In Terror’s Grip: Healing the Ravages of Trauma

Thursday, July 23rd, 2009 | Best of The Cutting Edge | No Comments

Note: This article was originally published in the Spring 2006 edition of Cutting Edge, the online newsletter of The Meadows.

In Terror’s Grip: Healing the Ravages of Trauma
By Bessel A. van der Kolk, MD

From research on trauma’s impact on various victim populations, we have learned that the great majority of people not affected immediately and personally by a terrible tragedy sustain no lasting damage. Most of those who witness devastating events are able, in the long term, to find ways of going on with their lives with little change in their capacity to experience love, trust, and hope for the future.

The critical difference between a stressful but normal event and trauma is a feeling of helplessness to change the outcome. This is obvious when people are trapped physically, or their cries for help go unheeded. A nightmarish example is the experience of waking up during anesthesia, which is thought to happen to some 30,000 people a year undergoing surgical procedures in the United States. If this were to happen to you, you would be conscious and aware of where you were and what was happening but, because of muscle relaxants and other drugs, you would be unable to move or speak. Psychological trauma is a frequent result.

As long as people can imagine having some control over what is happening to them, they usually can keep their wits about them. Only when they are faced with inevitable catastrophe do victims experience intense fear and feelings of loss and desertion. Hearing unanswered screams for help or witnessing mutilated human bodies, as happened to some survivors of the September 11th attacks in Manhattan and Washington D.C., is particularly disturbing. In addition, many trauma survivors, including rape and torture victims, have come face-to-face with human evil, witnessing people taking pleasure in inflicting humiliation and suffering.

Feeling helpless against a dire threat, people may experience numbness, withdrawal, confusion, shock, or speechless terror. Staying focused on problem solving, on doing something, however small, about the situation—rather than concentrating on one’s distress—reduces the chances of developing post-traumatic  stress disorder (PTSD). In contrast, spacing out (dissociating) during a traumatic event often predicts the development of subsequent PTSD. The longer the traumatic experience lasts, the more likely the victim is to react by dissociating. Once a person dissociates, he becomes incapable of goal-directed action.

People’s responses to the traumatic event change as time passes. Usually, there is an initial outcry, seeking of help and attempt to re-establish social connections. Once victims have regained a sense of physical safety, they can assess the damage and begin to adjust or assimilate—a process that may take months or years. It is primarily their social context that re-establishes the feeling of safety vital for successful recovery. This initial social response will shape the way the victim comes to perceive the safety of the world and the benevolence or malevolence of others. If people in the social environment refuse to step in when a person’s own resources are exhausted, this may become as great a source of devastation as the original trauma itself, seeding further helplessness, rage, and shame. Many people who feel powerless to change the outcome of events resort to “emotion-focused” coping; they try to alter their emotional state instead of the circumstances giving rise to it. About one-third of traumatized people eventually turn to alcohol or drugs in a (usually ill-fated) search for relief. This coping behavior is often a prelude to developing PTSD.

Failing to reset their equilibrium after a traumatic experience, people are prone to develop the cluster of symptoms that we diagnose as PTSD. At the core of PTSD is the concept that the imprint of the traumatic event comes to dominate how victims organize their lives. People with PTSD perceive most subsequent stressful life events in the light of their prior trauma. This focus on the past gradually robs their lives of meaning and pleasure.

People who merely remember a specific event usually do not also relive the images, smells, physical sensations, or sounds associated with that event. Instead, the remembered aspects of the experience coalesce into a story that captures the essence of what happened. As people tell others the story, the narrative gradually changes, and the event is understood as something belonging to the past.

Thus, the core pathology of PTSD is that certain sensations or emotions related to traumatic experiences are dissociated, keep returning in unbidden ways, and do not fade with time. It is normal to distort one’s memories over the years, but people with PTSD seem unable to put an event behind them or minimize its impact.

Traumatized people rarely realize that their intense feelings and reactions are based on past experience. They blame their present surroundings for the way they feel and thereby rationalize their feelings. The almost infinite capacity to rationalize in this way keeps them from having to confront the helplessness and horror of their past; they are protected from becoming aware of the true meaning of the messages they receive from the brain areas that specialize in self-preservation and detection of danger.

If the problem with PTSD is dissociation, treatment should consist of association. Freud wrote in Remembering, Repeating and Working Through that “While the patient lives it 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.” Thus, psychotherapy has emphasized helping patients to give a full account of their trauma in words, pictures, or some other symbolic form, such as theater or poetry. For traditional therapy, this has meant focusing on the construction of a narrative that explains why a person feels a particular way, the expectation being that, by understanding the context of the feelings, the symptoms (sensations, perceptions, and emotional and physical reactions) will disappear. Unfortunately, there is little evidence that simply creating a narrative, without the added process of association, succeeds.

Under ordinary conditions, the brain structures involved in interpreting what is going on around us function in harmony. The subcortical areas of the brain represent past experience differently than the more recently evolved parts of the brain, which are located in the prefrontal cortex. These higher cortical structures create language and symbols that enable us to communicate about our personal past. When people are frightened or aroused, the frontal areas of the brain, which analyze an experience and associate it with other knowledge, are deactivated.

In people with PTSD, specific deactivation of the dorsolateral prefrontal cortex (which is responsible for executive function) interferes with the ability to formulate a measured response to a threat. At the same time, high levels of arousal interfere with the adequate functioning of the brain region necessary to put one’s feelings into words: Broca’s area. Traumatized people suffer speechless terror.

Under conditions of intense arousal, the more primitive areas of the brain—the limbic system and brain stem—may generate sensations and emotions that contradict one’s conscious attitudes and beliefs. Sensations of fear and anxiety coming from the subcortex can cause traumatized people to behave irrationally in response to stimuli that are objectively neutral, or merely stressful.

The usual regulatory system of adults is a kind of top-down processing based on cognition and operated by the brain’s neocortex. This allows for high-level executive functioning: observing, monitoring, integrating, and planning. The system can function effectively only if it succeeds in inhibiting the input from lower brain levels. However, top-down processing techniques relied upon by traditional psychotherapy inhibit rather than process (or integrate) unpleasant sensations and emotions. A prime characteristic of both children and adults with PTSD is that, in the face of a threat, they cannot inhibit emotional states that originate in physical sensations.

When asked to put their trauma into words, many people respond physically—as if they were traumatized all over again— and so do not gain any relief. In fact, reliving the trauma without being firmly anchored in the present often leaves PTSD sufferers more traumatized. Because recalling the trauma can be so painful, many people with PTSD choose not to expose themselves to situations, including psychotherapy, in which they are asked to do so. A challenge in treating PTSD is to help people process and integrate their traumatic experiences without feeling retraumatized—to process trauma so that it is quenched, not kindled.

Above all, treatment should seek to decondition people from their trauma-based physical responses. Medications such as selective serotonin reuptake inhibitors can alleviate the distress of PTSD, but survivors still need to find ways to put the traumatic event into perspective—as an element of their personal history that happened at a particular time, in a particular place.

In summary, there are three critical steps in treating PTSD: safety, management of anxiety, and emotional processing.

When people’s own resources prove inadequate to deal with a threat, they need to rely on others for safety and care. It is critical that trauma victims re-establish contact with their natural social support system. If that system is inadequate to ensure one’s safety, the help of institutional resources will be needed.

After safety is assured, psychological intervention may be needed. People have to learn to put words to the problems they face, to name them, and to formulate appropriate solutions. Victims of assault must learn to distinguish between real threats and the haunting, irrational fears that are part of the disorder. If anxiety dominates, victims need help to strengthen their coping skills. Practical anxiety management skills may include training in deep muscle relaxation, control of breathing, role-playing, and yoga.

Trauma victims must gain enough distance from their sensory imprints and trauma-related emotions to observe and analyze them without becoming hyper-aroused or engaging in avoidance maneuvers. One tool for this is serotonin reuptake blockers, which can help PTSD patients gain the necessary emotional distance from traumatic stimuli to make sense of what is happening to them.

After alleviating the most distressing symptoms, it is important to help people with PTSD find a language for understanding and communicating their experiences. To put the traumatic event in perspective, the victim needs to relive it without feeling helpless. Traditionally, following Freud’s notion that words can substitute for action to resolve a trauma, victims are asked to articulate, in detail, what happened and what led up to it, their own contributions to what happened, their thoughts and fantasies during the event, the worst part of it, and their reactions to the event, including how it has affected their perceptions of themselves and others. This exposure therapy is thought to reduce symptoms by allowing patients to realize both that remembering the trauma is not equivalent to experiencing it again, and that the experience had a beginning, middle, and end. It belongs to their personal history—to the past, not the present.

The study of trauma has been perhaps the most fertile area within psychiatry and psychology in terms of promoting deeper understanding of how emotional, cognitive, social, and biological forces interact in human development. Trauma study has yielded entirely new insights into the way extreme experiences may profoundly affect our memory, how our bodies as well as our minds respond to stress, our ability to regulate our emotions, and our relationships to other people. Now, it promises to shed light on the fundamental question of how the mind integrates experience to prepare itself for future threats, even as it distinguishes between what belongs to the present and what belongs to the past. These discoveries, together with a range of new therapy approaches, are opening entirely new perspectives on how people who have been traumatized—whether by an individual in a private act of violence or by a disaster affecting an entire society—can be helped to overcome the tyranny of the past.

About the Author
Bessel A. van der Kolk, Clinical Consultant for The Meadows and Mellody House, is one of the world’s foremost authorities in the area of posttraumatic stress and related phenomena. His research work has ranged from the psychobiology of trauma to traumatic memory, and from the effectiveness of EMDR to the effects of trauma on human development. He is professor of psychiatry at Boston University School of Medicine and medical director of the Trauma Center in Boston, a Community Practice site of the National Child Traumatic Stress Network. The Trauma Center is one of the foremost training sites in the country for psychologists and psychiatrists specializing in the treatment of traumatized children and adults.

Pia Mellody’s, The Intimacy Factor, “Best. Books. Ever.”

Thursday, July 16th, 2009 | Meadows in the Media | No Comments

Newsweek Magazine, July 13, 2009, asked individuals some of their favorite books and listed them as, “Best. Books. Ever.” (pp.56.)  On the top of Dr. Drew Pinsky’s list as a “book to save your marriage, The Intimacy Factor,  by Pia Mellody and Laurence S. Freulich. ”

Preventing and Healing the Sacred Wound of Sexual Molestation

Thursday, July 9th, 2009 | Best of The Cutting Edge | No Comments

Note: This article is excerpted from the recent book by Peter A. Levine and Maggie Kline: Trauma Through a Child’s Eyes: Awakening the Ordinary Miracle of Healing (North Atlantic Books, 2007). The article originally appeared in the Spring 2007 edition of Cutting Edge, the online newsletter of The Meadows.

Preventing and Healing the Sacred Wound of Sexual Molestation
By Peter A. Levine & Maggie Kline

Unless you have personally experienced the deep wound of childhood sexual trauma, it may be difficult to imagine how complex, confusing, and varied the long-term effects can be. This is especially true when the molestation was perpetrated by someone the child trusted, or even loved. When a child’s   innocence is stolen, it affects his or her self-worth, personality development, socialization, achievement and, later, intimacy in adolescent and adult relationships. In addition, these children are prone to somatic symptoms – such as physical rigidity, awkwardness, or excessive weight gain/loss – born of a conscious or unconscious attempt to “lock out” others and not be in one’s own body. Also common are tendencies to live in a fantasy world, to have problems with attention (spacing out and daydreaming) and to dissociate in order to compartmentalize the awful experiences.

Sexual trauma varies widely, from overt sexual assault to covert desires that frighten and confuse a child by invading his or her delicate boundaries with unbounded adult sexual energies. When parents have experienced unresolved sexual violations themselves, or were lacked models for healthy adult sexuality in their families of origin, they may have difficulties protecting children without conveying a sense of fear and rigidity around issues of touch, affection, boundaries, and sensuality. Or conversely, parents might avoid offering either discussion or protection due to their own lack of experience in sensing, within themselves, the difference between potentially safe and dangerous situations and people.

Are Some Children More Vulnerable Than Others?

The majority of parents, communities, and school programs warn children to avoid “dangerous strangers.” Sadly, strangers are seldom the problem. Other myths persist as well, such as the beliefs that only girls are vulnerable and that most assaults happen at or after puberty. Although statistics vary, the numbers of preschoolers and school-age children reporting sexual assault are astonishing. Approximately 10 percent of sexual violations happen to children younger than 5 years old , more children between 8 and 12 report molestation than do teenagers, and 30 to 46 percent of all children are sexually violated in some way before they reach the age of 18.

Sexual trauma is pervasive – it prevails no matter one’s culture, socio-economic status, or religion. It is not uncommon even within the “perfect” family.

In other words, all children are vulnerable, and most sex offenders are “nice” people whom you already know! If you have been putting off talking with your children about sexual molestation until they are older, or because you are uncomfortable with the topic, we hope that what you learn here will bolster your confidence to begin these discussions sooner rather than later.

The Twin Dilemmas of Secrecy and Shame

The sexual molestation of children is further complicated by the added shroud of secrecy. Since 85 to 90 percent of sexual violations and inappropriate “boundary crossings” are committed by someone the victim knows and trusts, the symptoms are layered with the complexity of betrayal. Even if not admonished (or threatened) to keep the assault secret, children often do not tell due to embarrassment, shame, and guilt. In their naiveté, they mistakenly assume that they themselves are “bad.” They carry the shame that belongs to the molester.

In addition, children fear punishment and reprisal. They frequently anguish over “betraying” someone who is part of their family or social circle, and they fantasize about what might happen to the perpetrator. This is especially true if he or she is a family member on whom they depend. If not a family member, the violator is usually someone well-known. Neighbors, older children, babysitters, a parent’s boyfriend, and other friends of the family or step-family are frequently the offenders. Or it may be someone who has prestige and social
status or who serves as a mentor, such as a religious leader, teacher, or athletic coach. How can children know – unless you teach them – that they are not to blame when the perpetrator is not only someone
known, but someone revered?  Parents can pave the way to safety by teaching their children to trust and act on their own instincts, rather than submitting to an older child or adult who is using status for his or her own gratification.

What is Sexual Violation?

If sexual violation doesn’t typically involve a “dirty old man” using candy to lure a child into his car, what is it? Simply put, it is any instance of anyone taking advantage of a position of trust, age, or status to lead a child into a situation of real or perceived powerlessness around issues of sex and humiliation. In other words, when children must passively submit to the will of another, rather than having the choice to defend themselves or tell someone – whether or not they are “forced” – it constitutes sexual violation or assault.
This can range from being shown pornography by a teenage babysitter, to an insensitive medical examination of a child’s private parts, to being forced to have sexual intercourse with a parent or other adult. While actual rape by a parent or step-parent is less common, exposure to pornographic material or being asked to strip, look at, or handle exposed genitals, as well as rough handling during medical procedures, are far too common.

Steps Caregivers Can Take (and that adult survivors can learn) to Decrease Children’s Susceptibility

1. Model Healthy Boundaries: No one gets to touch, handle, or look at me in a way that feels uncomfortable.
2. Help Children Develop Good Sensory Awareness: Teach children to trust the felt sense of “uh-oh” they may feel as dread in the gut or rapid heartbeat, which lets them know something is wrong and they need to leave and get help.
3. Teach Children What Sexual Violation Is, Who Might Approach Them, and How to Avoid Being Lured: Teach children how to use their “sense detectors” as an early warning sign.
4. Offer Opportunities for Children to Practice their Right to Say “No.”
5. Teach Children What to Say and Do: Also, let them know that they should always tell you what has happened so that you can keep them safe and help them deal with their feelings.

In summary, let’s look further at boundary development:

Model Healthy Boundaries

There is a delightful children’s picture book by James Marshall about two hippopotami who are good friends. One’s name is George, the other Martha. They visit and play together and have dinner at each other’s houses. One day Martha is soaking in her bathtub and is shocked to see George peeking through the window, looking right at her! George was surprised at her outrage, and his feelings got hurt. He thought that this meant Martha didn’t like him anymore. Martha reassured George that she was very fond of him. She explained, in a kind manner, “Just because we are good friends, George, doesn’t mean that I don’t need privacy when I’m in the bathroom!” George understood.

This little George and Martha story models setting boundaries, communicating them clearly, and honoring the boundaries of others. Parents need to show good boundaries themselves, respect children’s need for privacy (especially between the ages of five to seven), and support them when they are in unappealing situations and are defenseless to help themselves.  This begins in infancy. The following illustration will help you understand how to offer this protection:

Little baby Arthur fussed and arched his back each time Auntie Jane tried to hold him. His
mother, not wanting to offend her sister, said, “Now, now, Arthur, it’s OK, this is your Auntie
Jane. She’s not going to hurt you!”

Ask yourself what message this sends to Arthur. He is already learning that his feelings aren’t important, and that adult needs take precedence over a dependent’s needs. Babies show us their feelings by vocal protests and body language. They are exquisitely attuned to the vocalizations and facial expressions of their parents. Their brain circuits are being formed by these very interactions that deal with respect for feelings and boundaries around touch.

For whatever reasons, Arthur did not feel safe or comfortable in Aunt Jane’s arms. Had his “right of refusal” been respected, he would have learned that his feelings do make a difference, that he does have choices, and that there are adults (in this case his mother) who will protect him from other adults whose touch he does not want. A few tactful words to Jane, such as, “Maybe later, Jane — Arthur’s not ready for you to hold him yet,” would leave an imprint impacting the baby’s newly developing sense of self. And if his mother’s appropriate protection continues, Arthur’s brain is more likely to forge pathways that promote self-protective responses that may safeguard him from an intrusion and assault later in his life. Although not in his conscious awareness, these unconscious body boundaries formed in the tender years of infancy will serve him well.

Trauma is a breach of energetic and personal boundaries. Sexual trauma, however, is a sacred wound – an intrusion into our deepest, most delicate and private parts. Children, therefore, need to be protected by honoring their rights to personal space, privacy, and control of their own bodies. As different situations develop at various ages and stages, children need to know that they do not have to subject themselves to “sloppy kisses,” lap sitting, and other forms of unwanted attention to please the adults in their lives.

Other Areas in Which Children Need Respect and the Protection of Boundaries

Children instinctively imitate their parents. Adults can capitalize on this favorable attribute when it comes to toileting behavior. A lot of power struggles and unpleasantness for toddlers and parents can be avoided altogether. By respecting your child’s timetable, you will encourage her to joyfully model mom’s behavior and toilet “train” herself. Take the “train” out of toileting, and your little boy will proudly do it like “Daddy does,” at his own pace.

Prevent unnecessary trauma in this major developmental area by following your child’s lead rather than by listening to the “experts” who believe in timetables. Forcing a child who is not ready to use the toilet disrespects his right to control his own bodily functions and sets a lifelong pattern of expecting to be dominated by someone else. By encouraging rather than pushing, you will be assisting your child to develop healthy self-regulatory habits and a natural curiosity about his or her own body. In some cases, you may even help to prevent eating disorders, digestive problems, constipation, and related difficulties. And, as a side effect, you’ll produce happy, spontaneous children.