You are being pro­vid­ed with a book chap­ter by chap­ter. I will request you to read the book for me after each chap­ter. After read­ing the chap­ter, 1. short­en the chap­ter to no less than 300 words and no more than 400 words. 2. Do not change the name, address, or any impor­tant nouns in the chap­ter. 3. Do not trans­late the orig­i­nal lan­guage. 4. Keep the same style as the orig­i­nal chap­ter, keep it con­sis­tent through­out the chap­ter. Your reply must com­ply with all four require­ments, or it’s invalid.
I will pro­vide the chap­ter now.

N
CHAPTER 13
HEALING FROM TRAUMA: OWNING
YOUR SELF
I don’t go to ther­a­py to find out if I’m a freak
I go and I find the one and only answer every week
And when I talk about ther­a­py, I know what peo­ple think
That it only makes you self­ish and in love with your shrink
But, oh how I loved every­body else
When I final­ly got to talk so much about myself
—Dar Williams, What Do You Hear in These Sounds
obody can “treat” a war, or abuse, rape, molesta­tion, or any oth­er
hor­ren­dous event, for that mat­ter; what has hap­pened can­not be
undone. But what can be dealt with are the imprints of the trau­ma on body,
mind, and soul: the crush­ing sen­sa­tions in your chest that you may label as
anx­i­ety or depres­sion; the fear of los­ing con­trol; always being on alert for
dan­ger or rejec­tion; the self-loathing; the night­mares and flash­backs; the
fog that keeps you from stay­ing on task and from engag­ing ful­ly in what
you are doing; being unable to ful­ly open your heart to anoth­er human
being.
Trau­ma robs you of the feel­ing that you are in charge of your­self, of
what I will call self-lead­er­ship in the chap­ters to come.1 The chal­lenge of
recov­ery is to reestab­lish own­er­ship of your body and your mind—of your
self. This means feel­ing free to know what you know and to feel what you
feel with­out becom­ing over­whelmed, enraged, ashamed, or col­lapsed. For
most peo­ple this involves (1) find­ing a way to become calm and focused,
(2) learn­ing to main­tain that calm in response to images, thoughts, sounds,
or phys­i­cal sen­sa­tions that remind you of the past, (3) find­ing a way to be
ful­ly alive in the present and engaged with the peo­ple around you, (4) not
hav­ing to keep secrets from your­self, includ­ing secrets about the ways that
you have man­aged to sur­vive.
These goals are not steps to be achieved, one by one, in some fixed
sequence. They over­lap, and some may be more dif­fi­cult than oth­ers,
depend­ing on indi­vid­ual cir­cum­stances. In each of the chap­ters that fol­low,
I’ll talk about spe­cif­ic meth­ods or approach­es to accom­plish them. I have
tried to make these chap­ters use­ful both to trau­ma sur­vivors and to the
ther­a­pists who are treat­ing them. Peo­ple under tem­po­rary stress may also
find them use­ful. I’ve used every one of these meth­ods exten­sive­ly to treat
my patients, and I have also expe­ri­enced them myself. Some peo­ple get
bet­ter using just one of these meth­ods, but most are helped by dif­fer­ent
approach­es at dif­fer­ent stages of their recov­ery.
I have done sci­en­tif­ic stud­ies of many of the treat­ments I describe here
and have pub­lished the research find­ings in peer-reviewed sci­en­tif­ic
journals.2 My aim in this chap­ter is to pro­vide an overview of under­ly­ing
prin­ci­ples, a pre­view of what’s to come, and some brief com­ments on
meth­ods I don’t cov­er in depth lat­er on.
A NEW FOCUS FOR RECOVERY
When we talk about trau­ma, we often start with a sto­ry or a ques­tion: “What
hap­pened dur­ing the war?” “Were you ever molest­ed?” “Let me tell you
about that acci­dent or that rape,” or “Was any­body in your fam­i­ly a prob­lem
drinker?” How­ev­er, trau­ma is much more than a sto­ry about some­thing that
hap­pened long ago. The emo­tions and phys­i­cal sen­sa­tions that were
imprint­ed dur­ing the trau­ma are expe­ri­enced not as mem­o­ries but as
dis­rup­tive phys­i­cal reac­tions in the present.
In order to regain con­trol over your self, you need to revis­it the trau­ma:
Soon­er or lat­er you need to con­front what has hap­pened to you, but only
after you feel safe and will not be retrau­ma­tized by it. The first order of
busi­ness is to find ways to cope with feel­ing over­whelmed by the sen­sa­tions
and emo­tions asso­ci­at­ed with the past.
As the pre­vi­ous parts of this book have shown, the engines of
post­trau­mat­ic reac­tions are locat­ed in the emo­tion­al brain. In con­trast with
the ratio­nal brain, which express­es itself in thoughts, the emo­tion­al brain
man­i­fests itself in phys­i­cal reac­tions: gut-wrench­ing sen­sa­tions, heart
pound­ing, breath­ing becom­ing fast and shal­low, feel­ings of heart­break,
speak­ing with an uptight and reedy voice, and the char­ac­ter­is­tic body
move­ments that sig­ni­fy col­lapse, rigid­i­ty, rage, or defen­sive­ness.
Why can’t we just be rea­son­able? And can under­stand­ing help? The
ratio­nal, exec­u­tive brain is good at help­ing us under­stand where feel­ings
come from (as in: “I get scared when I get close to a guy because my father
molest­ed me” or “I have trou­ble express­ing my love toward my son because
I feel guilty about hav­ing killed a child in Iraq”). How­ev­er, the ratio­nal
brain can­not abol­ish emo­tions, sen­sa­tions, or thoughts (such as liv­ing with a
low-lev­el sense of threat or feel­ing that you are fun­da­men­tal­ly a ter­ri­ble
per­son, even though you ratio­nal­ly know that you are not to blame for
hav­ing been raped). Under­stand­ing why you feel a cer­tain way does not
change how you feel. But it can keep you from sur­ren­der­ing to intense
reac­tions (for exam­ple, assault­ing a boss who reminds you of a per­pe­tra­tor,
break­ing up with a lover at your first dis­agree­ment, or jump­ing into the
arms of a stranger). How­ev­er, the more fraz­zled we are, the more our
ratio­nal brains take a back­seat to our emotions.3
LIMBIC SYSTEM THERAPY
The fun­da­men­tal issue in resolv­ing trau­mat­ic stress is to restore the prop­er
bal­ance between the ratio­nal and emo­tion­al brains, so that you can feel in
charge of how you respond and how you con­duct your life. When we’re
trig­gered into states of hyper- or hypoarousal, we are pushed out­side our
“win­dow of tolerance”—the range of opti­mal functioning.4 We become
reac­tive and dis­or­ga­nized; our fil­ters stop working—sounds and lights
both­er us, unwant­ed images from the past intrude on our minds, and we
pan­ic or fly into rages. If we’re shut down, we feel numb in body and mind;
our think­ing becomes slug­gish and we have trou­ble get­ting out of our
chairs.
As long as peo­ple are either hyper­aroused or shut down, they can­not
learn from expe­ri­ence. Even if they man­age to stay in con­trol, they become
so uptight (Alco­holics Anony­mous calls this “white-knuck­le sobri­ety”) that
they are inflex­i­ble, stub­born, and depressed. Recov­ery from trau­ma
involves the restora­tion of exec­u­tive func­tion­ing and, with it, self-
con­fi­dence and the capac­i­ty for play­ful­ness and cre­ativ­i­ty.
If we want to change post­trau­mat­ic reac­tions, we have to access the
emo­tion­al brain and do “lim­bic sys­tem ther­a­py”: repair­ing faulty alarm
sys­tems and restor­ing the emo­tion­al brain to its ordi­nary job of being a
qui­et back­ground pres­ence that takes care of the house­keep­ing of the body,
ensur­ing that you eat, sleep, con­nect with inti­mate part­ners, pro­tect your
chil­dren, and defend against dan­ger.
DRAWING BY LICIA SKY
Access­ing the emo­tion­al brain. The ratio­nal, ana­lyz­ing part of the brain, cen­tered on the
dor­so­lat­er­al pre­frontal cor­tex, has no direct con­nec­tions with the emo­tion­al brain, where most
imprints of trau­ma reside, but the medi­al pre­frontal cor­tex, the cen­ter of self-aware­ness, does.
The neu­ro­sci­en­tist Joseph LeDoux and his col­leagues have shown that
the only way we can con­scious­ly access the emo­tion­al brain is through self-
aware­ness, i.e. by acti­vat­ing the medi­al pre­frontal cor­tex, the part of the
brain that notices what is going on inside us and thus allows us to feel what
we’re feeling.5 (The tech­ni­cal term for this is “interoception”—Latin for
“look­ing inside.”) Most of our con­scious brain is ded­i­cat­ed to focus­ing on
the out­side world: get­ting along with oth­ers and mak­ing plans for the future.
How­ev­er, that does not help us man­age our­selves. Neu­ro­science research
shows that the only way we can change the way we feel is by becom­ing
aware of our inner expe­ri­ence and learn­ing to befriend what is going inside
our­selves.
BEFRIENDING THE EMOTIONAL BRAIN
1. DEALING WITH HYPERAROUSAL
Over the past few decades main­stream psy­chi­a­try has focused on using
drugs to change the way we feel, and this has become the accept­ed way to
deal with hyper- and hypoarousal. I will dis­cuss drugs lat­er in this chap­ter,
but first I need to stress the fact that we have a host of inbuilt skills to keep
us on an even keel. In chap­ter 5 we saw how emo­tions are reg­is­tered in the
body. Some 80 per­cent of the fibers of the vagus nerve (which con­nects the
brain with many inter­nal organs) are affer­ent; that is, they run from the
body into the brain.6 This means that we can direct­ly train our arousal
sys­tem by the way we breathe, chant, and move, a prin­ci­ple that has been
uti­lized since time immemo­r­i­al in places like Chi­na and India, and in every
reli­gious prac­tice that I know of, but that is sus­pi­cious­ly eyed as
“alter­na­tive” in main­stream cul­ture.
In research sup­port­ed by the Nation­al Insti­tutes of Health, my
col­leagues and I have shown that ten weeks of yoga prac­tice marked­ly
reduced the PTSD symp­toms of patients who had failed to respond to any
med­ica­tion or to any oth­er treatment.7 (I will dis­cuss yoga in chap­ter 16.)
Neu­ro­feed­back, the top­ic of chap­ter 19, also can be par­tic­u­lar­ly effec­tive
for chil­dren and adults who are so hyper­aroused or shut down that they
have trou­ble focus­ing and prioritizing.8
Learn­ing how to breathe calm­ly and remain­ing in a state of rel­a­tive
phys­i­cal relax­ation, even while access­ing painful and hor­ri­fy­ing mem­o­ries,
is an essen­tial tool for recovery.9 When you delib­er­ate­ly take a few slow,
deep breaths, you will notice the effects of the parasym­pa­thet­ic brake on
your arousal (as explained in chap­ter 5). The more you stay focused on your
breath­ing, the more you will ben­e­fit, par­tic­u­lar­ly if you pay atten­tion until
the very end of the out breath and then wait a moment before you inhale
again. As you con­tin­ue to breathe and notice the air mov­ing in and out of
your lungs you may think about the role that oxy­gen plays in nour­ish­ing
your body and bathing your tis­sues with the ener­gy you need to feel alive
and engaged. Chap­ter 16 doc­u­ments the full-body effects of this sim­ple
prac­tice.
Since emo­tion­al reg­u­la­tion is the crit­i­cal issue in man­ag­ing the effects
of trau­ma and neglect, it would make an enor­mous dif­fer­ence if teach­ers,
army sergeants, fos­ter par­ents, and men­tal health pro­fes­sion­als were
thor­ough­ly schooled in emo­tion­al-reg­u­la­tion tech­niques. Right now this still
is main­ly the domain of preschool and kinder­garten teach­ers, who deal with
imma­ture brains and impul­sive behav­ior on a dai­ly basis and who are often
very adept at man­ag­ing them.10
Main­stream West­ern psy­chi­atric and psy­cho­log­i­cal heal­ing tra­di­tions
have paid scant atten­tion to self-man­age­ment. In con­trast to the West­ern
reliance on drugs and ver­bal ther­a­pies, oth­er tra­di­tions from around the
world rely on mind­ful­ness, move­ment, rhythms, and action. Yoga in India,
tai chi and qigong in Chi­na, and rhyth­mi­cal drum­ming through­out Africa
are just a few exam­ples. The cul­tures of Japan and the Kore­an penin­su­la
have spawned mar­tial arts, which focus on the cul­ti­va­tion of pur­pose­ful
move­ment and being cen­tered in the present, abil­i­ties that are dam­aged in
trau­ma­tized indi­vid­u­als. Aiki­do, judo, tae kwon do, kendo, and jujit­su, as
well as capoeira from Brazil, are exam­ples. These tech­niques all involve
phys­i­cal move­ment, breath­ing, and med­i­ta­tion. Aside from yoga, few of
these pop­u­lar non-West­ern heal­ing tra­di­tions have been sys­tem­at­i­cal­ly
stud­ied for the treat­ment of PTSD.
2. NO MIND WITHOUT MINDFULNESS
At the core of recov­ery is self-aware­ness. The most impor­tant phras­es in
trau­ma ther­a­py are “Notice that” and “What hap­pens next?” Trau­ma­tized
peo­ple live with seem­ing­ly unbear­able sen­sa­tions: They feel heart­bro­ken
and suf­fer from intol­er­a­ble sen­sa­tions in the pit of their stom­ach or tight­ness
in their chest. Yet avoid­ing feel­ing these sen­sa­tions in our bod­ies increas­es
our vul­ner­a­bil­i­ty to being over­whelmed by them.
Body aware­ness puts us in touch with our inner world, the land­scape of
our organ­ism. Sim­ply notic­ing our annoy­ance, ner­vous­ness, or anx­i­ety
imme­di­ate­ly helps us shift our per­spec­tive and opens up new options oth­er
than our auto­mat­ic, habit­u­al reac­tions. Mind­ful­ness puts us in touch with
the tran­si­to­ry nature of our feel­ings and per­cep­tions. When we pay focused
atten­tion to our bod­i­ly sen­sa­tions, we can rec­og­nize the ebb and flow of our
emo­tions and, with that, increase our con­trol over them.
Trau­ma­tized peo­ple are often afraid of feel­ing. It is not so much the
per­pe­tra­tors (who, hope­ful­ly, are no longer around to hurt them) but their
own phys­i­cal sen­sa­tions that now are the ene­my. Appre­hen­sion about being
hijacked by uncom­fort­able sen­sa­tions keeps the body frozen and the mind
shut. Even though the trau­ma is a thing of the past, the emo­tion­al brain
keeps gen­er­at­ing sen­sa­tions that make the suf­fer­er feel scared and help­less.
It’s not sur­pris­ing that so many trau­ma sur­vivors are com­pul­sive eaters and
drinkers, fear mak­ing love, and avoid many social activ­i­ties: Their sen­so­ry
world is large­ly off lim­its.
In order to change you need to open your­self to your inner expe­ri­ence.
The first step is to allow your mind to focus on your sen­sa­tions and notice
how, in con­trast to the time­less, ever-present expe­ri­ence of trau­ma, phys­i­cal
sen­sa­tions are tran­sient and respond to slight shifts in body posi­tion,
changes in breath­ing, and shifts in think­ing. Once you pay atten­tion to your
phys­i­cal sen­sa­tions, the next step is to label them, as in “When I feel
anx­ious, I feel a crush­ing sen­sa­tion in my chest.” I may then say to a
patient: “Focus on that sen­sa­tion and see how it changes when you take a
deep breath out, or when you tap your chest just below your col­lar­bone, or
when you allow your­self to cry.” Prac­tic­ing mind­ful­ness calms down the
sym­pa­thet­ic ner­vous sys­tem, so that you are less like­ly to be thrown into
fight-or-flight.11 Learn­ing to observe and tol­er­ate your phys­i­cal reac­tions is
a pre­req­ui­site for safe­ly revis­it­ing the past. If you can­not tol­er­ate what you
are feel­ing right now, open­ing up the past will only com­pound the mis­ery
and retrau­ma­tize you further.12
We can tol­er­ate a great deal dis­com­fort as long as we stay con­scious of
the fact that the body’s com­mo­tions con­stant­ly shift. One moment your
chest tight­ens, but after you take a deep breath and exhale, that feel­ing
soft­ens and you may observe some­thing else, per­haps a ten­sion in your
shoul­der. Now you can start explor­ing what hap­pens when you take a
deep­er breath and notice how your rib cage expands.13 Once you feel
calmer and more curi­ous, you can go back to that sen­sa­tion in your
shoul­der. You should not be sur­prised if a mem­o­ry spon­ta­neous­ly aris­es in
which that shoul­der was some­how involved.
A fur­ther step is to observe the inter­play between your thoughts and
your phys­i­cal sen­sa­tions. How are par­tic­u­lar thoughts reg­is­tered in your
body? (Do thoughts like “My father loves me” or “my girl­friend dumped
me” pro­duce dif­fer­ent sen­sa­tions?) Becom­ing aware of how your body
orga­nizes par­tic­u­lar emo­tions or mem­o­ries opens up the pos­si­bil­i­ty of
releas­ing sen­sa­tions and impuls­es you once blocked in order to survive.14 In
chap­ter 20, on the ben­e­fits of the­ater, I’ll describe in more detail how this
works.
Jon Kabat-Zinn, one of the pio­neers in mind-body med­i­cine, found­ed
the Mind­ful­ness-Based Stress Reduc­tion (MBSR) pro­gram at the Uni­ver­si­ty
of Mass­a­chu­setts Med­ical Cen­ter in 1979, and his method has been
thor­ough­ly stud­ied for more than three decades. As he describes
mind­ful­ness, “One way to think of this process of trans­for­ma­tion is to think
of mind­ful­ness as a lens, tak­ing the scat­tered and reac­tive ener­gies of your
mind and focus­ing them into a coher­ent source of ener­gy for liv­ing, for
prob­lem solv­ing, for healing.”15
Mind­ful­ness has been shown to have a pos­i­tive effect on numer­ous
psy­chi­atric, psy­cho­so­mat­ic, and stress-relat­ed symp­toms, includ­ing
depres­sion and chron­ic pain.16 It has broad effects on phys­i­cal health,
includ­ing improve­ments in immune response, blood pres­sure, and cor­ti­sol
levels.17 It has also been shown to acti­vate the brain regions involved in
emo­tion­al regulation18 and to lead to changes in the regions relat­ed to body
aware­ness and fear.19 Research by my Har­vard col­leagues Brit­ta Hölzel and
Sara Lazar has shown that prac­tic­ing mind­ful­ness even decreas­es the
activ­i­ty of the brain’s smoke detec­tor, the amyg­dala, and thus decreas­es
reac­tiv­i­ty to poten­tial triggers.20
3. RELATIONSHIPS
Study after study shows that hav­ing a good sup­port net­work con­sti­tutes the
sin­gle most pow­er­ful pro­tec­tion against becom­ing trau­ma­tized. Safe­ty and
ter­ror are incom­pat­i­ble. When we are ter­ri­fied, noth­ing calms us down like
the reas­sur­ing voice or the firm embrace of some­one we trust. Fright­ened
adults respond to the same com­forts as ter­ri­fied chil­dren: gen­tle hold­ing and
rock­ing and the assur­ance that some­body big­ger and stronger is tak­ing care
of things, so you can safe­ly go to sleep. In order to recov­er, mind, body, and
brain need to be con­vinced that it is safe to let go. That hap­pens only when
you feel safe at a vis­cer­al lev­el and allow your­self to con­nect that sense of
safe­ty with mem­o­ries of past help­less­ness.
After an acute trau­ma, like an assault, acci­dent, or nat­ur­al dis­as­ter,
sur­vivors require the pres­ence of famil­iar peo­ple, faces, and voic­es;
phys­i­cal con­tact; food; shel­ter and a safe place; and time to sleep. It is
crit­i­cal to com­mu­ni­cate with loved ones close and far and to reunite as soon
as pos­si­ble with fam­i­ly and friends in a place that feels safe. Our attach­ment
bonds are our great­est pro­tec­tion against threat. For exam­ple, chil­dren who
are sep­a­rat­ed from their par­ents after a trau­mat­ic event are like­ly to suf­fer
seri­ous neg­a­tive long-term effects. Stud­ies con­duct­ed dur­ing World War II
in Eng­land showed that chil­dren who lived in Lon­don dur­ing the Blitz and
were sent away to the coun­try­side for pro­tec­tion against Ger­man bomb­ing
raids fared much worse than chil­dren who remained with their par­ents and
endured nights in bomb shel­ters and fright­en­ing images of destroyed
build­ings and dead people.21
Trau­ma­tized human beings recov­er in the con­text of rela­tion­ships: with
fam­i­lies, loved ones, AA meet­ings, vet­er­ans’ orga­ni­za­tions, reli­gious
com­mu­ni­ties, or pro­fes­sion­al ther­a­pists. The role of those rela­tion­ships is to
pro­vide phys­i­cal and emo­tion­al safe­ty, includ­ing safe­ty from feel­ing
shamed, admon­ished, or judged, and to bol­ster the courage to tol­er­ate, face,
and process the real­i­ty of what has hap­pened.
As we have seen, much the wiring of our brain cir­cuits is devot­ed to
being in tune with oth­ers. Recov­ery from trau­ma involves (re)connecting
with our fel­low human beings. This is why trau­ma that has occurred with­in
rela­tion­ships is gen­er­al­ly more dif­fi­cult to treat than trau­ma result­ing from
traf­fic acci­dents or nat­ur­al dis­as­ters. In our soci­ety the most com­mon
trau­mas in women and chil­dren occur at the hands of their par­ents or
inti­mate part­ners. Child abuse, molesta­tion, and domes­tic vio­lence all are
inflict­ed by peo­ple who are sup­posed to love you. That knocks out the most
impor­tant pro­tec­tion against being trau­ma­tized: being shel­tered by the
peo­ple you love.
If the peo­ple whom you nat­u­ral­ly turn to for care and pro­tec­tion ter­ri­fy
or reject you, you learn to shut down and to ignore what you feel.22 As we
saw in part 3, when your care­givers turn on you, you have to find
alter­na­tive ways to deal with feel­ing scared, angry, or frus­trat­ed. Man­ag­ing
your ter­ror all by your­self gives rise to anoth­er set of prob­lems:
dis­so­ci­a­tion, despair, addic­tions, a chron­ic sense of pan­ic, and rela­tion­ships
that are marked by alien­ation, dis­con­nec­tion, and explo­sions. Patients with
these his­to­ries rarely make the con­nec­tion between what hap­pened to them
long ago and how they cur­rent­ly feel and behave. Every­thing just seems
unman­age­able.
Relief does not come until they are able to acknowl­edge what has
hap­pened and rec­og­nize the invis­i­ble demons they’re strug­gling with.
Recall, for exam­ple, the men I described in chap­ter 11 who had been abused
by pedophile priests. They vis­it­ed the gym reg­u­lar­ly, took ana­bol­ic steroids,
and were strong as oxen. How­ev­er, in our inter­views they often act­ed like
scared kids; the hurt boys deep inside still felt help­less.
While human con­tact and attune­ment are the well­spring of
phys­i­o­log­i­cal self-reg­u­la­tion, the promise of close­ness often evokes fear of
get­ting hurt, betrayed, and aban­doned. Shame plays an impor­tant role in
this: “You will find out how rot­ten and dis­gust­ing I am and dump me as
soon as you real­ly get to know me.” Unre­solved trau­ma can take a ter­ri­ble
toll on rela­tion­ships. If your heart is still bro­ken because you were assault­ed
by some­one you loved, you are like­ly to be pre­oc­cu­pied with not get­ting
hurt again and fear open­ing up to some­one new. In fact, you may
unwit­ting­ly try to hurt them before they have a chance to hurt you.
This pos­es a real chal­lenge for recov­ery. Once you rec­og­nize that
post­trau­mat­ic reac­tions start­ed off as efforts to save your life, you may
gath­er the courage to face your inner music (or cacoph­o­ny), but you will
need help to do so. You have to find some­one you can trust enough to
accom­pa­ny you, some­one who can safe­ly hold your feel­ings and help you
lis­ten to the painful mes­sages from your emo­tion­al brain. You need a guide
who is not afraid of your ter­ror and who can con­tain your dark­est rage,
some­one who can safe­guard the whole­ness of you while you explore the
frag­ment­ed expe­ri­ences that you had to keep secret from your­self for so
long. Most trau­ma­tized indi­vid­u­als need an anchor and a great deal of
coach­ing to do this work.
Choos­ing a Pro­fes­sion­al Ther­a­pist
The train­ing of com­pe­tent trau­ma ther­a­pists involves learn­ing about the
impact of trau­ma, abuse, and neglect and mas­ter­ing a vari­ety of tech­niques
that can help to (1) sta­bi­lize and calm patients down, (2) help to lay
trau­mat­ic mem­o­ries and reen­act­ments to rest, and (3) recon­nect patients
with their fel­low men and women. Ide­al­ly the ther­a­pist will also have been
on the receiv­ing end of what­ev­er ther­a­py he or she prac­tices.
While it’s inap­pro­pri­ate and uneth­i­cal for ther­a­pists to tell you the
details of their per­son­al strug­gles, it is per­fect­ly rea­son­able to ask what
par­tic­u­lar forms of ther­a­py they have been trained in, where they learned
their skills, and whether they’ve per­son­al­ly ben­e­fit­ed from the ther­a­py they
pro­pose for you.
There is no one “treat­ment of choice” for trau­ma, and any ther­a­pist
who believes that his or her par­tic­u­lar method is the only answer to your
prob­lems is sus­pect of being an ide­o­logue rather than some­body who is
inter­est­ed in mak­ing sure that you get well. No ther­a­pist can pos­si­bly be
famil­iar with every effec­tive treat­ment, and he or she must be open to your
explor­ing options oth­er than the ones he or she offers. He or she also must
be open to learn­ing from you. Gen­der, race, and per­son­al back­ground are
rel­e­vant only if they inter­fere with help­ing the patient feel safe and
under­stood.
Do you feel basi­cal­ly com­fort­able with this ther­a­pist? Does he or she
seem to feel com­fort­able in his or her own skin and with you as a fel­low
human being? Feel­ing safe is a nec­es­sary con­di­tion for you to con­front your
fears and anx­i­eties. Some­one who is stern, judg­men­tal, agi­tat­ed, or harsh is
like­ly to leave you feel­ing scared, aban­doned, and humil­i­at­ed, and that
won’t help you resolve your trau­mat­ic stress. There may be times as old
feel­ings from the past are stirred up, when you become sus­pi­cious that the
ther­a­pist resem­bles some­one who once hurt or abused you. Hope­ful­ly, this
is some­thing you can work through togeth­er, because in my expe­ri­ence
patients get bet­ter only if they devel­op deep pos­i­tive feel­ings for their
ther­a­pists. I also don’t think that you can grow and change unless you feel
that you have some impact on the per­son who is treat­ing you.
The crit­i­cal ques­tion is this: Do you feel that your ther­a­pist is curi­ous to
find out who you are and what you, not some gener­ic “PTSD patient,”
need? Are you just a list of symp­toms on some diag­nos­tic ques­tion­naire, or
does your ther­a­pist take the time to find out why you do what you do and
think what you think? Ther­a­py is a col­lab­o­ra­tive process—a mutu­al
explo­ration of your self.
Patients who have been bru­tal­ized by their care­givers as chil­dren often
do not feel safe with any­one. I often ask my patients if they can think of any
per­son they felt safe with while they were grow­ing up. Many of them hold
tight to the mem­o­ry of that one teacher, neigh­bor, shop­keep­er, coach, or
min­is­ter who showed that he or she cared, and that mem­o­ry is often the
seed of learn­ing to reen­gage. We are a hope­ful species. Work­ing with
trau­ma is as much about remem­ber­ing how we sur­vived as it is about what
is bro­ken.
I also ask my patients to imag­ine what they were like as new­borns—
whether they were lov­able and filled with spunk. All of them believe they
were and have some image of what they must have been like before they
were hurt.
Some peo­ple don’t remem­ber any­body they felt safe with. For them,
engag­ing with hors­es or dogs may be much safer than deal­ing with human
beings. This prin­ci­ple is cur­rent­ly being applied in many ther­a­peu­tic
set­tings to great effect, includ­ing in jails, res­i­den­tial treat­ment pro­grams,
and vet­er­ans’ reha­bil­i­ta­tion. Jen­nifer, a mem­ber of the first grad­u­at­ing class
of the Van der Kolk Center,23 who had come to the pro­gram as an out-of-
con­trol, mute four­teen-year-old, said dur­ing her grad­u­a­tion cer­e­mo­ny that
hav­ing been entrust­ed with the respon­si­bil­i­ty of car­ing for a horse was the
crit­i­cal first step for her. Her grow­ing bond with her horse helped her feel
safe enough to begin to relate to the staff of the cen­ter and then to focus on
her class­es, take her SATs, and be accept­ed to college.24
4. COMMUNAL RHYTHMS AND SYNCHRONY
From the moment of our birth, our rela­tion­ships are embod­ied in respon­sive
faces, ges­tures, and touch. As we saw in chap­ter 7, these are the foun­da­tions
of attach­ment. Trau­ma results in a break­down of attuned phys­i­cal
syn­chrony: When you enter the wait­ing room of a PTSD clin­ic, you can
imme­di­ate­ly tell the patients from the staff by their frozen faces and
col­lapsed (but simul­ta­ne­ous­ly agi­tat­ed) bod­ies. Unfor­tu­nate­ly, many
ther­a­pists ignore those phys­i­cal com­mu­ni­ca­tions and focus only on the
words with which their patients com­mu­ni­cate.
The heal­ing pow­er of com­mu­ni­ty as expressed in music and rhythms
was brought home for me in the spring of 1997, when I was fol­low­ing the
work of the Truth and Rec­on­cil­i­a­tion Com­mis­sion in South Africa. In some
places we vis­it­ed, ter­ri­ble vio­lence con­tin­ued. One day I attend­ed a group
for rape sur­vivors in the court­yard of a clin­ic in a town­ship out­side
Johan­nes­burg. We could hear the sound of bul­lets being fired at a dis­tance
while smoke bil­lowed over the walls of the com­pound and the smell of
tear­gas hung in the air. Lat­er we heard that forty peo­ple had been killed.
Yet, while the sur­round­ings were for­eign and ter­ri­fy­ing, I rec­og­nized
this group all too well: The women sat slumped over—sad and frozen—like
so many rape ther­a­py groups I had seen in Boston. I felt a famil­iar sense of
help­less­ness, and, sur­round­ed by col­lapsed peo­ple, I felt myself men­tal­ly
col­lapse as well. Then one of the women start­ed to hum, while gen­tly
sway­ing back and forth. Slow­ly a rhythm emerged; bit by bit oth­er women
joined in. Soon the whole group was singing, mov­ing, and get­ting up to
dance. It was an astound­ing trans­for­ma­tion: peo­ple com­ing back to life,
faces becom­ing attuned, vital­i­ty return­ing to bod­ies. I made a vow to apply
what I was see­ing there and to study how rhythm, chant­i­ng, and move­ment
can help to heal trau­ma.
We will see more of this in chap­ter 20, on the­ater, where I show how
groups of young people—among them juve­nile offend­ers and at-risk fos­ter
kids—gradually learn to work togeth­er and to depend on one anoth­er,
whether as part­ners in Shake­speare­an sword­play or as the writ­ers and
per­form­ers of full-length musi­cals. Dif­fer­ent patients have told me how
much choral singing, aiki­do, tan­go danc­ing, and kick­box­ing have helped
them, and I am delight­ed to pass their rec­om­men­da­tions on to oth­er peo­ple I
treat.
I learned anoth­er pow­er­ful les­son about rhythm and heal­ing when
clin­i­cians at the Trau­ma Cen­ter were asked to treat a five-year-old mute
girl, Ying Mee, who had been adopt­ed from an orphan­age in Chi­na. After
months of failed attempts to make con­tact with her, my col­leagues Deb­o­rah
Rozelle and Liz Warn­er real­ized that her rhyth­mi­cal engage­ment sys­tem
didn’t work—she could not res­onate with the voic­es and faces of the peo­ple
around her. That led them to sen­so­ri­mo­tor therapy.25
The sen­so­ry inte­gra­tion clin­ic in Water­town, Mass­a­chu­setts, is a
won­drous indoor play­ground filled with swings, tubs full of mul­ti­col­ored
rub­ber balls so deep that you can make your­self dis­ap­pear, bal­ance beams,
crawl spaces fash­ioned from plas­tic tub­ing, and lad­ders that lead to
plat­forms from which you can dive onto foam-filled mats. The staff bathed
Ying Mee in the tub with plas­tic balls; that helped her feel sen­sa­tions on her
skin. They helped her sway on swings and crawl under weight­ed blan­kets.
After six weeks some­thing shifted—and she start­ed to talk.26
Ying Mee’s dra­mat­ic improve­ment inspired us to start a sen­so­ry
inte­gra­tion clin­ic at the Trau­ma Cen­ter, which we now also use in our
res­i­den­tial treat­ment pro­grams. We have not yet explored how well sen­so­ry
inte­gra­tion works for trau­ma­tized adults, but I reg­u­lar­ly incor­po­rate sen­so­ry
inte­gra­tion expe­ri­ences and dance in my sem­i­nars.
Learn­ing to become attuned pro­vides par­ents (and their kids) with the
vis­cer­al expe­ri­ence of reci­procity. Par­ent-child inter­ac­tion ther­a­py (PCIT) is
an inter­ac­tive ther­a­py that fos­ters this, as is SMART (sen­so­ry motor arousal
reg­u­la­tion treat­ment), devel­oped by my col­leagues at the Trau­ma Center.27
When we play togeth­er, we feel phys­i­cal­ly attuned and expe­ri­ence a
sense of con­nec­tion and joy. Impro­vi­sa­tion exer­cis­es (such as those found at
http://learnimprov.com/) also are a mar­velous way to help peo­ple con­nect in
joy and explo­ration. The moment you see a group of grim-faced peo­ple
break out in a gig­gle, you know that the spell of mis­ery has bro­ken.
5. GETTING IN TOUCH
Main­stream trau­ma treat­ment has paid scant atten­tion to help­ing ter­ri­fied
peo­ple to safe­ly expe­ri­ence their sen­sa­tions and emo­tions. Med­ica­tions such
as sero­tonin reup­take block­ers, Respiri­dol and Sero­quel increas­ing­ly have
tak­en the place of help­ing peo­ple to deal with their sen­so­ry world.28
How­ev­er, the most nat­ur­al way that we humans calm down our dis­tress is
by being touched, hugged, and rocked. This helps with exces­sive arousal
and makes us feel intact, safe, pro­tect­ed, and in charge.
Rem­brandt van Rijn: Christ Heal­ing the Sick. Ges­tures of com­fort are uni­ver­sal­ly
rec­og­niz­able and reflect the heal­ing pow­er of attuned touch.
Touch, the most ele­men­tary tool that we have to calm down, is
pro­scribed from most ther­a­peu­tic prac­tices. Yet you can’t ful­ly recov­er if
you don’t feel safe in your skin. There­fore, I encour­age all my patients to
engage in some sort of body­work, be it ther­a­peu­tic mas­sage, Feldenkrais, or
cran­iosacral ther­a­py.
I asked my favorite body­work prac­ti­tion­er, Licia Sky, about her
prac­tice with trau­ma­tized indi­vid­u­als. Here is some of what she told me: “I
nev­er begin a body­work ses­sion with­out estab­lish­ing a per­son­al con­nec­tion.
I’m not tak­ing a his­to­ry; I’m not find­ing out how trau­ma­tized a per­son is or
what hap­pened to them. I check in where they are in their body right now. I
ask them if there is any­thing they want me to pay atten­tion to. All the while,
I’m assess­ing their pos­ture; whether they look me in the eye; how tense or
relaxed they seem; are they con­nect­ing with me or not.
“The first deci­sion I make is if they will feel safer face up or face
down. If I don’t know them, I usu­al­ly start face up. I am very care­ful about
drap­ing; very care­ful to let them feel safe with what­ev­er cloth­ing they want
to leave on. These are impor­tant bound­aries to set up right at the begin­ning.
“Then, with my first touch, I make firm, safe con­tact. Noth­ing forced or
sharp. Noth­ing too fast. The touch is slow, easy for the client to fol­low,
gen­tly rhyth­mic. It can be as strong as a hand­shake. The first place I might
touch is their hand and fore­arm, because that’s the safest place to touch
any­body, the place where they can touch you back.
“You have to meet their point of resistance—the place that has the most
tension—and meet it with an equal amount of ener­gy. That releas­es the
frozen ten­sion. You can’t hes­i­tate; hes­i­ta­tion com­mu­ni­cates a lack of trust
in your­self. Slow move­ment, care­ful attun­ing to the client is dif­fer­ent from
hes­i­ta­tion. You have to meet them with tremen­dous con­fi­dence and
empa­thy, let the pres­sure of your touch meet the ten­sion they are hold­ing in
their bod­ies.”
What does body­work do for peo­ple? Licia’s reply: “Just like you can
thirst for water, you can thirst for touch. It is a com­fort to be met
con­fi­dent­ly, deeply, firm­ly, gen­tly, respon­sive­ly. Mind­ful touch and
move­ment grounds peo­ple and allows them to dis­cov­er ten­sions that they
may have held for so long that they are no longer even aware of them.
When you are touched, you wake up to the part of your body that is being
touched.
“The body is phys­i­cal­ly restrict­ed when emo­tions are bound up inside.
People’s shoul­ders tight­en; their facial mus­cles tense. They spend enor­mous
ener­gy on hold­ing back their tears—or any sound or move­ment that might
betray their inner state. When the phys­i­cal ten­sion is released, the feel­ings
can be released. Move­ment helps breath­ing to become deep­er, and as the
ten­sions are released, expres­sive sounds can be dis­charged. The body
becomes freer—breathing freer, being in flow. Touch makes it pos­si­ble to
live in a body that can move in response to being moved.
“Peo­ple who are ter­ri­fied need to get a sense of where their bod­ies are
in space and of their bound­aries. Firm and reas­sur­ing touch lets them know
where those bound­aries are: what’s out­side them, where their bod­ies end.
They dis­cov­er that they don’t con­stant­ly have to won­der who and where
they are. They dis­cov­er that their body is sol­id and that they don’t have to
be con­stant­ly on guard. Touch lets them know that they are safe.”
6. TAKING ACTION
The body responds to extreme expe­ri­ences by secret­ing stress hor­mones.
These are often blamed for sub­se­quent ill­ness and dis­ease. How­ev­er, stress
hor­mones are meant to give us the strength and endurance to respond to
extra­or­di­nary con­di­tions. Peo­ple who active­ly do some­thing to deal with a
disaster—rescuing loved ones or strangers, trans­port­ing peo­ple to a
hos­pi­tal, being part of a med­ical team, pitch­ing tents or cook­ing meals—
uti­lize their stress hor­mones for their prop­er pur­pose and there­fore are at
much low­er risk of becom­ing trau­ma­tized. (Nonethe­less, every­one has his
or her break­ing point, and even the best-pre­pared per­son may become
over­whelmed by the mag­ni­tude of the chal­lenge.)
Help­less­ness and immo­bi­liza­tion keep peo­ple from uti­liz­ing their stress
hor­mones to defend them­selves. When that hap­pens, their hor­mones still
are being pumped out, but the actions they’re sup­posed to fuel are thwart­ed.
Even­tu­al­ly, the acti­va­tion pat­terns that were meant to pro­mote cop­ing are
turned back against the organ­ism and now keep fuel­ing inap­pro­pri­ate
fight/flight and freeze respons­es. In order to return to prop­er func­tion­ing,
this per­sis­tent emer­gency response must come to an end. The body needs to
be restored to a base­line state of safe­ty and relax­ation from which it can
mobi­lize to take action in response to real dan­ger.
My friends and teach­ers Pat Ogden and Peter Levine have each
devel­oped pow­er­ful body-based ther­a­pies, sen­so­ri­mo­tor psychotherapy29
and somat­ic experiencing30 to deal with this issue. In these treat­ment
approach­es the sto­ry of what has hap­pened takes a back­seat to explor­ing
phys­i­cal sen­sa­tions and dis­cov­er­ing the loca­tion and shape of the imprints
of past trau­ma on the body. Before plung­ing into a full-fledged explo­ration
of the trau­ma itself, patients are helped to build up inter­nal resources that
fos­ter safe access sen­sa­tions and emo­tions that over­whelmed them at the
time of the trau­ma. Peter Levine calls this process pendulation—gently
mov­ing in and out of access­ing inter­nal sen­sa­tions and trau­mat­ic mem­o­ries.
In this way patients are helped to grad­u­al­ly expand their win­dow of
tol­er­ance.
Once patients can tol­er­ate being aware of their trau­ma-based phys­i­cal
expe­ri­ences, they are like­ly to dis­cov­er pow­er­ful phys­i­cal impulses—like
hit­ting, push­ing, or running—that arose dur­ing the trau­ma but were
sup­pressed in order to sur­vive. These impuls­es man­i­fest them­selves in
sub­tle body move­ments such as twist­ing, turn­ing, or back­ing away.
Ampli­fy­ing these move­ments and exper­i­ment­ing with ways to mod­i­fy them
begins the process of bring­ing the incom­plete, trau­ma-relat­ed “action
ten­den­cies” to com­ple­tion and can even­tu­al­ly lead to res­o­lu­tion of the
trau­ma. Somat­ic ther­a­pies can help patients to relo­cate them­selves in the
present by expe­ri­enc­ing that it is safe to move. Feel­ing the plea­sure of
tak­ing effec­tive action restores a sense of agency and a sense of being able
to active­ly defend and pro­tect them­selves.
Back in 1893 Pierre Janet, the first great explor­er of trau­ma, wrote
about “the plea­sure of com­plet­ed action,” and I reg­u­lar­ly observe that
plea­sure when I prac­tice sen­so­ri­mo­tor psy­chother­a­py and somat­ic
expe­ri­enc­ing: When patients can phys­i­cal­ly expe­ri­ence what it would have
felt like to fight back or run away, they relax, smile, and express a sense of
com­ple­tion.
When peo­ple are forced to sub­mit to over­whelm­ing pow­er, as is true
for most abused chil­dren, women trapped in domes­tic vio­lence, and
incar­cer­at­ed men and women, they often sur­vive with resigned com­pli­ance.
The best way to over­come ingrained pat­terns of sub­mis­sion is to restore a
phys­i­cal capac­i­ty to engage and defend. One of my favorite body-ori­ent­ed
ways to build effec­tive fight/flight respons­es is our local impact center’s
mod­el mug­ging pro­gram, in which women (and increas­ing­ly men) are
taught to active­ly fight off a sim­u­lat­ed attack.31 The pro­gram start­ed in
Oak­land, Cal­i­for­nia, in 1971 after a woman with a fifth-degree black belt in
karate was raped. Won­der­ing how this could have hap­pened to some­one
who sup­pos­ed­ly could kill with her bare hands, her friends con­clud­ed that
she had become de-skilled by fear. In the terms of this book, her exec­u­tive
functions—her frontal lobes—went off-line, and she froze. The mod­el
mug­ging pro­gram teach­es women to recon­di­tion the freeze response
through many rep­e­ti­tions of being placed in the “zero hour” (a mil­i­tary term
for the pre­cise moment of an attack) and learn­ing to trans­form fear into
pos­i­tive fight­ing ener­gy.
One of my patients, a col­lege stu­dent with a his­to­ry of unre­lent­ing child
abuse, took the course. When I first met her, she was col­lapsed, depressed,
and over­ly com­pli­ant. Three months lat­er, dur­ing her grad­u­a­tion cer­e­mo­ny,
she suc­cess­ful­ly fought off a gigan­tic male attack­er who end­ed up lying
cring­ing on the floor (shield­ed from her blows by a thick pro­tec­tive suit)
while she faced him, arms raised in a karate stance, calm­ly and clear­ly
yelling no.
Not long after­ward, she was walk­ing home from the library after
mid­night when three men jumped out of some bush­es, yelling: “Bitch, give
us your mon­ey.” She lat­er told me that she took that same karate stance and
yelled back: “Okay, guys, I’ve been look­ing for­ward to this moment. Who
wants to take me on first?” They ran away. If you’re hunched over and too
afraid to look around, you are easy prey to oth­er people’s sadism, but when
you walk around pro­ject­ing the mes­sage “Don’t mess with me,” you’re not
like­ly to be both­ered.
INTEGRATING TRAUMATIC MEMORIES
Peo­ple can­not put trau­mat­ic events behind until they are able to
acknowl­edge what has hap­pened and start to rec­og­nize the invis­i­ble demons
they’re strug­gling with. Tra­di­tion­al psy­chother­a­py has focused main­ly on
con­struct­ing a nar­ra­tive that explains why a per­son feels a par­tic­u­lar way or,
as Sig­mund Freud put it back in 1914 in Remem­ber­ing, Repeat­ing and
Work­ing Through:32 “While the patient lives [the trau­ma] through as
some­thing real and actu­al, we have to accom­plish the ther­a­peu­tic task,
which con­sists chiefly of trans­lat­ing it back again in terms of the past.”
Telling the sto­ry is impor­tant; with­out sto­ries, mem­o­ry becomes frozen; and
with­out mem­o­ry you can­not imag­ine how things can be dif­fer­ent. But as we
saw in part 4, telling a sto­ry about the event does not guar­an­tee that the
trau­mat­ic mem­o­ries will be laid to rest.
There is a rea­son for that. When peo­ple remem­ber an ordi­nary event,
they do not also relive the phys­i­cal sen­sa­tions, emo­tions, images, smells, or
sounds asso­ci­at­ed with that event. In con­trast, when peo­ple ful­ly recall their
trau­mas, they “have” the expe­ri­ence: They are engulfed by the sen­so­ry or
emo­tion­al ele­ments of the past. The brain scans of Stan and Ute Lawrence,
the acci­dent vic­tims in chap­ter 4, show how this hap­pens. When Stan was
remem­ber­ing his hor­ren­dous acci­dent, two key areas in his brain went
blank: the area that pro­vides a sense of time and per­spec­tive, which makes
it pos­si­ble to know that “that was then, but I am safe now,” and anoth­er area
that inte­grates the images, sounds, and sen­sa­tions of trau­ma into a coher­ent
sto­ry. When those parts of the brain are knocked out, you expe­ri­ence
some­thing not as an event with a begin­ning, a mid­dle, and an end but in
frag­ments of sen­sa­tions, images, and emo­tions.
A trau­ma can be suc­cess­ful­ly processed only if all those brain
struc­tures are kept online. In Stan’s case, eye move­ment desen­si­ti­za­tion and
repro­cess­ing (EMDR) allowed him to access his mem­o­ries of the acci­dent
with­out being over­whelmed by them. When the brain areas whose absence
is respon­si­ble for flash­backs can be kept online while remem­ber­ing what
has hap­pened, peo­ple can inte­grate their trau­mat­ic mem­o­ries as belong­ing
to the past.
Ute’s dis­so­ci­a­tion (as you recall, she shut down com­plete­ly)
com­pli­cat­ed recov­ery in a dif­fer­ent way. None of the brain struc­tures
nec­es­sary to engage in the present were online, so that deal­ing with the
trau­ma was sim­ply impos­si­ble. With­out a brain that is alert and present
there can be no inte­gra­tion and res­o­lu­tion. She need­ed to be helped to
increase her win­dow of tol­er­ance before she could deal with her PTSD
symp­toms.
Hyp­no­sis was the most wide­ly prac­ticed treat­ment for trau­ma from the
late 1800s, the time of Pierre Janet and Sig­mund Freud, until after World
War II. On YouTube you can still watch the doc­u­men­tary Let There Be
Light, by the great Hol­ly­wood direc­tor John Hus­ton, which shows men
under­go­ing hyp­no­sis to treat “war neu­ro­sis.” Hyp­no­sis fell out of favor in
the ear­ly 1990s and there have been no recent stud­ies of its effec­tive­ness for
treat­ing PTSD. How­ev­er, hyp­no­sis can induce a state of rel­a­tive calm from
which patients can observe their trau­mat­ic expe­ri­ences with­out being
over­whelmed by them. Since that capac­i­ty to qui­et­ly observe one­self is a
crit­i­cal fac­tor in the inte­gra­tion of trau­mat­ic mem­o­ries, it is like­ly that
hyp­no­sis, in some form, will make a come­back.
COGNITIVE BEHAVIORAL THERAPY (CBT)
Dur­ing their train­ing most psy­chol­o­gists are taught cog­ni­tive behav­ioral
ther­a­py. CBT was first devel­oped to treat pho­bias such as fear of spi­ders,
air­planes, or heights, to help patients com­pare their irra­tional fears with
harm­less real­i­ties. Patients are grad­u­al­ly desen­si­tized from their irra­tional
fears by bring­ing to mind what they are most afraid of, using their
nar­ra­tives and images (“imag­i­nal expo­sure”), or they are placed in actu­al
(but actu­al­ly safe) anx­i­ety-pro­vok­ing sit­u­a­tions (“in vivo expo­sure”), or
they are exposed to vir­tu­al-real­i­ty, com­put­er-sim­u­lat­ed scenes, for exam­ple,
in the case of com­bat-relat­ed PTSD, fight­ing in the streets of Fal­lu­jah.
The idea behind cog­ni­tive behav­ioral treat­ment is that when patients
are repeat­ed­ly exposed to the stim­u­lus with­out bad things actu­al­ly
hap­pen­ing, they grad­u­al­ly will become less upset; the bad mem­o­ries will
have become asso­ci­at­ed with “cor­rec­tive” infor­ma­tion of being safe.33 CBT
also tries to help patients deal with their ten­den­cy to avoid, as in “I don’t
want to talk about it.”34 It sounds sim­ple, but, as we have seen, reliv­ing
trau­ma reac­ti­vates the brain’s alarm sys­tem and knocks out crit­i­cal brain
areas nec­es­sary for inte­grat­ing the past, mak­ing it like­ly that patients will
relive rather than resolve the trau­ma.
Pro­longed expo­sure or “flood­ing” has been stud­ied more thor­ough­ly
than any oth­er PTSD treat­ment. Patients are asked to “focus their atten­tion
on the trau­mat­ic mate­r­i­al and … not dis­tract them­selves with oth­er
thoughts or activities.”35 Research has shown that up to one hun­dred
min­utes of flood­ing (in which anx­i­ety-pro­vok­ing trig­gers are pre­sent­ed in
an intense, sus­tained form) are required before decreas­es in anx­i­ety are
reported.36 Expo­sure some­times helps to deal with fear and anx­i­ety, but it
has not been proven to help with guilt or oth­er com­plex emotions.37
In con­trast to its effec­tive­ness for irra­tional fears such as spi­ders, CBT
has not done so well for trau­ma­tized indi­vid­u­als, par­tic­u­lar­ly those with
his­to­ries of child­hood abuse. Only about one in three par­tic­i­pants with
PTSD who fin­ish research stud­ies show some improvement.38 Those who
com­plete CBT treat­ment usu­al­ly have few­er PTSD symp­toms, but they
rarely recov­er com­plete­ly: Most con­tin­ue to have sub­stan­tial prob­lems with
their health, work, or men­tal well-being.39
In the largest pub­lished study of CBT for PTSD more than one-third of
the patients dropped out; the rest had a sig­nif­i­cant num­ber of adverse
reac­tions. Most of the women in the study still suf­fered from full-blown
PTSD after three months in the study, and only 15 per­cent no longer had
major PTSD symptoms.40 A thor­ough analy­sis of all the sci­en­tif­ic stud­ies of
CBT show that it works about as well as being in a sup­port­ive ther­a­py
relationship.41 The poor­est out­come in expo­sure treat­ments occurs in
patients who suf­fer from “men­tal defeat”—those who have giv­en up.42
Being trau­ma­tized is not just an issue of being stuck in the past; it is
just as much a prob­lem of not being ful­ly alive in the present. One form of
expo­sure treat­ment is vir­tu­al-real­i­ty ther­a­py in which vet­er­ans wear high-
tech gog­gles that make it pos­si­ble to refight the bat­tle of Fal­lu­jah in life­like
detail. As far as I know, the US Marines per­formed very well in com­bat.
The prob­lem is that they can­not tol­er­ate being home. Recent stud­ies of
Aus­tralian com­bat vet­er­ans show that their brains are rewired to be alert for
emer­gen­cies, at the expense of being focused on the small details of
every­day life.43 (We’ll learn more about this in chap­ter 19, on
neu­ro­feed­back.) More than vir­tu­al-real­i­ty ther­a­py, trau­ma­tized patients need
“real world” ther­a­py, which helps them to feel as alive when walk­ing
through the local super­mar­ket or play­ing with their kids as they did in the
streets of Bagh­dad.
Patients can ben­e­fit from reliv­ing their trau­ma only if they are not
over­whelmed by it. A good exam­ple is a study of Viet­nam vet­er­ans
con­duct­ed in the ear­ly 1990s by my col­league Roger Pitman.44 I vis­it­ed
Roger’s lab every week dur­ing that time, since we were con­duct­ing the
study of brain opi­oids in PTSD that I dis­cussed in chap­ter 2. Roger would
show me the video­tapes of his treat­ment ses­sions and we would dis­cuss
what we observed. He and his col­leagues pushed the vet­er­ans to talk
repeat­ed­ly about every detail of their expe­ri­ences in Viet­nam, but the
inves­ti­ga­tors had to stop the study because many patients became pan­icked
by their flash­backs, and the dread often per­sist­ed after the ses­sions. Some
nev­er returned, while many of those who stayed with the study became
more depressed, vio­lent, and fear­ful; some coped with their increased
symp­toms by increas­ing their alco­hol con­sump­tion, which led to fur­ther
vio­lence and humil­i­a­tion, as some of their fam­i­lies called the police to take
them to a hos­pi­tal.
DESENSITIZATION
Over the past two decades the pre­vail­ing treat­ment taught to psy­chol­o­gy
stu­dents has been some form of sys­tem­at­ic desen­si­ti­za­tion: help­ing patients
become less reac­tive to cer­tain emo­tions and sen­sa­tions. But is this the
cor­rect goal? Maybe the issue is not desen­si­ti­za­tion but inte­gra­tion: putting
the trau­mat­ic event into its prop­er place in the over­all arc of one’s life.
Desen­si­ti­za­tion makes me think of the small boy—he must have been
about five—I saw in front of my house recent­ly. His hulk­ing father was
yelling at him at the top of his voice as the boy rode his tri­cy­cle down my
street. The kid was unfazed, while my heart was rac­ing and I felt an impulse
to deck the guy. How much bru­tal­i­ty had it tak­en to numb a child this young
to his father’s bru­tal­i­ty? His indif­fer­ence to his father’s yelling must have
been the result of pro­longed expo­sure, but, I won­dered, at what price? Yes,
we can take drugs that blunt our emo­tions or we can learn to desen­si­tize
our­selves. As med­ical stu­dents we learned to stay ana­lyt­i­cal when we had to
treat chil­dren with third-degree burns. But, as the neu­ro­sci­en­tist Jean
Dece­ty at the Uni­ver­si­ty of Chica­go has shown, desen­si­ti­za­tion to our own
or to oth­er people’s pain tends to lead to an over­all blunt­ing of emo­tion­al
sensitivity.45
A 2010 report on 49,425 vet­er­ans with new­ly diag­nosed PTSD from
the Iraq and Afghanistan wars who sought care from the VA showed that
few­er than one out of ten actu­al­ly com­plet­ed the rec­om­mend­ed treatment.46
As in Pitman’s Viet­nam vet­er­ans, expo­sure treat­ment, as cur­rent­ly
prac­ticed, rarely works for them. We can only “process” hor­ren­dous
expe­ri­ences if they do not over­whelm us. And that means that oth­er
approach­es are nec­es­sary.
DRUGS TO SAFELY ACCESS TRAUMA?
When I was a med­ical stu­dent, I spent the sum­mer of 1966 work­ing for Jan
Bas­ti­aans, a pro­fes­sor at Lei­den Uni­ver­si­ty in the Nether­lands who was
known for his work treat­ing Holo­caust sur­vivors with LSD. He claimed to
have achieved spec­tac­u­lar results, but when col­leagues inspect­ed his
archives, they found few data to sup­port his claims. The poten­tial of mind-
alter­ing sub­stances for trau­ma treat­ment was sub­se­quent­ly neglect­ed until
2000, when Michael Mithoe­fer and his col­leagues in South Car­oli­na
received FDA per­mis­sion to con­duct an exper­i­ment with MDMA (ecsta­sy).
MDMA was clas­si­fied as a con­trolled sub­stance in 1985 after hav­ing been
used for years as a recre­ation­al drug. As with Prozac and oth­er psy­chotrop­ic
agents, we don’t know exact­ly how MDMA works, but it is known to
increase con­cen­tra­tions of a num­ber of impor­tant hor­mones includ­ing
oxy­tocin, vaso­pressin, cor­ti­sol, and prolactin.47 Most rel­e­vant for trau­ma
treat­ment, it increas­es people’s aware­ness of them­selves; they fre­quent­ly
report a height­ened sense of com­pas­sion­ate ener­gy, accom­pa­nied by
curios­i­ty, clar­i­ty, con­fi­dence, cre­ativ­i­ty, and con­nect­ed­ness. Mithoe­fer and
his col­leagues were look­ing for a med­ica­tion that would enhance the
effec­tive­ness of psy­chother­a­py, and they became inter­est­ed in MDMA
because it decreas­es fear, defen­sive­ness, and numb­ing, as well as help­ing to
access inner experience.48 They thought MDMA might enable patients to
stay with­in the win­dow of tol­er­ance so they could revis­it their trau­mat­ic
mem­o­ries with­out suf­fer­ing over­whelm­ing phys­i­o­log­i­cal and emo­tion­al
arousal.
The ini­tial pilot stud­ies have sup­port­ed that expectation.49 The first
study, involv­ing com­bat vet­er­ans, fire­fight­ers, and police offi­cers with
PTSD, had pos­i­tive results. In the next study, of a group of twen­ty vic­tims
of assault who had been unre­spon­sive to pre­vi­ous forms of ther­a­py, twelve
sub­jects received MDMA and eight received an inac­tive place­bo. Sit­ting or
lying in a com­fort­able room, they then all received two eight-hour
psy­chother­a­py ses­sions, main­ly using inter­nal fam­i­ly sys­tems (IFS) ther­a­py,
the sub­ject of chap­ter 17 of this book. Two months lat­er 83 per­cent of the
patients who received MDMA plus psy­chother­a­py were con­sid­ered
com­plete­ly cured, com­pared with 25 per­cent of the place­bo group. None of
the patients had adverse side effects. Per­haps most inter­est­ing, when the
par­tic­i­pants were inter­viewed more than a year after the study was
com­plet­ed, they had main­tained their gains.
By being able to observe the trau­ma from the calm, mind­ful state that
IFS calls Self (a term I’ll dis­cuss fur­ther in chap­ter 17), mind and brain are
in a posi­tion to inte­grate the trau­ma into the over­all fab­ric of life. This is
very dif­fer­ent from tra­di­tion­al desen­si­ti­za­tion tech­niques, which are about
blunt­ing a person’s response to past hor­rors. This is about asso­ci­a­tion and
integration—making a hor­ren­dous event that over­whelmed you in the past
into a mem­o­ry of some­thing that hap­pened a long time ago.
Nonethe­less, psy­che­del­ic sub­stances are pow­er­ful agents with a
trou­bled his­to­ry. They can eas­i­ly be mis­used through care­less
admin­is­tra­tion and poor main­te­nance of ther­a­peu­tic bound­aries. It is to be
hoped that MDMA will not be anoth­er mag­ic cure released from Pandora’s
box.
WHAT ABOUT MEDICATIONS?
Peo­ple have always used drugs to deal with trau­mat­ic stress. Each cul­ture
and each gen­er­a­tion has its preferences—gin, vod­ka, beer, or whiskey;
hashish, mar­i­jua­na, cannabis, or gan­ja; cocaine; opi­oids like oxy­con­tin;
tran­quil­iz­ers such as Val­i­um, Xanax, and Klonopin. When peo­ple are
des­per­ate, they will do just about any­thing to feel calmer and more in
control.50
Main­stream psy­chi­a­try fol­lows this tra­di­tion. Over the past decade the
Depart­ments of Defense and Vet­er­ans Affairs com­bined have spent over
$4.5 bil­lion on anti­de­pres­sants, antipsy­chotics, and antianx­i­ety drugs. A
June 2010 inter­nal report from the Defense Department’s
Phar­ma­coeco­nom­ic Cen­ter at Fort Sam Hous­ton in San Anto­nio showed
that 213,972, or 20 per­cent of the 1.1 mil­lion active-duty troops sur­veyed,
were tak­ing some form of psy­chotrop­ic drug: anti­de­pres­sants,
antipsy­chotics, seda­tive hyp­notics, or oth­er con­trolled substances.51
How­ev­er, drugs can­not “cure” trau­ma; they can only damp­en the
expres­sions of a dis­turbed phys­i­ol­o­gy. And they do not teach the last­ing
lessons of self-reg­u­la­tion. They can help to con­trol feel­ings and behav­ior,
but always at a price—because they work by block­ing the chem­i­cal sys­tems
that reg­u­late engage­ment, moti­va­tion, pain, and plea­sure. Some of my
col­leagues remain opti­mistic: I keep attend­ing meet­ings where seri­ous
sci­en­tists dis­cuss their quest for the elu­sive mag­ic bul­let that will
mirac­u­lous­ly reset the fear cir­cuits of the brain (as if trau­mat­ic stress
involved only one sim­ple brain cir­cuit). I also reg­u­lar­ly pre­scribe
med­ica­tions.
Just about every group of psy­chotrop­ic agents has been used to treat
some aspect of PTSD.52 The sero­tonin reup­take inhibitors (SSRIs) such as
Prozac, Zoloft, Effex­or, and Pax­il have been most thor­ough­ly stud­ied, and
they can make feel­ings less intense and life more man­age­able. Patients on
SSRIs often feel calmer and more in con­trol; feel­ing less over­whelmed
often makes it eas­i­er to engage in ther­a­py. Oth­er patients feel blunt­ed by
SSRIs—they feel they’re “los­ing their edge.” I approach it as an empir­i­cal
ques­tion: Let’s see what works, and only the patient can be the judge of
that. On the oth­er hand, if one SSRI does not work, it’s worth try­ing
anoth­er, because they all have slight­ly dif­fer­ent effects. It’s inter­est­ing that
the SSRIs are wide­ly used to treat depres­sion, but in a study in which we
com­pared Prozac with eye move­ment desen­si­ti­za­tion and repro­cess­ing
(EMDR) for patients with PTSD, many of whom were also depressed,
EMDR proved to be a more effec­tive anti­de­pres­sant than Prozac.53 I’ll
return to that sub­ject in chap­ter 15.54
Med­i­cines that tar­get the auto­nom­ic ner­vous sys­tem, like pro­pra­nolol
or cloni­dine, can help to decrease hyper­arousal and reac­tiv­i­ty to stress.55
This fam­i­ly of drugs works by block­ing the phys­i­cal effects of adren­a­line,
the fuel of arousal, and thus reduces night­mares, insom­nia, and reac­tiv­i­ty to
trau­ma triggers.56 Block­ing adren­a­line can help to keep the ratio­nal brain
online and make choic­es pos­si­ble: “Is this real­ly what I want to do?” Since I
have start­ed to inte­grate mind­ful­ness and yoga into my prac­tice, I use these
med­ica­tions less often, except occa­sion­al­ly to help patients sleep more
rest­ful­ly.
Trau­ma­tized patients tend to like tran­quil­iz­ing drugs, ben­zo­di­azepines
like Klonopin, Val­i­um, Xanax, and Ati­van. In many ways, they work like
alco­hol, in that they make peo­ple feel calm and keep them from wor­ry­ing.
(Casi­no own­ers love cus­tomers on ben­zo­di­azepines; they don’t get upset
when they lose and keep gam­bling.) But also, like alco­hol, ben­zos weak­en
inhi­bi­tions against say­ing hurt­ful things to peo­ple we love. Most civil­ian
doc­tors are reluc­tant to pre­scribe these drugs, because they have a high
addic­tion poten­tial and they may also inter­fere with trau­ma pro­cess­ing.
Patients who stop tak­ing them after pro­longed use usu­al­ly have with­draw­al
reac­tions that make them agi­tat­ed and increase post­trau­mat­ic symp­toms.
I some­times give my patients low dos­es of ben­zo­di­azepines to use as
need­ed, but not enough to take on a dai­ly basis. They have to choose when
to use up their pre­cious sup­ply, and I ask them to keep a diary of what was
going on when they decid­ed to take the pill. That gives us a chance to
dis­cuss the spe­cif­ic inci­dents that trig­gered them.
A few stud­ies have shown that anti­con­vul­sants and mood sta­bi­liz­ers,
such as lithi­um or val­proate, can have mild­ly pos­i­tive effects, tak­ing the
edge off hyper­arousal and panic.57 The most con­tro­ver­sial med­ica­tions are
the so-called sec­ond-gen­er­a­tion antipsy­chot­ic agents, such as Risperdal and
Sero­quel, the largest-sell­ing psy­chi­atric drugs in the Unit­ed States ($14.6
bil­lion in 2008). Low dos­es of these agents can be help­ful in calm­ing down
com­bat vet­er­ans and women with PTSD relat­ed to child­hood abuse.58
Using these drugs is some­times jus­ti­fied, for exam­ple when patients feel
com­plete­ly out of con­trol and unable to sleep or where oth­er meth­ods have
failed.59 But it’s impor­tant to keep in mind that these med­ica­tions work by
block­ing the dopamine sys­tem, the brain’s reward sys­tem, which also
func­tions as the engine of plea­sure and moti­va­tion.
Antipsy­chot­ic med­ica­tions such as Risperdal, Abil­i­fy, or Sero­quel can
sig­nif­i­cant­ly damp­en the emo­tion­al brain and thus make patients less
skit­tish or enraged, but they also may inter­fere with being able to appre­ci­ate
sub­tle sig­nals of plea­sure, dan­ger, or sat­is­fac­tion. They also cause weight
gain, increase the chance of devel­op­ing dia­betes, and make patients
phys­i­cal­ly inert, which is like­ly to fur­ther increase their sense of alien­ation.
These drugs are wide­ly used to treat abused chil­dren who are
inap­pro­pri­ate­ly diag­nosed with bipo­lar dis­or­der or mood dys­reg­u­la­tion
dis­or­der. More than half a mil­lion chil­dren and ado­les­cents in Amer­i­ca are
now tak­ing antipsy­chot­ic drugs, which may calm them down but also
inter­fere with learn­ing age-appro­pri­ate skills and devel­op­ing friend­ships
with oth­er children.60 A Colum­bia Uni­ver­si­ty study recent­ly found that
pre­scrip­tions of antipsy­chot­ic drugs for pri­vate­ly insured two- to five-year-
olds had dou­bled between 2000 and 2007.61 Only 40 per­cent of them had
received a prop­er men­tal health assess­ment.
Until it lost its patent, the phar­ma­ceu­ti­cal com­pa­ny John­son & John­son
doled out LEGO blocks stamped with the word “Risperdal” for the wait­ing
rooms of child psy­chi­a­trists. Chil­dren from low-income fam­i­lies are four
times as like­ly as the pri­vate­ly insured to receive antipsy­chot­ic med­i­cines.
In one year alone Texas Med­ic­aid spent $96 mil­lion on antipsy­chot­ic drugs
for teenagers and children—including three uniden­ti­fied infants who were
giv­en the drugs before their first birthdays.62 There have been no stud­ies on
the effects of psy­chotrop­ic med­ica­tions on the devel­op­ing brain.
Dis­so­ci­a­tion, self-muti­la­tion, frag­ment­ed mem­o­ries, and amne­sia gen­er­al­ly
do not respond to any of these med­ica­tions.
The Prozac study that I dis­cussed in chap­ter 2 was the first to dis­cov­er
that trau­ma­tized civil­ians tend to respond much bet­ter to med­ica­tions than
do com­bat veterans.63 Since then oth­er stud­ies have found sim­i­lar
dis­crep­an­cies. In this light it is wor­ri­some that the Depart­ment of Defense
and the VA pre­scribe enor­mous quan­ti­ties of med­ica­tions to com­bat sol­diers
and return­ing vet­er­ans, often with­out pro­vid­ing oth­er forms of ther­a­py.
Between 2001 and 2011 the VA spent about $1.5 bil­lion on Sero­quel and
Risperdal, while Defense spent about $90 mil­lion dur­ing the same peri­od,
even though a research paper pub­lished in 2001 showed that Risperdal was
no more effec­tive than a place­bo in treat­ing PTSD.64 Sim­i­lar­ly, between
2001 and 2012 the VA spent $72.1 mil­lion and Defense spent $44.1 mil­lion
on benzodiazepines65—medications that clin­i­cians gen­er­al­ly avoid
pre­scrib­ing to civil­ians with PTSD because of their addic­tion poten­tial and
lack of sig­nif­i­cant effec­tive­ness for PTSD symp­toms.
THE ROAD OF RECOVERY IS THE ROAD OF LIFE
In the first chap­ter of this book I intro­duced you to a patient named Bill
whom I met over thir­ty years ago at the VA. Bill became one of my
long­time patient-teach­ers, and our rela­tion­ship is also the sto­ry of my
evo­lu­tion of trau­ma treat­ment.
Bill had served as a medic in Viet­nam in 1967–71, and after he
returned, he tried to use the skills he had learned in the army by work­ing on
a burn unit in a local hos­pi­tal. Nurs­ing kept him fraz­zled, explo­sive, and on
edge, but he had no idea that these prob­lems had any­thing to do with what
he had expe­ri­enced in Viet­nam. After all, the PTSD diag­no­sis did not yet
exist, and Irish work­ing-class guys in Boston didn’t con­sult shrinks. His
night­mares and insom­nia sub­sided a bit after he left nurs­ing and enrolled in
a sem­i­nary to become a min­is­ter. He did not seek help until after his first
son was born in 1978.
The baby’s cry­ing trig­gered unre­lent­ing flash­backs, in which he saw,
heard, and smelled burned and muti­lat­ed chil­dren in Viet­nam. He was so
out of con­trol that some of my col­leagues at the VA want­ed to put him in
the hos­pi­tal to treat what they thought was a psy­chosis. How­ev­er, as he and
I start­ed to work togeth­er and he began to feel safe with me, he grad­u­al­ly
opened up about what he had wit­nessed in Viet­nam, and he slow­ly start­ed
to tol­er­ate his feel­ings with­out becom­ing over­whelmed. This helped him to
refo­cus on tak­ing care of his fam­i­ly and on fin­ish­ing his train­ing as a
min­is­ter. After two years he was a pas­tor with his own parish, and we felt
that our work was done.
I had no fur­ther con­tact with Bill until he called me up eigh­teen years
to the day after I first met him. He was expe­ri­enc­ing exact­ly the same
symptoms—flashbacks, ter­ri­ble night­mares, feel­ings that he was going
crazy—that he’d had right after his baby was born. That son had just turned
eigh­teen, and Bill had accom­pa­nied him to reg­is­ter for the draft—at the
same armory from which Bill him­self had been shipped off to Viet­nam. By
then I knew much more about treat­ing trau­mat­ic stress, and Bill and I dealt
with the spe­cif­ic mem­o­ries of what he had seen, heard, and smelled back in
Viet­nam, details that he had been too scared to recall when we first met. We
could now inte­grate these mem­o­ries with EMDR, so that they became
sto­ries of what hap­pened long ago instead of instant trans­ports into the hell
of Viet­nam. Once he felt more set­tled, he want­ed to deal with his child­hood:
his bru­tal upbring­ing and his guilt about hav­ing left behind his younger
schiz­o­phrenic broth­er when he enlist­ed for Viet­nam, unpro­tect­ed against
their father’s vio­lent out­bursts.
Anoth­er impor­tant theme of our time togeth­er was the day-to-day pain
Bill con­front­ed as a minister—having to bury ado­les­cents killed in car
crash­es only a few years after he’d bap­tized them or hav­ing cou­ples he’d
mar­ried come back in cri­sis over domes­tic vio­lence. Bill went on to
orga­nize a sup­port group for fel­low cler­gy faced with sim­i­lar trau­mas, and
he became an impor­tant force in his com­mu­ni­ty.
Bill’s third treat­ment start­ed five years lat­er, when he devel­oped a
seri­ous neu­ro­log­i­cal ill­ness at age fifty-three. He had sud­den­ly start­ed to
expe­ri­ence episod­ic paral­y­sis in sev­er­al parts of his body, and he was
begin­ning to accept that he would prob­a­bly spend the rest of his life in a
wheel­chair. I thought his prob­lems might be due to mul­ti­ple scle­ro­sis, but
his neu­rol­o­gists could not find spe­cif­ic lesions, and they said there was no
cure for his con­di­tion. He told me how grate­ful he was for his wife’s
sup­port. She already had arranged to have a wheel­chair ramp built to the
kitchen entrance to their house.
Giv­en his grim prog­no­sis, I urged Bill to find a way to ful­ly feel and
befriend the dis­tress­ing feel­ings in his body, just as he had learned to
tol­er­ate and live with his most painful mem­o­ries of the war. I sug­gest­ed that
he con­sult a body work­er who had intro­duced me to Feldenkrais, a gen­tle,
hands-on approach to rear­rang­ing phys­i­cal sen­sa­tions and mus­cle
move­ments. When Bill came back to report on how he was doing, he
expressed delight with his increased sense of con­trol. I men­tioned that I’d
recent­ly start­ed to do yoga myself and that we had just opened up a yoga
pro­gram at the Trau­ma Cen­ter. I invit­ed him to explore that as his next step.
Bill found a local Bikram yoga class, a hot and intense prac­tice usu­al­ly
reserved for young and ener­getic peo­ple. Bill loved it, even though parts of
his body occa­sion­al­ly gave way in class. Despite his phys­i­cal dis­abil­i­ty, he
gained a sense of bod­i­ly plea­sure and mas­tery that he had nev­er felt before.
Bill’s psy­cho­log­i­cal treat­ment had helped him put the hor­ren­dous
expe­ri­ence of Viet­nam in the past. Now befriend­ing his body was keep­ing
him from orga­niz­ing his life around the loss of phys­i­cal con­trol. He decid­ed
to become cer­ti­fied as a yoga instruc­tor, and he began teach­ing yoga at his
local armory to the vet­er­ans who were return­ing from Iraq and Afghanistan.
Today, ten years lat­er, Bill con­tin­ues to be ful­ly engaged in life—with
his chil­dren and grand­chil­dren, through his work with vet­er­ans, and in his
church. He copes with his phys­i­cal lim­i­ta­tions as an incon­ve­nience. To date
he has taught yoga class­es to more than 1,300 return­ing com­bat vet­er­ans.
He still reg­u­lar­ly suf­fers from the sud­den weak­ness in his limbs that
requires him to sit or lie down. But, like his mem­o­ries of child­hood and