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demarcy · 3 months

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The Body Keeps The Score - Bessel van der Kolk

Tout ce que j'ai surligné dans cet excellent livre sur le stress post-traumatique.

I] THE REDISCOVERY OF TRAUMA

Revolutions in understanding mind and brain

1. "Could it be that these “hallucinations” were in fact the fragmented memories of real experiences?"

2. "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."

3. "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."

4. "You can be fully in charge of your life only if you can acknowledge the reality of your body, in all its visceral dimensions."

5. "The way medicine approaches human suffering has always been determined by the technology available at any given time."

6. "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?"

7. "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."

8. "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."

9. "Fear and aversion, in some perverse way, can be transformed into pleasure."

10. “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."

11. "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. The social environment interacts with brain chemistry."

12. "When their serotonin levels rose, many of my patients became less reactive."

13. "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. In many places drugs have displaced therapy and enabled patients to suppress their problems without addressing the underlying issues."

14. "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."

15. "When we ignore these quintessential dimensions of humanity, we deprive people of ways to heal from trauma and restore their autonomy. Being a patient, rather than a participant in one’s healing process, separates suffering people from their community and alienates them from an inner sense of self."

Looking into the brain: the neuroscience revolution

1. "Broca’s area is one of the speech centers of the brain, which is often affected in stroke patients when the blood supply to that region is cut off. Without a functioning Broca’s area, you cannot put your thoughts and feelings into words. Our scans showed that Broca’s area went offline whenever a flashback was triggered. In other words, we had visual proof that the effects of trauma are not necessarily different from —and can overlap with—the effects of physical lesions like strokes."

2. "When words fail, haunting images capture the experience and return as nightmares and flashbacks. In contrast to the deactivation of Broca’s area, another region, Brodmann’s area, lit up in our participants. This is a region in the visual cortex that registers images when they first enter the brain."

3. "We now know that the two halves of the brain do speak different languages. The right is intuitive, emotional, visual, spatial, and tactual, and the left is linguistic, sequential, and analytical."

4. "Under ordinary circumstances the two sides of the brain work together more or less smoothly, even in people who might be said to favor one side over the other. However, having one side or the other shut down, even temporarily, or having one side cut off entirely (as sometimes happened in early brain surgery) is disabling."

5. "Adrenaline is one of the hormones that are critical to help us fight back or flee in the face of danger. Increased adrenaline was responsible for our participants’ dramatic rise in heart rate and blood pressure while listening to their trauma narrative."

6. "After repeatedly rehearsing the details of the trauma with a therapist, her biological responses might become muted, so that she could realize and remember that “that was then and this is now,” rather than reliving the experience over and over." 7. "It is so much easier for them to talk about what has been done to them—to tell a story of victimization and revenge—than to notice, feel, and put into words the reality of their internal experience."

II] THIS IS YOUR BRAIN ON TRAUMA

Running for your life: the anatomy of survival

1. "After trauma the world is experienced with a different nervous system. The survivor’s energy now becomes focused on suppressing inner chaos, at the expense of spontaneous involvement in their lives."

2. "When the old brain takes over, it partially shuts down the higher brain, our conscious mind, and propels the body to run, hide, fight, or, on occasion, freeze."

3. "If for some reason the normal response is blocked—for example, when people are held down, trapped, or otherwise prevented from taking effective action, be it in a war zone, a car accident, domestic violence, or a rape—the brain keeps secreting stress chemicals, and the brain’s electrical circuits continue to fire in vain."

4. "Psychological problems occur when our internal signals don’t work, when our maps don’t lead us where we need to go, when we are too paralyzed to move, when our actions do not correspond to our needs, or when our relationships break down."

5. "The reptilian brain is responsible for all the things that newborn babies can do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating. The brain stem and the hypothalamus (which sits directly above it) together control the energy levels of the body."

6. "Right above the reptilian brain is the limbic system. It’s also known as the mammalian brain, because all animals that live in groups and nurture their young possess one. Development of this part of the brain truly takes off after a baby is born. It is the seat of the emotions, the monitor of danger, the judge of what is pleasurable or scary, the arbiter of what is or is not important for survival purposes. It is also a central command post for coping with the challenges of living within our complex social networks."

7. "This is another way of describing neuroplasticity, the relatively recent discovery that neurons that “fire together, wire together.” When a circuit fires repeatedly, it can become a default setting—the response most likely to occur. If you feel safe and loved, your brain becomes specialized in exploration, play, and cooperation; if you are frightened and unwanted, it specializes in managing feelings of fear and abandonment."

8. "The reptilian brain and limbic system make up what I’ll call the “emotional brain."

9. "The neocortex, our rational brain. [...] The frontal lobes, which make up the bulk of our neocortex."

10. "Mirror neurons explained many previously unexplainable aspects of the mind, such as empathy, imitation, synchrony, and even the development of language. One writer compared mirror neurons to “neural WiFi”—we pick up not only another person’s movement but her emotional state and intentions as well."

11. "Treatment needs to reactivate the capacity to safely mirror, and be mirrored, by others, but also to resist being hijacked by others’ negative emotions."

12. "Thalamus, an area inside the limbic system that acts as the cook. [...] The pathway to the amygdala is the low road and that to the frontal cortex the high road. [...] The amygdala, which I call the brain’s smoke detector [...] sends an instant message down to the hypothalamus and the brain stem, recruiting the stress-hormone system and the autonomic nervous system (ANS) to orchestrate a whole-body response."

13. "If the amygdala is the smoke detector in the brain, think of the frontal lobes—and specifically the medial prefrontal cortex (MPFC), located directly above our eyes—as the watchtower. [...] As long as you are not too upset, your frontal lobes can restore your balance by helping you realize that you are responding to a false alarm and abort the stress response."

14. "Top-down regulation involves strengthening the capacity of the watchtower to monitor your body’s sensations. Mindfulness meditation and yoga can help with this. Bottom-up regulation involves recalibrating the autonomic nervous system, (which, as we have seen, originates in the brain stem). We can access the ANS through breath, movement, or touch."

15. "Our emotions assign value to experiences and thus are the foundation of reason."

16. "Whenever the limbic system decides that something is a question of life or death, the pathways between the frontal lobes and the limbic system become extremely tenuous."

17. "The sensory fragments of memory intrude into the present, where they are literally relived."

18. "As a result, shame becomes the dominant emotion and hiding the truth the central preoccupation."

19. "The right and left dorsolateral prefrontal cortex. When those areas are deactivated, people lose their sense of time and become trapped in the moment, without a sense of past, present, or future."

20. "The context and meaning of an experience are determined by the system that includes the dorsolateral prefrontal cortex (DLPFC) and the hippocampus."

21. "Being anchored in the present while revisiting the trauma opens the possibility of deeply knowing that the terrible events belong to the past."

22. "If you are able to stay focused on this page, your thalamus is helping you distinguish between sensory information that is relevant and information that you can safely ignore." 23. "People with PTSD have their floodgates wide open. Lacking a filter, they are on constant sensory overload. In order to cope, they try to shut themselves down and develop tunnel vision and hyperfocus. If they can’t shut down naturally, they may enlist drugs or alcohol to block out the world. The tragedy is that the price of closing down includes filtering out sources of pleasure and joy, as well."

24. "Ute’s response is depersonalization. Anyone who deals with traumatized men, women, or children is sooner or later confronted with blank stares and absent minds, the outward manifestation of the biological freeze reaction. [...] Ute’s brain automatically went into the same survival mode—she made herself disappear."

25. "The acting-out kids tend to get attention; the blanked-out ones don’t bother anybody and are left to lose their future bit by bit."

Body-brain connections

1. "If an organism is stuck in survival mode, its energies are focused on fighting off unseen enemies, which leaves no room for nurture, care, and love."

2. "The two branches of the autonomic nervous system (ANS): the sympathetic, which acts as the body’s accelerator, and the parasympathetic, which serves as its brake."

3. "Our brains are built to help us function as members of a tribe."

4. "Almost all mental suffering involves either trouble in creating workable and satisfying relationships or difficulties in regulating arousal."

5. "Social support is not the same as merely being in the presence of others. The critical issue is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart."

6. "Focusing on a shared history of trauma and victimization alleviates their searing sense of isolation, but usually at the price of having to deny their individual differences: Members can belong only if they conform to the common code."

7. "The autonomic nervous system regulates three fundamental physiological states. The level of safety determines which one of these is activated at any particular time. Whenever we feel threatened, we instinctively turn to the first level, social engagement. We call out for help, support, and comfort from the people around us. But if no one comes to our aid, or we’re in immediate danger, the organism reverts to a more primitive way to survive: fight or flight. We fight off our attacker, or we run to a safe place. However, if this fails—we can’t get away, we’re held down or trapped—the organism tries to preserve itself by shutting down and expending as little energy as possible. We are then in a state of freeze or collapse."

8. "The social-engagement system depends on nerves that have their origin in the brain stem regulatory centers, primarily the vagus—also known as the tenth cranial nerve—together with adjoining nerves that activate the muscles of the face, throat, middle ear, and voice box or larynx. When the “ventral vagal complex” (VVC) runs the show, we smile when others smile at us, we nod our heads when we agree, and we frown when friends tell us of their misfortunes."

9. "Finally, if there’s no way out, and there’s nothing we can do to stave off the inevitable, we will activate the ultimate emergency system: the dorsal vagal complex (DVC). This system reaches down below the diaphragm to the stomach, kidneys, and intestines and drastically reduces metabolism throughout the body. Heart rate plunges (we feel our heart “drop”), we can’t breathe, and our gut stops working or empties (literally “scaring the shit out of” us). This is the point at which we disengage, collapse, and freeze."

10. "The mammalian fight-or-flight system, which is protective and keeps us from shutting down, and the reptilian brain, which produces the collapse response."

11. "Immobilization is at the root of most traumas."

12. "It is especially challenging for traumatized people to discern when they are actually safe and to be able to activate their defenses when they are in danger."

13. "Steve had created a small, safe place where the social-engagement system could begin to reemerge. In the same way, severely traumatized people may get more out of simply helping to arrange chairs before a meeting or joining others in tapping out a musical rhythm on the chair seats than they would from sitting in those same chairs and discussing the failures in their life."

Losing your body, losing your self

1. "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."

2. "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."

3. "The extreme disconnection from the body that so many people with histories of trauma and neglect experience."

4. "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."

5. "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 selfawareness."

6. "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."

7. "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."

8. "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."

9. "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."

10. "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."

11. "To feel present you have to know where you are and be aware of what is going on with you."

12. "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."

13. "Trauma has shut down their inner compass and robbed them of the imagination they need to create something better."

14. "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."

15. "Self-regulation depends on having a friendly relationship with your body. Without it you have to rely on external regulation."

16. "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."

17. "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."

18. "A group of neuroscientists at the University of Geneva 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."

19. "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."

20. "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."

21. "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."

22. "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."

23. "The prefrontal cortex (PFC) normally helps us to assess the person coming toward us, and our mirror neurons help to pick up his intentions."

24. "The primitive areas known as the Periaqueductal Gray, which generates startle, hypervigilance, cowering, and other self-protective behaviors. There was no activation of any part of the brain involved in social engagement. In response to being looked at they simply went into survival mode."

III] THE MINDS OF CHILDREN

Getting on the same wavelength: attachment and attunement

1. "The roots of resilience... are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other."

2. "For abused children, the whole world is filled with triggers. As long as they can imagine only disastrous outcomes to relatively benign situations, anybody walking into a room, any stranger, any image, on a screen or on a billboard might be perceived as a harbinger of catastrophe."

3. "Scientists study what puzzles them most, so that they often become experts in subjects that others take for granted. [...] Most research is me-search."

4. "Human beings may be induced to sacrifice everything they hold dear and true—including their sense of self—for the sake of being loved and approved of by someone in a position of authority."

5. "The expression of the great French psychiatrist Pierre Janet: “Every life is a piece of art, put together with all means available."

6. "Having a safe haven promotes self-reliance and instills a sense of sympathy and helpfulness to others in distress."

7. "You can tell equilibrium has been restored when the physiology calms down."

8. "Associating intense sensations with safety, comfort, and mastery is the foundation of self-regulation, self-soothing, and self-nurture."

9. "In contrast, children with histories of abuse and neglect learn that their terror, pleading, and crying do not register with their caregiver. Nothing they can do or say stops the beating or brings attention and help. In effect they’re being conditioned to give up when they face challenges later in life."

10. "Having to discount its inner sensations, and trying to adjust to its caregiver’s needs, means the child perceives that “something is wrong” with the way it is. Children who lack physical attunement are vulnerable to shutting down the direct feedback from their bodies, the seat of pleasure, purpose, and direction."

11. "Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync."

12. "Children who overreact to their peers’ aggression, who don’t pick up on other kids’ needs, who easily shut down or lose control of their impulses, are likely to be shunned and left out of sleepovers or play dates. Eventually they may learn to cover up their fear by putting up a tough front. Or they may spend more and more time alone, watching TV or playing computer games, falling even further behind on interpersonal skills and emotional self-regulation."

13. "Children will develop a coping style based on their attempt to get at least some of their needs met."

14. "In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.” Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies."

15. "In another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.” They seem to have concluded that unless they make a spectacle, nobody is going to pay attention to them. They become enormously upset when they do not know where their mother is but derive little comfort from her return. And even though they don’t seem to enjoy her company, they stay passively or angrily focused on her, even in situations when other children would rather play."

16. "In school avoidant children are likely to bully other kids, while the anxious children are often their victims."

17. "... began to identify a group of children (about 15 percent of those they studied) who seemed to be unable to figure out how to engage with their caregivers. The critical issue turned out to be that the caregivers themselves were a source of distress or terror to the children. Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear. They “can neither approach (the secure and ambivalent ‘strategies’), shift [their] attention (the avoidant ‘strategy’), nor flee.” If you observe such children in a nursery school or attachment laboratory, you see them look toward their parents when they enter the room and then quickly turn away. Unable to choose between seeking closeness and avoiding the parent, they may rock on their hands and knees, appear to go into a trance, freeze with their arms raised, or get up to greet their parent and then fall to the ground. Not knowing who is safe or whom they belong to, they may be intensely affectionate with strangers or may trust nobody. Main called this pattern “disorganized attachment.” Disorganized attachment is “fright without solution.”

18. "Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection."

19. "Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child."

20. "If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it. When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences."

21. "They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs."

22. "They failed to greet their children after having been away and did not pick them up when the children were distressed."

23. "Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse."

24. "Infants with seriously disrupted emotional communication patterns with their mothers at eighteen months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving, and binge eating), inappropriate and intense anger, and recurrent suicidal behavior."

25. "Emotional withdrawal had the most profound and long-lasting impact."

26. "Dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down. She found a “striking and unexpected” relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood."

27. "Dissociation means simultaneously knowing and not knowing. Bowlby wrote: “What cannot be communicated to the mother cannot be communicated to the self. [...] Dissociation is learned early."

28. "The critical underlying issue was that these patients didn’t know how to feel safe. Lack of safety within the early caregiving relationship led to an impaired sense of inner reality, excessive clinging, and self-damaging behavior."

29. "Early caregiving is critically important in preventing mental health problems, independent of other traumas."

30. "You may realize that your fear of intimacy has something to do with your mother’s postpartum depression or with the fact that she herself was molested as a child, but that alone is unlikely to open you to happy, trusting engagement with others."

Trapped in relationships: the cost of abuse and neglect

1. "As the poet W. H. Auden wrote: Truth, like love and sleep, resents Approaches that are too intense."

2. "It’s not important for me to know every detail of a patient’s trauma. What is critical is that the patients themselves learn to tolerate feeling what they feel and knowing what they know."

3. "Conversion reaction, in which patients express their conflicts by losing function in some part of their body."

4. "This makes the immune system oversensitive to threat, so that it is prone to mount a defense when none is needed, even when this means attacking the body’s own cells."

5. "As a result, if we later hook up with somebody who treats us badly, we will be outraged. It won’t feel right: It’s not familiar; it’s not like home. But if we are abused or ignored in childhood, or grow up in a family where sexuality is treated with disgust, our inner map contains a different message. Our sense of our self is marked by contempt and humiliation, and we are more likely to think “he (or she) has my number” and fail to protest if we are mistreated."

6. "I instinctively blame myself for everything bad that happens to the people around me. I know that isn’t rational, and I feel really dumb for feeling this way, but I do. When you try to talk me into being more reasonable I only feel even more lonely and isolated—and it confirms the feeling that nobody in the whole world will ever understand what it feels like to be me.”

7. "My responsibility goes much deeper: I have to help them reconstruct their inner map of the world."

8. "But the moment we feel trapped, enraged, or rejected, we are vulnerable to activating old maps and to follow their directions. Change begins when we learn to “own” our emotional brains. That means learning to observe and tolerate the heartbreaking and gut-wrenching sensations that register misery and humiliation. Only after learning to bear what is going on inside can we start to befriend, rather than obliterate, the emotions that keep our maps fixed and immutable."

9. "Terror increases the need for attachment, even if the source of comfort is also the source of terror."

10. "Rage that has nowhere to go is redirected against the self, in the form of depression, self-hatred, and self-destructive actions." 11. "We must also be able trust our memories and be able to tell them apart from our imagination. Losing the ability to make these distinctions is one sign of what psychoanalyst William Niederland called “soul murder.” Erasing awareness and cultivating denial are often essential to survival, but the price is that you lose track of who you are, of what you are feeling, and of what and whom you can trust."

12. "Marilyn exemplified the power of the life force, the will to live and to own one’s life, the energy that counteracts the annihilation of trauma."

What's love got to do with it?

1. "BPD is marked by clinging but highly unstable relationships, extreme mood swings, and self-destructive behavior, including self-mutilation and repeated suicide attempts."

2. "Different forms of abuse have different impacts on various brain areas at different stages of development."

3. "When children are pervasively filled with rage, it is due to rejection or harsh treatment. When children experience intense inner conflict regarding their angry feelings, this is likely because expressing them may be forbidden or even dangerous."

4. "The patients who remained self-destructive had told us that they did not remember feeling safe with anybody as a child."

5. "However, if you lack a deep memory of feeling loved and safe, the receptors in the brain that respond to human kindness may simply fail to develop."

6. "We voted nineteen to two to create a new trauma diagnosis for victims of interpersonal trauma: “Disorders of Extreme Stress, Not Otherwise Specified” (DESNOS), or “Complex PTSD” for short."

7. "Incidents of abuse are never stand-alone events."

8. "Obesity, which is considered a major public health problem, may in fact be a personal solution for many. Consider the implications: If you mistake someone’s solution for a problem to be eliminated, not only are they likely to fail treatment, as often happens in addiction programs, but other problems may emerge. One female rape victim told Felitti, “Overweight is overlooked, and that’s the way I need to be."

9. "What one sees, the presenting problem, is often only the marker for the real problem, which lies buried in time, concealed by patient shame, secrecy and sometimes amnesia—and frequently clinician discomfort."

Developmental trauma: the hidden epidemic

1. "We have failed to find consistent genetic patterns for schizophrenia—or for any other psychiatric illness."

2. "It turns out that many genes work together to influence a single outcome. Even more important, genes are not fixed; life events can trigger biochemical messages that turn them on or off by attaching methyl groups, a cluster of carbon and hydrogen atoms, to the outside of the gene (a process called methylation), making it more or less sensitive to messages from the body. While life events can change the behavior of the gene, they do not alter its fundamental structure. Methylation patterns, however, can be passed on to offspring—a phenomenon known as epigenetics."

3. "Major changes to our bodies can be made not just by chemicals and toxins, but also in the way the social world talks to the hard-wired world."

4. "The uptight, anxious females don’t play well with others and thus often lack social support when they give birth and are at high risk for neglecting or abusing their firstborns. But when these females belong to a stable social group they often become diligent mothers who carefully watch out for their young. Under some conditions being an anxious mom can provide much needed protection. The aggressive mothers, on the other hand, did not provide any social advantages: very punitive with their offspring, there is lots of hitting, kicking, and biting. If the infants survive, their mothers usually keep them from making friends with their peers." (à propos de singes) 5. "This leads to the conclusion that, at least in monkeys, early experience has at least as much impact on biology as heredity does."

6. "Safe and protective early relationships are critical to protect children from long-term problems. In addition, even parents with their own genetic vulnerabilities can pass on that protection to the next generation provided that they are given the right support."

7. "The trauma may be over, but it keeps being replayed in continually recycling memories and in a reorganized nervous system."

8. "These children’s moods and feelings rapidly shifted from one extreme to another —from temper tantrums and panic to detachment, flatness, and dissociation. When they got upset (which was much of the time), they could neither calm themselves down nor describe what they were feeling. Having a biological system that keeps pumping out stress hormones to deal with real or imagined threats leads to physical problems: sleep disturbances, headaches, unexplained pain, oversensitivity to touch or sound. Being so agitated or shut down keeps them from being able to focus their attention and concentration. To relieve their tension, they engage in chronic masturbation, rocking, or self-harming activities (biting, cutting, burning, and hitting themselves, pulling their hair out, picking at their skin until it bled). It also leads to difficulties with language processing and fine-motor coordination. Spending all their energy on staying in control, they usually have trouble paying attention to things, like schoolwork, that are not directly relevant to survival, and their hyperarousal makes them easily distracted. Having been frequently ignored or abandoned leaves them clinging and needy, even with the people who have abused them. Having been chronically beaten, molested, and otherwise mistreated, they can not help but definethemselves as defective and worthless. They come by their self-loathing, sense of defectiveness, and worthlessness honestly. Was it any surprise that they didn’t trust anyone? Finally, the combination of feeling fundamentally despicable and overreacting to slight frustrations makes it difficult for them to make friends."

9. "By numbing out she no longer reacts to distress the way she should, for example, by taking protective action."

10. "They don’t have friends of either gender because they can’t trust; they hate themselves, and their biology is against them, leading them either to overreact or numb out. They can’t keep up in the normal envy-driven inclusion/exclusion games, in which players have to stay cool under stress. Other kids usually don’t want anything to do with them—they simply are too weird."

11. "Like so many of the adolescents we see, Ayesha can’t articulate what she wants or needs and can’t think through how she might protect herself."

12. "With DSM-5 psychiatry firmly regressed to early-nineteenth-century medical practice. Despite the fact that we know the origin of many of the problems it identifies, its “diagnoses” describe surface phenomena that completely ignore the underlying causes."

13. "The sources of psychological suffering in the DSM-5 were identified “as located within individuals” and overlooked the “undeniable social causation of many such problems."

14. "Mental illness, however, is not at all like cancer: Humans are social animals, and mental problems involve not being able to get along with other people, not fitting in, not belonging, and in general not being able to get on the same wavelength."

15. "Social support is a biological necessity, not an option, and this reality should be the backbone of all prevention and treatment."

IV] THE IMPRINT OF TRAUMA

Uncovering secrets: the problem of traumatic memory

1. "When the subject of blame arises, the central issue that needs to be addressed is usually self-blame—accepting that the trauma was not their fault, that it was not caused by some defect in themselves, and that no one could ever have deserved what happened to them."

2. "When my brothers, sisters, and I talk about events in our childhood, we always end up feeling that we grew up in different families—so many of our memories simply do not match. Such autobiographical memories are not precise reflections of reality; they are stories we tell to convey our personal take on our experience."

3. "With the passage of time, events had been bleached of their intense horror. In contrast, those who had been traumatized and subsequently developed PTSD did not modify their accounts; their memories were preserved essentially intact forty-five years after the war ended."

4. "We remember insults and injuries best: The adrenaline that we secrete to defend against potential threats helps to engrave those incidents into our minds. Even if the content of the remark fades, our dislike for the person who made it usually persists."

5. "The more adrenaline you secrete, the more precise your memory will be. But that is true only up to a certain point. Confronted with horror—especially the horror of “inescapable shock”—this system becomes overwhelmed and breaks down."

6. "Traumatized people simultaneously remember too little and too much."

7. "The traumatic enactment serves no function. In contrast, ordinary memory is adaptive; our stories are flexible and can be modified to fit the circumstances. Ordinary memory is essentially social; it’s a story that we tell for a purpose. [...] But there is nothing social about traumatic memory. Julian’s rage at his girlfriend’s remark served no useful purpose. Reenactments are frozen in time, unchanging, and they are always lonely, humiliating, and alienating experiences."

The unbearable heaviness of remembering

1. "I am aware that I, without realizing it, have lost my feelings—I don’t belong here anymore, I live in an alien world. I prefer to be left alone, not disturbed by anybody. They talk too much—I can’t relate to them —they are only busy with superficial things."

2. "As long as a memory is inaccessible, the mind is unable to change it. But as soon as a story starts being told, particularly if it is told repeatedly, it changes—the act of telling itself changes the tale. The mind cannot help but make meaning out of what it knows, and the meaning we make of our lives changes how and what we remember."

3. "Weddings, births, and graduations were recalled as events from the past, stories with a beginning, a middle, and an end. Nobody said that there were periods when they’d completely forgotten any of these events. In contrast, the traumatic memories were disorganized. Our subjects remembered some details all too clearly (the smell of the rapist, the gash in the forehead of a dead child) but could not recall the sequence of events or other vital details."

4. "Traumatic memories are fundamentally different from the stories we tell about the past. They are dissociated: The different sensations that entered the brain at the time of the trauma are not properly assembled into a story, a piece of autobiography."

5. "As we will see, finding words to describe what has happened to you can be transformative, but it does not always abolish flashbacks or improve concentration, stimulate vital involvement in your life or reduce hypersensitivity to disappointments and perceived injuries."

6. "I found a stronger physical core, as well as a community of women who willingly gave acceptance and social support that had been distant in my life since the trauma. This combination of core strengthening—psychological, social, and physical—created a sense of personal safety and mastery, relegating my memories to the distant past, allowing the present and future to emerge."

V] PATHS TO RECOVERY

Healing from trauma: owning your self

1. "Trauma robs you of the feeling that you are in charge of yourself, of what I will call self-leadership in the chapters to come."

2. "(1) finding a way to become calm and focused, (2) learning to maintain that calm in response to images, thoughts, sounds, or physical sensations that remind you of the past, (3) finding a way to be fully alive in the present and engaged with the people around you, (4) not having to keep secrets from yourself, including secrets about the ways that you have managed to survive."

3. "When we talk about trauma, we often start with a story or a question: “What happened during the war?” “Were you ever molested?” “Let me tell you about that accident or that rape,” or “Was anybody in your family a problem drinker?” However, trauma is much more than a story about something that happened long ago."

4. "However, the rational brain cannot abolish emotions, sensations, or thoughts (such as living with a low-level sense of threat or feeling that you are fundamentally a terrible person, even though you rationally know that you are not to blame for having been raped)."

5. "The fundamental issue in resolving traumatic stress is to restore the proper balance between the rational and emotional brains, so that you can feel in charge of how you respond and how you conduct your life. When we’re triggered into states of hyper-or hypoarousal, we are pushed outside our “window of tolerance”—the range of optimal functioning."

6. "As long as people are either hyperaroused or shut down, they cannot learn from experience. Even if they manage to stay in control, they become so uptight (Alcoholics Anonymous calls this “white-knuckle sobriety”) that they are inflexible, stubborn, and depressed."

7. "We have to access the emotional brain and do “limbic system therapy”: repairing faulty alarm systems and restoring the emotional brain to its ordinary job of being a quiet background presence that takes care of the housekeeping of the body, ensuring that you eat, sleep, connect with intimate partners, protect your children, and defend against danger."

8. "The neuroscientist Joseph LeDoux and his colleagues have shown that the only way we can consciously access the emotional brain is through selfawareness, i.e. by activating the medial prefrontal cortex, the part of the brain that notices what is going on inside us and thus allows us to feel what we’re feeling. (The technical term for this is “interoception.”)"

9. "Learning how to breathe calmly and remaining in a state of relative physical relaxation, even while accessing painful and horrifying memories, is an essential tool for recovery."

10. "At the core of recovery is self-awareness. The most important phrases in trauma therapy are “Notice that” and “What happens next?”"

11. "Mindfulness puts us in touch with the transitory nature of our feelings and perceptions. When we pay focused attention to our bodily sensations, we can recognize the ebb and flow of our emotions and, with that, increase our control over them."

12. "Traumatized people are often afraid of feeling. It is not so much the perpetrators (who, hopefully, are no longer around to hurt them) but their own physical sensations that now are the enemy. Apprehension about being hijacked by uncomfortable sensations keeps the body frozen and the mind shut."

13. "Once you pay attention to your physical sensations, the next step is to label them, as in “When I feel anxious, I feel a crushing sensation in my chest.” I may then say to a patient: “Focus on that sensation and see how it changes when you take a deep breath out, or when you tap your chest just below your collarbone, or when you allow yourself to cry.”"

14. "Becoming aware of how your body organizes particular emotions or memories opens up the possibility of releasing sensations and impulses you once blocked in order to survive."

15. "Having a good support network constitutes the single most powerful protection against becoming traumatized. Safety and terror are incompatible."

16. "After an acute trauma, like an assault, accident, or natural disaster, survivors require the presence of familiar people, faces, and voices; physical contact; food; shelter and a safe place; and time to sleep."

17. "If the people whom you naturally turn to for care and protection terrify or reject you, you learn to shut down and to ignore what you feel."

18. "Managing your terror all by yourself gives rise to another set of problems: dissociation, despair, addictions, a chronic sense of panic, and relationships that are marked by alienation, disconnection, and explosions."

19. "While human contact and attunement are the wellspring of physiological self-regulation, the promise of closeness often evokes fear of getting hurt, betrayed, and abandoned. Shame plays an important role in this: “You will find out how rotten and disgusting I am and dump me as soon as you really get to know me.”"

20. "If your heart is still broken because you were assaulted by someone you loved, you are likely to be preoccupied with not getting hurt again and fear opening up to someone new. In fact, you may unwittingly try to hurt them before they have a chance to hurt you. This poses a real challenge for recovery. Once you recognize that posttraumatic reactions started off as efforts to save your life, you may gather the courage to face your inner music (or cacophony)."

21. "Most traumatized individuals need an anchor."

22. "(1) stabilize and calm patients down, (2) help to lay traumatic memories and reenactments to rest, and (3) reconnect patients with their fellow men and women."

23. "Therapy is a collaborative process—a mutual exploration of your self."

24. "Working with trauma is as much about remembering how we survived as it is about what is broken."

25. "Our relationships are embodied in responsive faces, gestures, and touch."

26. "Trauma results in a breakdown of attuned physical synchrony: When you enter the waiting room of a PTSD clinic, you can immediately tell the patients from the staff by their frozen faces and collapsed (but simultaneously agitated) bodies."

27. "Learning to become attuned provides parents (and their kids) with the visceral experience of reciprocity. [...] People connect in joy and exploration. [...] Helping terrified people to safely experience their sensations and emotions."

28. "The most natural way that we humans calm down our distress is by being touched, hugged, and rocked."

29. "You can’t fully recover if you don’t feel safe in your skin."

30. "I’m assessing their posture; whether they look me in the eye; how tense or relaxed they seem; are they connecting with me or not. [...] Hesitation communicates a lack of trust in yourself."

31. "Mindful touch and movement grounds people and allows them to discover tensions that they may have held for so long that they are no longer even aware of them. When you are touched, you wake up to the part of your body that is being touched."

32. "“The body is physically restricted when emotions are bound up inside. People’s shoulders tighten; their facial muscles tense. They spend enormous energy on holding back their tears—or any sound or movement that might betray their inner state. When the physical tension is released, the feelings can be released."

33. "Touch makes it possible to live in a body that can move in response to being moved. [...] Firm and reassuring touch lets them know where those boundaries are: what’s outside them, where their bodies end. They discover that they don’t constantly have to wonder who and where they are. They discover that their body is solid and that they don’t have to be constantly on guard. Touch lets them know that they are safe."

34. "People who actively do something to deal with a disaster—rescuing loved ones or strangers, transporting people to a hospital, being part of a medical team, pitching tents or cooking meals—utilize their stress hormones for their proper purpose and therefore are at much lower risk of becoming traumatized."

35. "Helplessness and immobilization keep people from utilizing their stress hormones to defend themselves. When that happens, their hormones still are being pumped out, but the actions they’re supposed to fuel are thwarted."

36. "Patients are helped to build up internal resources that foster safe access sensations and emotions that overwhelmed them at the time of the trauma. Peter Levine calls this process pendulation—gently moving in and out of accessing internal sensations and traumatic memories. In this way patients are helped to gradually expand their window of tolerance."

37. "Once patients can tolerate being aware of their trauma-based physical experiences, they are likely to discover powerful physical impulses—like hitting, pushing, or running—that arose during the trauma but were suppressed in order to survive. These impulses manifest themselves in subtle body movements such as twisting, turning, or backing away. Amplifying these movements and experimenting with ways to modify them begins the process of bringing the incomplete, trauma-related “action tendencies” to completion and can eventually lead to resolution of the trauma. Somatic therapies can help patients to relocate themselves in the present by experiencing that it is safe to move. Feeling the pleasure of taking effective action restores a sense of agency and a sense of being able to actively defend and protect themselves."

38. "They often survive with resigned compliance. The best way to overcome ingrained patterns of submission is to restore a physical capacity to engage and defend."

39. "If you’re hunched over and too afraid to look around, you are easy prey to other people’s sadism, but when you walk around projecting the message “Don’t mess with me,” you’re not likely to be bothered."

40. "We have to accomplish the therapeutic task, which consists chiefly of translating it back again in terms of the past. Telling the story is important; without stories, memory becomes frozen; and without memory you cannot imagine how things can be different."

41. "Eye movement desensitization and reprocessing (EMDR)"

42. "When the brain areas whose absence is responsible for flashbacks can be kept online while remembering what has happened, people can integrate their traumatic memories as belonging to the past. Ute’s dissociation (as you recall, she shut down completely) complicated recovery in a different way. None of the brain structures necessary to engage in the present were online, so that dealing with the trauma was simply impossible. Without a brain that is alert and present there can be no integration and resolution. She needed to be helped to increase her window of tolerance before she could deal with her PTSD symptoms."

43. "Hypnosis can induce a state of relative calm from which patients can observe their traumatic experiences without being overwhelmed by them."

44. "Cognitive Behavioral Therapy (CBT) [...] Patients are gradually desensitized from their irrational fears by bringing to mind what they are most afraid of. [...] The idea behind cognitive behavioral treatment is that when patients are repeatedly exposed to the stimulus without bad things actually happening, they gradually will become less upset; the bad memories will have become associated with “corrective” information of being safe. CBT also tries to help patients deal with their tendency to avoid, as in “I don’t want to talk about it."

45. "Exposure sometimes helps to deal with fear and anxiety, but it has not been proven to help with guilt or other complex emotions. In contrast to its effectiveness for irrational fears such as spiders, CBT has not done so well for traumatized individuals, particularly those with histories of childhood abuse."

46. "More than virtual-reality therapy, traumatized patients need “real world” therapy, which helps them to feel as alive when walking through the local supermarket or playing with their kids as they did in the streets of Baghdad."

47. "The issue is not desensitization but integration: putting the traumatic event into its proper place in the overall arc of one’s life."

48. "Desensitization to our own or to other people’s pain tends to lead to an overall blunting of emotional sensitivity."

49. "By being able to observe the trauma from the calm, mindful state that IFS calls Self, mind and brain are in a position to integrate the trauma into the overall fabric of life. This is very different from traditional desensitization techniques, which are about blunting a person’s response to past horrors. This is about association and integration."

50. "Drugs cannot “cure” trauma; they can only dampen the expressions of a disturbed physiology. And they do not teach the lasting lessons of self-regulation. They can help to control feelings and behavior, but always at a price—because they work by blocking the chemical systems that regulate engagement, motivation, pain, and pleasure."

51. "They can make feelings less intense and life more manageable. Patients on SSRIs often feel calmer and more in control; feeling less overwhelmed often makes it easier to engage in therapy. Other patients feel blunted by SSRIs—they feel they’re “losing their edge.”"

52. "Benzos weaken inhibitions against saying hurtful things to people we love. [...] Patients who stop taking them after prolonged use usually have withdrawal reactions that make them agitated and increase posttraumatic symptoms."

53. "Now befriending his body was keeping him from organizing his life around the loss of physical control."

Language: miracle and tyranny

1. "The most helpful interventions focused on relieving the physical burdens generated by trauma."

2. "But the apparent lack of interest in talk therapy raises a basic question: What good is it to talk about your trauma?"

3. "Silence reinforces the godforsaken isolation of trauma. Being able to say aloud to another human being, “I was raped” or “I was battered by my husband” or “My parents called it discipline, but it was abuse” or “I’m not making it since I got back from Iraq,” is a sign that healing can begin."

4. "We may think we can control our grief, our terror, or our shame by remaining silent, but naming offers the possibility of a different kind of control. [...] If you’ve been hurt, you need to acknowledge and name what happened to you."

5. "Only when I could forgive him for having been as scared and submissive as he was, did I start to enjoy the pleasure of my own company."

6. "Without language and context, your awareness may be limited to: “I’m scared.” Yet, determined to stay in control, you are likely to avoid anybody or anything that reminds you even vaguely of your trauma. You may also alternate between being inhibited and being uptight or reactive and explosive—all without knowing why. As long as you keep secrets and suppress information, you are fundamentally at war with yourself."

7. "The critical issue is allowing yourself to know what you know. That takes an enormous amount of courage."

8. "Getting perspective on your terror and sharing it with others can reestablish the feeling that you are a member of the human race."

9. "Before she acquired language, she was bewildered and self-centered—looking back, she called that creature “Phantom.” And indeed, our kids come across as phantoms until they can discover who they are and feel safe enough to communicate what is going on with them."

10. "Therapeutic relationship: finding words where words were absent before and, as a result, being able to share your deepest pain and deepest feelings with another human being. This is one of most profound experiences we can have, and such resonance, in which hitherto unspoken words can be discovered, uttered, and received, is fundamental to healing the isolation of trauma—especially if other people in our lives have ignored or silenced us. Communicating fully is the opposite of being traumatized."

11. "Anyone who enters talk therapy, however, almost immediately confronts the limitations of language."

12. "How difficult it was to feel my feelings deeply and simultaneously report them to someone else."

13. "I could either focus on reliving old scenes in my mind’s eye and let myself feel what I had felt back then, or I could tell my analyst logically and coherently what had transpired. When I chose the latter, I would quickly lose touch with myself and start to focus on his opinion of what I was telling him. The slightest hint of doubt or judgment would shut me down, and I would shift my attention to regaining his approval."

14. "Two distinct forms of self-awareness: one that keeps track of the self across time and one that registers the self in the present moment. The first, our autobiographical self, creates connections among experiences and assembles them into a coherent story. This system is rooted in language. Our narratives change with the telling, as our perspective changes and as we incorporate new input. The other system, moment-to-moment self-awareness, is based primarily in physical sensations, but if we feel safe are not rushed, we can find words to communicate that experience as well."

15. "One system creates a story for public consumption, and if we tell that story often enough, we are likely to start believing that it contains the whole truth. But the other system registers a different truth: how we experience the situation deep inside. It is this second system that needs to be accessed, befriended, and reconciled."

16. "Blaming is a universal human trait that helps people feel good while feeling bad."

17. "The task of describing most private experiences can be likened to reaching down to a deep well to pick up small fragile crystal figures while you are wearing thick leather mittens."

18. "What happens inside when he tells me about that boy who never saw his father again? Where is it registered in his body? When you activate your gut feelings and listen to your heartbreak—when you follow the interoceptive pathways to your innermost recesses—things begin to change."

19. "When we talk with someone with whom we don’t feel completely safe, our social editor jumps in on full alert and our guard is up. Writing is different. [...] You are free to go into a sort of a trance state in which your pen (or keyboard) seems to channel whatever bubbles up from inside."

19. "Stressful experiences—whether divorce or final exams or loneliness—have a negative effect on immune function."

20. "When his subjects talked about intimate or difficult issues, they often changed their tone of voice and speaking style."

21. "For example, one woman described her plans for the day in a childlike, high-pitched voice, but a few minutes later, when she described stealing one hundred dollars from an open cash register, both the volume and pitch of her voice became so much lower that she sounded like an entirely different person. Alterations in emotional states were also reflected in the subjects’ handwriting. As participants changed topics, they might move from cursive to block letters and back to cursive; there were also variations in the slant of the letters and in the pressure of their pens. Such changes are called “switching” in clinical practice."

22. "Switching manifests not only as remarkably different vocal patterns but also in different facial expressions and body movements."

23. "If patients who present in such dramatically different states are treated as fakes, or if they are told to stop showing their unpredictably annoying parts, they are likely to become mute. They probably will continue to seek help, but after they have been silenced they will transmit their cries for help not by talking but by acting: with suicide attempts, depression, and rage attacks."

24. "The capacity of art, music, and dance to circumvent the speechlessness that comes with terror may be one reason they are used as trauma treatments in cultures around the world."

25. "...That the object of writing is to write to yourself, to let your self know what you have been trying to avoid."

26. "The real reason [that soldiers fall silent] is that soldiers have discovered that no one is very interested in the bad news they have to report. What listener wants to be torn and shaken when he doesn’t have to be?"

27. "Talking about painful events doesn’t necessarily establish community—often quite the contrary. Families and organizations may reject members who air the dirty laundry; friends and family can lose patience with people who get stuck in their grief or hurt. This is one reason why trauma victims often withdraw and why their stories become rote narratives, edited into a form least likely to provoke rejection."

28. "A different problem arises when trauma victims themselves become literally speechless—when the language area of the brain shuts down."

29. "Others try to recount their history in a way that keeps them from being triggered. This can make them come across as evasive and unreliable witnesses."

30. "I might ask a patient if her hands feel okay, and if she says yes, I’ll ask her to move them, exploring their lightness and warmth and flexibility. Later, if I see her chest tighten and her breath almost disappear, I can stop her and ask her to focus on her hands and move them, so that she can feel herself as separate from the trauma. Or I might ask her to focus on her out breath and notice how she can change it, or ask her to lift her arms up and down with each breath—a qigong movement."

31. "Some patients discover their own islands of safety—they begin to “get” that they can create body sensations to counterbalance feeling out of control."

32. "Normal subjects hesitated when they saw threatening words like “blood,” “wound,” or “rape”; McFarlane’s PTSD subjects reacted just as hesitantly to ordinary words like “wool,” “ice cream,” and “bicycle.” After a while most people with PTSD don’t spend a great deal of time or effort on dealing with the past—their problem is simply making it through the day."

33. "There is no question traumatized people have irrational thoughts: “I was to blame for being so sexy.” “The other guys weren’t afraid—they’re real men.” “I should have known better than to walk down that street.” It’s best to treat those thoughts as cognitive flashbacks—you don’t argue with them any more than you would argue with someone who keeps having visual flashbacks of a terrible accident."

34. "Like a splinter that causes an infection, it is the body’s response to the foreign object that becomes the problem more than the object itself. Modern neuroscience solidly supports Freud’s notion that many of our conscious thoughts are complex rationalizations for the flood of instincts, reflexes, motives, and deep-seated memories that emanate from the unconscious. As we have seen, trauma interferes with the proper functioning of brain areas that manage and interpret experience. A robust sense of self—one that allows a person to state confidently, “This is what I think and feel” and “This is what is going on with me”—depends on a healthy and dynamic interplay among these areas."

35. "The insula can transmit signals to the amygdala that trigger fight/fight responses. This does not require any cognitive input or any conscious recognition that something has gone awry—you just feel on edge and unable to focus or, at worst, have a sense of imminent doom. These powerful feelings are generated deep inside the brain and cannot be eliminated by reason or understanding. Being constantly assaulted by, but consciously cut off from, the origin of bodily sensations produces alexithymia: not being able to sense and communicate what is going on with you."

Letting go of the past: EMDR

1. "Remembered it from inside her child’s body. [...] And yet, she told us, even as she relived the incident she was able to observe it from the point of view of her twenty-nine-year-old self."

2. "(1) EMDR loosens up something in the mind/brain that gives people rapid access to loosely associated memories and images from their past. This seems to help them put the traumatic experience into a larger context or perspective. People may be able to heal from trauma without talking about it. (2) EMDR enables them to observe their experiences in a new way, without verbal give-and-take with another person. (3) EMDR can help even if the patient and the therapist do not have a trusting relationship. This was particularly intriguing because trauma, understandably, rarely leaves people with an open, trusting heart."

3. "“I remember it as though it was a real memory, but it was more distant. Typically, I drowned in it, but this time I was floating on top. I had the feeling that I was in control.”"

4. "EMDR was related to rapid eye movement (REM) sleep—the phase of sleep in which dreaming occurs. Research had already shown that sleep, and dream sleep in particular, plays a major role in mood regulation. As the article in 'Dreaming' pointed out, the eyes move rapidly back and forth in REM sleep, just as they do in EMDR. Increasing our time in REM sleep reduces depression, while the less REM sleep we get, the more likely we are to become depressed."

5. "The sleeping brain reshapes memory by increasing the imprint of emotionally relevant information while helping irrelevant material fade away. In a series of elegant studies Stickgold and his colleagues showed that the sleeping brain can even make sense out of information whose relevance is unclear while we are awake and integrate it into the larger memory system."

6. "In REM sleep we activate more distant associations than in either non-REM sleep or the normal waking state. For example, when subjects are wakened from non-REM sleep and given a word-association test, they give standard responses: hot/cold, hard/soft, etc. Wakened from REM sleep, they make less conventional connections, such as thief/wrong. They also solve simple anagrams more easily after REM sleep. This shift toward activation of distant associations could explain why dreams are so bizarre."

7. "The inability to recombine experiences is also one of the striking features of PTSD. While Noam in chapter 4 could imagine a trampoline to save future victims of terrorism, traumatized people are trapped in frozen associations: Anybody who wears a turban will try to kill me; any man who finds me attractive wants to rape me."

8. "EMDR spends very little time revisiting the original trauma. The trauma itself is certainly the starting point, but the focus is on stimulating and opening up the associative process."

9. "Those who received EMDR no longer experienced the distinct imprints of the trauma: It had become a story of a terrible event that had happened a long time ago. As one of my patients said, making a dismissive hand gesture: “It’s over."

Learning to inhabit your body: yoga

1. "The memory of helplessness is stored is as muscle tension or feelings of disintegration in the affected body areas."

2. "Self-numbing. They may become serially obese or anorexic or addicted to exercise or work. [...] The flip side of numbing is sensation seeking. Many people cut themselves to make the numbing go away, while others try bungee jumping or high-risk activities like prostitution and gambling. Any of these methods can give them a false and paradoxical feeling of control."

3. "Helping her learn to tolerate her physical sensations for what they were—just sensations in the present, with a beginning, a middle, and an end. We worked on helping her stay calm enough to notice what she felt without judgment, so she could observe these unbidden images and feelings as residues of a terrible past and not as unending threats to her life today."

4. "The sympathetic nervous system (SNS) uses chemicals like adrenaline to fuel the body and brain to take action, while the parasympathetic nervous system (PNS) uses acetylcholine to help regulate basic body functions like digestion, wound healing, and sleep and dream cycles."

5. "Heart rate variability measures the relative balance between the sympathetic and the parasympathetic systems."

6. "In healthy individuals inhalations and exhalations produce steady, rhythmical fluctuations in heart rate: Good heart rate variability is a measure of basic well-being."

7. "Effective arousal modulation gives us control over our impulses and emotions: As long as we manage to stay calm, we can choose how we want to respond. Individuals with poorly modulated autonomic nervous systems are easily thrown off balance, both mentally and physically."

8. "People with PTSD have unusually low HRV. In other words, in PTSD the sympathetic and parasympathetic nervous systems are out of sync."

9. "All yoga programs consist of a combination of breath practices (pranayama), stretches or postures (asanas), and meditation. [...] The emphasis is not on getting the poses “right” but on helping the participants notice which muscles are active at different times. The sequences are designed to create a rhythm between tension and relaxation—something we hope they will begin to perceive in their day-to-day lives."

10. "Rather than going into a state of quiet repose, our students’ muscles often continue to prepare them to fight unseen enemies. A major challenge in recovering from trauma remains being able to achieve a state of total relaxation and safe surrender."

11. "There is so much I can learn if I am open to it and then I won’t have to fight myself every minute of every day."

12. "This helps you anticipate the end of discomfort and strengthens your capacity to deal with physical and emotional distress. Awareness that all experience is transitory changes your perspective on yourself."

13. "People who feel safe in their bodies can begin to translate the memories that previously overwhelmed them into language."

14. "If we notice our breath we are in the present because we can’t breathe in the future or the past."

Putting the pieces together: self-leadership

1. "For many children it is safer to hate themselves than to risk their relationship with their caregivers by expressing anger or by running away. As a result, abused children are likely to grow up believing that they are fundamentally unlovable; that was the only way their young minds could explain why they were treated so badly. They survive by denying, ignoring, and splitting off large chunks of reality: They forget the abuse; they suppress their rage or despair; they numb their physical sensations."

2. "His mind automatically associates passive surrender with the paralysis he felt when his friend was killed. So another protective part steps in to create a diversion: He gets angry and, having no idea what set him off, he thinks he’s mad about something his girlfriend did."

3. "Just as we need to revisit traumatic memories in order to integrate them, we need to revisit the parts of ourselves that developed the defensive habits that helped us to survive."

4. "How well we get along with ourselves depends largely on our internal leadership skills—how well we listen to our different parts, make sure they feel taken care of, and keep them from sabotaging one another. Parts often come across as absolutes when in fact they represent only one element in a complex constellation of thoughts, emotions, and sensations."

5. "Every major school of psychology recognizes that people have subpersonalities and gives them different names. [...] The reconciliation of these opposites is a major problem. Thus, the adversary is none other than ‘the other in me.’” Modern neuroscience has confirmed this notion of the mind as a kind of society."

6. "Like members of a family, the different minds can work together to help each other, each still having its own mental experiences that the others never know about.”

7. "The mind of each of us is like a family in which the members have different levels of maturity, excitability, wisdom, and pain. The parts form a network or system in which change in any one part will affect all the others. The IFS model helped me realize that dissociation occurs on a continuum. In trauma the self-system breaks down, and parts of the self become polarized and go to war with one another. Self-loathing coexists (and fights) with grandiosity; loving care with hatred; numbing and passivity with rage and aggression. These extreme parts bear the burden of the trauma. In IFS a part is considered not just a passing emotional state or customary thought pattern but a distinct mental system with its own history, abilities, needs, and worldview."

8. "When we are abused, these are the parts that are hurt the most, and they become frozen, carrying the pain, terror, and betrayal of abuse. This burden makes them toxic—parts of ourselves that we need to deny at all costs. Because they are locked away inside, IFS calls them the exiles. At this point other parts organize to protect the internal family from the exiles. These protectors keep the toxic parts away, but in so doing they take on some of the energy of the abuser. Critical and perfectionistic managers can make sure we never get close to anyone or drive us to be relentlessly productive. Another group of protectors, which IFS calls firefighters, are emergency responders, acting impulsively whenever an experience triggers an exiled emotion. Each split-off part holds different memories, beliefs, and physical sensations; some hold the shame, others the rage, some the pleasure and excitement, another the intense loneliness or the abject compliance. These are all aspects of the abuse experience. The critical insight is that all these parts have a function: to protect the self from feeling the full terror of annihilation."

9. "If one accepts the basic idea that people have an innate drive toward nurturing their own health, this implies that, when people have chronic problems, something gets in the way of accessing inner resources. Recognizing this, the role of therapists is to collaborate rather than to teach, confront, or fill holes in your psyche. The first step in this collaboration is to assure the internal system that all parts are welcome and that all of them—even those that are suicidal or destructive—were formed in an attempt to protect the self-system, no matter how much they now seem to threaten it."

10. "Mindfulness not only makes it possible to survey our internal landscape with compassion and curiosity but can also actively steer us in the right direction for self-care."

11. "The internal system of an abuse victim differs from the non-abuse system with regard to the consistent absence of effective leadership, the extreme rules under which the parts function, and the absence of any consistent balance or harmony. Typically, the parts operate around outdated assumptions and beliefs derived from the childhood abuse, believing, for example, that it is still extremely dangerous to reveal secrets about childhood experiences which were endured."

12. "What happens when the self is no longer in charge? IFS calls this “blending”: a condition in which the Self identifies with a part, as in “I want to kill myself” or “I hate you.” Notice the difference from “A part of me wishes that I were dead” or “A part of me gets triggered when you do that and makes me want to kill you.”"

13. "Beneath the surface of the protective parts of trauma survivors there exists an undamaged essence, a Self that is confident, curious, and calm, a Self that has been sheltered from destruction by the various protectors that have emerged in their efforts to ensure survival. Once those protectors trust that it is safe to separate, the Self will spontaneously emerge, and the parts can be enlisted in the healing process."

14. "This mindful Self can help reorganize the inner system and communicate with the parts in ways that help those parts trust that there is someone inside who can handle things."

15. "“This part of me is like a little child, and that part of me is more mature but feels like a victim.” They might not like many of these parts, but identifying them makes them less intimidating or overwhelming. The next step is to encourage patients to simply ask each protective part as it emerges to “stand back” temporarily so that we can see what it is protecting. When this is done again and again, the parts begin to unblend from the Self and make space for mindful self-observation. Patients learn to put their fear, rage, or disgust on hold and open up into states of curiosity and self-reflection. From the stable perspective of Self they can begin constructive inner dialogues with their parts."

16. "“How do you feel toward that (sad, vengeful, terrified) part of you?” This sets the stage for mindful self-observation by separating the “you” from the part in question. [...] “What do you say to the part about that?” or “Where do you want to go now?” or “What feels like the right next step?” as well as the ubiquitous Self-detecting question, “How do you feel toward the part now?"

17. "I realized that the only way to counter her defensiveness was by showing a high level of interest in the details of her life, demonstrating unwavering support for the risk she took in talking with me, and accepting the parts she was most ashamed of. [...] The critic was obviously a manager: Not only was it protecting Joan from me, but it was trying to preempt her mother’s criticism."

18. "I could not provide her with the love and caring she had missed as a child. If, as a therapist, teacher, or mentor, you try to fill the holes of early deprivation, you come up against the fact that you are the wrong person, at the wrong time, in the wrong place."

19. "An aggressive childlike part that threw tantrums, a promiscuous adolescent part, a suicidal part, an obsessive manager, a prissy moralist, and so on. As usual, we met the managers first. Their job was to prevent humiliation and abandonment and to keep her organized and safe. Some managers may be aggressive, like Joan’s critic, while others are perfectionistic or reserved, careful not to draw too much attention to themselves. They may tell us to turn a blind eye to what is going on and keep us passive to avoid risk. Internal managers also control how much access we have to emotions, so that the selfsystem doesn’t get overwhelmed. It requires an enormous amount of energy to keep the system under control. A single flirtatious comment may trigger several parts simultaneously: one that becomes intensely sexually aroused, another filled with self-loathing, a third that tries to calm things down by self-cutting. Other managers create obsessions and distractions or deny reality altogether. But each part should be approached as an internal protector who maintains an important defensive position."

20. "It is normal to simultaneously experience conflicting feelings or thoughts [...]. Instead of believing that hate consumed her entire being, she learned that only a part of her felt paralyzed by it."

21. "Firefighters will do anything to make emotional pain go away. Aside from sharing the task of keeping the exiles locked up, they are the opposite of managers: Managers are all about staying in control, while firefighters will destroy the house in order to extinguish the fire. [...] I’ve met firefighters who shop, drink, play computer games addictively, have impulsive affairs, or exercise compulsively."

22. "Exiles are the toxic waste dump of the system. [...] When exiles overwhelm managers, they take us over—we are nothing but that rejected, weak, unloved, and abandoned child. The Self becomes “blended” with the exiles, and every possible alternative for our life is eclipsed. Then, as Schwartz points out, “We see ourselves, and the world, through their eyes and believe it is ‘the’ world. In this state it won’t occur to us that we have been hijacked.”"

23. "Usually those are your most sensitive, creative, intimacy-loving, lively, playful and innocent parts. By exiling them when they get hurt, they suffer a double whammy—the insult of your rejection is added to their original injury."

24. "Internal managers who are obsessed with power are usually created as a bulwark against feeling helpless."

25. "“If you criticize others, they don’t dare to hurt you.” Then: “If you are perfect, nobody can criticize you.” I asked him to thank his critic for protecting him against hurt and humiliation, and as he became silent again, I could see his shoulders relax and his breathing become slower and deeper."

26. "I asked him to have his critic show him what he protected. [...] I asked the critic if he would be willing to step aside so we could see what was going on with that boy. [...] There were other scenes, like running to embrace his father at the door and getting slapped for having disobeyed his mother. [...] Again I suggested he find the protective parts that were interrupting the witnessing of the boy’s pain and request that they move temporarily to another room. And each time he was able to return to his grief. [...] Then I asked him to show the boy that he cared about him. [...] I urged Peter to go back into the scene and take the boy away with him. Peter imagined himself confronting his dad as a grown man, telling him: “If you ever mess with that boy again, I’ll come and kill you.” He then, in his imagination, took the child to a beautiful campground he knew, where the boy could play and frolic with ponies while he watched over him. [...] This is the stage IFS calls “unburdening,” and it corresponds to nursing those exiled parts back to health."

Filling in the holes: creating structures

1. "If you grew up unwanted and ignored, it is a major challenge to develop a visceral sense of agency and self-worth."

2. "Those who did not remember feeling safe with anyone while growing up, did not fully benefit from conventional psychotherapy, presumably because they could not activate old traces of feeling cared for."

3. "He tracked subtle shifts in body posture, facial expression, tone of voice, and eye gaze, the nonverbal expressions of emotion. (This is called “microtracking” in psychomotor therapy)."

4. "Protagonists became the directors of their own plays, creating around them the past they never had, and they clearly experienced profound physical and mental relief after these imaginary scenarios."

5. "As you place your “real mother” in the corner, cowering in terror, you may feel a deep longing to protect her and realize how powerless you felt as a child. But if you then create an ideal mother, who stands up to your father and who knows how to avoid getting trapped in abusive relationships, you may experience a visceral sense of relief and an unburdening of that old guilt and helplessness."

6. "You can tell the placeholder for your depressed and frightened mother how terrible you felt about not being able to take care of her. You can experiment with distance and proximity and explore what happens as you move placeholders around."

7. "Structures do not erase bad memories, or even neutralize them the way EMDR does. Instead, a structure offers fresh options—an alternative memory in which your basic human needs are met and your longings for love and protection are fulfilled."

8. "The “witness figure” enters the structure at the very beginning and takes the role of an accepting, nonjudgmental observer who joins the protagonist by reflecting his or her emotional state and noting the context in which that state has emerged (as when I mentioned Maria’s “volunteering to do a structure”). Being validated by feeling heard and seen is a precondition for feeling safe, which is critical when we explore the dangerous territory of trauma and abandonment. A neuroimaging study has shown that when people hear a statement that mirrors their inner state, the right amygdala momentarily lights up, as if to underline the accuracy of the reflection."

9. "Structures promote one of the essential conditions for deep therapeutic change: a trancelike state in which multiple realities can live side by side—past and present."

10. "“My sadness goes out to my mom; how incapable she was of standing up to my father and protecting us. She just shuts down, pretending everything’s okay, and in her mind it probably is, and that makes me mad today. I want to say to her: ‘Mom, when I see you react to dad when he is being mean . . . when I see your face, you look disgusted and I don’t know why you don’t say, “Fuck off.” You don’t know how to fight—you are such a pushover—there is a part of you that is not good and not alive. I don’t even know what I want you to say. I just want you to be different—nothing you do is right, like you accept everything when it is totally not okay.’”"

11. "“What do you want your ideal mother to say to your dad?” I asked. “I want her to say, ‘If you are going to talk like that, I am going to leave you and take the kids,’” she answered. “‘We are not going to sit here and listen to this shit.’” [...] “Allow yourself to feel that joy as you look at an ideal dad who would have cared for you.”"

12. "A child who has been ignored or chronically humiliated is likely to lack self-respect. Children who have not been allowed to assert themselves will probably have difficulty standing up for themselves as adults, and most grown-ups who were brutalized as children carry a smoldering rage that will take a great deal of energy to contain. Our relationships will suffer as well. The more early pain and deprivation we have experienced, the more likely we are to interpret other people’s actions as being directed against us and the less understanding we will be of their struggles, insecurities, and concerns. If we cannot appreciate the complexity of their lives, we may see anything they do as a confirmation that we are going to get hurt and disappointed."

13. "Anticipating rejection, ridicule, and deprivation, they are reluctant to try out new options, certain that these will lead to failure. This lack of experimentation traps people in a matrix of fear, isolation, and scarcity where it is impossible to welcome the very experiences that might change their basic worldview."

14. "In contrast, a structure creates a three-dimensional image of whom and what you had to deal with and gives you a chance to create a different outcome."

15. "The scene you re-create in a structure may or may not be precisely what happened, but it represents the structure of your inner world: your internal map and the hidden rules that you have been living by."

Rewiring the brain; neurofeedback

1. "Slow-wave prefrontal activity was certified by the Food and Drug Administration as a biomarker for ADHD. Slow frontal lobe electrical activity explains why these kids have poor executive functioning: Their rational brains lack proper control over their emotional brains, which also occurs when abuse and trauma have made the emotional centers hyperalert to danger and organized for fight or flight."

2. "The brain waves of traumatized subjects were more loosely coordinated and failed to come together into a coherent pattern. Specifically, they did not generate the brainwave pattern that helps people pay attention on the task at hand by filtering out irrelevant information."

3. "The depth of the wave determines how well we are able to take in and analyze new data."

4. "So many traumatized people have trouble learning from experience and fully engaging in their daily lives. Their brains are not organized to pay careful attention to what is going on in the present moment."

5. "Neurofeedback nudges the brain to make more of some frequencies and less of others, creating new patterns that enhance its natural complexity and its bias toward self-regulation. [...] The feedback would reinforce selected brainwave patterns while discouraging others."

6. "In some ways neurofeedback is similar to watching someone’s face during a conversation. If you see smiles or slight nods, you’re rewarded, and you go on telling your story or making your point. But the moment your conversation partner looks bored or shifts her gaze, you’ll start to wrap up or change the topic. In neurofeedback the reward is a tone or movement on the screen instead of a smile, and the inhibition is far more neutral than a frown—it’s simply an undesired pattern." 7. "With neurofeedback we hope to intervene in the circuitry that promotes and sustains states of fear and traits of fearfulness, shame, and rage. It is the repetitive firing of these circuits that defines trauma.” Patients need help to change the habitual brain patterns created by trauma and its aftermath."

8. "Neurofeedback simply stabilizes the brain and increases resiliency, allowing us to develop more choices in how to respond."

9. "Alpha waves, which are associated with relaxation. [...] enter voluntarily into an alpha state in response to a simple sound cue."

10. "In general, the more problems a patient has, the more abnormalities show up in the qEEG (quantitative EEG)."

11. "Other traumatized patients show patterns of hyperactivity the moment they close their eyes: Not seeing what is going on around them makes them panic and their brain waves go wild. We train them to produce more relaxed brain patterns. Yet another group overreacts to sounds and light, a sign that the thalamus has difficulty filtering out irrelevant information. In those patients we focus on changing communication patterns at the back of the brain."

12. "Hypnagogic states—the essence of hypnotic trance—[...] When theta waves predominate in the brain, the mind’s focus is on the internal world, a world of free-floating imagery. Alpha brain waves may act as a bridge from the external world to the internal, and vice versa."

13. "Loosen the conditioned connections between particular stimuli and responses, such as loud cracks signaling gunfire, a harbinger of death. A new association can be created in which that same crack can come to be linked to Fourth of July fireworks at the end of a day at the beach with loved ones."

14. "A return to understanding mind and brain in terms of the rhythms and patterns of electrical communication: “Brain regions that function together to carry out normal (and abnormal) mental operations can be thought of as analogous to electrical circuits—the latest research shows that the malfunctioning of entire circuits may underlie many mental disorders."

Finding your voice: communal rhythms and theater

1. "In order to find our voice, we have to be in our bodies—able to breathe fully and able to access our inner sensations. This is the opposite of dissociation, of being “out of body” and making yourself disappear. It’s also the opposite of depression, lying slumped in front of a screen that provides passive entertainment. Acting is an experience of using your body to take your place in life."

2. "Greek drama may have served as a ritual reintegration for combat veterans."

3. "Collective movement and music create a larger context for our lives, a meaning beyond our individual fate."

4. "Music binds together people who might individually be terrified but who collectively become powerful advocates for themselves and others. Along with language, dancing, marching, and singing are uniquely human ways to install a sense of hope and courage."

5. "The historical role of dance and military drill in creating what McNeill calls “muscular bonding”."

6. "Confrontation of the painful realities of life and symbolic transformation through communal action. Love and hate, aggression and surrender, loyalty and betrayal are the stuff of theater and the stuff of trauma. As a culture we are trained to cut ourselves off from the truth of what we’re feeling."

7. "Traumatized people are terrified to feel deeply. They are afraid to experience their emotions, because emotions lead to loss of control. In contrast, theater is about embodying emotions, giving voice to them, becoming rhythmically engaged, taking on and embodying different roles."

8. "Theater gives trauma survivors a chance to connect with one another by deeply experiencing their common humanity. Traumatized people are afraid of conflict. They fear losing control and ending up on the losing side once again. Conflict is central to theater—inner conflicts, interpersonal conflicts, family conflicts, social conflicts, and their consequences. Trauma is about trying to forget, hiding how scared, enraged, or helpless you are. Theater is about finding ways of telling the truth and conveying deep truths to your audience. This requires pushing through blockages to discover your own truth, exploring and examining your own internal experience so that it can emerge in your voice and body on stage."

9. "The secret is to go slow and engage them bit by bit. [...] If you take too big a jump, you’ll see them hit the wall."

10. "Mirroring loosens their preoccupation with what other people think of them and helps them attune viscerally, not cognitively, to someone else’s experience."

11. "We were shocked to discover that, in scenes where someone was in physical danger, the students always sided with the aggressors. Because they could not tolerate any sign of weakness in themselves, they could not accept it in others. They showed nothing but contempt for potential victims, yelling things like, “Kill the bitch, she deserves it,” during a skit about dating violence."

12. "Another foster-care buzzword is “independence,” which Paul counters with “interdependence.” “We’re all interdependent,” he points out. “The idea that we’re asking our young people to go out in the world completely alone and call themselves independent is crazy. We need to teach them how to be interdependent, which means teaching them how to have relationships."

13. "The group will learn that if they can embody their experiences well enough, other people will listen."

14. "When the job goes bad, when a cherished project fails, when someone you count on leaves you or dies, there are few things as helpful as moving your muscles and doing something that demands focused attention."

15. "You cannot help, fix, or save the young people you are working with. What you can do is work side by side with them, help them to understand their vision, and realize it with them. By doing that you give them back control. We’re healing trauma without anyone ever mentioning the word."

16. "Learning to experience and tolerate deep emotions is essential for recovery from trauma."

Choices to be made

1. "Poverty, unemployment, inferior schools, social isolation, widespread availability of guns, and substandard housing all are breeding grounds for trauma. Trauma breeds further trauma; hurt people hurt other people."

2. "What are these patients trying to cope with? What are their internal or external resources? How do they calm themselves down? Do they have caring relationships with their bodies, and what do they do to cultivate a physical sense of power, vitality, and relaxation? Do they have dynamic interactions with other people? Who really knows them, loves them, and cares about them? Whom can they count on when they’re scared, when their babies are ill, or when they are sick themselves? Are they members of a community, and do they play vital roles in the lives of the people around them? What specific skills do they need to focus, pay attention, and make choices? Do they have a sense of purpose? What are they good at? How can we help them feel in charge of their lives?"

3. "All of us, but especially children, need such confidence—confidence that others will know, affirm, and cherish us. Without that we can’t develop a sense of agency that will enable us to assert: “This is what I believe in; this is what I stand for; this is what I will devote myself to.”"

4. "But if we feel abandoned, worthless, or invisible, nothing seems to matter. Fear destroys curiosity and playfulness."

5. "Resilience is the product of agency."

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