The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

Part One: The Rediscovery of Trauma

Lessons from Vietnam Veterans

The author’s first encounters with Vietnam veterans revealed that trauma survivors become trapped in reliving past experiences, with their loyalty to traumatic memories preventing recovery and normal functioning.

• Vietnam veteran Tom refused medication for nightmares because he believed taking pills would abandon his dead comrades and make their deaths meaningless
  • Tom had nightmares about an ambush in a rice paddy where all his platoon members were killed
  • “I realized that if I take the pills and the nightmares go away, I will have abandoned my friends, and their deaths will have been in vain. I need to be a living memorial to my friends who died in Vietnam” —Tom
  • Tom’s loyalty to the dead was keeping him from living his own life, just as his father’s devotion to his friends had kept him from living
• Traumatized veterans displayed extreme rage responses to minor frustrations, similar to toddler tantrums but without the expectation of natural maturation that occurs in children
  • Public areas of the clinic were pockmarked with impacts of veterans’ fists on drywall
  • Security was kept constantly busy protecting claims agents and receptionists from enraged veterans
  • The author felt confident his toddlers would learn self-regulation with proper care, but was skeptical veterans could reacquire lost self-control skills
• Abram Kardiner’s 1941 research on World War I veterans identified the same phenomena the author observed, coining the term ’traumatic neuroses’ and establishing that PTSD has a physiological basis
  • The library at the VA didn’t have a single book about war neurosis, shell shock, or battle fatigue
  • “The nucleus of the neurosis is a physioneurosis” —Abram Kardiner
  • Kardiner understood that symptoms have their origin in the entire body’s response to trauma, not just the mind
• Traumatized veterans could not bridge the gap between wartime experiences and current lives, feeling fully alive only when revisiting their traumatic past
  • Veterans would recount war stories repeatedly rather than discuss relationships with wives, children, or work satisfaction
  • The very event that caused them so much pain had also become their sole source of meaning
  • They felt fully alive only when they were revisiting their traumatic past
• The 1980 creation of PTSD as an official diagnosis by Vietnam veterans and psychoanalysts represented a turning point that legitimized trauma suffering and enabled systematic research
  • Veterans worked with psychoanalysts Chaim Shatan and Robert J. Lifton to lobby the American Psychiatric Association
  • The diagnosis gave a name to suffering of people overwhelmed by horror and helplessness
  • A grant proposal to study trauma biology was initially rejected with the note that PTSD had never been shown relevant to VA mission

Revolutions in Understanding Mind and Brain

The shift from psychotherapy to pharmacological treatment in psychiatry, while producing some beneficial medications, has overshadowed the importance of relationships, language, and self-regulation in healing trauma.

• At Massachusetts Mental Health Center, traumatized psychiatric patients shared stories of childhood abuse and family violence during nighttime visits, but these experiences were rarely mentioned in formal medical discussions
  • Patients told stories of being hit, assaulted, or molested, often by their own parents
  • More than half the people who seek psychiatric care have been assaulted, abandoned, neglected, or raped as children
  • During morning rounds the young doctors rarely mentioned stories like the ones heard at night
• Eugen Bleuler’s 1911 observations of schizophrenic patients described sexual hallucinations that may have been fragmented memories of real abuse experiences
  • “Among schizophrenic body hallucinations, the sexual ones are by far the most frequent and the most important” —Eugen Bleuler
  • “The majority of hallucinations correspond to real sensations despite their symbolic meaning” —Eugen Bleuler
  • This raised questions about whether hallucinations were concoctions of sick brains or fragmented memories of real experiences
• Elvin Semrad taught that healing depends on helping people acknowledge, experience, and bear the reality of life rather than focusing on psychiatric diagnoses
  • “Most human suffering is related to love and loss and the job of therapists is to help people acknowledge, experience, and bear the reality of life” —Elvin Semrad
  • “The greatest sources of our suffering are the lies we tell ourselves” —Elvin Semrad
  • “People can never get better without knowing what they know and feeling what they feel” —Elvin Semrad
  • “When asked what to call a patient—schizophrenic or schizoaffective—Semrad replied ‘I think I’d call him Michael McIntyre’” —Elvin Semrad
• The 1968 study showing that schizophrenic patients treated with drugs alone had better outcomes than those receiving therapy marked psychiatry’s shift toward a brain-disease model
  • Results were published in the American Journal of Psychiatry showing drugs were superior to therapy
  • Anger, lust, pride, greed, and other human struggles were recast as ‘disorders’ fixable by appropriate chemicals
  • Many psychiatrists were relieved to become ‘real scientists’ like their colleagues with laboratories and expensive equipment
• Martin Seligman’s learned helplessness experiments with dogs revealed that traumatized animals give up even when escape becomes possible, paralleling human trauma responses
  • Dogs subjected to inescapable electric shock would not flee when cage doors were opened, just lying whimpering and defecating
  • The only way to teach traumatized dogs to escape was to repeatedly drag them out of cages so they could physically experience how to get away
  • Traumatized dogs secreted much larger amounts of stress hormones than normal
• The development of Prozac and SSRIs showed that increasing serotonin levels could help traumatized people regulate emotions and gain perspective, though effects varied between populations
  • A patient with bulimia reported after four days on Prozac: ‘I ate when I was hungry, and the rest of the time I did my schoolwork’
  • “You have a drug that helps people to be in the present, instead of being locked in the past” —the author
  • Prozac worked significantly better than placebo for Trauma Center patients but had no effect on combat veterans at the VA
• The brain-disease model overlooks four fundamental truths about human healing: our capacity to heal each other, the power of language, our ability to self-regulate, and the importance of safe social environments
  • Our capacity to destroy one another is matched by our capacity to heal one another
  • We have the ability to regulate our own physiology through basic activities as breathing, moving, and touching
  • We can change social conditions to create environments where children and adults can feel safe and thrive

Looking into the Brain: The Neuroscience Revolution

Brain imaging revealed that trauma causes specific neurological changes including amygdala hyperactivation, shutdown of Broca’s speech area, and right-brain dominance during flashbacks, proving trauma’s biological reality.

• Marsha’s brain scan during trauma recall showed her amygdala activated as if the car accident were happening in real time, thirteen years after her daughter’s death
  • Marsha picked up her five-year-old daughter from day camp when she heard persistent beeping indicating the seatbelt wasn’t fastened
  • When she reached over to adjust the belt, she ran a red light and another car killed her daughter instantly
  • The moment the tape recorder turned on, her heart raced and blood pressure jumped, replicating physiological responses from the original accident
• Trauma flashbacks shut down Broca’s area, the brain’s speech center, creating a white spot on brain scans and explaining why traumatized people cannot put their experiences into words
  • Broca’s area went offline whenever a flashback was triggered, showing effects similar to physical brain lesions like strokes
  • All trauma is preverbal - victims may scream obscenities, call for mothers, or simply shut down
  • “Oh horror! horror! horror! Tongue nor heart cannot conceive nor name thee!” —Shakespeare
• During flashbacks, the left hemisphere shuts down while the right hemisphere activates, explaining why trauma survivors lose logical thinking and become trapped in emotional, visual, and somatic memories
  • The right brain is intuitive, emotional, visual, spatial, and tactual, while the left is linguistic, sequential, and analytical
  • The left brain remembers facts and vocabulary of events, while the right brain stores memories of sound, touch, smell, and emotions
  • Deactivation of the left hemisphere impacts capacity to organize experience into logical sequences and translate feelings into words
• Bill’s PTSD flashback was triggered by his newborn baby’s cries, which activated visual and auditory hallucinations of dying Vietnamese children from his time as a combat medic
  • Bill was a seminary graduate assigned to his first parish when his wife returned to work, leaving him alone with their newborn
  • “This is that child that I saw being blown up in Vietnam. In the middle, you see the charred flesh, the wounds, and the blood is spurting out all over” —Bill
  • “I think this man is suffering from memories” —the author
• Rorschach tests revealed that traumatized veterans either superimposed trauma imagery onto neutral stimuli or went completely blank, showing loss of imagination and mental flexibility
  • Sixteen of twenty-one veterans interpreted the second Rorschach card as scenes from wartime trauma
  • Five veterans saw nothing at all, saying ‘This is nothing, just a bunch of ink’
  • Normal responses include dancing monks, fluttering butterflies, or men on motorcycles
• Stan and Ute Lawrence’s brain scans from the same car crash showed two different trauma responses: Stan had explosive flashbacks while Ute dissociated completely
  • They were trapped in car thirteen of an eighty-seven-car pileup, the worst road disaster in Canadian history
  • Stan’s scan showed activation similar to Marsha’s, with racing heart and sweating during the flashback
  • Ute’s brain showed markedly decreased activity in nearly every area, and she reported feeling nothing during the scan

Part Two: This Is Your Brain on Trauma

Running for Your Life: The Anatomy of Survival

The brain’s survival systems, organized from primitive brain stem to sophisticated frontal cortex, can become dysregulated by trauma, causing people to remain stuck in defensive states even when safe.

• Five-year-old Noam processed witnessing the 9/11 attacks by drawing people jumping from towers but added a trampoline at the bottom, using his imagination to create a hopeful alternative
  • Noam witnessed the first plane slam into the World Trade Center from his classroom at PS 234, less than 1,500 feet away
  • His drawing showed an airplane hitting the tower, people jumping, but also included a black circle at the bottom
  • “So that the next time when people have to jump they will be safe” —Noam
• The brain develops from bottom to top, with the reptilian brain stem controlling basic survival functions, the limbic mammalian brain managing emotions and social bonds, and the neocortex enabling language and planning
  • The reptilian brain stem controls breathing, eating, sleeping, and basic life-sustaining systems
  • The limbic system is the seat of emotions, danger monitoring, and social bonding that develops through caregiver interaction
  • The neocortex enables language, abstract thought, planning, and the qualities that make us unique in the animal kingdom
• Mirror neurons create brain-to-brain connections that enable empathy and social synchronization but also make people vulnerable to others’ emotional states
  • Italian scientists discovered that monkey brain cells fired when watching researchers eat, even though the monkeys weren’t moving
  • Mirror neurons have been compared to ’neural WiFi’ that picks up others’ movements, emotions, and intentions
  • Trauma almost invariably involves not being seen, not being mirrored, and not being taken into account
• The amygdala acts as the brain’s smoke detector, rapidly identifying threats and triggering stress responses before conscious awareness, while the medial prefrontal cortex serves as the watchtower that can modulate these reactions
  • The amygdala processes information faster than the frontal lobes, deciding if incoming information threatens survival before conscious awareness
  • “Joseph LeDoux calls the pathway to the amygdala ’the low road’ and to the frontal cortex ’the high road’” —Joseph LeDoux
  • In PTSD the critical balance between the amygdala and medial prefrontal cortex shifts radically, making it harder to control emotions
• Stan’s flashback brain scan showed his amygdala lighting up as if the car crash were happening in the present, while his dorsolateral prefrontal cortex went offline, eliminating his sense of time
  • Stan came out of the scanner sweating with racing heart and elevated blood pressure
  • “This was just the way I felt during the accident. I was sure I was going to die, and there was nothing I could do to save myself” —Stan
  • The dorsolateral prefrontal cortex serves as the brain’s timekeeper, telling us how present experience relates to past and future
• Ute’s dissociative response showed nearly complete brain shutdown, representing the freeze response where people make themselves disappear when fight or flight is impossible
  • Ute responded to her trauma script by going numb with decreased activity in nearly every brain area
  • “I felt just like I felt at the time of the accident: I felt nothing” —Ute
  • Ute had learned this survival strategy in childhood to cope with her mother’s harsh treatment after her father died

Body-Brain Connections

Darwin’s insights about emotions as embodied experiences that prepare organisms for action provide the foundation for understanding how trauma disrupts the autonomic nervous system’s balance between arousal and calm.

• Charles Darwin established that emotions are fundamentally biological, rooted in physical movements that communicate mental states and initiate actions necessary for survival
  • Darwin noted that humans share physical signs of animal emotion, like hair standing up when frightened or baring teeth when enraged
  • Emotions give shape and direction to whatever we do, and their primary expression is through muscles of the face and body
  • “Heart, guts, and brain communicate intimately via the ‘pneumogastric’ nerve, critical for expressing and managing emotions” —Charles Darwin
• The autonomic nervous system balances the sympathetic system’s fight-or-flight arousal with the parasympathetic system’s rest-and-digest functions, measurable through heart rate variability
  • The sympathetic nervous system moves blood to muscles and triggers adrenaline release for quick action
  • The parasympathetic nervous system promotes self-preservative functions like digestion and wound healing
  • Taking a deep breath activates the sympathetic system, while exhaling activates the parasympathetic system to calm down
• Stephen Porges’ Polyvagal Theory revealed that the vagus nerve creates three levels of safety responses: social engagement, fight-or-flight, and freeze-or-collapse
  • The ventral vagal complex enables social engagement through facial expressions, voice, and calming of heart and lungs
  • When social engagement fails, the sympathetic nervous system activates fight-or-flight responses
  • If escape is impossible, the dorsal vagal complex triggers collapse, slowing heart rate and reducing metabolism
• Human beings are fundamentally tribal creatures whose mirror neurons create automatic attunement to others’ emotional states, making social support the most powerful protection against trauma
  • Our brains are built to help us function as members of a tribe, even when we’re alone
  • “Jerome Kagan told the Dalai Lama that for every act of cruelty there are hundreds of small acts of kindness and connection” —Jerome Kagan
  • Social support is not just being in others’ presence but being truly heard and seen, feeling held in someone else’s mind and heart
• Neuroception describes the unconscious capacity to evaluate safety and danger, which becomes faulty in trauma survivors who may lose the ability to feel safe even in objectively secure situations
  • Porges coined ’neuroception’ to describe the capacity to evaluate relative danger and safety in one’s environment
  • Women with early abuse histories were seven times more likely to be raped in adulthood
  • Achieving deep intimacy requires allowing oneself to experience immobilization without fear
• Steve Gross demonstrated that simple rhythmic, attuned movements like playing catch can reactivate the social engagement system in traumatized children more effectively than verbal therapy
  • Steve would ‘accidentally’ drop a beach ball near angry or frozen kids in the waiting room
  • He would nudge the ball toward the child, gradually creating a back-and-forth interaction with emerging smiles
  • From simple, rhythmically attuned movements, Steve created a small, safe place where the social-engagement system could reemerge

Losing Your Body, Losing Your Self

Traumatized people often lose connection to their bodily sensations and self-awareness, requiring treatment approaches that restore the capacity to feel and befriend internal physical experiences.

• Sherry, who grew up in foster care feeling unwanted, developed compulsive skin-picking as her only way to feel alive and connected to her body
  • Sherry’s mother ran a foster home with up to fifteen transient, disruptive children
  • “I know I wasn’t wanted. She’d tell me, ‘I don’t think you belong in this family. I think they gave us the wrong baby’” —Sherry
  • She started picking at her skin because it gave her relief from feeling numb and made her feel more alive
• Ruth Lanius’s brain scan study of the default state network revealed that people with chronic childhood trauma showed almost no activation in self-sensing brain areas
  • Normal subjects showed activation in the ‘Mohawk of self-awareness’ - midline brain structures involved in sense of self
  • Eighteen chronic PTSD patients showed almost no activation in self-sensing areas including medial prefrontal cortex, anterior cingulate, and insula
  • In response to trauma, patients had learned to shut down brain areas that transmit visceral feelings and emotions
• Antonio Damasio’s research established that self-awareness rests on physical sensations conveying the inner states of the body, which he called ‘primordial feelings’
  • “Primordial feelings provide a direct experience of one’s own living body, wordless, unadorned, and connected to nothing but sheer existence” —Antonio Damasio
  • “All feelings of emotion are complex musical variations on primordial feelings” —Antonio Damasio
  • “It is not possible to manage life and maintain homeostatic balance without data on the current state of the organism’s body” —Antonio Damasio
• Agency, the feeling of being in charge of one’s life, starts with interoception—awareness of subtle body-based feelings—making mindfulness practice essential for trauma recovery
  • Agency starts with interoception, our awareness of subtle sensory, body-based feelings
  • If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation
  • Mindfulness practice, which strengthens the medial prefrontal cortex, is a cornerstone of recovery from trauma
• Alexithymia, having no words for feelings, affects many trauma survivors who substitute the language of action for emotion and register feelings as physical problems
  • When asked how they’d feel seeing a truck coming at eighty miles per hour, alexithymics might say ‘I’d get out of the way’ instead of ‘I’d be terrified’
  • About three-quarters of anorexia patients and half of bulimia patients have great difficulty describing emotional feelings
  • Henry Krystal found that Holocaust survivors were professionally successful but had bleak, distant intimate relationships
• Brain scans of people with PTSD making eye contact showed they could not activate social engagement areas but instead went into primitive survival mode
  • PTSD subjects did not activate any part of their frontal lobe when viewing a direct gaze, so could not muster curiosity about the stranger
  • Instead they showed intense activation in the Periaqueductal Gray, which generates startle, hypervigilance, and self-protective behaviors
  • In response to being looked at they simply went into survival mode with no activation of brain areas involved in social engagement

Part Three: The Minds of Children

Getting on the Same Wavelength: Attachment and Attunement

Secure attachment develops through emotional attunement between caregivers and infants, creating internal maps that guide relationships throughout life and determine resilience to trauma.

• Abused children at the Children’s Clinic interpreted innocent images as dangerous, seeing family scenes as opportunities for violence and harm
  • A picture of kids watching dad repair a car prompted one girl to describe the girl smashing her father’s skull with a hammer
  • A nine-year-old abuse victim told a story about the boy kicking away the jack so the car would mangle his father’s body
  • Control children from the same violent neighborhood still trusted in an essentially benign universe and could imagine ways out of bad situations
• John Bowlby developed attachment theory by studying how children’s disturbed behavior resulted from actual life experiences rather than infantile sexual fantasies
  • Bowlby was made persona non grata in British psychoanalysis for claiming children’s problems came from neglect, brutality, and separation
  • Children are captivated by faces and voices and are exquisitely sensitive to facial expression, posture, and tone of voice
  • Attachment is the secure base from which a child moves out into the world
• The dance of attunement begins with mirror neurons creating brain-to-brain connections that allow infants and caregivers to synchronize emotionally and physiologically
  • Andrew Meltzoff showed that six-hour-old babies could mirror lip pursing and tongue protrusion
  • When infants and caregivers are emotionally in sync, they’re also physically synchronized with steady heartbeat, breathing, and low stress hormones
  • A twelve-second sequence of delight, rupture, repair, and new delight between mother and infant demonstrates attunement
• Donald Winnicott proposed that the way mothers hold their babies lays the groundwork for the child’s sense of self and lifelong identity
  • “Physical interactions create ’the ability to feel the body as the place where the psyche lives’” —Donald Winnicott
  • “If a mother cannot meet her baby’s impulses and needs, ’the baby learns to become the mother’s idea of what the baby is’” —Donald Winnicott
  • Children who lack physical attunement are vulnerable to shutting down direct feedback from their bodies
• Mary Ainsworth’s Strange Situation identified three organized attachment patterns: secure, avoidant, and anxious, based on how infants respond to maternal separation and reunion
  • Securely attached infants are distressed when mother leaves but show delight when she returns and settle down to resume play
  • Avoidant infants appear unaffected by separation but show chronically increased heart rates indicating constant hyperarousal
  • Anxious infants constantly draw attention through crying and clinging but derive little comfort from mother’s return
• Mary Main discovered disorganized attachment in children whose caregivers are simultaneously sources of comfort and terror, creating an unsolvable dilemma
  • About 15 percent of children cannot figure out how to engage with caregivers who are sources of distress or terror
  • Children with disorganized attachment may rock on hands and knees, go into a trance, freeze with arms raised, or fall to the ground
  • “Main called this pattern ‘fright without solution’” —Mary Main
• Karlen Lyons-Ruth’s longitudinal study found that emotional withdrawal and role reversal in early childhood had the most profound impact on adult mental stability
  • Infants with disrupted emotional communication at eighteen months became young adults with unstable self-sense and self-damaging impulsivity
  • Emotional distance and role reversal were linked to aggressive behavior against self and others in adulthood
  • “What cannot be communicated to the mother cannot be communicated to the self” —John Bowlby

Trapped in Relationships: The Cost of Abuse and Neglect

Childhood abuse creates distorted internal maps of relationships and self-worth, while also affecting the immune system’s ability to distinguish between safety and danger.

• Marilyn’s family portrait drawing revealed her trauma history through images of a terrified child in a cage threatened by nightmarish figures and a large erect penis
  • Marilyn said she ‘must have had’ a happy childhood but could remember very little from before age twelve
  • She had violent confrontations with her alcoholic father at sixteen and ran away from home
  • Her drawing showed a wild and terrified child trapped and threatened by three nightmarish figures, one with no eyes
• A study of incest survivors found abnormalities in immune system memory cells, with bodies having trouble distinguishing between danger and safety on a cellular level
  • Marilyn was the third person that year suspected of incest history who was diagnosed with an autoimmune disease
  • Incest survivors had abnormal CD45 RA-to-RO ratios, with more activated memory cells ready to respond to past threats
  • The immune system becomes oversensitive to threat and prone to attack the body’s own cells
• Childhood abuse creates internal maps marked by contempt and humiliation, making victims more likely to accept mistreatment as familiar rather than outrageous
  • If parents keep telling us we’re the cutest, most delicious thing in the world, we carry that sense with us throughout life
  • If we grow up with abuse or disgust, our inner map contains contempt and humiliation as normal
  • Marilyn was convinced that men didn’t give a damn about others’ feelings and women were too weak to stand up for themselves
• Patient Kathy taught the author that challenging trauma survivors’ irrational beliefs makes them feel more isolated, requiring therapists to help reconstruct inner maps rather than argue with perceptions
  • “I know how important it is for you to be a good therapist, so when you make stupid comments like that, I usually thank you profusively” —Kathy
  • “I was trained to take care of the needs of grown-up, insecure men” —Kathy
  • “When you try to talk me into being more reasonable I only feel more lonely and isolated” —Kathy
• Marilyn’s memories returned as flashbacks of wallpaper patterns she focused on during childhood rapes, demonstrating how trauma memories emerge as fragments rather than coherent narratives
  • Marilyn’s first memories were flashbacks of wallpaper in her childhood bedroom
  • She realized this was what she had focused on when her father raped her at age eight
  • When she ran to her mother for protection, she was met with only a limp embrace and sometimes scolding for ‘making Daddy so angry’
• Children cannot escape abusive families and must organize themselves to survive within them, developing loyalty to caregivers even when they are sources of terror
  • Children have no choice but to organize themselves to survive within the families they have
  • Terror increases the need for attachment, even if the source of comfort is also the source of terror
  • Children under ten who were tortured at home would still choose to stay with family rather than go to foster care
• Marilyn’s recovery involved learning to distinguish between past trauma sensations and present reality, recognizing that Michael’s leg touching hers was not her father molesting her
  • Marilyn learned calming techniques like focusing on breathing at six breaths per minute combined with tapping acupressure points
  • Mindfulness helped her stand back and observe her experience rather than being immediately hijacked by feelings
  • She began to recognize that someone’s leg brushing against her belonged to Michael, not to her abusive father

What’s Love Got to Do with It?

Children with histories of abuse and neglect present with complex symptoms that don’t fit standard diagnostic categories, revealing how early trauma fundamentally disrupts development in ways that require new approaches to diagnosis and treatment.

• Patients with childhood trauma histories typically receive multiple unrelated psychiatric diagnoses that fail to capture the core issue of developmental disruption from early abuse and neglect
  • If doctors focus on mood swings, patients get diagnosed as bipolar; if they focus on despair, patients get major depression; if they focus on restlessness, patients get ADHD
  • “None of these diagnoses will be completely off the mark, and none of them will begin to meaningfully describe who these patients are and what they suffer from” —the author
  • Before they reach their twenties, many patients have been given four, five, six, or more impressive but meaningless labels
• The Cambridge Hospital study found that 81 percent of patients diagnosed with borderline personality disorder reported severe histories of child abuse and/or neglect, with the vast majority beginning before age seven
  • The study used the Traumatic Antecedents Questionnaire (TAQ) to gradually uncover trauma histories through carefully designed questions
  • One out of four patients could not recall anyone they had felt safe with as a child
  • Patients reported frequent relocations, caregivers who went to jail or mental hospitals, and moving from foster home to foster home
• Self-destructive behaviors like cutting and repeated suicide attempts serve as predictable responses to having no memory of feeling safe with anyone during childhood
  • Patients who remained self-destructive had told researchers they did not remember feeling safe with anybody as a child
  • “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” —the author
  • 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
• The DSM work group voted overwhelmingly to create a new diagnosis called ‘Disorders of Extreme Stress, Not Otherwise Specified’ (DESNOS) for victims of interpersonal trauma, but it was mysteriously excluded from the final DSM-IV publication
  • The field trial studied 525 adult patients at five sites and found clear differences between groups, particularly those with childhood abuse versus natural disaster survivors
  • The work group voted nineteen to two to create the new trauma diagnosis, but none of the members were consulted about its final exclusion
  • “You cannot develop a treatment for a condition that does not exist” —the author
• The Adverse Childhood Experiences (ACE) Study of 17,421 middle-class patients revealed that traumatic childhood experiences are far more common than expected and create a dose-response relationship with adult health problems
  • Only one-third of respondents reported no adverse childhood experiences, despite being mostly white, middle class, well-educated, and financially secure
  • More than a quarter of the population is likely to have been repeatedly physically abused as a child
  • For those with an ACE score of four or more, chronic depression prevalence is 66 percent in women and 35 percent in men, compared with 12 percent in those with a score of zero
  • From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts
• Many behaviors labeled as health risks, including obesity, addiction, and promiscuity, actually serve as adaptive solutions to childhood trauma rather than problems to be eliminated
  • “Overweight is overlooked, and that’s the way I need to be” —female rape victim
  • “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” —Vincent Felitti
  • “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” —ACE study group

Developmental Trauma: The Hidden Epidemic

Children with complex trauma histories display pervasive developmental disruptions that require a new diagnostic framework focused on dysregulation, attachment problems, and identity issues rather than surface behavioral symptoms.

• Children like Anthony, Maria, and Virginia present with multiple psychiatric diagnoses that fail to capture their core reality of being scared to death and fighting for their lives without trusting that caregivers can help them
  • Anthony would likely be diagnosed with depression, oppositional defiant disorder, anxiety, reactive attachment disorder, ADHD, and PTSD
  • “None of these diagnoses would clarify what was wrong with Anthony: that he was scared to death and fighting for his life, and he did not trust that his mother could help him” —the author
  • Virginia had diagnoses of bipolar disorder, intermittent explosive disorder, reactive attachment disorder, ADD hyperactive subtype, oppositional defiant disorder, and substance use disorder
• Genetic research has failed to find consistent patterns for mental illness, while epigenetic studies show that life events can turn genes on or off through methylation, with effects that can be passed to offspring
  • After thirty years and millions upon millions of dollars’ worth of research, we have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness
  • Mother rats that lick and groom their pups intensively during the first twelve hours after birth permanently affect brain chemicals and modify over a thousand genes
  • “Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world” —Moshe Szyf
• Stephen Suomi’s forty-year study of rhesus monkeys demonstrates that environmental factors can override genetic predispositions, with early relationships determining whether genetic vulnerabilities lead to behavioral problems
  • Monkeys with the short serotonin allele that were raised by adequate mothers behaved normally, while those raised with peers became aggressive risk takers
  • Young monkeys taken from their mothers and raised solely with peers become intensely attached, desperately clinging and lacking healthy exploration and play
  • Safe and protective early relationships are critical to protect children from long-term problems, even for parents with genetic vulnerabilities
• The National Child Traumatic Stress Network survey of nearly 2,000 children revealed that the vast majority came from extremely dysfunctional families, mirroring the adult ACE study findings
  • More than half had been emotionally abused and/or had a caregiver who was too impaired to care for their needs
  • About 50 percent had temporarily lost caregivers to jail, treatment programs, or military service
  • About half reported witnessing domestic violence, and a quarter were victims of sexual and/or physical abuse
• Standard PTSD criteria fail to capture the reality of chronically traumatized children, with 82 percent of traumatized children in the NCTSN not meeting PTSD diagnostic criteria despite severe symptoms
  • Children rarely talk about having been hit, abandoned, or molested, even when asked
  • “They now receive pseudoscientific diagnoses such as ‘oppositional defiant disorder,’ meaning ‘This kid hates my guts and won’t do anything I tell him to do’” —the author
  • These treatments rarely work and often cause more damage
• The proposed Developmental Trauma Disorder diagnosis captures a consistent pattern of pervasive dysregulation, attention problems, and difficulties with self and others that stems from early abuse and neglect
  • Children’s moods and feelings rapidly shifted from one extreme to another—from temper tantrums and panic to detachment, flatness, and dissociation
  • 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 cannot help but define themselves as defective and worthless
• The American Psychiatric Association rejected the Developmental Trauma Disorder diagnosis in 2009, claiming that early childhood adverse experiences leading to developmental disruptions was ‘more clinical intuition than research-based fact’
  • “The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact” —American Psychiatric Association
  • The National Association of State Mental Health Program Directors wrote a letter supporting DTD, representing 6.1 million people annually with a budget of $29.5 billion
  • “One million children who are abused and neglected every year in the United States a ‘diagnostic niche’?” —the author
• The Minnesota Longitudinal Study found that quality of early parent-child relationships, not biological factors, predicted whether children would develop behavioral problems in adolescence
  • Neither the mother’s personality, nor the infant’s neurological anomalies at birth, nor its IQ, nor its temperament predicted whether a child would develop serious behavioral problems
  • The key issue was the nature of the parent-child relationship: how parents felt about and interacted with their kids
  • By far the most important predictor of how well subjects coped with life’s inevitable disappointments was the level of security established with their primary caregiver during the first two years

Part Four: The Imprint of Trauma

Uncovering Secrets: The Problem of Traumatic Memory

Traumatic memories differ fundamentally from ordinary memories, being stored as fragmented sensory and emotional traces rather than coherent narratives, which explains why trauma victims may forget and later remember abuse in ways that seem inconsistent but are neurologically accurate.

• Julian’s case demonstrates how traumatic memories can be forgotten for decades then suddenly resurface as fragmented sensations and images triggered by specific cues, rather than as coherent narratives
  • During his phone conversation with his girlfriend about Father Shanley, Julian suddenly saw the priest silhouetted in a doorframe and went into panic
  • The moment he heard himself say ‘It happened to me, too,’ he knew for certain that Shanley had molested him—even though he did not remember the details
  • His memories were quite incoherent and fragmentary: flashes of images of Shanley’s face, isolated incidents, the priest’s dark blue corduroy pants
• Normal memories are flexible stories that change with retelling, while traumatic memories remain frozen and unchanged, as demonstrated by Harvard’s Grant Study of World War II veterans
  • Forty-five years later, the majority gave very different accounts from the narratives recorded in their immediate postwar interviews: events had been bleached of their intense horror
  • Those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended
  • The more adrenaline you secrete, the more precise your memory will be, but only up to a certain point—confronted with horror, this system becomes overwhelmed and breaks down
• High arousal during trauma disconnects critical brain areas necessary for memory integration, causing traumatic experiences to be stored as fragmented sensory and emotional traces rather than coherent narratives
  • High arousal knocks out the frontal lobe, including the region necessary to put feelings into words and the region that creates our sense of location in time
  • The imprints of traumatic experiences are organized not as coherent logical narratives but in fragmented sensory and emotional traces: images, sounds, and physical sensations
  • The emotional brain expresses its altered activation through changes in emotional arousal, body physiology, and muscular action
• Pierre Janet’s work with hysteria patients in the 1890s established the fundamental distinction between narrative memory and traumatic memory, showing how trauma creates dissociated memory systems
  • Traumatic memories are precipitated by specific triggers, and when one element is triggered, other elements automatically follow
  • Janet coined the term ‘dissociation’ to describe the splitting off and isolation of memory imprints
  • “Unable to integrate their traumatic memories, they seem to lose their capacity to assimilate new experiences as well” —Pierre Janet
  • “If the problem with PTSD is dissociation, the goal of treatment would be association: integrating the cut-off elements into the ongoing narrative of life” —the author
• Freud and Breuer’s 1893 formulation established the ’talking cure’ based on the principle that traumatic memories must be brought to consciousness with full emotional expression to achieve healing
  • “Hysterics suffer mainly from reminiscences” —Freud and Breuer
  • “Each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event and arousing its accompanying affect” —Freud and Breuer
  • “Language serves as a substitute for action; by its help, an affect can be ‘abreacted’ almost as effectively” —Freud and Breuer
• Contemporary trauma patients still exhibit the same patterns of reenactment without memory that Janet and Freud observed, as seen in cases like the Cocoanut Grove survivor and Vietnam veteran who staged anniversary reactions
  • A woman who had been a cigarette girl at the Cocoanut Grove nightclub annually reenacted her escape on Newbury Street, resulting in psychiatric hospitalizations
  • A Vietnam veteran yearly staged an ‘armed robbery’ on the exact anniversary of a buddy’s death by putting a finger in his pocket and claiming it was a pistol
  • “How can doctors, police officers, or social workers recognize that someone is suffering from traumatic stress as long as he reenacts rather than remember?” —the author
• The Father Shanley trial represented a legal test case for the admissibility of recovered traumatic memories, with the Massachusetts Supreme Judicial Court ultimately upholding the conviction based on dissociative amnesia
  • Almost one hundred leading psychiatrists and psychologists signed a brief stating that ‘repressed memory’ has never been shown to exist and should not be admitted as evidence
  • “The judge’s finding that the lack of scientific testing did not make unreliable the theory that an individual may experience dissociative amnesia was supported in the record” —Supreme Judicial Court of Massachusetts
  • “There was no abuse of discretion in the admission of expert testimony on the subject of dissociative amnesia” —Supreme Judicial Court of Massachusetts

The Unbearable Heaviness of Remembering

The reality of traumatic memory loss and recovery has been repeatedly documented across different historical periods and conflicts, but political and social forces have caused this knowledge to be forgotten and rediscovered multiple times, creating cycles of awareness and denial.

• Each generation’s response to trauma has been shaped by political needs rather than scientific evidence, with diagnoses and treatments alternately recognized and suppressed based on social convenience
  • Early in World War I the British created ‘shell shock,’ which entitled combat veterans to treatment and a disability pension, while ’neurasthenia’ provided neither
  • In 1917 the British General Staff issued an order stating that ‘In no circumstances whatever will the expression shell shock be used verbally or be recorded in any casualty report’
  • The 1922 Southborough Report suggested that well-trained troops, properly led, would not suffer from shell shock
• The societal treatment of traumatized veterans has often mirrored the trauma itself, with abandonment and rejection compounding the original injury, as seen in the 1932 Bonus Army incident
  • In 1932 fifteen thousand unemployed and penniless World War I veterans camped on the Mall in Washington DC to petition for immediate payment of their bonuses
  • President Hoover ordered the army to clear out the veterans’ encampment, with General MacArthur commanding troops supported by six tanks
  • Soldiers with fixed bayonets charged, hurling tear gas into the crowd of veterans
• Cultural expressions like literature and film have preserved the reality of trauma when medical and political institutions have denied it, as exemplified by ‘All Quiet on the Western Front’
  • “I am aware that I, without realizing it, have lost my feelings—I don’t belong here anymore, I live in an alien world” —Paul Bäumer in All Quiet on the Western Front
  • The novel instantly became an international best seller, with translations in twenty-five languages
  • When Hitler came to power, ‘All Quiet on the Western Front’ was one of the first ‘degenerate’ books the Nazis burned
• The 1980s and 1990s witnessed a massive emergence of trauma survivors coming forward, followed by a backlash claiming ‘False Memory Syndrome’ that ignored a century of documented research on memory loss
  • In 1974 Freedman and Kaplan’s textbook stated that incest occurs in no more than 1 out of 1.1 million people and claimed it allowed for ‘better adjustment to the external world’
  • Articles appeared claiming there was no evidence that people remember trauma differently than ordinary events, despite extensive historical documentation
  • “When does a hypothesis become a scientifically established fact?” —the author
• Linda Meyer Williams’ longitudinal study of 136 sexually abused children found that 38 percent had no memory of their documented abuse seventeen years later, with recovered memories being as accurate as continuous ones
  • More than a third of the women (38 percent) did not recall the abuse that was documented in their medical records
  • Women who were younger at the time of the incident and those who were molested by someone they knew were more likely to have forgotten their abuse
  • The recovered memories were approximately as accurate as those that had never been lost: All the women’s memories were accurate for the central facts
• Laboratory studies of memory cannot replicate the conditions under which traumatic memories are formed, making them irrelevant to understanding trauma despite their use to discredit survivors
  • Events that take place in the laboratory cannot be considered equivalent to the conditions under which traumatic memories are created
  • The terror and helplessness associated with PTSD simply can’t be induced de novo in a laboratory setting
  • Roger Pitman’s film ‘Faces of Death’ did not cause normal volunteers to develop symptoms of PTSD
• The Massachusetts General Hospital study revealed fundamental differences between normal and traumatic memories, with trauma memories lacking narrative coherence while retaining intense sensory and emotional fragments
  • Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end
  • Traumatic memories were disorganized: subjects remembered some details all too clearly but could not recall the sequence of events or other vital details
  • Most continue to have substantial problems with their health, work, or mental well-being even after remembering the trauma with full emotional expression
• Nancy’s experience of anesthesia awareness demonstrates how trauma creates a dual reality where survivors must navigate between a secure present and an ever-present traumatic past
  • “I tried desperately to move, to speak, but my body didn’t work. I couldn’t understand this” —Nancy
  • “There is a strangeness, bizarreness to this dual existence. I tire of it. Yet I cannot give up on life” —Nancy
  • “The pull to the past is strong; it is the dark side of my life; and I must dwell there from time to time” —Nancy

Part Five: Paths to Recovery

Healing from Trauma: Owning Your Self

Recovery from trauma requires restoring self-leadership and ownership of body and mind through approaches that address the emotional brain’s dysregulation, since trauma cannot be ’treated’ but its imprints can be transformed.

• Trauma recovery involves reestablishing ownership of your body and mind through becoming calm and focused, tolerating reminders without being overwhelmed, and staying fully alive in the present
  • “Trauma robs you of the feeling that you are in charge of yourself, of what I will call self-leadership” —the author
  • “The challenge of recovery is to reestablish ownership of your body and your mind—of your self” —the author
  • This means feeling free to know what you know and to feel what you feel without becoming overwhelmed, enraged, ashamed, or collapsed
• The emotional brain, not rational thought, drives posttraumatic reactions, requiring ’limbic system therapy’ that directly addresses the brain’s alarm systems rather than trying to reason with symptoms
  • The engines of posttraumatic reactions are located in the emotional brain, which manifests itself in physical reactions: gut-wrenching sensations, heart pounding, breathing becoming fast and shallow
  • Understanding why you feel a certain way does not change how you feel, but it can keep you from surrendering to intense reactions
  • The only way we can consciously access the emotional brain is through self-awareness, by activating the medial prefrontal cortex
• Body-based approaches like breathing, yoga, and movement can directly train the arousal system using the body’s natural self-regulation capacity, which has been utilized across cultures for millennia
  • Some 80 percent of the fibers of the vagus nerve run from the body into the brain, meaning we can directly train our arousal system by the way we breathe, chant, and move
  • Ten weeks of yoga practice markedly reduced the PTSD symptoms of patients who had failed to respond to any medication or other treatment
  • This principle has been utilized since time immemorial in places like China and India, and in every religious practice that I know of
• Mindfulness and body awareness are essential for recovery because traumatized people often experience their own physical sensations as the enemy, leading to avoidance behaviors that maintain trauma symptoms
  • It is not so much the perpetrators but their own physical sensations that now are the enemy
  • “The most important phrases in trauma therapy, as in yoga, are ‘Notice that’ and ‘What happens next?’” —the author
  • Once you pay attention to your physical sensations, the next step is to label them and see how they change with breathing or movement
• Relationships and social support constitute the most powerful protection against trauma, but traumatized people often struggle with intimacy due to fears of betrayal and abandonment rooted in their original injuries
  • Study after study shows that having a good support network constitutes the single most powerful protection against becoming traumatized
  • Much of the wiring of our brain circuits is devoted to being in tune with others, so recovery from trauma involves reconnecting with our fellow human beings
  • If the people whom you naturally turn to for care and protection terrify or reject you, you learn to shut down and ignore what you feel
• Taking effective action and restoring a sense of agency are crucial for recovery, as helplessness and immobilization prevent people from using stress hormones for their proper defensive purpose
  • People who actively do something to deal with a disaster are at much lower risk of becoming traumatized than those who remain helpless
  • When helplessness prevents the use of stress hormones for defense, the activation patterns meant to promote coping are turned back against the organism
  • The best way to overcome ingrained patterns of submission is to restore a physical capacity to engage and defend
• Medications can help manage trauma symptoms but cannot cure trauma, often working by blocking the chemical systems that regulate engagement and motivation, creating a trade-off between control and aliveness
  • Drugs cannot ‘cure’ trauma; they can only dampen the expressions of a disturbed physiology
  • They work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure
  • Between 2001 and 2011 the VA spent about $1.5 billion on Seroquel and Risperdal, even though research showed Risperdal was no more effective than placebo for PTSD
• Bill’s thirty-year treatment journey illustrates how recovery is an ongoing process that may require different approaches at different life stages, ultimately leading to integration rather than cure
  • Bill’s treatment involved three distinct phases over three decades: initial stabilization, memory processing with EMDR, and finally body-based work with yoga
  • Today, ten years later, Bill continues to be fully engaged in life and has taught yoga classes to more than 1,300 returning combat veterans
  • Like his memories of childhood and Vietnam, his physical limitations do not dominate his existence—they are simply part of the ongoing, evolving story of his life

Language: Miracle and Tyranny

While finding words for traumatic experiences is essential for breaking isolation and creating meaning, language alone is insufficient for healing trauma, which requires accessing and integrating the body-based emotional brain through various forms of expression.

• After 9/11, trauma survivors sought body-based treatments like acupuncture, massage, and yoga rather than the expert-recommended talk therapies, suggesting that physical interventions address trauma more effectively than words alone
  • Expert panels recommended only psychoanalytically oriented therapy and cognitive behavioral therapy for 9/11 survivors
  • Almost nobody showed up for the recommended treatments
  • Asked what had been most helpful, survivors credited acupuncture, massage, yoga, and EMDR, in that order
• Traumatic events resist translation into words because they are initially imprinted as sensory fragments rather than stories, requiring external help to create coherent narratives
  • Traumatic events are almost impossible to put into words
  • The initial imprints of September 11 were not stories but images: frantic people running, an airplane smashing into Tower One, distant specks that were people jumping
  • “What can not be spoken to the mother cannot be told to the self” —John Bowlby
• Breaking silence about trauma is essential for healing because secrecy reinforces isolation, while naming experiences enables recognition and the possibility of different responses to triggers
  • “Silence = Death” —AIDS activists
  • “Silence about trauma also leads to death—the death of the soul. Silence reinforces the godforsaken isolation of trauma” —the author
  • As long as you keep secrets and suppress information, you are fundamentally at war with yourself
• Humans possess two distinct self-awareness systems: an autobiographical narrative system based in language and a moment-to-moment awareness system based in physical sensations, with only the latter able to change the emotional brain
  • 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
  • Only the system devoted to self-awareness, which is based in the medial prefrontal cortex, can change the emotional brain
  • The language center of the brain is about as far removed from the center for experiencing one’s self as is geographically possible
• Helen Keller’s acquisition of language demonstrates how words create both selfhood and community, transforming an isolated ‘phantom’ into a connected person capable of sharing inner experience
  • “Water! That word startled my soul, and it awoke, full of the spirit of the morning” —Helen Keller
  • “Before my teacher came to me, I did not know that I am. I lived in a world that was a no-world” —Helen Keller
  • “Oh, what happiness! To talk freely with other children! To feel at home in the great world!” —Helen Keller
• Writing to oneself provides a powerful way to access inner experience without the social editing that occurs in conversation, allowing unconscious material to emerge through free association
  • When you write to yourself, you don’t have to worry about other people’s judgment—you just listen to your own thoughts and let their flow take over
  • James Pennebaker’s study showed that students who wrote about both facts and emotions related to trauma had a 50 percent drop in doctor visits
  • Writing about their deepest thoughts and feelings about traumas improved mood and resulted in better physical health
• Art, music, and dance may circumvent the speechlessness of trauma, but research suggests that translating experiences into language remains necessary for complete healing and integration
  • The capacity of art, music, and dance to circumvent the speechlessness that comes with terror may be one reason they are used as trauma treatments in cultures around the world
  • Only the expressive movement group that also wrote showed objective evidence: better physical health and an improved grade-point average
  • “The mere expression of the trauma is not sufficient. Health does appear to require translating experiences into language” —Pennebaker and Krantz
• Language has limitations for trauma healing because trauma fundamentally changes brain structure, creating alexithymia and requiring body-based approaches to restore the sense of embodied selfhood
  • Trauma interferes with the proper functioning of brain areas that manage and interpret experience
  • Almost every brain-imaging study of trauma patients finds abnormal activation of the insula, which integrates input from internal organs to generate the sense of being embodied
  • “In order to overcome trauma, you need help to get back in touch with your body, with your Self” —the author

Letting Go of the Past: EMDR

Eye Movement Desensitization and Reprocessing (EMDR) enables people to process traumatic memories by activating the brain’s natural memory integration system, allowing traumatic experiences to be transformed from overwhelming present realities into manageable past events.

• David’s case demonstrates how EMDR can rapidly transform a traumatic memory from a source of ongoing rage and dysfunction into a completed past experience that no longer controls present behavior
  • David’s violent rage attacks were making his home a living hell, and he felt that losing his eye gave him permission to abuse other people
  • After EMDR, the memory of the stabbing had lost its intensity—it was now something unpleasant that had happened a long time ago
  • At the fifth session he reported inner peace for the first time in his life, and a year later he and his wife had grown closer and started practicing yoga together
• Maggie’s experience with EMDR demonstrated how the technique allows people to simultaneously relive trauma from their child’s perspective while observing it from their adult self, creating integration without retraumatization
  • During EMDR she vividly remembered her father’s rape when she was seven—remembered it from inside her child’s body while observing from her twenty-nine-year-old self
  • “I was such a little girl. How could a huge man do this to a little girl?” —Maggie
  • “It wasn’t my fault. I was a little girl and there was nothing I could do to keep him from molesting me” —Maggie
• EMDR research showed that patients who received EMDR had substantially better outcomes than those on Prozac or placebo, with 60 percent completely cured eight months later compared to complete relapse in the Prozac group
  • After eight EMDR sessions one in four were completely cured compared with one in ten of the Prozac group
  • Eight months later, 60 percent of those who received EMDR scored as being completely cured, while all those who had taken Prozac relapsed when they went off the drug
  • “Once you kick the log, the river will start flowing. Once people started to integrate their traumatic memories, they spontaneously continued to improve” —Milton Erickson
• EMDR works differently for adults traumatized as children versus those traumatized as adults, with childhood abuse survivors showing slower but still significant improvement over time
  • Almost half of the adult-onset group that received EMDR scored as completely cured after eight weeks, while only 9 percent of the child-abuse group showed such improvement
  • Eight months later the cure rate was 73 percent for the adult-onset group, compared with 25 percent for those with histories of child abuse
  • Chronic childhood abuse causes very different mental and biological adaptations than discrete traumatic events in adulthood
• EMDR appears to activate the brain’s natural memory processing system, similar to what occurs during REM sleep, allowing traumatic memories to be integrated with broader life experience
  • Robert Stickgold suggested that EMDR may reproduce what happens in the dreaming brain by taking advantage of sleep-dependent memory processing
  • Dreams help to forge new relationships between apparently unrelated memories, which is essential to healing
  • “If the bilateral stimulation of EMDR can alter brain states similar to REM sleep, it should allow effective memory processing blocked in PTSD sufferers” —Robert Stickgold
• Kathy’s detailed EMDR session illustrates how the technique unleashes the mind’s associative powers, allowing traumatic material to be spontaneously integrated with protective images and self-compassion
  • During EMDR, Kathy’s mind moved from traumatic memories to protective images: ‘I was in a karate class; it was great! I really kicked butt!’
  • “She experienced integration: ‘I have pictures of a bulldozer flattening the house I grew up in. It’s over!’” —Kathy
  • “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” —the author
• Unlike exposure therapy which focuses on desensitization, EMDR integrates traumatic memories by transforming them from overwhelming present experiences into coherent stories about the past
  • After EMDR people thought of the trauma as a coherent event in the past, instead of experiencing sensations and images divorced from any context
  • One man reported: ‘I remember it as though it was a real memory, but it was more distant. Typically, I drowned in it, but this time I was floating on top’
  • EMDR spends very little time revisiting the original trauma. The focus is on stimulating and opening up the associative process

Learning to Inhabit Your Body: Yoga

Yoga provides a unique pathway to trauma recovery by helping people develop interoception and self-regulation, enabling them to safely experience and befriend their bodies rather than treating physical sensations as enemies.

• Annie’s initial presentation of severe terror and body disconnection illustrates how trauma survivors often experience their own physical sensations as threats, requiring gentle body-based approaches to restore safety
  • Annie was slumped over, legs visibly shaking, staring at the floor, too terrified to engage in conversation or provide routine information
  • We spent about half an hour with gentle breathing and qigong movements until her face softened, spine straightened, and she showed a glimmer of a smile
  • She often coped with disagreements by making her mind disappear and would cut her arms and breasts with a razor blade to relieve tension
• Trauma survivors develop malfunctioning alarm systems where the amygdala interprets normal situations as life-threatening, creating chronic states of fight, flight, or freeze that persist long after danger has passed
  • Her smoke detector, her amygdala, had been rewired to interpret certain situations as harbingers of life-threatening danger
  • When Annie started to like the therapist, she began to look forward to meetings but would arrive in intense panic because her mind associated excitement about seeing someone she loved with terror of being molested
  • Small children compartmentalize experience, so Annie’s natural love for her father and her dread of his assaults were held in separate states of consciousness
• Heart rate variability research revealed that people with PTSD have poorly coordinated autonomic nervous systems, leading the research team to explore yoga as a method for improving physiological self-regulation
  • Heart rate variability measures the relative balance between the sympathetic and parasympathetic systems through breathing-related fluctuations in heart rate
  • People with PTSD have unusually low HRV, meaning their sympathetic and parasympathetic nervous systems are out of sync
  • Google listed seventeen thousand yoga sites claiming that yoga improved HRV, but we were unable to find any supporting studies in 1998
• The yoga study comparing trauma survivors in yoga classes versus dialectical behavior therapy found that yoga significantly improved arousal problems and relationships to bodies while DBT did not affect arousal levels
  • Yoga significantly improved arousal problems in PTSD and dramatically improved subjects’ relationships to their bodies
  • Subjects reported: ‘I now take care of my body’ and ‘I listen to what my body needs’
  • Eight weeks of DBT did not affect their arousal levels or PTSD symptoms
• Annie’s yoga journey demonstrates how body-based practices can gradually restore the capacity to feel and interpret physical sensations, transforming the relationship between mind and body from fear to friendship
  • “Your body has things to say. I said back to myself, ‘I will try and listen.’” —Annie
  • “My jaw and the whole area from where my legs end to my bellybutton is where I am tight, tense and holding the pain and memories” —Annie
  • “I think about how unbalanced I have been and about how hard I have tried to deny the past, which is a part of my true self” —Annie
• Interoception, the ability to feel and interpret physical sensations, is fundamental to emotional awareness and self-regulation, with yoga providing a systematic way to cultivate this essential capacity
  • Our sense of ourselves is anchored in a vital connection with our bodies. We do not truly know ourselves unless we can feel and interpret our physical sensations
  • In yoga you focus attention on breathing and sensations moment to moment. You begin to notice the connection between emotions and body
  • Simply noticing what you feel fosters emotional regulation, and it helps you to stop trying to ignore what is going on inside you
• Neuroscience research shows that yoga practice increases activation of brain areas critical for self-regulation, particularly the insula and medial prefrontal cortex involved in self-awareness
  • Brain researchers have shown that intensive meditation has a positive effect on exactly those brain areas that are critical for physiological self-regulation
  • Twenty weeks of yoga practice increased activation of the basic self-system, the insula and the medial prefrontal cortex
  • “My emotions feel more powerful. Maybe it’s just that I can recognize them now” —yoga study participant
• Annie’s recovery through yoga enabled her to communicate traumatic memories verbally and develop intimate relationships, showing how body-based healing can restore the capacity for connection and communication
  • After practicing yoga three times a week for about a year, she noticed she was able to talk much more freely about what had happened to her
  • “Did you notice that I have been able to say the words out loud? I didn’t have to write them down to tell you what was happening” —Annie
  • “All this helped me finally feel intimate with my husband” —Annie

Putting the Pieces Together: Self-Leadership

Internal Family Systems (IFS) therapy recognizes that trauma creates internal parts or subpersonalities that need to be understood and integrated under the leadership of the Self, rather than trying to eliminate or suppress these adaptive survival mechanisms.

• Tom’s case illustrates how trauma can fragment the personality into distinct parts, with his ‘Avenger’ part taking control during triggers while his core Self remained hidden beneath protective mechanisms
  • Tom was a successful salesman and devoted family man, but would transform into a different person when triggered by feelings of being dismissed or ignored
  • When his ‘Avenger’ was activated, Tom became cold, rageful, and calculating, methodically planning to destroy whoever had hurt him
  • The Avenger had first emerged when Tom was eight and his parents sent him to military school after his baby brother was born
• Richard Schwartz’s Internal Family Systems model revolutionized trauma therapy by recognizing that internal parts are not pathological but adaptive survival mechanisms that need to be understood and appreciated
  • Schwartz noticed that his patients spoke about themselves in the plural: ‘Part of me wants this, but another part of me wants that’
  • Instead of trying to ‘get rid of’ the angry part, as most therapies do, he’d say something like: ‘So there’s a part of you that gets very angry. Can you tell me more about that part?’
  • “The parts are not internal demons but internal guardians—they have our best interests at heart” —the author
• IFS distinguishes between three types of parts: exiles (wounded child parts), managers (parts that control daily life), and firefighters (parts that handle crises), all of which need Self-leadership to function harmoniously
  • Exiles carry the memories and pain from the past and need attention and comfort
  • Managers handle day-to-day life by trying to keep the exiled parts safely locked away
  • Firefighters spring into action when the exiles’ pain breaks through, using whatever means necessary to distract from or numb the pain
• The Self in IFS is not another part but the core essence that possesses natural leadership qualities like curiosity, clarity, compassion, and courage when not hijacked by protective parts
  • Self is not a part. When we are in Self, we feel lighter, more fluid, and more alive
  • “Self naturally embodies leadership qualities that I have come to call the eight Cs: curiosity, clarity, compassion, creativity, calm, connectedness, courage, and centeredness” —Richard Schwartz
  • Even the most shut-down, hopeless, abused clients have all the qualities of this Self
• Trauma-based therapy often fails because it tries to access memories and feelings directly, which activates protective parts that will sabotage treatment to protect wounded exiles from further harm
  • Many people seek therapy because they are bothered by their symptoms, but symptoms usually are carried by the exiled parts
  • If we try to approach them directly, the managers will become agitated and the firefighters are likely to stage a revolt
  • The protective parts do whatever they can to prevent us from experiencing the raw grief, terror, rage, or abandonment of the exiles
• IFS therapy focuses on helping the Self develop relationships with all parts, understanding their protective functions and building trust before attempting to access and heal wounded exiles
  • IFS therapy starts by asking the managers and firefighters what they are trying to protect and what they need in order to trust Self to take care of the system
  • We cannot eliminate what we regard as bad. What we resist persists. Parts are not damaged goods to be repaired; they are our internal wisdom
  • “Only the Self can create safety. The Self can reassure the protective parts that it will not permit anyone or anything to hurt the exiles” —the author
• When protective parts trust the Self to handle the system, exiles can be safely accessed, heard, and healed, often leading to dramatic shifts in the entire internal system
  • Once protective parts give the Self permission to address the exiles, the internal system is likely to come back into balance
  • The same parts that once protected the client from trauma can now be enlisted to safeguard his or her healing and growth
  • Tom’s Avenger became his ally in his work as a financial adviser, and the exiled eight-year-old was now free to be playful with his own children
• IFS therapy has proven effective for a wide range of trauma survivors and has been successfully adapted for various populations, from individual therapy to group work with combat veterans
  • IFS has been used effectively with a large variety of problems, including eating disorders, substance abuse, depression, and physical and sexual abuse
  • Frank Anderson developed protocols for IFS therapy with combat veterans that have proven very successful
  • The therapy helps people become truly self-confident—confident that they can trust their Self to handle whatever the day brings

Filling in the Holes: Creating Structures

Psychomotor therapy creates three-dimensional structures that allow people to externalize and rework their internal landscape, providing corrective experiences that can supplement traumatic memories with new embodied experiences of safety and care.

• Albert Pesso developed psychomotor therapy as a way to create three-dimensional structures where people can project their inner world and experiment with different outcomes, potentially creating new supplemental memories of being cherished and protected
  • Albert Pesso was a stocky former dancer with the Martha Graham Dance Company who exuded kindness and confidence and claimed he had found a way of fundamentally changing people’s relationship to their core, somatic selves
  • Structures do not erase bad memories, or even neutralize them the way EMDR does. Instead, a structure offers fresh options—an alternative memory in which your basic human needs are met
  • Could this technique instill imprints of safety and comfort alongside those of terror and abandonment, decades after the original shaping of mind and brain?
• The spatial positioning of internal family members in structures reveals unconscious internal maps, as demonstrated when van der Kolk positioned his parents as hulking, dark objects while representing wife and children as tiny, insignificant items
  • “I chose a gigantic black leather couch to represent my father and asked Al to put it upright about eight feet in front of me, slightly to the left. For my mother I chose a heavy lamp, approximately the same height as the upright couch” —van der Kolk
  • I had re-created my inner image of my stern Calvinistic parents from the time I was a little boy. My chest felt tight, and I’m sure that my voice sounded even tighter
  • When Al interposed his body directly between me and the couch and lamp, making them disappear from my line of sight, instantaneously I felt a deep release in my body
• Maria’s structure work demonstrates how witnessing and validation create safety for exploring family trauma, allowing her to experience both the pain of her real parents’ failures and the healing possibility of ideal parents who would have protected her
  • “There is always a sense of fear in everything I do. It doesn’t look like I am afraid, but I am always pushing myself. It is really difficult for me to be up here” —Maria
  • “I wanted you to protect me. My sadness goes out to my mom; how incapable she was of standing up to my father and protecting us” —Maria
  • “I would have been able to be a safe, happy little girl” —Maria
• Mark’s structure work around discovering his father’s affair with his aunt shows how family secrets become inner toxins that contaminate development, and how speaking forbidden truths can begin to free people from their isolating effects
  • At age thirteen Mark had accidentally overheard his father having phone sex with his aunt, his mother’s sister, but when he tried to talk with his father about it, he was told that he had a filthy imagination
  • Secrets like these become inner toxins—realities that you are not allowed to acknowledge to yourself or to others but that nevertheless become the template of your life
  • “Oh my God, life would have been so different if I could have trusted my father and talked about what was going on. I could have had a father” —Mark
• Psychomotor structures create virtual memories that can serve as antidotes to painful realities by providing sensory experiences of safety, mastery, and connection that directly contradict the static feelings of the traumatized self
  • Like the model mugging classes, the structures hold out the possibility of forming virtual memories that live side by side with the painful realities of the past
  • The healing tableaus of structures offer an experience that many participants have never believed was possible for them: to be welcomed into a world where people delight in them, protect them, meet their needs, and make you feel at home
  • We can never undo what happened, but we can create new emotional scenarios intense and real enough to defuse and counter some of those old ones

Rewiring the Brain: Neurofeedback

Neurofeedback training uses real-time brain wave monitoring to help people learn to regulate their neural activity, offering a promising treatment for trauma that can reduce hyperarousal and improve attention and emotional stability.

• Alexander McFarlane’s research revealed that traumatized people have disorganized brain wave patterns that interfere with their ability to filter information and focus attention, explaining why trauma survivors struggle with learning from experience and engaging in daily life
  • In the ’normal’ group key parts of the brain worked together to produce a coherent pattern of filtering, focus, and analysis, while the brain waves of traumatized subjects were more loosely coordinated
  • Their brains are not organized to pay careful attention to what is going on in the present moment
  • “Traumatic stress is an illness of not being able to be fully alive in the present” —Pierre Janet
• Sebern Fisher’s neurofeedback work with a severely traumatized foster child demonstrated dramatic improvements in developmental functioning, with the child’s drawings advancing six years of complexity in just four months of treatment
  • A ten-year-old boy had such severe temper tantrums, learning disabilities, and overall difficulties with self-organization that he could not be handled in school
  • His first family portrait was at the developmental level of a three-year-old, but after twenty sessions his drawing showed marked improvement in complexity
  • “I had never come across a treatment that could produce such a dramatic change in mental functioning in so brief a period of time” —van der Kolk
• Lisa’s recovery from severe dissociative identity disorder through neurofeedback demonstrates how regulating brain waves can restore a continuous sense of self and enable meaningful therapeutic relationships for the first time
  • “Every time we tried to talk about what had happened to me growing up, I would have a breakdown. I would wake up with cuts and burns and I wouldn’t be able to eat” —Lisa
  • “After half a year of neurofeedback I stopped hearing those noises. I integrated, I guess. Everything just came together” —Lisa
  • “For the first time I started being able to do therapy. Up till then I didn’t have enough distance and I couldn’t calm down enough” —Lisa
• Different brain wave frequencies correspond to different states of consciousness and functioning, with delta waves associated with sleep, theta with creativity and trance, alpha with calm focus, and beta with external attention and potential anxiety
  • Delta waves (2–5 Hz) are seen most often during sleep, and if people have too much slow-wave activity while awake, their thinking is foggy with poor judgment and impulse control
  • Alpha waves (8–12 Hz) are accompanied by a sense of peace and calm and are familiar to anyone who has learned mindfulness meditation
  • High beta (over 20 Hz) is associated with agitation, anxiety, and body tenseness—we are constantly scanning the environment for danger
• The Peniston and Kulkosky study of alpha-theta neurofeedback with Vietnam veterans achieved one of the best recorded outcomes for PTSD treatment, with sustained improvements in symptoms and dramatic reductions in hospitalization and medication use
  • Twenty-nine Vietnam veterans with a twelve- to fifteen-year history of chronic combat-related PTSD were treated, with fifteen receiving alpha-theta training and fourteen serving as controls
  • Only three of the fifteen neurofeedback-treated veterans reported disturbing flashbacks and nightmares after treatment, while every vet in the comparison group experienced an increase in PTSD symptoms
  • All of those given standard treatment were readmitted to the hospital within eighteen months, while only one neurofeedback patient needed further hospitalization
• Neurofeedback shows promise for treating addiction alongside trauma, with studies suggesting it may be more effective than standard treatment approaches in maintaining sobriety and reducing relapse rates
  • Approximately one-third to one-half of severely traumatized people develop substance abuse problems, creating a circular relationship where drugs provide temporary relief but withdrawal increases hyperarousal
  • One of the first women van der Kolk trained with neurofeedback had her long-standing cocaine addiction clear after the first two sessions and had not returned five years later
  • Between 75 percent and 80 percent of patients admitted for detox and alcohol and drug abuse treatment will relapse, but neurofeedback studies show dramatically better outcomes

Finding Your Voice: Communal Rhythms and Theater

Theater and communal rhythmic activities provide powerful healing opportunities for trauma survivors by offering safe spaces to embody emotions, practice new roles, and experience meaningful connection with others through shared creative expression.

• Theater has historically served as communal ritual for processing traumatic experiences, as evidenced by ancient Greek drama which likely helped reintegrate combat veterans through shared witnessing of stories about war, betrayal, and violence
  • Ancient Greek theater seems to have grown out of religious rites that involved dancing, singing, and reenacting mythical stories, with audiences seated in a horseshoe around the stage to see one another’s emotions
  • Sophocles was a general officer in Athens’s wars against the Persians, and his play Ajax reads like a textbook description of traumatic stress
  • “Anyone who has come into contact with extreme pain, suffering or death has no trouble understanding Greek drama. It’s all about bearing witness to the stories of veterans” —Bryan Doerries
• Collective rhythmic activities like marching, singing, and dancing create muscular bonding that enables groups to overcome individual fear and achieve coordinated action, as demonstrated in military drill, civil rights movements, and resistance movements
  • Prince Maurice of Orange instituted close-order drill, accompanied by drums, flutes, and trumpets, in his ragtag army after reading Roman military manuals
  • Music binds together people who might individually be terrified but who collectively become powerful advocates for themselves and others
  • In June 1987 more than ten thousand concertgoers at the Tallinn Song Festival Grounds linked hands and began to sing patriotic songs that had been forbidden during Soviet occupation
• Urban Improv’s school-based theater program effectively reduced aggression and improved cooperation among fourth graders, but eighth graders showed no improvement because they had experienced significantly more trauma exposure that overwhelmed the intervention’s capacity
  • Students in the UI group showed substantially fewer fights and angry outbursts, more cooperation and self-assertion with peers, and more attentiveness and engagement in the classroom
  • Every single eighth grader in these typical American inner-city schools had witnessed serious violence, with two-thirds having observed five or more incidents including stabbings, gunfights, killings, and domestic assaults
  • In scenes where someone was in physical danger, the students always sided with the aggressors, showing nothing but contempt for potential victims
• The Possibility Project demonstrates how foster care youth can overcome their survival-based mistrust and isolation by collaboratively creating and performing their own musical productions, building interdependence and discovering their voices
  • Five years after maturing out of care, some 60 percent will have been convicted of a crime, 75 percent will be on public assistance, and only 6 percent will have completed even a community college degree
  • “If you treat kids in foster care with love or generosity, they often don’t know what to make of it or how to respond. Rudeness feels more familiar; cynicism they understand” —Paul Griffin
  • “We’re healing trauma without anyone ever mentioning the word” —Paul Griffin
• Shakespeare in the Courts helps juvenile offenders discover emotional language and self-control through intensive work with Shakespeare’s texts, teaching them to embody complex emotions safely while developing verbal sophistication
  • These adolescents are all ‘adjudicated offenders’ found guilty of fighting, drinking, stealing, and property crimes, sentenced by a judge to six weeks of intensive acting study
  • With no words to express the effects of their capricious upbringing, these adolescents act out their emotions with violence
  • Larry, a fifty-nine-year-old Vietnam veteran with twenty-seven detox hospitalizations, started his first job in seven years after learning to experience and tolerate deep emotions through his Brutus role
• Theater programs create safety for traumatized individuals to experience embodiment and emotional expression through incremental exercises that build trust, attunement, and the capacity to take on new roles beyond their trauma identities
  • “The secret is to go slow and engage them bit by bit. The initial challenge is simply to get participants to be more present in the room” —Kevin Coleman
  • You have to make it safe for them to notice each other. Once their bodies are a little more free, you can gradually work up to making eye contact
  • Theater offers a unique way to access a full range of emotions and physical sensations that not only put them in touch with the habitual ‘set’ of their bodies, but also let them explore alternative ways of engaging with life

Epilogue: Choices to be Made

While advances in trauma research have provided effective treatments and prevention strategies, society must choose to address trauma’s social and political roots rather than merely treating symptoms in isolation.

• Modern neuroscience research has provided unprecedented understanding of how trauma changes brain development and functioning, while also revealing how experiences throughout life can alter brain structure, gene expression, and even genetic inheritance patterns
  • Advances in neuroscience have given us a better understanding of how trauma changes brain development, self-regulation, and the capacity to stay focused and in tune with others
  • We have learned how, throughout life, experiences change the structure and function of the brain—and even affect the genes we pass on to our children
  • We know not only how to treat trauma but also, increasingly, how to prevent it
• Trauma remains a massive public health crisis with social and political roots, as poverty, substandard housing, inferior schools, and widespread gun availability create breeding grounds for trauma that far exceed the impact of foreign wars
  • Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan
  • American women are twice as likely to suffer domestic violence as breast cancer, and the American Academy of Pediatrics estimates that firearms kill twice as many children as cancer does
  • In today’s world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life
• Current psychiatric practice often compounds trauma by focusing on symptom suppression through medication rather than addressing underlying causes and building self-care capacity, exemplified by the rampant prescription of painkillers that now kill more people than guns or car accidents
  • Many psychiatrists today work in assembly-line offices where they see patients they hardly know for fifteen minutes and then dole out pills to relieve pain, anxiety, or depression
  • One tragic example of this orientation is the rampant prescription of painkillers, which now kill more people each year in the United States than guns or car accidents
  • What are these patients trying to cope with? What are their internal or external resources? How do they calm themselves down?
• The National Child Traumatic Stress Network has grown into a comprehensive system of over 150 centers nationwide, demonstrating that trauma-informed approaches in schools and communities can effectively help children develop self-regulation and resilience
  • Since we came together to establish the National Child Traumatic Stress Network in 2001, it has grown into a collaborative network of more than 150 centers nationwide
  • More than 50 percent of the children served by Head Start have had three or more adverse childhood experiences like incarcerated family members, depression, violence, abuse, or drug use in the home
  • Kids become less anxious and emotionally reactive and are less aggressive or withdrawn; they get along better and their school performance improves
• Effective trauma treatment in schools requires teaching all staff to recognize trauma effects and focus on safety, predictability, and genuine human connection rather than punishment, while helping children develop emotional intelligence and self-regulation skills
  • Most teachers we work with are intrigued to learn that abused and neglected students are likely to interpret any deviation from routine as danger
  • More than anything else, being able to feel safe with other people defines mental health; safe connections are fundamental to meaningful and satisfying lives
  • In addition to reading, writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and communication as part of their core curriculum
• Many great social change leaders have emerged from personal trauma experiences, suggesting that societies can transform devastating experiences into sources of wisdom, compassion, and advocacy for justice and healing
  • Most great instigators of social change have intimate personal knowledge of trauma. Oprah Winfrey comes to mind, as do Maya Angelou, Nelson Mandela, and Elie Wiesel
  • Many of our most profound advances grew out of experiencing trauma: the abolition of slavery from the Civil War, Social Security in response to the Great Depression
  • Trauma is now our most urgent public health issue, and we have the knowledge necessary to respond effectively. The choice is ours to act on what we know