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.

S
CHAPTER 6
LOSING YOUR BODY, LOSING YOUR
SELF
Be patient toward all that is unsolved in your heart and try to love
the ques­tions them­selves.… Live the ques­tions now. Per­haps you
will grad­u­al­ly, with­out notic­ing it, live along some dis­tant day into
the answer.
—Rain­er Maria Rilke, Let­ters to a Young Poet
her­ry walked into my office with her shoul­ders slumped, her chin
near­ly touch­ing her chest. Even before we spoke a word, her body was
telling me that she was afraid to face the world. I also noticed that her long
sleeves only par­tial­ly cov­ered the scabs on her fore­arms. After sit­ting down,
she told me in a high-pitched monot­o­ne that she couldn’t stop her­self from
pick­ing at the skin on her arms and chest until she bled.
As far back as Sher­ry could remem­ber, her moth­er had run a fos­ter
home, and their house was often packed with as many as fif­teen strange,
dis­rup­tive, fright­ened, and fright­en­ing kids who dis­ap­peared as sud­den­ly as
they arrived. Sher­ry had grown up tak­ing care of these tran­sient chil­dren,
feel­ing that there was no room for her and her needs. “I know I wasn’t
want­ed,” she told me. “I’m not sure when I first real­ized that, but I’ve
thought about things that my moth­er said to me, and the signs were always
there. She’d tell me, ‘You know, I don’t think you belong in this fam­i­ly. I
think they gave us the wrong baby.’ And she’d say it with a smile on her
face. But, of course, peo­ple often pre­tend to joke when they say some­thing
seri­ous.”
Over the years our research team has repeat­ed­ly found that chron­ic
emo­tion­al abuse and neglect can be just as dev­as­tat­ing as phys­i­cal abuse
and sex­u­al molestation.1 Sher­ry turned out to be a liv­ing exam­ple of these
find­ings: Not being seen, not being known, and hav­ing nowhere to turn to
feel safe is dev­as­tat­ing at any age, but it is par­tic­u­lar­ly destruc­tive for
young chil­dren, who are still try­ing to find their place in the world.
Sher­ry had grad­u­at­ed from col­lege, but she now worked in a joy­less
cler­i­cal job, lived alone with her cats, and had no close friends. When I
asked her about men, she told me that her only “rela­tion­ship” had been with
a man who’d kid­napped her while she was on a col­lege vaca­tion in Flori­da.
He’d held her cap­tive and raped her repeat­ed­ly for five con­sec­u­tive days.
She remem­bered hav­ing been curled up, ter­ri­fied and frozen for most of that
time, until she real­ized she could try to get away. She escaped by sim­ply
walk­ing out while he was in the bath­room. When she called her moth­er
col­lect for help, her moth­er refused to take the call. Sher­ry final­ly man­aged
to get home with assis­tance from a domes­tic vio­lence shel­ter.
Sher­ry told me that she’d start­ed to pick at her skin because it gave her
some relief from feel­ing numb. The phys­i­cal sen­sa­tions made her feel more
alive but also deeply ashamed—she knew she was addict­ed to these actions
but could not stop them. She’d con­sult­ed many men­tal health pro­fes­sion­als
before me and had been ques­tioned repeat­ed­ly about her “sui­ci­dal
behav­ior.” She’d also been sub­ject­ed to invol­un­tary hos­pi­tal­iza­tion by a
psy­chi­a­trist who refused to treat her unless she could promise that she
would nev­er pick at her­self again. How­ev­er, in my expe­ri­ence, patients who
cut them­selves or pick at their skin like Sher­ry, are sel­dom sui­ci­dal but are
try­ing to make them­selves feel bet­ter in the only way they know.
This is a dif­fi­cult con­cept for many peo­ple to under­stand. As I
dis­cussed in the pre­vi­ous chap­ter, the most com­mon response to dis­tress is
to seek out peo­ple we like and trust to help us and give us the courage to go
on. We may also calm down by engag­ing in a phys­i­cal activ­i­ty like bik­ing
or going to the gym. We start learn­ing these ways of reg­u­lat­ing our feel­ings
from the first moment some­one feeds us when we’re hun­gry, cov­ers us
when we’re cold, or rocks us when we’re hurt or scared.
But if no one has ever looked at you with lov­ing eyes or bro­ken out in a
smile when she sees you; if no one has rushed to help you (but instead said,
“Stop cry­ing, or I’ll give you some­thing to cry about”), then you need to
dis­cov­er oth­er ways of tak­ing care of your­self. You are like­ly to exper­i­ment
with anything—drugs, alco­hol, binge eat­ing, or cutting—that offers some
kind of relief.
While Sher­ry duti­ful­ly came to every appoint­ment and answered my
ques­tions with great sin­cer­i­ty, I did not feel we were mak­ing the sort of vital
con­nec­tion that is nec­es­sary for ther­a­py to work. Struck by how frozen and
uptight she was, I sug­gest­ed that she see Liz, a mas­sage ther­a­pist I had
worked with pre­vi­ous­ly. Dur­ing their first meet­ing Liz posi­tioned Sher­ry on
the mas­sage table, then moved to the end of the table and gen­tly held
Sherry’s feet. Lying there with her eyes closed, Sher­ry sud­den­ly yelled in a
pan­ic: “Where are you?” Some­how Sher­ry had lost track of Liz, even
though Liz was right there, with her hands on Sherry’s feet.
Sher­ry was one of the first patients who taught me about the extreme
dis­con­nec­tion from the body that so many peo­ple with his­to­ries of trau­ma
and neglect expe­ri­ence. I dis­cov­ered that my pro­fes­sion­al train­ing, with its
focus on under­stand­ing and insight, had large­ly ignored the rel­e­vance of the
liv­ing, breath­ing body, the foun­da­tion of our selves. Sher­ry knew that
pick­ing her skin was a destruc­tive thing to do and that it was relat­ed to her
mother’s neglect, but under­stand­ing the source of the impulse made no
dif­fer­ence in help­ing her con­trol it.
LOSING YOUR BODY
Once I was alert­ed to this, I was amazed to dis­cov­er how many of my
patients told me they could not feel whole areas of their bod­ies. Some­times
I’d ask them to close their eyes and tell me what I had put into their
out­stretched hands. Whether it was a car key, a quar­ter, or a can open­er,
they often could not even guess what they were holding—their sen­so­ry
per­cep­tions sim­ply weren’t work­ing.
I talked this over with my friend Alexan­der McFar­lane in Aus­tralia,
who had observed the same phe­nom­e­non. In his lab­o­ra­to­ry in Ade­laide he
had stud­ied the ques­tion: How do we know with­out look­ing at it that we’re
hold­ing a car key? Rec­og­niz­ing an object in the palm of your hand requires
sens­ing its shape, weight, tem­per­a­ture, tex­ture, and posi­tion. Each of those
dis­tinct sen­so­ry expe­ri­ences is trans­mit­ted to a dif­fer­ent part of the brain,
which then needs to inte­grate them into a sin­gle per­cep­tion. McFar­lane
found that peo­ple with PTSD often have trou­ble putting the pic­ture
together.2
When our sens­es become muf­fled, we no longer feel ful­ly alive. In an
arti­cle called “What Is an Emo­tion?” (1884),3 William James, the father of
Amer­i­can psy­chol­o­gy, report­ed a strik­ing case of “sen­so­ry insen­si­bil­i­ty” in
a woman he inter­viewed: “I have … no human sen­sa­tions,” she told him.
“[I am] sur­round­ed by all that can ren­der life hap­py and agree­able, still to
me the fac­ul­ty of enjoy­ment and of feel­ing is want­i­ng.… Each of my
sens­es, each part of my prop­er self, is as it were sep­a­rat­ed from me and can
no longer afford me any feel­ing; this impos­si­bil­i­ty seems to depend upon a
void which I feel in the front of my head, and to be due to the diminu­tion of
the sen­si­bil­i­ty over the whole sur­face of my body, for it seems to me that I
nev­er actu­al­ly reach the objects which I touch. All this would be a small
mat­ter enough, but for its fright­ful result, which is that of the impos­si­bil­i­ty
of any oth­er kind of feel­ing and of any sort of enjoy­ment, although I
expe­ri­ence a need and desire of them that ren­der my life an
incom­pre­hen­si­ble tor­ture.”
This response to trau­ma rais­es an impor­tant ques­tion: How can
trau­ma­tized peo­ple learn to inte­grate ordi­nary sen­so­ry expe­ri­ences so that
they can live with the nat­ur­al flow of feel­ing and feel secure and com­plete
in their bod­ies?
HOW DO WE KNOW WE’RE ALIVE?
Most ear­ly neu­roimag­ing stud­ies of trau­ma­tized peo­ple were like those
we’ve seen in chap­ter 3; they focused on how sub­jects react­ed to spe­cif­ic
reminders of the trau­ma. Then, in 2004, my col­league Ruth Lanius, who
scanned Stan and Ute Lawrence’s brains, posed a new ques­tion: What
hap­pens in the brains of trau­ma sur­vivors when they are not think­ing about
the past? Her stud­ies on the idling brain, the “default state net­work” (DSN),
opened up a whole new chap­ter in under­stand­ing how trau­ma affects self-
aware­ness, specif­i­cal­ly sen­so­ry self-awareness.4
Dr. Lanius recruit­ed a group of six­teen “nor­mal” Cana­di­ans to lie in a
brain scan­ner while think­ing about noth­ing in par­tic­u­lar. This is not easy for
any­one to do—as long as we are awake, our brains are churning—but she
asked them to focus their atten­tion on their breath­ing and try to emp­ty their
minds as much as pos­si­ble. She then repeat­ed the same exper­i­ment with
eigh­teen peo­ple who had his­to­ries of severe, chron­ic child­hood abuse.
What is your brain doing when you have noth­ing in par­tic­u­lar on your
mind? It turns out that you pay atten­tion to your­self: The default state
acti­vates the brain areas that work togeth­er to cre­ate your sense of “self.”
When Ruth looked at the scans of her nor­mal sub­jects, she found
acti­va­tion of DSN regions that pre­vi­ous researchers had described. I like to
call this the Mohawk of self-aware­ness, the mid­line struc­tures of the brain,
start­ing out right above our eyes, run­ning through the cen­ter of the brain all
the way to the back. All these mid­line struc­tures are involved in our sense
of self. The largest bright region at the back of the brain is the pos­te­ri­or
cin­gu­late, which gives us a phys­i­cal sense of where we are—our inter­nal
GPS. It is strong­ly con­nect­ed to the medi­al pre­frontal cor­tex (MPFC), the
watch­tow­er I dis­cussed in chap­ter 4. (This con­nec­tion doesn’t show up on
the scan because the fMRI can’t mea­sure it.) It is also con­nect­ed with brain
areas that reg­is­ter sen­sa­tions com­ing from the rest of the body: the insu­la,
which relays mes­sages from the vis­cera to the emo­tion­al cen­ters; the
pari­etal lobes, which inte­grate sen­so­ry infor­ma­tion; and the ante­ri­or
cin­gu­late, which coor­di­nates emo­tions and think­ing. All of these areas
con­tribute to con­scious­ness.
Locat­ing the self. The Mohawk of self-aware­ness. Start­ing from the front of the brain (at
right), this con­sists of: the orbital pre­frontal cor­tex, the medi­al pre­frontal cor­tex, the ante­ri­or
cin­gu­late, the pos­te­ri­or cin­gu­late, and the insu­la. In indi­vid­u­als with his­to­ries of chron­ic trau­ma
the same regions show sharply decreased activ­i­ty, mak­ing it dif­fi­cult to reg­is­ter inter­nal states
and assess­ing the per­son­al rel­e­vance of incom­ing infor­ma­tion.
The con­trast with the scans of the eigh­teen chron­ic PTSD patients with
severe ear­ly-life trau­ma was star­tling. There was almost no acti­va­tion of
any of the self-sens­ing areas of the brain: The MPFC, the ante­ri­or cin­gu­late,
the pari­etal cor­tex, and the insu­la did not light up at all; the only area that
showed a slight acti­va­tion was the pos­te­ri­or cin­gu­late, which is respon­si­ble
for basic ori­en­ta­tion in space.
There could be only one expla­na­tion for such results: In response to the
trau­ma itself, and in cop­ing with the dread that per­sist­ed long after­ward,
these patients had learned to shut down the brain areas that trans­mit the
vis­cer­al feel­ings and emo­tions that accom­pa­ny and define ter­ror. Yet in
every­day life, those same brain areas are respon­si­ble for reg­is­ter­ing the
entire range of emo­tions and sen­sa­tions that form the foun­da­tion of our self-
aware­ness, our sense of who we are. What we wit­nessed here was a trag­ic
adap­ta­tion: In an effort to shut off ter­ri­fy­ing sen­sa­tions, they also dead­ened
their capac­i­ty to feel ful­ly alive.
The dis­ap­pear­ance of medi­al pre­frontal acti­va­tion could explain why so
many trau­ma­tized peo­ple lose their sense of pur­pose and direc­tion. I used to
be sur­prised by how often my patients asked me for advice about the most
ordi­nary things, and then by how rarely they fol­lowed it. Now I under­stood
that their rela­tion­ship with their own inner real­i­ty was impaired. How could
they make deci­sions, or put any plan into action, if they couldn’t define
what they want­ed or, to be more pre­cise, what the sen­sa­tions in their bod­ies,
the basis of all emo­tions, were try­ing to tell them?
The lack of self-aware­ness in vic­tims of chron­ic child­hood trau­ma is
some­times so pro­found that they can­not rec­og­nize them­selves in a mir­ror.
Brain scans show that this is not the result of mere inat­ten­tion: The
struc­tures in charge of self-recog­ni­tion may be knocked out along with the
struc­tures relat­ed to self-expe­ri­ence.
When Ruth Lanius showed me her study, a phrase from my clas­si­cal
high school edu­ca­tion came back to me. The math­e­mati­cian Archimedes,
teach­ing about the lever, is sup­posed to have said: “Give me a place to stand
and I will move the world.” Or, as the great twen­ti­eth-cen­tu­ry body
ther­a­pist Moshe Feldenkrais put it: “You can’t do what you want till you
know what you’re doing.” The impli­ca­tions are clear: to feel present you
have to know where you are and be aware of what is going on with you. If
the self-sens­ing sys­tem breaks down we need to find ways to reac­ti­vate it.
THE SELF-SENSING SYSTEM
It was fas­ci­nat­ing to see how much Sher­ry ben­e­fit­ed from her mas­sage
ther­a­py. She felt more relaxed and adven­tur­ous in her day-to-day life and
she was also more relaxed and open with me. She became tru­ly involved in
her ther­a­py and was gen­uine­ly curi­ous about her behav­ior, thoughts, and
feel­ings. She stopped pick­ing at her skin, and when sum­mer came she
start­ed to spend evenings sit­ting out­side on her stoop, chat­ting with her
neigh­bors. She even joined a church choir, a won­der­ful expe­ri­ence of group
syn­chrony.
It was at about this time that I met Anto­nio Dama­sio at a small think
tank that Dan Schac­ter, the chair of the psy­chol­o­gy depart­ment at Har­vard,
had orga­nized. In a series of bril­liant sci­en­tif­ic arti­cles and books Dama­sio
clar­i­fied the rela­tion­ship among body states, emo­tions, and sur­vival. A
neu­rol­o­gist who has treat­ed hun­dreds of peo­ple with var­i­ous forms of brain
dam­age, he became fas­ci­nat­ed with con­scious­ness and with iden­ti­fy­ing the
areas of the brain nec­es­sary for know­ing what you feel. He has devot­ed his
career to map­ping out what is respon­si­ble for our expe­ri­ence of “self.” The
Feel­ing of What Hap­pens is, for me, his most impor­tant book, and read­ing
it was a revelation.5 Dama­sio starts by point­ing out the deep divide between
our sense of self and the sen­so­ry life of our bod­ies. As he poet­i­cal­ly
explains, “Some­times we use our minds not to dis­cov­er facts, but to hide
them.… One of the things the screen hides most effec­tive­ly is the body,
our own body, by which I mean the ins of it, its inte­ri­ors. Like a veil thrown
over the skin to secure its mod­esty, the screen par­tial­ly removes from the
mind the inner states of the body, those that con­sti­tute the flow of life as it
wan­ders in the jour­ney of each day.”6
He goes on to describe how this “screen” can work in our favor by
enabling us to attend to press­ing prob­lems in the out­side world. Yet it has a
cost: “It tends to pre­vent us from sens­ing the pos­si­ble ori­gin and nature of
what we call self.”7 Build­ing on the cen­tu­ry-old work of William James,
Dama­sio argues that the core of our self-aware­ness rests on the phys­i­cal
sen­sa­tions that con­vey the inner states of the body:
[P]rimordial feel­ings pro­vide a direct expe­ri­ence of one’s own
liv­ing body, word­less, unadorned, and con­nect­ed to noth­ing but
sheer exis­tence. These pri­mor­dial feel­ings reflect the cur­rent state
of the body along var­ied dimen­sions, … along the scale that
ranges from plea­sure to pain, and they orig­i­nate at the lev­el of the
brain stem rather than the cere­bral cor­tex. All feel­ings of emo­tion
are com­plex musi­cal vari­a­tions on pri­mor­dial feelings.8
Our sen­so­ry world takes shape even before we are born. In the womb
we feel amni­ot­ic flu­id against our skin, we hear the faint sounds of rush­ing
blood and a diges­tive tract at work, we pitch and roll with our mother’s
move­ments. After birth, phys­i­cal sen­sa­tion defines our rela­tion­ship to
our­selves and to our sur­round­ings. We start off being our wet­ness, hunger,
sati­a­tion, and sleepi­ness. A cacoph­o­ny of incom­pre­hen­si­ble sounds and
images press­es in on our pris­tine ner­vous sys­tem. Even after we acquire
con­scious­ness and lan­guage, our bod­i­ly sens­ing sys­tem pro­vides cru­cial
feed­back on our moment-to-moment con­di­tion. Its con­stant hum
com­mu­ni­cates changes in our vis­cera and in the mus­cles of our face, tor­so,
and extrem­i­ties that sig­nal pain and com­fort, as well as urges such as
hunger and sex­u­al arousal. What is tak­ing place around us also affects our
phys­i­cal sen­sa­tions. See­ing some­one we rec­og­nize, hear­ing par­tic­u­lar
sounds—a piece of music, a siren—or sens­ing a shift in tem­per­a­ture all
change our focus of atten­tion and, with­out our being aware of it, prime our
sub­se­quent thoughts and actions.
As we have seen, the job of the brain is to con­stant­ly mon­i­tor and
eval­u­ate what is going on with­in and around us. These eval­u­a­tions are
trans­mit­ted by chem­i­cal mes­sages in the blood­stream and elec­tri­cal
mes­sages in our nerves, caus­ing sub­tle or dra­mat­ic changes through­out the
body and brain. These shifts usu­al­ly occur entire­ly with­out con­scious input
or aware­ness: The sub­cor­ti­cal regions of the brain are astound­ing­ly effi­cient
in reg­u­lat­ing our breath­ing, heart­beat, diges­tion, hor­mone secre­tion, and
immune sys­tem. How­ev­er, these sys­tems can become over­whelmed if we
are chal­lenged by an ongo­ing threat, or even the per­cep­tion of threat. This
accounts for the wide array of phys­i­cal prob­lems researchers have
doc­u­ment­ed in trau­ma­tized peo­ple.
Yet our con­scious self also plays a vital role in main­tain­ing our inner
equi­lib­ri­um: We need to reg­is­ter and act on our phys­i­cal sen­sa­tions to keep
our bod­ies safe. Real­iz­ing we’re cold com­pels us to put on a sweater;
feel­ing hun­gry or spacey tells us our blood sug­ar is low and spurs us to get
a snack; the pres­sure of a full blad­der sends us to the bath­room. Dama­sio
points out that all of the brain struc­tures that reg­is­ter back­ground feel­ings
are locat­ed near areas that con­trol basic house­keep­ing func­tions, such as
breath­ing, appetite, elim­i­na­tion, and sleep/wake cycles: “This is because the
con­se­quences of hav­ing emo­tion and atten­tion are entire­ly relat­ed to the
fun­da­men­tal busi­ness of man­ag­ing life with­in the organ­ism. It is not
pos­si­ble to man­age life and main­tain home­o­sta­t­ic bal­ance with­out data on
the cur­rent state of the organism’s body.”9 Dama­sio calls these
house­keep­ing areas of the brain the “pro­to-self,” because they cre­ate the
“word­less knowl­edge” that under­lies our con­scious sense of self.
THE SELF UNDER THREAT
In 2000 Dama­sio and his col­leagues pub­lished an arti­cle in the world’s
fore­most sci­en­tif­ic pub­li­ca­tion, Sci­ence, which report­ed that reliv­ing a
strong neg­a­tive emo­tion caus­es sig­nif­i­cant changes in the brain areas that
receive nerve sig­nals from the mus­cles, gut, and skin—areas that are cru­cial
for reg­u­lat­ing basic bod­i­ly func­tions. The team’s brain scans showed that
recall­ing an emo­tion­al event from the past caus­es us to actu­al­ly
reex­pe­ri­ence the vis­cer­al sen­sa­tions felt dur­ing the orig­i­nal event. Each type
of emo­tion pro­duced a char­ac­ter­is­tic pat­tern, dis­tinct from the oth­ers. For
exam­ple, a par­tic­u­lar part of the brain stem was “active in sad­ness and
anger, but not in hap­pi­ness or fear.”10 All of these brain regions are below
the lim­bic sys­tem, to which emo­tions are tra­di­tion­al­ly assigned, yet we
acknowl­edge their involve­ment every time we use one of the com­mon
expres­sions that link strong emo­tions with the body: “You make me sick”;
“It made my skin crawl”; “I was all choked up”; “My heart sank”; “He
makes me bris­tle.”
The ele­men­tary self sys­tem in the brain stem and lim­bic sys­tem is
mas­sive­ly acti­vat­ed when peo­ple are faced with the threat of anni­hi­la­tion,
which results in an over­whelm­ing sense of fear and ter­ror accom­pa­nied by
intense phys­i­o­log­i­cal arousal. To peo­ple who are reliv­ing a trau­ma, noth­ing
makes sense; they are trapped in a life-or-death sit­u­a­tion, a state of
par­a­lyz­ing fear or blind rage. Mind and body are con­stant­ly aroused, as if
they are in immi­nent dan­ger. They star­tle in response to the slight­est nois­es
and are frus­trat­ed by small irri­ta­tions. Their sleep is chron­i­cal­ly dis­turbed,
and food often los­es its sen­su­al plea­sures. This in turn can trig­ger des­per­ate
attempts to shut those feel­ings down by freez­ing and dissociation.11
How do peo­ple regain con­trol when their ani­mal brains are stuck in a
fight for sur­vival? If what goes on deep inside our ani­mal brains dic­tates
how we feel, and if our body sen­sa­tions are orches­trat­ed by sub­cor­ti­cal
(sub­con­scious) brain struc­tures, how much con­trol over them can we
actu­al­ly have?
AGENCY: OWNING YOUR LIFE
“Agency” is the tech­ni­cal term for the feel­ing of being in charge of your
life: know­ing where you stand, know­ing that you have a say in what
hap­pens to you, know­ing that you have some abil­i­ty to shape your
cir­cum­stances. The vet­er­ans who put their fists through dry­wall at the VA
were try­ing to assert their agency—to make some­thing hap­pen. But they
end­ed up feel­ing even more out of con­trol, and many of these once-
con­fi­dent men were trapped in a cycle between fran­tic activ­i­ty and
immo­bil­i­ty.
Agency starts with what sci­en­tists call inte­ro­cep­tion, our aware­ness of
our sub­tle sen­so­ry, body-based feel­ings: the greater that aware­ness, the
greater our poten­tial to con­trol our lives. Know­ing what we feel is the first
step to know­ing why we feel that way. If we are aware of the con­stant
changes in our inner and out­er envi­ron­ment, we can mobi­lize to man­age
them. But we can’t do this unless our watch­tow­er, the MPFC, learns to
observe what is going on inside us. This is why mind­ful­ness prac­tice, which
strength­ens the MPFC, is a cor­ner­stone of recov­ery from trauma.12
After I saw the won­der­ful movie March of the Pen­guins, I found
myself think­ing about some of my patients. The pen­guins are sto­ic and
endear­ing, and it’s trag­ic to learn how, from time immemo­r­i­al, they have
trudged sev­en­ty miles inland from the sea, endured inde­scrib­able hard­ships
to reach their breed­ing grounds, lost numer­ous viable eggs to expo­sure, and
then, almost starv­ing, dragged them­selves back to the ocean. If pen­guins
had our frontal lobes, they would have used their lit­tle flip­pers to build
igloos, devised a bet­ter divi­sion of labor, and reor­ga­nized their food
sup­plies. Many of my patients have sur­vived trau­ma through tremen­dous
courage and per­sis­tence, only to get into the same kinds of trou­ble over and
over again. Trau­ma has shut down their inner com­pass and robbed them of
the imag­i­na­tion they need to cre­ate some­thing bet­ter.
The neu­ro­science of self­hood and agency val­i­dates the kinds of somat­ic
ther­a­pies that my friends Peter Levine13 and Pat Ogden14 have devel­oped.
I’ll dis­cuss these and oth­er sen­so­ri­mo­tor approach­es in more detail in part
V, but in essence their aim is three­fold:
to draw out the sen­so­ry infor­ma­tion that is blocked and frozen
by trau­ma;
to help patients befriend (rather than sup­press) the ener­gies
released by that inner expe­ri­ence;
to com­plete the self-pre­serv­ing phys­i­cal actions that were
thwart­ed when they were trapped, restrained, or immo­bi­lized by
ter­ror.
Our gut feel­ings sig­nal what is safe, life sus­tain­ing, or threat­en­ing, even
if we can­not quite explain why we feel a par­tic­u­lar way. Our sen­so­ry
inte­ri­or­i­ty con­tin­u­ous­ly sends us sub­tle mes­sages about the needs of our
organ­ism. Gut feel­ings also help us to eval­u­ate what is going on around us.
They warn us that the guy who is approach­ing feels creepy, but they also
con­vey that a room with west­ern expo­sure sur­round­ed by daylilies makes us
feel serene. If you have a com­fort­able con­nec­tion with your inner
sensations—if you can trust them to give you accu­rate information—you
will feel in charge of your body, your feel­ings, and your self.
How­ev­er, trau­ma­tized peo­ple chron­i­cal­ly feel unsafe inside their
bod­ies: The past is alive in the form of gnaw­ing inte­ri­or dis­com­fort. Their
bod­ies are con­stant­ly bom­bard­ed by vis­cer­al warn­ing signs, and, in an
attempt to con­trol these process­es, they often become expert at ignor­ing
their gut feel­ings and in numb­ing aware­ness of what is played out inside.
They learn to hide from their selves.
The more peo­ple try to push away and ignore inter­nal warn­ing signs,
the more like­ly they are to take over and leave them bewil­dered, con­fused,
and ashamed. Peo­ple who can­not com­fort­ably notice what is going on
inside become vul­ner­a­ble to respond to any sen­so­ry shift either by shut­ting
down or by going into a panic—they devel­op a fear of fear itself.
We now know that pan­ic symp­toms are main­tained large­ly because the
indi­vid­ual devel­ops a fear of the bod­i­ly sen­sa­tions asso­ci­at­ed with pan­ic
attacks. The attack may be trig­gered by some­thing he or she knows is
irra­tional, but fear of the sen­sa­tions keeps them esca­lat­ing into a full-body
emer­gency. “Scared stiff” and “frozen in fear” (col­laps­ing and going numb)
describe pre­cise­ly what ter­ror and trau­ma feel like. They are its vis­cer­al
foun­da­tion. The expe­ri­ence of fear derives from prim­i­tive respons­es to
threat where escape is thwart­ed in some way. People’s lives will be held
hostage to fear until that vis­cer­al expe­ri­ence changes.
The price for ignor­ing or dis­tort­ing the body’s mes­sages is being unable
to detect what is tru­ly dan­ger­ous or harm­ful for you and, just as bad, what is
safe or nour­ish­ing. Self-reg­u­la­tion depends on hav­ing a friend­ly
rela­tion­ship with your body. With­out it you have to rely on exter­nal
regulation—from med­ica­tion, drugs like alco­hol, con­stant reas­sur­ance, or
com­pul­sive com­pli­ance with the wish­es of oth­ers.
Many of my patients respond to stress not by notic­ing and nam­ing it
but by devel­op­ing migraine headaches or asth­ma attacks.15 Sandy, a
mid­dle-aged vis­it­ing nurse, told me she’d felt ter­ri­fied and lone­ly as a child,
unseen by her alco­holic par­ents. She dealt with this by becom­ing def­er­en­tial
to every­body she depend­ed on (includ­ing me, her ther­a­pist). When­ev­er her
hus­band made an insen­si­tive remark, she would come down with an asth­ma
attack. By the time she noticed that she couldn’t breathe, it was too late for
an inhaler to be effec­tive, and she had to be tak­en to the emer­gency room.
Sup­press­ing our inner cries for help does not stop our stress hor­mones
from mobi­liz­ing the body. Even though Sandy had learned to ignore her
rela­tion­ship prob­lems and block out her phys­i­cal dis­tress sig­nals, they
showed up in symp­toms that demand­ed her atten­tion. Her ther­a­py focused
on iden­ti­fy­ing the link between her phys­i­cal sen­sa­tions and her emo­tions,
and I also encour­aged her to enroll in a kick­box­ing pro­gram. She had no
emer­gency room vis­its dur­ing the three years she was my patient.
Somat­ic symp­toms for which no clear phys­i­cal basis can be found are
ubiq­ui­tous in trau­ma­tized chil­dren and adults. They can include chron­ic
back and neck pain, fibromyal­gia, migraines, diges­tive prob­lems, spas­tic
colon/irritable bow­el syn­drome, chron­ic fatigue, and some forms of
asthma.16 Trau­ma­tized chil­dren have fifty times the rate of asth­ma as their
non­trau­ma­tized peers.17 Stud­ies have shown that many chil­dren and adults
with fatal asth­ma attacks were not aware of hav­ing breath­ing prob­lems
before the attacks.
ALEXITHYMIA: NO WORDS FOR FEELINGS
I had a wid­owed aunt with a painful trau­ma his­to­ry who became an
hon­orary grand­moth­er to our chil­dren. She came on fre­quent vis­its that
were marked by much doing—making cur­tains, rear­rang­ing kitchen
shelves, sewing children’s clothes—and very lit­tle talk­ing. She was always
eager to please, but it was dif­fi­cult to fig­ure out what she enjoyed. After
sev­er­al days of exchang­ing pleas­antries, con­ver­sa­tion would come to a halt,
and I’d have to work hard to fill the long silences. On the last day of her
vis­its I’d dri­ve her to the air­port, where she’d give me a stiff good-bye hug
while tears streamed down her face. With­out a trace of irony she’d then
com­plain that the cold wind at Logan Inter­na­tion­al Air­port made her eyes
water. Her body felt the sad­ness that her mind couldn’t register—she was
leav­ing our young fam­i­ly, her clos­est liv­ing rel­a­tives.
Psy­chi­a­trists call this phe­nom­e­non alexithymia—Greek for not hav­ing
words for feel­ings. Many trau­ma­tized chil­dren and adults sim­ply can­not
describe what they are feel­ing because they can­not iden­ti­fy what their
phys­i­cal sen­sa­tions mean. They may look furi­ous but deny that they are
angry; they may appear ter­ri­fied but say that they are fine. Not being able to
dis­cern what is going on inside their bod­ies caus­es them to be out of touch
with their needs, and they have trou­ble tak­ing care of them­selves, whether it
involves eat­ing the right amount at the right time or get­ting the sleep they
need.
Like my aunt, alex­ithymics sub­sti­tute the lan­guage of action for that of
emo­tion. When asked, “How would you feel if you saw a truck com­ing at
you at eighty miles per hour?” most peo­ple would say, “I’d be ter­ri­fied” or
“I’d be frozen with fear.” An alex­ithymic might reply, “How would I feel? I
don’t know.… I’d get out of the way.”18 They tend to reg­is­ter emo­tions as
phys­i­cal prob­lems rather than as sig­nals that some­thing deserves their
atten­tion. Instead of feel­ing angry or sad, they expe­ri­ence mus­cle pain,
bow­el irreg­u­lar­i­ties, or oth­er symp­toms for which no cause can be found.
About three quar­ters of patients with anorex­ia ner­vosa, and more than half
of all patients with bulim­ia, are bewil­dered by their emo­tion­al feel­ings and
have great dif­fi­cul­ty describ­ing them.19 When researchers showed pic­tures
of angry or dis­tressed faces to peo­ple with alex­ithymia, they could not
fig­ure out what those peo­ple were feeling.20
One of the first peo­ple who taught me about alex­ithymia was the
psy­chi­a­trist Hen­ry Krys­tal, who worked with more than a thou­sand
Holo­caust sur­vivors in his effort to under­stand mas­sive psy­chic trauma.21
Krys­tal, him­self a con­cen­tra­tion camp sur­vivor, found that many of his
patients were pro­fes­sion­al­ly suc­cess­ful, but their inti­mate rela­tion­ships were
bleak and dis­tant. Sup­press­ing their feel­ings had made it pos­si­ble to attend
to the busi­ness of the world, but at a price. They learned to shut down their
once over­whelm­ing emo­tions, and, as a result, they no longer rec­og­nized
what they were feel­ing. Few of them had any inter­est in ther­a­py.
Paul Frewen at the Uni­ver­si­ty of West­ern Ontario did a series of brain
scans of peo­ple with PTSD who suf­fered from alex­ithymia. One of the
par­tic­i­pants told him: “I don’t know what I feel, it’s like my head and body
aren’t con­nect­ed. I’m liv­ing in a tun­nel, a fog, no mat­ter what hap­pens it’s
the same reaction—numbness, noth­ing. Hav­ing a bub­ble bath and being
burned or raped is the same feel­ing. My brain doesn’t feel.” Frewen and his
col­league Ruth Lanius found that the more peo­ple were out of touch with
their feel­ings, the less activ­i­ty they had in the self-sens­ing areas of the
brain.22
Because trau­ma­tized peo­ple often have trou­ble sens­ing what is going
on in their bod­ies, they lack a nuanced response to frus­tra­tion. They either
react to stress by becom­ing “spaced out” or with exces­sive anger. What­ev­er
their response, they often can’t tell what is upset­ting them. This fail­ure to be
in touch with their bod­ies con­tributes to their well-doc­u­ment­ed lack of self-
pro­tec­tion and high rates of revictimization23 and also to their remark­able
dif­fi­cul­ties feel­ing plea­sure, sen­su­al­i­ty, and hav­ing a sense of mean­ing.
Peo­ple with alex­ithymia can get bet­ter only by learn­ing to rec­og­nize
the rela­tion­ship between their phys­i­cal sen­sa­tions and their emo­tions, much
as col­or­blind peo­ple can only enter the world of col­or by learn­ing to
dis­tin­guish and appre­ci­ate shades of gray. Like my aunt and Hen­ry
Krystal’s patients, they usu­al­ly are reluc­tant to do that: Most seem to have
made an uncon­scious deci­sion that it is bet­ter to keep vis­it­ing doc­tors and
treat­ing ail­ments that don’t heal than to do the painful work of fac­ing the
demons of the past.
DEPERSONALIZATION
One step fur­ther down on the lad­der to self-obliv­ion is deper­son­al­iza­tion—
los­ing your sense of your­self. Ute’s brain scan in chap­ter 4 is, in its very
blank­ness, a vivid illus­tra­tion of deper­son­al­iza­tion. Deper­son­al­iza­tion is
com­mon dur­ing trau­mat­ic expe­ri­ences. I was once mugged late at night in a
park close to my home and, float­ing above the scene, saw myself lying in
the snow with a small head wound, sur­round­ed by three knife-wield­ing
teenagers. I dis­so­ci­at­ed the pain of their stab wounds on my hands and did
not feel the slight­est fear as I calm­ly nego­ti­at­ed for the return of my
emp­tied wal­let.
I did not devel­op PTSD, part­ly, I think, because I was intense­ly curi­ous
about hav­ing an expe­ri­ence I had stud­ied so close­ly in oth­ers, and part­ly
because I had the delu­sion that I would be able make a draw­ing of my
mug­gers to show to the police. Of course, they were nev­er caught, but my
fan­ta­sy of revenge must have giv­en me a sat­is­fy­ing sense of agency.
Trau­ma­tized peo­ple are not so for­tu­nate and feel sep­a­rat­ed from their
bod­ies. One par­tic­u­lar­ly good descrip­tion of deper­son­al­iza­tion comes from
the Ger­man psy­cho­an­a­lyst Paul Schilder, writ­ing in Berlin in 1928:24 “To
the deper­son­al­ized indi­vid­ual the world appears strange, pecu­liar, for­eign,
dream-like. Objects appear at times strange­ly dimin­ished in size, at times
flat. Sounds appear to come from a dis­tance.… The emo­tions like­wise
under­go marked alter­ation. Patients com­plain that they are capa­ble of
expe­ri­enc­ing nei­ther pain nor plea­sure.… They have become strangers to
them­selves.”
I was fas­ci­nat­ed to learn that a group of neu­ro­sci­en­tists at the
Uni­ver­si­ty of Geneva25 had induced sim­i­lar out-of-body expe­ri­ences by
deliv­er­ing mild elec­tric cur­rent to a spe­cif­ic spot in the brain, the tem­po­ral
pari­etal junc­tion. In one patient this pro­duced a sen­sa­tion that she was
hang­ing from the ceil­ing, look­ing down at her body; in anoth­er it induced
an eerie feel­ing that some­one was stand­ing behind her. This research
con­firms what our patients tell us: that the self can be detached from the
body and live a phan­tom exis­tence on its own. Sim­i­lar­ly, Lanius and
Frewen, as well as a group of researchers at the Uni­ver­si­ty of Gronin­gen in
the Netherlands,26 did brain scans on peo­ple who dis­so­ci­at­ed their ter­ror
and found that the fear cen­ters of the brain sim­ply shut down as they
recalled the event.
BEFRIENDING THE BODY
Trau­ma vic­tims can­not recov­er until they become famil­iar with and
befriend the sen­sa­tions in their bod­ies. Being fright­ened means that you live
in a body that is always on guard. Angry peo­ple live in angry bod­ies. The
bod­ies of child-abuse vic­tims are tense and defen­sive until they find a way
to relax and feel safe. In order to change, peo­ple need to become aware of
their sen­sa­tions and the way that their bod­ies inter­act with the world around
them. Phys­i­cal self-aware­ness is the first step in releas­ing the tyran­ny of the
past.
How can peo­ple open up to and explore their inter­nal world of
sen­sa­tions and emo­tions? In my prac­tice I begin the process by help­ing my
patients to first notice and then describe the feel­ings in their bodies—not
emo­tions such as anger or anx­i­ety or fear but the phys­i­cal sen­sa­tions
beneath the emo­tions: pres­sure, heat, mus­cu­lar ten­sion, tin­gling, cav­ing in,
feel­ing hol­low, and so on. I also work on iden­ti­fy­ing the sen­sa­tions
asso­ci­at­ed with relax­ation or plea­sure. I help them become aware of their
breath, their ges­tures and move­ments. I ask them to pay atten­tion to sub­tle
shifts in their bod­ies, such as tight­ness in their chests or gnaw­ing in their
bel­lies, when they talk about neg­a­tive events that they claim did not both­er
them.
Notic­ing sen­sa­tions for the first time can be quite dis­tress­ing, and it
may pre­cip­i­tate flash­backs in which peo­ple curl up or assume defen­sive
pos­tures. These are somat­ic reen­act­ments of the undi­gest­ed trau­ma and
most like­ly rep­re­sent the pos­tures they assumed when the trau­ma occurred.
Images and phys­i­cal sen­sa­tions may del­uge patients at this point, and the
ther­a­pist must be famil­iar with ways to stem tor­rents of sen­sa­tion and
emo­tion to pre­vent them from becom­ing retrau­ma­tized by access­ing the
past. (School­teach­ers, nurs­es, and police offi­cers are often very skilled at
sooth­ing ter­ror reac­tions because many of them are con­front­ed almost dai­ly
with out-of-con­trol or painful­ly dis­or­ga­nized peo­ple.)
All too often, how­ev­er, drugs such as Abil­i­fy, Zyprexa, and Sero­quel,
are pre­scribed instead of teach­ing peo­ple the skills to deal with such
dis­tress­ing phys­i­cal reac­tions. Of course, med­ica­tions only blunt sen­sa­tions
and do noth­ing to resolve them or trans­form them from tox­ic agents into
allies.
The most nat­ur­al way for human beings to calm them­selves when they
are upset is by cling­ing to anoth­er per­son. This means that patients who
have been phys­i­cal­ly or sex­u­al­ly vio­lat­ed face a dilem­ma: They des­per­ate­ly
crave touch while simul­ta­ne­ous­ly being ter­ri­fied of body con­tact. The mind
needs to be reed­u­cat­ed to feel phys­i­cal sen­sa­tions, and the body needs to be
helped to tol­er­ate and enjoy the com­forts of touch. Indi­vid­u­als who lack
emo­tion­al aware­ness are able, with prac­tice, to con­nect their phys­i­cal
sen­sa­tions to psy­cho­log­i­cal events. Then they can slow­ly recon­nect with
themselves.27
CONNECTING WITH YOURSELF, CONNECTING WITH
OTHERS
I’ll end this chap­ter with one final study that demon­strates the cost of los­ing
your body. After Ruth Lanius and her group scanned the idling brain, they
focused on anoth­er ques­tion from every­day life: What hap­pens in
chron­i­cal­ly trau­ma­tized peo­ple when they make face-to-face con­tact?
Many patients who come to my office are unable to make eye con­tact. I
imme­di­ate­ly know how dis­tressed they are by their dif­fi­cul­ty meet­ing my
gaze. It always turns out that they feel dis­gust­ing and that they can’t stand
hav­ing me see how despi­ca­ble they are. It nev­er occurred to me that these
intense feel­ings of shame would be reflect­ed in abnor­mal brain acti­va­tion.
Ruth Lanius once again showed that mind and brain are indis­tin­guish­able—
what hap­pens in one is reg­is­tered in the oth­er.