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.

I
CHAPTER 2
REVOLUTIONS IN UNDERSTANDING
MIND AND BRAIN
The greater the doubt, the greater the awak­en­ing; the small­er the
doubt, the small­er the awak­en­ing. No doubt, no awak­en­ing.
—C.-C. Chang, The Prac­tice of Zen
You live through that lit­tle piece of time that is yours, but that
piece of time is not only your own life, it is the sum­ming-up of all
the oth­er lives that are simul­ta­ne­ous with yours.… What you are
is an expres­sion of His­to­ry.
—Robert Penn War­ren, World Enough and Time
n the late 1960s, dur­ing a year off between my first and sec­ond years of
med­ical school, I became an acci­den­tal wit­ness to a pro­found tran­si­tion
in the med­ical approach to men­tal suf­fer­ing. I had land­ed a plum job as an
atten­dant on a research ward at the Mass­a­chu­setts Men­tal Health Cen­ter,
where I was in charge of orga­niz­ing recre­ation­al activ­i­ties for the patients.
MMHC had long been con­sid­ered one of the finest psy­chi­atric hos­pi­tals in
the coun­try, a jew­el in the crown of the Har­vard Med­ical School teach­ing
empire. The goal of the research on my ward was to deter­mine whether
psy­chother­a­py or med­ica­tion was the best way to treat young peo­ple who
had suf­fered a first men­tal break­down diag­nosed as schiz­o­phre­nia.
The talk­ing cure, an off­shoot of Freudi­an psy­cho­analy­sis, was still the
pri­ma­ry treat­ment for men­tal ill­ness at MMHC. How­ev­er, in the ear­ly 1950s
a group of French sci­en­tists had dis­cov­ered a new com­pound,
chlor­pro­mazine (sold under the brand name Tho­razine), that could
“tran­quil­ize” patients and make them less agi­tat­ed and delu­sion­al. That
inspired hope that drugs could be devel­oped to treat seri­ous men­tal
prob­lems such as depres­sion, pan­ic, anx­i­ety, and mania, as well as to
man­age some of the most dis­turb­ing symp­toms of schiz­o­phre­nia.
As an atten­dant I had noth­ing to do with the research aspect of the ward
and was nev­er told what treat­ment any of the patients was receiv­ing. They
were all close to my age—college stu­dents from Har­vard, MIT, and Boston
Uni­ver­si­ty. Some had tried to kill them­selves; oth­ers cut them­selves with
knives or razor blades; sev­er­al had attacked their room­mates or had
oth­er­wise ter­ri­fied their par­ents or friends with their unpre­dictable,
irra­tional behav­ior. My job was to keep them involved in nor­mal activ­i­ties
for col­lege stu­dents, such as eat­ing at the local piz­za par­lor, camp­ing in a
near­by state for­est, attend­ing Red Sox games, and sail­ing on the Charles
Riv­er.
Total­ly new to the field, I sat in rapt atten­tion dur­ing ward meet­ings,
try­ing to deci­pher the patients’ com­pli­cat­ed speech and log­ic. I also had to
learn to deal with their irra­tional out­bursts and ter­ri­fied with­draw­al. One
morn­ing I found a patient stand­ing like a stat­ue in her bed­room with one
arm raised in a defen­sive ges­ture, her face frozen in fear. She remained
there, immo­bile, for at least twelve hours. The doc­tors gave me the name
for her con­di­tion, cata­to­nia, but even the text­books I con­sult­ed didn’t tell
me what could be done about it. We just let it run its course.
TRAUMA BEFORE DAWN
I spent many nights and week­ends on the unit, which exposed me to things
the doc­tors nev­er saw dur­ing their brief vis­its. When patients could not
sleep, they often wan­dered in their tight­ly wrapped bathrobes into the
dark­ened nurs­ing sta­tion to talk. The qui­et of the night seemed to help them
open up, and they told me sto­ries about hav­ing been hit, assault­ed, or
molest­ed, often by their own par­ents, some­times by rel­a­tives, class­mates, or
neigh­bors. They shared mem­o­ries of lying in bed at night, help­less and
ter­ri­fied, hear­ing their moth­er being beat­en by their father or a boyfriend,
hear­ing their par­ents yell hor­ri­ble threats at each oth­er, hear­ing the sounds
of fur­ni­ture break­ing. Oth­ers told me about fathers who came home drunk
—hear­ing their foot­steps on the land­ing and how they wait­ed for them to
come in, pull them out of bed, and pun­ish them for some imag­ined offense.
Sev­er­al of the women recalled lying awake, motion­less, wait­ing for the
inevitable—a broth­er or father com­ing in to molest them.
Dur­ing morn­ing rounds the young doc­tors pre­sent­ed their cas­es to their
super­vi­sors, a rit­u­al that the ward atten­dants were allowed to observe in
silence. They rarely men­tioned sto­ries like the ones I’d heard. How­ev­er,
many lat­er stud­ies have con­firmed the rel­e­vance of those mid­night
con­fes­sions: We now know that more than half the peo­ple who seek
psy­chi­atric care have been assault­ed, aban­doned, neglect­ed, or even raped
as chil­dren, or have wit­nessed vio­lence in their families.1 But such
expe­ri­ences seemed to be off the table dur­ing rounds. I was often sur­prised
by the dis­pas­sion­ate way patients’ symp­toms were dis­cussed and by how
much time was spent on try­ing to man­age their sui­ci­dal thoughts and self-
destruc­tive behav­iors, rather than on under­stand­ing the pos­si­ble caus­es of
their despair and help­less­ness. I was also struck by how lit­tle atten­tion was
paid to their accom­plish­ments and aspi­ra­tions; whom they cared for, loved,
or hat­ed; what moti­vat­ed and engaged them, what kept them stuck, and
what made them feel at peace—the ecol­o­gy of their lives.
A few years lat­er, as a young doc­tor, I was con­front­ed with an
espe­cial­ly stark exam­ple of the med­ical mod­el in action. I was then
moon­light­ing at a Catholic hos­pi­tal, doing phys­i­cal exam­i­na­tions on women
who’d been admit­ted to receive elec­troshock treat­ment for depres­sion.
Being my curi­ous immi­grant self, I’d look up from their charts to ask them
about their lives. Many of them spilled out sto­ries about painful mar­riages,
dif­fi­cult chil­dren, and guilt over abor­tions. As they spoke, they vis­i­bly
bright­ened and often thanked me effu­sive­ly for lis­ten­ing to them. Some of
them won­dered if they real­ly still need­ed elec­troshock after hav­ing got­ten
so much off their chests. I always felt sad at the end of these meet­ings,
know­ing that the treat­ments that would be admin­is­tered the fol­low­ing
morn­ing would erase all mem­o­ry of our con­ver­sa­tion. I did not last long in
that job.
On my days off from the ward at MMHC, I often went to the Count­way
Library of Med­i­cine to learn more about the patients I was sup­posed to
help. One Sat­ur­day after­noon I came across a trea­tise that is still revered
today: Eugen Bleuler’s 1911 text­book Demen­tia Prae­cox. Bleuler’s
obser­va­tions were fas­ci­nat­ing:
Among schiz­o­phrenic body hal­lu­ci­na­tions, the sex­u­al ones are by
far the most fre­quent and the most impor­tant. All the rap­tures and
joys of nor­mal and abnor­mal sex­u­al sat­is­fac­tion are expe­ri­enced
by these patients, but even more fre­quent­ly every obscene and
dis­gust­ing prac­tice which the most extrav­a­gant fan­ta­sy can con­jure
up. Male patients have their semen drawn off; painful erec­tions are
stim­u­lat­ed. The women patients are raped and injured in the most
dev­il­ish ways.… In spite of the sym­bol­ic mean­ing of many such
hal­lu­ci­na­tions, the major­i­ty of them cor­re­spond to real sensations.2
This made me won­der: Our patients had hallucinations—the doc­tors
rou­tine­ly asked about them and not­ed them as signs of how dis­turbed the
patients were. But if the sto­ries I’d heard in the wee hours were true, could
it be that these “hal­lu­ci­na­tions” were in fact the frag­ment­ed mem­o­ries of
real expe­ri­ences? Were hal­lu­ci­na­tions just the con­coc­tions of sick brains?
Could peo­ple make up phys­i­cal sen­sa­tions they had nev­er expe­ri­enced?
Was there a clear line between cre­ativ­i­ty and patho­log­i­cal imag­i­na­tion?
Between mem­o­ry and imag­i­na­tion? These ques­tions remain unan­swered to
this day, but research has shown that peo­ple who’ve been abused as
chil­dren often feel sen­sa­tions (such as abdom­i­nal pain) that have no obvi­ous
phys­i­cal cause; they hear voic­es warn­ing of dan­ger or accus­ing them of
heinous crimes.
There was no ques­tion that many patients on the ward engaged in
vio­lent, bizarre, and self-destruc­tive behav­iors, par­tic­u­lar­ly when they felt
frus­trat­ed, thwart­ed, or mis­un­der­stood. They threw tem­per tantrums, hurled
plates, smashed win­dows, and cut them­selves with shards of glass. At that
time I had no idea why some­one might react to a sim­ple request (“Let me
clean that goop out of your hair”) with rage or ter­ror. I usu­al­ly fol­lowed the
lead of the expe­ri­enced nurs­es, who sig­naled when to back off or, if that did
not work, to restrain a patient. I was sur­prised and alarmed by the
sat­is­fac­tion I some­times felt after I’d wres­tled a patient to the floor so a
nurse could give an injec­tion, and I grad­u­al­ly real­ized how much of our
pro­fes­sion­al train­ing was geared to help­ing us stay in con­trol in the face of
ter­ri­fy­ing and con­fus­ing real­i­ties.
Sylvia was a gor­geous nine­teen-year-old Boston Uni­ver­si­ty stu­dent
who usu­al­ly sat alone in the cor­ner of the ward, look­ing fright­ened to death
and vir­tu­al­ly mute, but whose rep­u­ta­tion as the girl­friend of an impor­tant
Boston mafioso gave her an aura of mys­tery. After she refused to eat for
more than a week and rapid­ly start­ed to lose weight, the doc­tors decid­ed to
force-feed her. It took three of us to hold her down, anoth­er to push the
rub­ber feed­ing tube down her throat, and a nurse to pour the liq­uid nutri­ents
into her stom­ach. Lat­er, dur­ing a mid­night con­fes­sion, Sylvia spoke timid­ly
and hes­i­tant­ly about her child­hood sex­u­al abuse by her broth­er and uncle. I
real­ized then our dis­play of “car­ing” must have felt to her much like a gang
rape. This expe­ri­ence, and oth­ers like it, helped me for­mu­late this rule for
my stu­dents: If you do some­thing to a patient that you would not do to your
friends or chil­dren, con­sid­er whether you are unwit­ting­ly repli­cat­ing a
trau­ma from the patient’s past.
In my role as recre­ation leader I noticed oth­er things: As a group the
patients were strik­ing­ly clum­sy and phys­i­cal­ly unco­or­di­nat­ed. When we
went camp­ing, most of them stood help­less­ly by as I pitched the tents. We
almost cap­sized once in a squall on the Charles Riv­er because they hud­dled
rigid­ly in the lee, unable to grasp that they need­ed to shift posi­tion to
bal­ance the boat. In vol­ley­ball games the staff mem­bers invari­ably were
much bet­ter coor­di­nat­ed than the patients. Anoth­er char­ac­ter­is­tic they
shared was that even their most relaxed con­ver­sa­tions seemed stilt­ed,
lack­ing the nat­ur­al flow of ges­tures and facial expres­sions that are typ­i­cal
among friends. The rel­e­vance of these obser­va­tions became clear only after
I’d met the body-based ther­a­pists Peter Levine and Pat Ogden; in the lat­er
chap­ters I’ll have a lot to say about how trau­ma is held in people’s bod­ies.
MAKING SENSE OF SUFFERING
After my year on the research ward I resumed med­ical school and then, as a
new­ly mint­ed MD, returned to MMHC to be trained as a psy­chi­a­trist, a
pro­gram to which I was thrilled to be accept­ed. Many famous psy­chi­a­trists
had trained there, includ­ing Eric Kan­del, who lat­er won the Nobel Prize in
Phys­i­ol­o­gy and Med­i­cine. Allan Hob­son dis­cov­ered the brain cells
respon­si­ble for the gen­er­a­tion of dreams in a lab in the hos­pi­tal base­ment
while I trained there, and the first stud­ies on the chem­i­cal under­pin­nings of
depres­sion were also con­duct­ed at MMHC. But for many of us res­i­dents,
the great­est draw was the patients. We spent six hours each day with them
and then met as a group with senior psy­chi­a­trists to share our obser­va­tions,
pose our ques­tions, and com­pete to make the wit­ti­est remarks.
Our great teacher, Elvin Sem­rad, active­ly dis­cour­aged us from read­ing
psy­chi­a­try text­books dur­ing our first year. (This intel­lec­tu­al star­va­tion diet
may account for the fact that most of us lat­er became vora­cious read­ers and
pro­lif­ic writ­ers.) Sem­rad did not want our per­cep­tions of real­i­ty to become
obscured by the pseudo­cer­tain­ties of psy­chi­atric diag­noses. I remem­ber
ask­ing him once: “What would you call this patient—schizophrenic or
schizoaf­fec­tive?” He paused and stroked his chin, appar­ent­ly in deep
thought. “I think I’d call him Michael McIn­tyre,” he replied.
Sem­rad taught us that most human suf­fer­ing is relat­ed to love and loss
and that the job of ther­a­pists is to help peo­ple “acknowl­edge, expe­ri­ence,
and bear” the real­i­ty of life—with all its plea­sures and heart­break. “The
great­est sources of our suf­fer­ing are the lies we tell our­selves,” he’d say,
urg­ing us to be hon­est with our­selves about every facet of our expe­ri­ence.
He often said that peo­ple can nev­er get bet­ter with­out know­ing what they
know and feel­ing what they feel.
I remem­ber being sur­prised to hear this dis­tin­guished old Har­vard
pro­fes­sor con­fess how com­fort­ed he was to feel his wife’s bum against him
as he fell asleep at night. By dis­clos­ing such sim­ple human needs in him­self
he helped us rec­og­nize how basic they were to our lives. Fail­ure to attend to
them results in a stunt­ed exis­tence, no mat­ter how lofty our thoughts and
world­ly accom­plish­ments. Heal­ing, he told us, depends on expe­ri­en­tial
knowl­edge: You can be ful­ly in charge of your life only if you can
acknowl­edge the real­i­ty of your body, in all its vis­cer­al dimen­sions.
Our pro­fes­sion, how­ev­er, was mov­ing in a dif­fer­ent direc­tion. In 1968
the Amer­i­can Jour­nal of Psy­chi­a­try had pub­lished the results of the study
from the ward where I’d been an atten­dant. They showed unequiv­o­cal­ly
that schiz­o­phrenic patients who received drugs alone had a bet­ter out­come
than those who talked three times a week with the best ther­a­pists in
Boston.3 This study was one of many mile­stones on a road that grad­u­al­ly
changed how med­i­cine and psy­chi­a­try approached psy­cho­log­i­cal prob­lems:
from infi­nite­ly vari­able expres­sions of intol­er­a­ble feel­ings and rela­tion­ships
to a brain-dis­ease mod­el of dis­crete “dis­or­ders.”
The way med­i­cine approach­es human suf­fer­ing has always been
deter­mined by the tech­nol­o­gy avail­able at any giv­en time. Before the
Enlight­en­ment aber­ra­tions in behav­ior were ascribed to God, sin, mag­ic,
witch­es, and evil spir­its. It was only in the nine­teenth cen­tu­ry that sci­en­tists
in France and Ger­many began to inves­ti­gate behav­ior as an adap­ta­tion to
the com­plex­i­ties of the world. Now a new par­a­digm was emerg­ing: Anger,
lust, pride, greed, avarice, and sloth—as well as all the oth­er prob­lems we
humans have always strug­gled to manage—were recast as “dis­or­ders” that
could be fixed by the admin­is­tra­tion of appro­pri­ate chemicals.4 Many
psy­chi­a­trists were relieved and delight­ed to become “real sci­en­tists,” just
like their med school class­mates who had lab­o­ra­to­ries, ani­mal exper­i­ments,
expen­sive equip­ment, and com­pli­cat­ed diag­nos­tic tests, and set aside the
wooly-head­ed the­o­ries of philoso­phers like Freud and Jung. A major
text­book of psy­chi­a­try went so far as to state: “The cause of men­tal ill­ness
is now con­sid­ered an aber­ra­tion of the brain, a chem­i­cal imbalance.”5
Like my col­leagues, I eager­ly embraced the phar­ma­co­log­i­cal
rev­o­lu­tion. In 1973 I became the first chief res­i­dent in psy­chophar­ma­col­o­gy
at MMHC. I may also have been the first psy­chi­a­trist in Boston to
admin­is­ter lithi­um to a man­ic-depres­sive patient. (I’d read about John
Cade’s work with lithi­um in Aus­tralia, and I received per­mis­sion from a
hos­pi­tal com­mit­tee to try it.) On lithi­um a woman who had been man­ic
every May for the past thir­ty-five years, and sui­ci­dal­ly depressed every
Novem­ber, stopped cycling and remained sta­ble for the three years she was
under my care. I was also part of the first U.S. research team to test the
antipsy­chot­ic Clozaril on chron­ic patients who were ware­housed in the back
wards of the old insane asylums.6 Some of their respons­es were mirac­u­lous:
Peo­ple who had spent much of their lives locked in their own sep­a­rate,
ter­ri­fy­ing real­i­ties were now able to return to their fam­i­lies and
com­mu­ni­ties; patients mired in dark­ness and despair start­ed to respond to
the beau­ty of human con­tact and the plea­sures of work and play. These
amaz­ing results made us opti­mistic that we could final­ly con­quer human
mis­ery.
Antipsy­chot­ic drugs were a major fac­tor in reduc­ing the num­ber of
peo­ple liv­ing in men­tal hos­pi­tals in the Unit­ed States, from over 500,000 in
1955 to few­er than 100,000 in 1996.7 For peo­ple today who did not know
the world before the advent of these treat­ments, the change is almost
unimag­in­able. As a first-year med­ical stu­dent I vis­it­ed Kanka­kee State
Hos­pi­tal in Illi­nois and saw a burly ward atten­dant hose down dozens of
filthy, naked, inco­her­ent patients in an unfur­nished day­room sup­plied with
gut­ters for the runoff water. This mem­o­ry now seems more like a night­mare
than like some­thing I wit­nessed with my own eyes. My first job after
fin­ish­ing my res­i­den­cy in 1974 was as the sec­ond-to-last direc­tor of a once-
ven­er­a­ble insti­tu­tion, the Boston State Hos­pi­tal, which had for­mer­ly housed
thou­sands of patients and been spread over hun­dreds of acres with dozens
of build­ings, includ­ing green­hous­es, gar­dens, and workshops—most of
them by then in ruins. Dur­ing my time there patients were grad­u­al­ly
dis­persed into “the com­mu­ni­ty,” the blan­ket term for the anony­mous
shel­ters and nurs­ing homes where most of them end­ed up. (Iron­i­cal­ly, the
hos­pi­tal was start­ed as an “asy­lum,” a word mean­ing “sanc­tu­ary” that
grad­u­al­ly took on a sin­is­ter con­no­ta­tion. It actu­al­ly did offer a shel­tered
com­mu­ni­ty where every­body knew the patients’ names and idio­syn­crasies.)
In 1979, short­ly after I went to work at the VA, the Boston State Hospital’s
gates were per­ma­nent­ly locked, and it became a ghost town.
Dur­ing my time at Boston State I con­tin­ued to work in the MMHC
psy­chophar­ma­col­o­gy lab, which was now focus­ing on anoth­er direc­tion for
research. In the 1960s sci­en­tists at the Nation­al Insti­tutes of Health had
begun to devel­op tech­niques for iso­lat­ing and mea­sur­ing hor­mones and
neu­ro­trans­mit­ters in blood and the brain. Neu­ro­trans­mit­ters are chem­i­cal
mes­sen­gers that car­ry infor­ma­tion from neu­ron to neu­ron, enabling us to
engage effec­tive­ly with the world.
Now that sci­en­tists were find­ing evi­dence that abnor­mal lev­els of
nor­ep­i­neph­rine were asso­ci­at­ed with depres­sion, and of dopamine with
schiz­o­phre­nia, there was hope that we could devel­op drugs that tar­get
spe­cif­ic brain abnor­mal­i­ties. That hope was nev­er ful­ly real­ized, but our
efforts to mea­sure how drugs could affect men­tal symp­toms led to anoth­er
pro­found change in the pro­fes­sion. Researchers’ need for a pre­cise and
sys­tem­at­ic way to com­mu­ni­cate their find­ings result­ed in the devel­op­ment
of the so-called Research Diag­nos­tic Cri­te­ria, to which I con­tributed as a
low­ly research assis­tant. These even­tu­al­ly became the basis for the first
sys­tem­at­ic sys­tem to diag­nose psy­chi­atric prob­lems, the Amer­i­can
Psy­chi­atric Association’s Diag­nos­tic and Sta­tis­ti­cal Man­u­al of Men­tal
Dis­or­ders (DSM), which is com­mon­ly referred to as the “bible of
psy­chi­a­try.” The fore­word to the land­mark 1980 DSM-III was appro­pri­ate­ly
mod­est and acknowl­edged that this diag­nos­tic sys­tem was imprecise—so
impre­cise that it nev­er should be used for foren­sic or insur­ance purposes.8
As we will see, that mod­esty was trag­i­cal­ly short-lived.
INESCAPABLE SHOCK
Pre­oc­cu­pied with so many lin­ger­ing ques­tions about trau­mat­ic stress, I
became intrigued with the idea that the nascent field of neu­ro­science could
pro­vide some answers and start­ed to attend the meet­ings of the Amer­i­can
Col­lege of Neu­ropsy­chophar­ma­col­o­gy (ACNP). In 1984 the ACNP offered
many fas­ci­nat­ing lec­tures about drug devel­op­ment, but it was not until a
few hours before my sched­uled flight back to Boston that I heard a
pre­sen­ta­tion by Steven Maier of the Uni­ver­si­ty of Col­orado, who had
col­lab­o­rat­ed with Mar­tin Selig­man of the Uni­ver­si­ty of Penn­syl­va­nia. His
top­ic was learned help­less­ness in ani­mals. Maier and Selig­man had
repeat­ed­ly admin­is­tered painful elec­tric shocks to dogs who were trapped in
locked cages. They called this con­di­tion “inescapable shock.”9 Being a dog
lover, I real­ized that I could nev­er have done such research myself, but I
was curi­ous about how this cru­el­ty would affect the ani­mals.
After admin­is­ter­ing sev­er­al cours­es of elec­tric shock, the researchers
opened the doors of the cages and then shocked the dogs again. A group of
con­trol dogs who had nev­er been shocked before imme­di­ate­ly ran away, but
the dogs who had ear­li­er been sub­ject­ed to inescapable shock made no
attempt to flee, even when the door was wide open—they just lay there,
whim­per­ing and defe­cat­ing. The mere oppor­tu­ni­ty to escape does not
nec­es­sar­i­ly make trau­ma­tized ani­mals, or peo­ple, take the road to free­dom.
Like Maier and Seligman’s dogs, many trau­ma­tized peo­ple sim­ply give up.
Rather than risk exper­i­ment­ing with new options they stay stuck in the fear
they know.
I was riv­et­ed by Maier’s account. What they had done to these poor
dogs was exact­ly what had hap­pened to my trau­ma­tized human patients.
They, too, had been exposed to some­body (or some­thing) who had inflict­ed
ter­ri­ble harm on them—harm they had no way of escap­ing. I made a rapid
men­tal review of the patients I had treat­ed. Almost all had in some way
been trapped or immo­bi­lized, unable to take action to stave off the
inevitable. Their fight/flight response had been thwart­ed, and the result was
either extreme agi­ta­tion or col­lapse.
Maier and Selig­man also found that trau­ma­tized dogs secret­ed much
larg­er amounts of stress hor­mones than was nor­mal. This sup­port­ed what
we were begin­ning to learn about the bio­log­i­cal under­pin­nings of trau­mat­ic
stress. A group of young researchers, among them Steve South­wick and
John Krys­tal at Yale, Arieh Shalev at Hadas­sah Med­ical School in
Jerusalem, Frank Put­nam at the Nation­al Insti­tute of Men­tal Health
(NIMH), and Roger Pit­man, lat­er at Har­vard, were all find­ing that
trau­ma­tized peo­ple keep secret­ing large amounts of stress hor­mones long
after the actu­al dan­ger has passed, and Rachel Yehu­da at Mount Sinai in
New York con­front­ed us with her seem­ing­ly para­dox­i­cal find­ings that the
lev­els of the stress hor­mone cor­ti­sol are low in PTSD. Her dis­cov­er­ies only
start­ed to make sense when her research clar­i­fied that cor­ti­sol puts an end to
the stress response by send­ing an all-safe sig­nal, and that, in PTSD, the
body’s stress hor­mones do, in fact, not return to base­line after the threat has
passed.
Ide­al­ly our stress hor­mone sys­tem should pro­vide a light­ning-fast
response to threat, but then quick­ly return us to equi­lib­ri­um. In PTSD
patients, how­ev­er, the stress hor­mone sys­tem fails at this bal­anc­ing act.
Fight/flight/freeze sig­nals con­tin­ue after the dan­ger is over, and, as in the
case of the dogs, do not return to nor­mal. Instead, the con­tin­ued secre­tion of
stress hor­mones is expressed as agi­ta­tion and pan­ic and, in the long term,
wreaks hav­oc with their health.
I missed my plane that day because I had to talk with Steve Maier. His
work­shop offered clues not only about the under­ly­ing prob­lems of my
patients but also poten­tial keys to their res­o­lu­tion. For exam­ple, he and
Selig­man had found that the only way to teach the trau­ma­tized dogs to get
off the elec­tric grids when the doors were open was to repeat­ed­ly drag them
out of their cages so they could phys­i­cal­ly expe­ri­ence how they could get
away. I won­dered if we also could help my patients with their fun­da­men­tal
ori­en­ta­tion that there was noth­ing they could do to defend them­selves? Did
my patients also need to have phys­i­cal expe­ri­ences to restore a vis­cer­al
sense of con­trol? What if they could be taught to phys­i­cal­ly move to escape
a poten­tial­ly threat­en­ing sit­u­a­tion that was sim­i­lar to the trau­ma in which
they had been trapped and immo­bi­lized? As I will dis­cuss in the treat­ment
part 5 of this book, that was one of the con­clu­sions I even­tu­al­ly reached.
Fur­ther ani­mal stud­ies involv­ing mice, rats, cats, mon­keys, and
ele­phants brought more intrigu­ing data.10 For exam­ple, when researchers
played a loud, intru­sive sound, mice that had been raised in a warm nest
with plen­ty of food scur­ried home imme­di­ate­ly. But anoth­er group, raised in
a noisy nest with scarce food sup­plies, also ran for home, even after
spend­ing time in more pleas­ant surroundings.11
Scared ani­mals return home, regard­less of whether home is safe or
fright­en­ing. I thought about my patients with abu­sive fam­i­lies who kept
going back to be hurt again. Are trau­ma­tized peo­ple con­demned to seek
refuge in what is famil­iar? If so, why, and is it pos­si­ble to help them
become attached to places and activ­i­ties that are safe and pleasurable?12
ADDICTED TO TRAUMA: THE PAIN OF PLEASURE AND
THE PLEASURE OF PAIN
One of the things that struck my col­league Mark Green­berg and me when
we ran ther­a­py groups for Viet­nam com­bat vet­er­ans was how, despite their
feel­ings of hor­ror and grief, many of them seemed to come to life when
they talked about their heli­copter crash­es and their dying com­rades.
(For­mer New York Times cor­re­spon­dent Chris Hedges, who cov­ered a
num­ber of bru­tal con­flicts, enti­tled his book War Is a Force That Gives Us
Meaning.13) Many trau­ma­tized peo­ple seem to seek out expe­ri­ences that
would repel most of us,14 and patients often com­plain about a vague sense
of empti­ness and bore­dom when they are not angry, under duress, or
involved in some dan­ger­ous activ­i­ty.
My patient Julia was bru­tal­ly raped at gun­point in a hotel room at age
six­teen. Short­ly there­after she got involved with a vio­lent pimp who
pros­ti­tut­ed her. He reg­u­lar­ly beat her up. She was repeat­ed­ly jailed for
pros­ti­tu­tion, but she always went back to her pimp. Final­ly her grand­par­ents
inter­vened and paid for an intense rehab pro­gram. After she suc­cess­ful­ly
com­plet­ed inpa­tient treat­ment, she start­ed work­ing as a recep­tion­ist and
tak­ing cours­es at a local col­lege. In her soci­ol­o­gy class she wrote a term
paper about the lib­er­at­ing pos­si­bil­i­ties of pros­ti­tu­tion, for which she read
the mem­oirs of sev­er­al famous pros­ti­tutes. She grad­u­al­ly dropped all her
oth­er cours­es. A brief rela­tion­ship with a class­mate quick­ly went sour—he
bored her to tears, she said, and she was repelled by his box­er shorts. She
then picked up an addict on the sub­way who first beat her up and then
start­ed to stalk her. She final­ly became moti­vat­ed to return to treat­ment
when she was once again severe­ly beat­en.
Freud had a term for such trau­mat­ic reen­act­ments: “the com­pul­sion to
repeat.” He and many of his fol­low­ers believed that reen­act­ments were an
uncon­scious attempt to get con­trol over a painful sit­u­a­tion and that they
even­tu­al­ly could lead to mas­tery and res­o­lu­tion. There is no evi­dence for
that theory—repetition leads only to fur­ther pain and self-hatred. In fact,
even reliv­ing the trau­ma repeat­ed­ly in ther­a­py may rein­force pre­oc­cu­pa­tion
and fix­a­tion.
Mark Green­berg and I decid­ed to learn more about attractors—the
things that draw us, moti­vate us, and make us feel alive. Nor­mal­ly attrac­tors
are meant to make us feel bet­ter. So, why are so many peo­ple attract­ed to
dan­ger­ous or painful sit­u­a­tions? We even­tu­al­ly found a study that explained
how activ­i­ties that cause fear or pain can lat­er become thrilling
experiences.15 In the 1970s Richard Solomon of the Uni­ver­si­ty of
Penn­syl­va­nia had shown that the body learns to adjust to all sorts of stim­uli.
We may get hooked on recre­ation­al drugs because they right away make us
feel so good, but activ­i­ties like sauna bathing, marathon run­ning, or
para­chute jump­ing, which ini­tial­ly cause dis­com­fort and even ter­ror, can
ulti­mate­ly become very enjoy­able. This grad­ual adjust­ment sig­nals that a
new chem­i­cal bal­ance has been estab­lished with­in the body, so that
marathon run­ners, say, get a sense of well-being and exhil­a­ra­tion from
push­ing their bod­ies to the lim­it.
At this point, just as with drug addic­tion, we start to crave the activ­i­ty
and expe­ri­ence with­draw­al when it’s not avail­able. In the long run peo­ple
become more pre­oc­cu­pied with the pain of with­draw­al than the activ­i­ty
itself. This the­o­ry could explain why some peo­ple hire some­one to beat
them, or burn them­selves with cig­a­rettes. or why they are only attract­ed to
peo­ple who hurt them. Fear and aver­sion, in some per­verse way, can be
trans­formed into plea­sure.
Solomon hypoth­e­sized that endorphins—the mor­phine­like chem­i­cals
that the brain secretes in response to stress—play a role in the para­dox­i­cal
addic­tions he described. I thought of his the­o­ry again when my library habit
led me to a paper titled “Pain in Men Wound­ed in Bat­tle,” pub­lished in
1946. Hav­ing observed that 75 per­cent of severe­ly wound­ed sol­diers on the
Ital­ian front did not request mor­phine, a sur­geon by the name of Hen­ry K.
Beech­er spec­u­lat­ed that “strong emo­tions can block pain.”16
Were Beecher’s obser­va­tions rel­e­vant to peo­ple with PTSD? Mark
Green­berg, Roger Pit­man, Scott Orr, and I decid­ed to ask eight Viet­nam
com­bat vet­er­ans if they would be will­ing to take a stan­dard pain test while
they watched scenes from a num­ber of movies. The first clip we showed
was from Oliv­er Stone’s graph­i­cal­ly vio­lent Pla­toon (1986), and while it
ran we mea­sured how long the vet­er­ans could keep their right hands in a
buck­et of ice water. We then repeat­ed this process with a peace­ful (and
long-for­got­ten) movie clip. Sev­en of the eight vet­er­ans kept their hands in
the painful­ly cold water 30 per­cent longer dur­ing Pla­toon. We then
cal­cu­lat­ed that the amount of anal­ge­sia pro­duced by watch­ing fif­teen
min­utes of a com­bat movie was equiv­a­lent to that pro­duced by being
inject­ed with eight mil­ligrams of mor­phine, about the same dose a per­son
would receive in an emer­gency room for crush­ing chest pain.
We con­clud­ed that Beecher’s spec­u­la­tion that “strong emo­tions can
block pain” was the result of the release of mor­phine­like sub­stances
man­u­fac­tured in the brain. This sug­gest­ed that for many trau­ma­tized
peo­ple, reex­po­sure to stress might pro­vide a sim­i­lar relief from anxiety.17 It
was an inter­est­ing exper­i­ment, but it did not ful­ly explain why Julia kept
going back to her vio­lent pimp.
SOOTHING THE BRAIN
The 1985 ACNP meet­ing was, if pos­si­ble, even more thought pro­vok­ing
than the pre­vi­ous year’s ses­sion. Kings Col­lege pro­fes­sor Jef­frey Gray gave
a talk about the amyg­dala, a clus­ter of brain cells that deter­mines whether a
sound, image, or body sen­sa­tion is per­ceived as a threat. Gray’s data
showed that the sen­si­tiv­i­ty of the amyg­dala depend­ed, at least in part, on the
amount of the neu­ro­trans­mit­ter sero­tonin in that part of the brain. Ani­mals
with low sero­tonin lev­els were hyper­re­ac­tive to stress­ful stim­uli (like loud
sounds), while high­er lev­els of sero­tonin damp­ened their fear sys­tem,
mak­ing them less like­ly to become aggres­sive or frozen in response to
poten­tial threats.18
That struck me as an impor­tant find­ing: My patients were always
blow­ing up in response to small provo­ca­tions and felt dev­as­tat­ed by the
slight­est rejec­tion. I became fas­ci­nat­ed by the pos­si­ble role of sero­tonin in
PTSD. Oth­er researchers had shown that dom­i­nant male mon­keys had much
high­er lev­els of brain sero­tonin than low­er-rank­ing ani­mals but that their
sero­tonin lev­els dropped when they were pre­vent­ed from main­tain­ing eye
con­tact with the mon­keys they had once lord­ed over. In con­trast, low-
rank­ing mon­keys who were giv­en sero­tonin sup­ple­ments emerged from the
pack to assume leadership.19 The social envi­ron­ment inter­acts with brain
chem­istry. Manip­u­lat­ing a mon­key into a low­er posi­tion in the dom­i­nance
hier­ar­chy made his sero­tonin drop, while chem­i­cal­ly enhanc­ing sero­tonin
ele­vat­ed the rank of for­mer sub­or­di­nates.
The impli­ca­tions for trau­ma­tized peo­ple were obvi­ous. Like Gray’s
low-sero­tonin ani­mals, they were hyper­re­ac­tive, and their abil­i­ty to cope
social­ly was often com­pro­mised. If we could find ways to increase brain
sero­tonin lev­els, per­haps we could address both prob­lems simul­ta­ne­ous­ly.
At that same 1985 meet­ing I learned that drug com­pa­nies were devel­op­ing
two new prod­ucts to do pre­cise­ly that, but since nei­ther was yet avail­able, I
exper­i­ment­ed briefly with the health-food-store sup­ple­ment L‑tryptophan,
which is a chem­i­cal pre­cur­sor of sero­tonin in the body. (The results were
dis­ap­point­ing.) One of the drugs under inves­ti­ga­tion nev­er made it to the
mar­ket. The oth­er was flu­ox­e­tine, which, under the brand name Prozac,
became one of the most suc­cess­ful psy­choac­tive drugs ever cre­at­ed.
On Mon­day, Feb­ru­ary 8, 1988, Prozac was released by the drug
com­pa­ny Eli Lil­ly. The first patient I saw that day was a young woman with
a hor­ren­dous his­to­ry of child­hood abuse who was now strug­gling with
bulimia—she basi­cal­ly spent much of her life binge­ing and purg­ing. I gave
her a pre­scrip­tion for this brand-new drug, and when she returned on
Thurs­day she said, “I’ve had a very dif­fer­ent last few days: I ate when I was
hun­gry, and the rest of the time I did my school­work.” This was one of the
most dra­mat­ic state­ments I had ever heard in my office.
On Fri­day I saw anoth­er patient to whom I’d giv­en Prozac the pre­vi­ous
Mon­day. She was a chron­i­cal­ly depressed moth­er of two school-aged
chil­dren, pre­oc­cu­pied with her fail­ures as a moth­er and wife and
over­whelmed by demands from the par­ents who had bad­ly mis­treat­ed her as
a child. After four days on Prozac she asked me if she could skip her
appoint­ment the fol­low­ing Mon­day, which was Pres­i­dents’ Day. “After all,”
she explained, “I’ve nev­er tak­en my kids skiing—my hus­band always does
—and they are off that day. It would real­ly be nice for them to have some
good mem­o­ries of us hav­ing fun togeth­er.”
This was a patient who had always strug­gled mere­ly to get through the
day. After her appoint­ment I called some­one I knew at Eli Lil­ly and said,
“You have a drug that helps peo­ple to be in the present, instead of being
locked in the past.” Lil­ly lat­er gave me a small grant to study the effects of
Prozac on PTSD in six­ty-four people—twenty-two women and forty-two
men—the first study of the effects of this new class of drugs on PTSD. Our
Trau­ma Clin­ic team enrolled thir­ty-three non­vet­er­ans and my col­lab­o­ra­tors,
for­mer col­leagues at the VA, enrolled thir­ty-one com­bat vet­er­ans. For eight
weeks half of each group received Prozac and the oth­er half a place­bo. The
study was blind­ed: Nei­ther we nor the patients knew which sub­stance they
were tak­ing, so that our pre­con­cep­tions could not skew our assess­ments.
Every­one in the study—even those who had received the place­bo—
improved, at least to some degree. Most treat­ment stud­ies of PTSD find a
sig­nif­i­cant place­bo effect. Peo­ple who screw up their courage to par­tic­i­pate
in a study for which they aren’t paid, in which they’re repeat­ed­ly poked
with nee­dles, and in which they have only a fifty-fifty chance of get­ting an
active drug are intrin­si­cal­ly moti­vat­ed to solve their prob­lem. Maybe their
reward is only the atten­tion paid to them, the oppor­tu­ni­ty to respond to
ques­tions about how they feel and think. But maybe the mother’s kiss­es that
soothe her child’s scrapes are “just” a place­bo as well.
Prozac worked sig­nif­i­cant­ly bet­ter than the place­bo for the patients
from the Trau­ma Clin­ic. They slept more sound­ly; they had more con­trol
over their emo­tions and were less pre­oc­cu­pied with the past than those who
received a sug­ar pill.20 Sur­pris­ing­ly, how­ev­er, the Prozac had no effect at all
on the com­bat vet­er­ans at the VA—their PTSD symp­toms were unchanged.
These results have held true for most sub­se­quent phar­ma­co­log­i­cal stud­ies
on vet­er­ans: While a few have shown mod­est improve­ments, most have not
ben­e­fit­ed at all. I have nev­er been able to explain this, and I can­not accept
the most com­mon expla­na­tion: that receiv­ing a pen­sion or dis­abil­i­ty
ben­e­fits pre­vents peo­ple from get­ting bet­ter. After all, the amyg­dala knows
noth­ing of pensions—it just detects threats.
Nonethe­less, med­ica­tions such as Prozac and relat­ed drugs like Zoloft,
Celexa, Cym­bal­ta, and Pax­il, have made a sub­stan­tial con­tri­bu­tion to the
treat­ment of trau­ma-relat­ed dis­or­ders. In our Prozac study we used the
Rorschach test to mea­sure how trau­ma­tized peo­ple per­ceive their
sur­round­ings. These data gave us an impor­tant clue to how this class of
drugs (for­mal­ly known as selec­tive sero­tonin reup­take inhibitors, or SSRIs)
might work. Before tak­ing Prozac these patients’ emo­tions con­trolled their
reac­tions. I think of a Dutch patient, for exam­ple (not in the Prozac study)
who came to see me for treat­ment for a child­hood rape and who was
con­vinced that I would rape her as soon as she heard my Dutch accent.
Prozac made a rad­i­cal dif­fer­ence: It gave PTSD patients a sense of
perspective21 and helped them to gain con­sid­er­able con­trol over their
impuls­es. Jef­frey Gray must have been right: When their sero­tonin lev­els
rose, many of my patients became less reac­tive.
THE TRIUMPH OF PHARMACOLOGY
It did not take long for phar­ma­col­o­gy to rev­o­lu­tion­ize psy­chi­a­try. Drugs
gave doc­tors a greater sense of effi­ca­cy and pro­vid­ed a tool beyond talk
ther­a­py. Drugs also pro­duced income and prof­its. Grants from the
phar­ma­ceu­ti­cal indus­try pro­vid­ed us with lab­o­ra­to­ries filled with ener­getic
grad­u­ate stu­dents and sophis­ti­cat­ed instru­ments. Psy­chi­a­try depart­ments,
which had always been locat­ed in the base­ments of hos­pi­tals, start­ed to
move up, both in terms of loca­tion and pres­tige.
One sym­bol of this change occurred at MMHC, where in the ear­ly
1990s the hospital’s swim­ming pool was paved over to make space for a
lab­o­ra­to­ry, and the indoor bas­ket­ball court was carved up into cubi­cles for
the new med­ica­tion clin­ic. For decades doc­tors and patients had
demo­c­ra­t­i­cal­ly shared the plea­sures of splash­ing in the pool and pass­ing
balls down the court. I’d spent hours in the gym with patients back when I
was a ward atten­dant. It was the one place where we all could restore a
sense of phys­i­cal well-being, an island in the midst of the mis­ery we faced
every day. Now it had become a place for patients to “get fixed.”
The drug rev­o­lu­tion that start­ed out with so much promise may in the
end have done as much harm as good. The the­o­ry that men­tal ill­ness is
caused pri­mar­i­ly by chem­i­cal imbal­ances in the brain that can be cor­rect­ed
by spe­cif­ic drugs has become broad­ly accept­ed, by the media and the pub­lic
as well as by the med­ical profession.22 In many places drugs have dis­placed
ther­a­py and enabled patients to sup­press their prob­lems with­out address­ing
the under­ly­ing issues. Anti­de­pres­sants can make all the dif­fer­ence in the
world in help­ing with day-to-day func­tion­ing, and if it comes to a choice
between tak­ing a sleep­ing pill and drink­ing your­self into a stu­por every
night to get a few hours of sleep, there is no ques­tion which is prefer­able.
For peo­ple who are exhaust­ed from try­ing to make it on their own through
yoga class­es, work­out rou­tines, or sim­ply tough­ing it out, med­ica­tions often
can bring life-sav­ing relief. The SSRIs can be very help­ful in mak­ing
trau­ma­tized peo­ple less enslaved by their emo­tions, but they should only be
con­sid­ered adjuncts in their over­all treatment.23
After con­duct­ing numer­ous stud­ies of med­ica­tions for PTSD, I have
come to real­ize that psy­chi­atric med­ica­tions have a seri­ous down­side, as
they may deflect atten­tion from deal­ing with the under­ly­ing issues. The
brain-dis­ease mod­el takes con­trol over people’s fate out of their own hands
and puts doc­tors and insur­ance com­pa­nies in charge of fix­ing their
prob­lems.
Over the past three decades psy­chi­atric med­ica­tions have become a
main­stay in our cul­ture, with dubi­ous con­se­quences. Con­sid­er the case of
anti­de­pres­sants. If they were indeed as effec­tive as we have been led to
believe, depres­sion should by now have become a minor issue in our
soci­ety. Instead, even as anti­de­pres­sant use con­tin­ues to increase, it has not
made a dent in hos­pi­tal admis­sions for depres­sion. The num­ber of peo­ple
treat­ed for depres­sion has tripled over the past two decades, and one in ten
Amer­i­cans now take antidepressants.24
The new gen­er­a­tion of antipsy­chotics, such as Abil­i­fy, Risperdal,
Zyprexa, and Sero­quel, are the top-sell­ing drugs in the Unit­ed States. In
2012 the pub­lic spent $1,526,228,000 on Abil­i­fy, more than on any oth­er
med­ica­tion. Num­ber three was Cym­bal­ta, an anti­de­pres­sant that sold well
over a bil­lion dol­lars’ worth of pills,25 even though it has nev­er been shown
to be supe­ri­or to old­er anti­de­pres­sants like Prozac, for which much cheap­er
gener­ics are avail­able. Med­ic­aid, the gov­ern­ment health pro­gram for the
poor, spends more on antipsy­chotics than on any oth­er class of drugs.26 In
2008, the most recent year for which com­plete data are avail­able, it fund­ed
$3.6 bil­lion for antipsy­chot­ic med­ica­tions, up from $1.65 bil­lion in 1999.
The num­ber of peo­ple under the age of twen­ty receiv­ing Med­ic­aid-fund­ed
pre­scrip­tions for antipsy­chot­ic drugs tripled between 1999 and 2008. On
Novem­ber 4, 2013, John­son & John­son agreed to pay more than $2.2
bil­lion in crim­i­nal and civ­il fines to set­tle accu­sa­tions that it had improp­er­ly
pro­mot­ed the antipsy­chot­ic drug Risperdal to old­er adults, chil­dren, and
peo­ple with devel­op­men­tal disabilities.27 But nobody is hold­ing the doc­tors
who pre­scribed them account­able.
Half a mil­lion chil­dren in the Unit­ed States cur­rent­ly take antipsy­chot­ic
drugs. Chil­dren from low-income fam­i­lies are four times as like­ly as
pri­vate­ly insured chil­dren to receive antipsy­chot­ic med­i­cines. These
med­ica­tions often are used to make abused and neglect­ed chil­dren more
tractable. In 2008 19,045 chil­dren age five and under were pre­scribed
antipsy­chotics through Medicaid.28 One study, based on Med­ic­aid data in
thir­teen states, found that 12.4 per­cent of chil­dren in fos­ter care received
antipsy­chotics, com­pared with 1.4 per­cent of Med­ic­aid-eli­gi­ble chil­dren in
general.29 These med­ica­tions make chil­dren more man­age­able and less
aggres­sive, but they also inter­fere with moti­va­tion, play, and curios­i­ty,
which are indis­pens­able for matur­ing into a well-func­tion­ing and
con­tribut­ing mem­ber of soci­ety. Chil­dren who take them are also at risk of
becom­ing mor­bid­ly obese and devel­op­ing dia­betes. Mean­while, drug