotions turns out to be an extraordinary exploration of the foundations of emotional life, filled with observations and anecdotes drawn from decades of inquiry,

We instinctively read the dynamic between two people simply from their tension or relaxation, their postures and tone of voice, their changing facial expressions. Watch a movie in a language you don’t know, and you can still guess the quality of the relationship between the characters. We often can read other mammals (monkeys, dogs, horses) in the same way.

Darwin goes on to observe that the fundamental purpose of emotions is to initiate movement that will restore the organism to safety and physical equilibrium.

If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love.

Heart, guts, and brain communicate intimately via the ˜pneumogastric’ nerve, the critical nerve involved in the expression and management of emotions in both humans and animals. When the mind is strongly excited, it instantly affects the state of the viscera; so that under excitement there will be much mutual action and reaction between these, the two most important organs of the body.

How many mental health problems, from drug addiction to self-injurious behavior, start as attempts to cope with the unbearable physical pain of our emotions?

All are a product of the synchrony between the two branches of the autonomic nervous system (ANS): the sympathetic, which acts as the body’s accelerator, and the parasympathetic, which serves as its brake.6 These are the reciprocals Darwin spoke of, and working together they play an important role in managing the body’s energy flow, one preparing for its expenditure, the other for its conservation.

The sympathetic nervous system (SNS) is responsible for arousal, including the fight-or-flight response (Darwin’s escape or avoidance behavior). Almost two thousand years ago the Roman physician Galen gave it the name sympathetic because he observed that it functioned with the emotions (sym pathos). The SNS moves blood to the muscles for quick action, partly by triggering the adrenal glands to squirt out adrenaline, which speeds up the heart rate and increases blood pressure.

The second branch of the ANS is the parasympathetic (against emotions) nervous system (PNS), which promotes self-preservative functions like digestion and wound healing. It triggers the release of acetylcholine to put a brake on arousal, slowing the heart down, relaxing muscles, and returning breathing to normal.

Whenever you take a deep breath, you activate the SNS. The resulting burst of adrenaline speeds up your heart, which explains why many athletes take a few short, deep breaths before starting competition. Exhaling, in turn, activates the PNS, which slows down the heart.

We continually speed up and slow down the heart, and because of that the interval between two successive heartbeats is never precisely the same. A measurement called heart rate variability (HRV) can be used to test the flexibility of this system, and good HRV the more fluctuation, the better is a sign that the brake and accelerator in your arousal system are both functioning properly and in balance.

(Polyvagal refers to the many branches of the vagus nerveDarwin’s pneumogastric nerve which connects numerous organs, including the brain, lungs, heart, stomach, and intestines.)

Human beings are astoundingly attuned to subtle emotional shifts in the people (and animals) around them. Slight changes in the tension of the brow, wrinkles around the eyes, curvature of the lips, and angle of the neck quickly signal to us how comfortable, suspicious, relaxed, or frightened someone is. Our mirror neurons register their inner experience, and our own bodies make internal adjustments to whatever we notice. Just so, the muscles of our own faces give others clues about how calm or excited we feel, whether our heart is racing or quiet, and whether we’re ready to pounce on them or run away.

Our brains are built to help us function as members of a tribe.

Being able to feel safe with other people is probably the single most important aspect of mental health; safe connections are fundamental to meaningful and satisfying lives.

Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart. For our physiology to calm down, heal, and grow we need a visceral feeling of safety.

In the past two decades it has become widely recognized that when adults or children are too skittish or shut down to derive comfort from human beings, relationships with other mammals can help.

The social-engagement system depends on nerves that have their origin in the brain stem regulatory centers, primarily the vagus also known as the tenth cranial nerve together with adjoining nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx.

Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart drop), we can’t breathe, and our gut stops working or empties (literally scaring the shit out of us). This is the point at which we disengage, collapse, and freeze.

Many traumatized individuals are too hypervigilant to enjoy the ordinary pleasures that life has to offer, while others are too numb to absorb new experiences or to be alert to signs of real danger.

Despite the well-documented effects of anger, fear, and anxiety on the ability to reason, many programs continue to ignore the need to engage the safety system of the brain before trying to promote new ways of thinking. The last things that should be cut from school schedules are chorus, physical education, recess, and anything else involving movement, play, and joyful engagement.

The polyvagal theory helped us understand and explain why all these disparate, unconventional techniques worked so well. It enabled us to become more conscious of combining top-down approaches (to activate social engagement) with bottom-up methods (to calm the physical tensions in the body).

Ranging from breath exercises (pranayama) and chanting to martial arts like qigong to drumming and group singing and dancing. All rely on interpersonal rhythms, visceral awareness, and vocal and facial communication, which help shift people out of fight/flight states, reorganize their perception of danger, and increase their capacity to manage relationships.

But if no one has ever looked at you with loving eyes or broken out in a smile when she sees you; if no one has rushed to help you (but instead said, Stop crying, or I’ll give you something to cry about), then you need to discover other ways of taking care of yourself. You are likely to experiment with anything drugs, alcohol, binge eating, or cutting that offers some kind of relief.

Recognizing an object in the palm of your hand requires sensing its shape, weight, temperature, texture, and position. Each of those distinct sensory experiences is transmitted to a different part of the brain, which then needs to integrate them into a single perception. McFarlane found that people with PTSD often have trouble putting the picture together.

William James, the father of American psychology,

The lack of self-awareness in victims of chronic childhood trauma is sometimes so profound that they cannot recognize themselves in a mirror.

The implications are clear: to feel present you have to know where you are and be aware of what is going on with you.

Agency is the technical term for the feeling of being in charge of your life: knowing where you stand, knowing that you have a say in what happens to you, knowing that you have some ability to shape your circumstances.

Knowing what we feel is the first step to knowing why we feel that way.

Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort.

The price for ignoring or distorting the body’s messages is being unable to detect what is truly dangerous or harmful for you and, just as bad, 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 from medication, drugs like alcohol, constant reassurance, or compulsive compliance with the wishes of others.

Psychiatrists call this phenomenon alexithymia: Greek for not having words for feelings.

Many traumatized children and adults simply cannot describe what they are feeling because they cannot identify what their physical sensations mean.

When researchers showed pictures of angry or distressed faces to people with alexithymia, they could not figure out what those people were feeling.

People with alexithymia can get better only by learning to recognize the relationship between their physical sensations and their emotions, much as colorblind people can only enter the world of color by learning to distinguish and appreciate shades of gray.

How can people open up to and explore their internal world of sensations and emotions? In my practice I begin the process by helping my patients to first notice and then describe the feelings in their bodies not emotions such as anger or anxiety or fear but the physical sensations beneath the emotions: pressure, heat, muscular tension, tingling, caving in, feeling hollow, and so on. I also work on identifying the sensations associated with relaxation or pleasure. I help them become aware of their breath, their gestures and movements. I ask them to pay attention to subtle shifts in their bodies, such as tightness in their chests or gnawing in their bellies, when they talk about negative events that they claim did not bother them.

The most natural way for human beings to calm themselves when they are upset is by clinging to another person. This means that patients who have been physically or sexually violated face a dilemma: They desperately crave touch while simultaneously being terrified of body contact.

By the late 1940s Bowlby had become persona non grata in the British psychoanalytic community, as a result of his radical claim that children’s disturbed behavior was a response to actual life experiences to neglect, brutality, and separation rather than the product of infantile sexual fantasies. Undaunted, he devoted the rest of his life to developing what came to be called attachment theory.

As we grow up, we gradually learn to take care of ourselves, both physically and emotionally, but we get our first lessons in self-care from the way that we are cared for.

Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage a kind of buffer against the worst that fate can hand them.

Bowlby saw attachment as the secure base from which a child moves out into the world.

Secure attachment develops when caregiving includes emotional attunement. Attunement starts at the most subtle physical levels of interaction between babies and their caretakers, and it gives babies the feeling of being met and understood.

Securely attached children learn what makes them feel good; they discover what makes them (and others) feel bad, and they acquire a sense of agency: that their actions can change how they feel and how others respond. Securely attached kids learn the difference between situations they can control and situations where they need help. They learn that they can play an active role when faced with difficult situations.

Donald Winnicott, is the father of modern studies of attunement.

Most human beings simply cannot tolerate being disengaged from others for any length of time. People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.

I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse.

For that reason treatment needs to address not only the imprints of specific traumatic events but also the consequences of not having been mirrored, attuned to, and given consistent care and affection: dissociation and loss of self-regulation.

My work with veterans had prepared me to listen to painful stories like Marilyn’s without trying to jump in immediately to fix the problem. Therapy often starts with some inexplicable behavior:

It takes time and patience to allow the reality behind such symptoms to reveal itself.

In fact, I’ve learned that it’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know.

In patients with histories of incest, the proportion of RA cells that are ready to pounce is larger than normal. This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells.

How do people learn what is safe and what is not safe, what is inside and what is outside, what should be resisted and what can safely be taken in?

If we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think he (or she) has my number and fail to protest if we are mistreated.

I genuinely thanked her for her feedback, and I’ve tried ever since not to tell my patients that they should not feel the way they do. Kathy taught me that my responsibility goes much deeper: I have to help them reconstruct their inner map of the world.

Attachment researchers have shown that our earliest caregivers don’t only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met.

These responses are not reasonable and therefore cannot be changed simply by reframing irrational beliefs. Our maps of the world are encoded in the emotional brain, and changing them means having to reorganize that part of the central nervous system,

Nonetheless, learning to recognize irrational thoughts and behavior can be a useful first step.

Change begins when we learn to own our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable.

Yet even though she’d drawn a girl who was being sexually molested, she or at least her cognitive, verbal self had no idea what had actually happened to her.

Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience.

This was combined with tapping acupressure points, which helped her not to become overwhelmed.

Children sense even if it they are not explicitly threatened that if they talked about their beatings or molestation to teachers they would be punished. Instead, they focus their energy on not thinking about what has happened and not feeling the residues of terror and panic in their bodies. Because they cannot tolerate knowing what they have experienced, they also cannot understand that their anger, terror, or collapse has anything to do with that experience. They don’t talk; they act and deal with their feelings by being enraged, shut down, compliant, or defiant.

Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them.

In order to know who we are to have an identity we must know (or at least feel that we know) what is and what was real. We must observe what we see around us and label it correctly; we must also be able trust our memories and be able to tell them apart from our imagination. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called soul murder. Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust.

Memories initially return as they did for Marilyn: as flashbacks that contain fragments of the experience, isolated images, sounds, and body sensations that initially have no context other than fear and panic.

The way we define their problems, our diagnosis, will determine how we approach their care. Such patients typically receive five or six different unrelated diagnoses in the course of their psychiatric treatment. If their doctors focus on their mood swings, they will be identified as bipolar and prescribed lithium or valproate. If the professionals are most impressed with their despair, they will be told they are suffering from major depression and given antidepressants. If the doctors focus on their restlessness and lack of attention, they may be categorized as ADHD and treated with Ritalin or other stimulants. And if the clinic staff happens to take a trauma history, and the patient actually volunteers the relevant information, he or she might receive the diagnosis of PTSD.

Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision.

Insurance companies require a DSM diagnosis for reimbursement, until recently all research funding was based on DSM diagnoses, and academic programs are organized around DSM categories.

A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves.

Borderline personality disorder (BPD) told us horror stories about their childhoods. BPD is marked by clinging but highly unstable relationships, extreme mood swings, and self-destructive behavior, including self-mutilation and repeated suicide attempts.

I realized that the BPD group’s problems dissociation, desperate clinging to whomever might be enlisted to help had probably started off as ways of dealing with overwhelming emotions and inescapable brutality.

81 percent of the patients diagnosed with BPD at Cambridge Hospital reported severe histories of child abuse and/or neglect; in the vast majority the abuse began before age seven.4 This finding was particularly important because it suggested that the impact of abuse depends, at least in part, on the age at which it begins.

Our study showed that having a history of childhood sexual and physical abuse was a strong predictor of repeated suicide attempts and self-cutting.8 I wondered if their suicidal ruminations had started when they were very young and whether they had found comfort in plotting their escape by hoping to die or doing damage to themselves. Does inflicting harm on oneself begin as a desperate attempt to gain some sense of control?

I concluded that, if you carry a memory of having felt safe with somebody long ago, the traces of that earlier affection can be reactivated in attuned relationships when you are an adult, whether these occur in daily life or in good therapy. However, if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop.

For example, numerous studies have shown that girls who witness domestic violence while growing up are at much higher risk of ending up in violent relationships themselves, while for boys who witness domestic violence, the risk that they will abuse their own partners rises sevenfold.18 More than 12 percent of study participants had seen their mothers being battered.

Felitti points out that obesity, which is considered a major public health problem, may in fact be a personal solution for many. Consider the implications: If you mistake someone’s solution for a problem to be eliminated, not only are they likely to fail treatment, as often happens in addiction programs, but other problems may emerge.

The ACE study group concluded: Although widely understood to be harmful to health, each adaptation [such as smoking, drinking, drugs, obesity] is notably difficult to give up. Little consideration is given to the possibility that many long-term health risks might also be personally beneficial in the short term. We repeatedly hear from patients of the benefits of these ‘health risks.’ The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia and frequently clinician discomfort.

This leads to the conclusion that, at least in monkeys, early experience has at least as much impact on biology as heredity does.

Safe and protective early relationships are critical to protect children from long-term problems.

Vincent Felitti had studied in the Adverse Childhood Experiences (ACE) Study.

The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others, causing intense fear, helplessness, or horror, which results in a variety of manifestations: intrusive re-experiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal (insomnia, hypervigilance, or irritability).

Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted.

Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they can not help but define themselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly.

Children who received consistent caregiving became well-regulated kids, while erratic caregiving produced kids who were chronically physiologically aroused.

Compared with girls of the same age, race, and social circumstances, sexually abused girls suffer from a large range of profoundly negative effects, including cognitive deficits, depression, dissociative symptoms, troubled sexual development, high rates of obesity, and self-mutilation.

Over time the body adjusts to chronic trauma. One of the consequences of numbing is that teachers, friends, and others are not likely to notice that a girl is upset; she may not even register it herself. By numbing out she no longer reacts to distress the way she should, for example, by taking protective action.

They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out.

The abused, isolated girls with incest histories mature sexually a year and a half earlier than the non-abused girls.

Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength.

Our great challenge is to apply the lessons of neuroplasticity, the flexibility of brain circuits, to rewire the brains and reorganize the minds of people who have been programmed by life itself to experience others as threats and themselves as helpless.

As a therapist treating people with a legacy of trauma, my primary concern is not to determine exactly what happened to them but to help them tolerate the sensations, emotions, and reactions they experience without being constantly hijacked by them. When the subject of blame arises, the central issue that needs to be addressed is usually self-blame accepting that the trauma was not their fault, that it was not caused by some defect in themselves, and that no one could ever have deserved what happened to them.

The names of some of the greatest pioneers in neurology and psychiatry, such as Jean-Martin Charcot, Pierre Janet, and Sigmund Freud, are associated with the discovery that trauma is at the root of hysteria, particularly the trauma of childhood sexual abuse.

Normal memory integrates the elements of each experience into the continuous flow of self-experience by a complex process of association;

If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements of the trauma into the ongoing narrative of life, so that the brain can recognize that that was then, and this is now.

The Courage to Heal (1988), a best-selling self-help book for survivors of incest, and Judith Herman’s book Trauma and Recovery (1992), discussed the stages of treatment and recovery in great detail.

Then we asked them about the traumas that had brought them into the study many of them rapes. Do you ever suddenly remember how your rapist smelled? we asked, and, Do you ever experience the same physical sensations you had when you were raped?

There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events. In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events or other vital details (the first person who arrived to help, whether an ambulance or a police car took them to the hospital).

Almost all had repeated flashbacks: They felt overwhelmed by images, sounds, sensations, and emotions. As time went on, even more sensory details and feelings were activated, but most participants also started to be able to make some sense out of them. They began to know what had happened and to be able to tell the story to other people, a story that we call the memory of the trauma.

Gradually the images and flashbacks decreased in frequency, but the greatest improvement was in the participants’ ability to piece together the details and sequence of the event.

Traumatic memories are fundamentally different from the stories we tell about the past.

As we will see, finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries.

Some degree of anesthesia awareness is now estimated to occur in approximately thirty thousand surgical patients in the United States every year,

This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed. For most people this involves (1) finding a way to become calm and focused, (2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) finding a way to be fully alive in the present and engaged with the people around you, (4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive.

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.

Understanding why you feel a certain way does not change how you feel.

When we’re triggered into states of hyper- or hypo-arousal, we are pushed outside our window of tolerance the range of optimal functioning. 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.

Recovery from trauma involves the restoration of executive functioning and, with it, self-confidence and the capacity for playfulness and creativity.

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.

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.

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.

When you deliberately take a few slow, deep breaths, you will notice the effects of the parasympathetic brake on your arousal.

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.

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.

At the core of recovery is self-awareness. The most important phrases in trauma therapy are Notice that and What happens next?

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.

Even though the trauma is a thing of the past, the emotional brain keeps generating sensations that make the sufferer feel scared and helpless.

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.

If you cannot tolerate what you are feeling right now, opening up the past will only compound the misery and retraumatize you further.

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.

RELATIONSHIPS Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized.

In order to recover, mind, body, and brain need to be convinced that it is safe to let go.

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.

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.

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.

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.

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.

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.

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?

I often ask my patients if they can think of any person they felt safe with while they were growing up.

Working with trauma is as much about remembering how we survived as it is about what is broken.

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.

Different patients have told me how much choral singing, aikido, tango dancing, and kickboxing have helped them,

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.

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.

People cannot put traumatic events behind until they are able to acknowledge what has happened and start to recognize the invisible demons they’re struggling with.

As Sigmund Freud put it back in 1914 in Remembering, Repeating and Working Through:32 While the patient lives [the trauma] through as something real and actual, we have to accomplish the therapeutic task, which consists chiefly of translating it back again in terms of the past.

When people fully recall their traumas, they have the experience: They are engulfed by the sensory or emotional elements of the past.

On YouTube you can still watch the documentary Let There Be Light, by the great Hollywood director John Huston, which shows men undergoing hypnosis to treat war neurosis.

CBT was first developed to treat phobias such as fear of spiders, airplanes, or heights, to help patients compare their irrational fears with harmless realities.

Patients are gradually desensitized from their irrational fears by bringing to mind what they are most afraid of, using their narratives and images (imaginal exposure), or they are placed in actual (but actually safe) anxiety-provoking situations (in vivo exposure), or they are exposed to virtual-reality, computer-simulated scenes, for example, in the case of combat-related PTSD, fighting in the streets of Fallujah.

drugs cannot cure trauma; they can only dampen the expressions of a disturbed physiology. And they do not teach the lasting lessons of self-regulation. They can help to control feelings and behavior, but always at a price because they work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure.

Feldenkrais, a gentle, hands-on approach to rearranging physical sensations and muscle movements.

Asked what had been most helpful in overcoming the effects of their experience, the survivors credited acupuncture, massage, yoga, and EMDR, in that order.

If you’ve been hurt, you need to acknowledge and name what happened to you.

Feeling listened to and understood changes our physiology; being able to articulate a complex feeling, and having our feelings recognized, lights up our limbic brain and creates an aha moment.

Hiding your core feelings takes an enormous amount of energy, it saps your motivation to pursue worthwhile goals, and it leaves you feeling bored and shut down.

Only after you identify the source of these responses can you start using your feelings as signals of problems that require your urgent attention.

The critical issue is allowing yourself to know what you know.

Helen later recalled that moment in The Story of My Life:

In a later book, The World I Live In, Keller…

neuroscience research has shown that we possess two distinct forms of self-awareness: one that keeps track of the self across time and one that registers the self in the present moment. The first, our autobiographical self, creates connections among experiences and assembles them into a coherent story. This system is rooted in language. Our narratives change with the telling, as our perspective changes and as we incorporate new input. The other system, moment-to-moment self-awareness, is based primarily in physical sensations, but if we feel safe are not rushed, we can find words to communicate that experience as well.

That forced her to check in with herself, as she had no ready-made script for that question.

If a patient tells me that he was eight when his father deserted the family, I am likely to stop and ask him to check in with himself: What happens inside when he tells me about that boy who never saw his father again? Where is it registered in his body? When you activate your gut feelings and listen to your heartbreak when you follow the interoceptive pathways to your innermost recesses things begin to change.

In the practice called free writing, you can use any object as your own personal Rorschach test for entering a stream of associations. Simply write the first thing that comes to your mind as you look at the object in front of you and then keep going without stopping, rereading, or crossing out.

Writing about their deepest thoughts and feelings about traumas had improved their mood and resulted in a more optimistic attitude and better physical health.

Finding a responsive community in which to tell your truth makes recovery possible.

That is why therapists need to have done their own intensive therapy, so they can take care of themselves and remain emotionally available to their patients, even when their patients’ stories arouse feelings of rage or revulsion.

We don’t avoid confronting the details, but we teach our patients how to safely dip one toe in the water and then take it out again, thus approaching the truth gradually.

This sets the stage for trauma resolution: pendulating between states of exploration and safety, between language and body, between remembering the past and feeling alive in the present.

Modern neuroscience solidly supports Freud’s notion that many of our conscious thoughts are complex rationalizations for the flood of instincts, reflexes, motives, and deep-seated memories that emanate from the unconscious.

Eye movement desensitization and reprocessing (EMDR).

1987 psychologist Francine Shapiro was walking through a park, preoccupied with some painful memories, when she noticed that rapid eye movements produced a dramatic relief from her distress.

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.

The sleeping brain reshapes memory by increasing the imprint of emotionally relevant information while helping irrelevant material fade away.

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.

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.

Heart rate variability measures the relative balance between the sympathetic and the parasympathetic systems. When we inhale, we stimulate the SNS, which results in an increase in heart rate. Exhalations stimulate the PNS, which decreases how fast the heart beats. In healthy individuals inhalations and exhalations produce steady, rhythmical fluctuations in heart rate: Good heart rate variability is a measure of basic well-being.

Devices that train people to slow their breathing and synchronize it with their heart rate, resulting in a state of cardiac coherence

Thus, our interest in yoga gradually evolved from a focus on learning whether yoga can change HRV (which it can) to helping traumatized people learn to comfortably inhabit their tortured bodies.

We do not truly know ourselves unless we can feel and interpret our physical sensations; we need to register and act on these sensations to navigate safely through life.

Traumatized people need to learn that they can tolerate their sensations, befriend their inner experiences, and cultivate new action patterns.

Simply noticing what you feel fosters emotional regulation, and it helps you to stop trying to ignore what is going on inside you.

The two most important phrases in therapy, as in yoga, are Notice that and What happens next?

Knowing how much energy the sheer act of survival requires keeps me from being surprised at the price they often pay: the absence of a loving relationship with their own bodies, minds, and souls.

Parts are not just feelings but distinct ways of being, with their own beliefs, agendas, and roles in the overall ecology of our lives.

In 1890 William James wrote: [I]t must be admitted that the total possible consciousness may be split into parts which coexist, but mutually ignore each other, and share the objects of knowledge between them. Carl Jung wrote: The psyche is a self-regulating system that maintains its equilibrium just as the body does, The natural state of the human psyche consists in a jostling together of its components and in their contradictory behavior, and The reconciliation of these opposites is a major problem. Thus, the adversary is none other than ˜the other in me.’

The Social Brain (1985)

At the core of IFS 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 IFS a part is considered not just a passing emotional state or customary thought pattern but a distinct mental system with its own history, abilities, needs, and worldview.

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.

Another group of protectors, which IFS calls firefighters, are emergency responders, acting impulsively whenever an experience triggers an exiled emotion.

The critical insight is that all these parts have a function: to protect the self from feeling the full terror of annihilation.

The first step in this collaboration is to assure the internal system that all parts are welcome and that all of them even those that are suicidal or destructive were formed in an attempt to protect the self-system, no matter how much they now seem to threaten it.

As Richard Schwartz explains: The internal system of an abuse victim differs from the non-abuse system with regard to the consistent absence of effective leadership, the extreme rules under which the parts function, and the absence of any consistent balance or harmony. Typically, the parts operate around outdated assumptions and beliefs derived from the childhood abuse,

The first is that this Self does not need to be cultivated or developed. 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.

The second assumption is that, rather than being a passive observer, 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.

Patients are asked to identify the part involved in the current problem, like feeling worthless, abandoned, or obsessed with vengeful thoughts.

Next the therapist asks, How do you feel toward that (sad, vengeful, terrified) part of you?

What do you say to the part about that? or Where do you want to go now? or What feels like the right next step? as well as the ubiquitous Self-detecting question, How do you feel toward the part now?

Showing a high level of interest in the details of her life, demonstrating unwavering support for the risk she took in talking with me, and accepting the parts she was most ashamed of.

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.

For Joan to be able to deal with her misery and hurt, we would have to recruit her own strength and self-love, enabling her to heal herself.

If, as a therapist, teacher, or mentor, you try to fill the holes of early deprivation, you come up against the fact that you are the wrong person, at the wrong time, in the wrong place. The therapy would focus on Joan’s relationship with her parts rather than with me.

When I asked her to see where that powerless part was located in her body and how she felt toward it,

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 firefighters will destroy the house in order to extinguish the fire. 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.

Exiles are the toxic waste dump of the system. Because they hold the memories, sensations, beliefs, and emotions associated with trauma, it is hazardous to release them.

In Schwartz’s words: 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.

As in EMDR the resolution of the trauma was the result of her ability to access her imagination and rework the scenes in which she had become frozen so long ago.

The goal of the IFS group was to teach patients how to accept and understand their inevitable fear, hopelessness, and anger and to treat those feelings as members of their own internal family.

Asked how they were feeling, they almost always replied, I’m fine. Their stoic parts clearly helped them cope, but these managers also kept them in a state of denial. Some shut out their bodily sensations and emotions to the extent that they could not collaborate effectively with their doctors.

At our next session I asked him to let his body relax, close his eyes, focus his attention inside, and ask that critical part the one his wife had identified what it was afraid would happen if he stopped his ruthless judging.

How old it was. He said about seven. I asked him to have his critic show him what he protected.

I asked Peter to tell the boy that he now understood how bad the experience had been.

I urged Peter to go back into the scene and take the boy away with him.

This is the stage IFS calls unburdening, and it corresponds to nursing those exiled parts back to health.

The greatest discovery of my generation is that human beings can alter their lives by altering their attitudes of mind. William James

It is not that something different is seen, but that one sees differently. It is as though the spatial act of seeing were changed by a new dimension. Carl Jung

It is one thing to process memories of trauma, but it is an entirely different matter to confront the inner void the holes in the soul that result from not having been wanted, not having been seen, and not having been allowed to speak the truth. If your parents’ faces never lit up when they looked at you, it’s hard to know what it feels like to be loved and cherished. If you come from an incomprehensible world filled with secrecy and fear, it’s almost impossible to find the words to express what you have endured. If you grew up unwanted and ignored, it is a major challenge to develop a visceral sense of agency and self-worth.

How can we help people become viscerally acquainted with feelings that were lacking early in their lives?

Projecting your inner world into the three-dimensional space of a structure enables you to see what’s happening in the theater of your mind and gives you a much clearer perspective on your reactions to people and events in the past.

Although the structures involve dialogue, psychomotor therapy does not explain or interpret the past. Instead, it allows you to feel what you felt back then, to visualize what you saw, and to say what you could not say when it actually happened.

Feeling safe means you can say things to your father (or, rather, the placeholder who represents him) that you wish you could have said as a five-year-old. You can tell the placeholder for your depressed and frightened mother how terrible you felt about not being able to take care of her. You can experiment with distance and proximity and explore what happens as you move placeholders around. As an active participant, you can lose yourself in a scene in a way you cannot when you simply tell a story.

Instead, a structure offers fresh options an alternative memory in which your basic human needs are met and your longings for love and protection are fulfilled.

The witness figure enters the structure at the very beginning and takes the role of an accepting, nonjudgmental observer who joins the protagonist by reflecting his or her emotional state and noting the context in which that state has emerged.

(Note that this work is not about improvisation but about accurately enacting the dialogue and directions provided by the witness and protagonist.)

Protagonists always know exactly where the various characters in their structures should be located.

The people who enroll seem to become the people he or she had to deal with back then not only to the protagonist but often to the other participants as well.

Structures promote one of the essential conditions for deep therapeutic change: a trancelike state in which multiple realities can live side by side past and present, knowing that you’re an adult while feeling the way you did as a child,

I encouraged Maria to look at Kristin and then I asked, So what happens when you look at her? Maria angrily said, Nothing. A witness would see how you stiffen as you look at your real mom and angrily say that you feel nothing, I noted.

In order to change, people need to become viscerally familiar with realities that directly contradict the static feelings of the frozen or panicked self of trauma, replacing them with sensations rooted in safety, mastery, delight, and connection.

Neurofeedback changes brain connectivity patterns; the mind follows by creating new patterns of engagement.

Delta waves, the slowest frequencies (25 Hz) are seen most often during sleep. The brain is in an idling state, and the mind is turned inward. If people have too much slow-wave activity while they’re awake, their thinking is foggy and they exhibit poor judgment and poor impulse control.

Theta frequencies (58 Hz) predominate at the edge of sleep, as in the floating hypnopompic state.

Theta waves create a frame of mind unconstrained by logic or by the ordinary demands of life and thus open the potential for making novel connections and associations.

On the downside, theta frequencies also occur when we’re out of it or depressed.

Alpha waves (812 Hz) are accompanied by a sense of peace and calm.13 They are familiar to anyone who has learned mindfulness meditation.

I use alpha training most often in my practice to help people who are either too numb or too agitated to achieve a state of focused relaxation.

Beta waves are the fastest frequencies (1320 Hz). When they dominate, the brain is oriented to the outside world. Beta enables us to engage in focused attention while performing a task. However, high beta (over 20 Hz) is associated with agitation, anxiety, and body tenseness in effect, we are constantly scanning the environment for danger.

Sports psychologist Len Zaichkowsky,

Once the brain has been trained to produce different patterns of electrical communication, no further treatment is necessary, in contrast to drugs, which do not change fundamental brain activity and work only as long as the patient keeps taking them.

We can show them the patterns that seem to be responsible for their difficulty focusing or for their lack of emotional control. They can see why different brain areas need to be trained to generate different frequencies and communication patterns. These explanations help them shift from self-blaming attempts to control their behavior to learning to process information differently.

Approximately one-third to one-half of severely traumatized people develop substance abuse problems.

In my practice I use neurofeedback primarily to help with the hyper-arousal, confusion, and concentration problems of people who suffer from developmental trauma.

Theater gave him a chance to deeply and physically experience what it was like to be someone other than the learning-disabled, oversensitive boy that he had gradually become. Being a valued contributor to a group gave him a visceral experience of power and competence.

Along with language, dancing, marching, and singing are uniquely human ways to install a sense of hope and courage.

It is surprising how little research exists on how collective ceremonies affect the mind and brain and how they might prevent or alleviate trauma.

The job of any director, like that of any therapist, is to slow things down so the actors can establish a relationship with themselves, with their bodies.

The idea is to inspire the actors to sense their reactions to the words and so to discover the character. Rather than I have to remember my lines, the emphasis is on What do these words mean to me? What effect do I have on my fellow actors? And what happens to me when I hear their lines?

So we never say, ˜How did that feel?’ at the end of a scene, because it invites them to go to the judgment part of their brain. Instead Coleman asks, Did you notice any specific feelings that came up for you doing that scene? That way they learn to name emotional experiences..

What makes therapy effective is deep, subjective resonance and that deep sense of truth and veracity that lives in the body. I am still hoping that someday we will prove Tina wrong and combine the rigor of scientific methods with the power of embodied intuition.

The body keeps the score: If trauma is encoded in heartbreaking and gut-wrenching sensations, then our first priority is to help people move out of fight-or-flight states, reorganize their perception of danger, and manage relationships.

Our increasing use of drugs to treat these conditions doesn’t address the real issues: What are these patients trying to cope with? What are their internal or external resources? How do they calm themselves down? Do they have caring relationships with their bodies, and what do they do to cultivate a physical sense of power, vitality, and relaxation? Do they have dynamic interactions with other people? Who really knows them, loves them, and cares about them? Whom can they count on when they’re scared, when their babies are ill, or when they are sick themselves? Are they members of a community, and do they play vital roles in the lives of the people around them? What specific skills do they need to focus, pay attention, and make choices? Do they have a sense of purpose? What are they good at? How can we help them feel in charge of their lives?

What would our school systems look like if all children could attend well-staffed preschools that cultivated cooperation, self-regulation, perseverance, and concentration (as opposed to focusing on passing tests, which will likely happen once children are allowed to follow their natural curiosity and desire to excel, and are not shut down by hopelessness, fear, and hyper-arousal)?

As the ACE study has shown, child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse,

The critical challenge in a classroom setting is to foster reciprocity: truly hearing and being heard; really seeing and being seen by other people.

We make certain that the children are greeted by name every morning and that teachers make face-to-face contact with each and every one of them.

We always start the day with check-ins: taking the time to share what’s on everybody’s mind.

Instead of yelling, Stop! when a child is throwing a tantrum or making her sit alone in the corner, teachers are encouraged to notice and name the child’s experience, as in I can see how upset you are; to give her choices, as in Would you like to go to the safe spot or sit on my lap?; and to help her find words to describe her feelings and begin to find her voice, as in: What will happen when you get home after class?

In such situations the first step is acknowledging that a child is upset; then the teacher should calm him, then explore the cause and discuss possible solutions.

In addition to reading, writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and communication as part of their core curriculum. Just as we teach history and geography, we need to teach children how their brains and bodies work. For adults and children alike, being in control of ourselves requires becoming familiar with our inner world and accurately identifying what scares, upsets, or delights us.

Emotional intelligence starts with labeling your own feelings and attuning to the emotions of the people around you. We begin very simply: with mirrors. Looking into a mirror helps kids to be aware of what they look like when they are sad, angry, bored, or disappointed. Then we ask them, How do you feel when you see a face like that? We teach them how their brains are built, what emotions are for, and where they are registered in their bodies, and how they can communicate their feelings to the people around them. They learn that their facial muscles give clues about what they are feeling and then experiment with how their facial expressions affect other people.

What does anger feel like, and what can they do to change that sensation in their body?

Oprah Winfrey comes to mind, as do Maya Angelou, Nelson Mandela, and Elie Wiesel.

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