The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

EPILOGUE

CHOICES TO BE MADE

We are on the verge of becoming a trauma-conscious society. Almost every day one of my colleagues publishes another report on how trauma disrupts the workings of mind, brain, and body. The ACE study showed how early abuse devastates health and social functioning, while James Heckman won a Nobel Prize for demonstrating the vast savings produced by early intervention in the lives of children from poor and troubled families: more high school graduations, less criminality, increased employment, and decreased family and community violence. All over the world I meet people who take these data seriously and who work tirelessly to develop and apply more effective interventions, whether devoted teachers, social workers, doctors, therapists, nurses, philanthropists, theater directors, prison guards, police officers, or meditation coaches. If you have come this far with me in The Body Keeps the Score, you have also become part of this community.

Advances in neuroscience have given us a better understanding of how trauma changes brain development, self-regulation, and the capacity to stay focused and in tune with others. Sophisticated imaging techniques have identified the origins of PTSD in the brain, so that we now understand why traumatized people become disengaged, why they are bothered by sounds and lights, and why they may blow up or withdraw in response to the slightest provocation. We have learned how, throughout life, experiences change the structure and function of the brain—and even affect the genes we pass on to our children. Understanding many of the fundamental processes that underlie traumatic stress opens the door to an array of interventions that can bring the brain areas related to self-regulation, self-perception, and attention back online. We know not only how to treat trauma but also, increasingly, how to prevent it.

And yet, after attending another wake for a teenager who was killed in a drive-by shooting in the Blue Hill Avenue section of Boston or after reading about the latest school budget cuts in impoverished cities and towns, I find myself close to despair. In many ways we seem to be regressing, with measures like the callous congressional elimination of food stamps for kids whose parents are unemployed or in jail; with the stubborn opposition to universal health care in some quarters; with psychiatry’s obtuse refusal to make connection between psychic suffering and social conditions; with the refusal to prohibit the sale or possession of weapons whose only purpose is to kill large numbers of human beings; and with our tolerance for incarcerating a huge segment of our population, wasting their lives as well as our resources.

Discussions of PTSD still tend to focus on recently returned soldiers, victims of terrorist bombings, or survivors of terrible accidents. But trauma remains a much larger public health issue, arguably the greatest threat to our national well-being. Since 2001 far more Americans have died at the hands of their partners or other family members than in the wars in Iraq and Afghanistan. American women are twice as likely to suffer domestic violence as breast cancer. The American Academy of Pediatrics estimates that firearms kill twice as many children as cancer does. All around Boston I see signs advertising the Jimmy Fund, which fights children’s cancer, and for marches to fund research on breast cancer and leukemia, but we seem too embarrassed or discouraged to mount a massive effort to help children and adults learn to deal with the fear, rage, and collapse, the predictable consequences of having been traumatized.

When I give presentations on trauma and trauma treatment, participants sometimes ask me to leave out the politics and confine myself to talking about neuroscience and therapy. I wish I could separate trauma from politics, but as long as we continue to live in denial and treat only trauma while ignoring its origins, we are bound to fail. In today’s world your ZIP code, even more than your genetic code, determines whether you will lead a safe and healthy life. People’s income, family structure, housing, employment, and educational opportunities affect not only their risk of developing traumatic stress but also their access to effective help to address it. 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.

My most profound experience with healing from collective trauma was witnessing the work of the South African Truth and Reconciliation Commission, which was based on the central guiding principle of Ubuntu, a Xhosa word that denotes sharing what you have, as in “My humanity is inextricably bound up in yours.” Ubuntu recognizes that true healing is impossible without recognition of our common humanity and our common destiny.

We are fundamentally social creatures—our brains are wired to foster working and playing together. Trauma devastates the social-engagement system and interferes with cooperation, nurturing, and the ability to function as a productive member of the clan. In this book we have seen how many mental health problems, from drug addiction to self-injurious behavior, start off as attempts to cope with emotions that became unbearable because of a lack of adequate human contact and support. Yet institutions that deal with traumatized children and adults all too often bypass the emotional-engagement system that is the foundation of who we are and instead focus narrowly on correcting “faulty thinking” and on suppressing unpleasant emotions and troublesome behaviors.

People can learn to control and change their behavior, but only if they feel safe enough to experiment with new solutions. The body keeps the score: If trauma is encoded in heartbreaking and gut-wrenching sensations, then our first priority is to help people move out of fight-or-flight states, reorganize their perception of danger, and manage relationships. Where traumatized children are concerned, the last things we should be cutting from school schedules are the activities that can do precisely that: chorus, physical education, recess, and anything else that involves movement, play, and other forms of joyful engagement.

As we’ve seen, my own profession often compounds, rather than alleviates, the problem. Many psychiatrists today work in assembly-line offices where they see patients they hardly know for fifteen minutes and then dole out pills to relieve pain, anxiety, or depression. Their message seems to be “Leave it to us to fix you; just be compliant and take these drugs and come back in three months—but be sure not to use alcohol or (illegal) drugs to relieve your problems.” Such shortcuts in treatment make it impossible to develop self-care and self-leadership. One tragic example of this orientation is the rampant prescription of painkillers, which now kill more people each year in the United States than guns or car accidents.

Our increasing use of drugs to treat these conditions doesn’t address the real issues: 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?

I like to believe that once our society truly focuses on the needs of children, all forms of social support for families—a policy that remains so controversial in this country—will gradually come to seem not only desirable but also doable. What difference would it make if all American children had access to high-quality day care where parents could safely leave their children as they went off to work or school? What would our school systems look like if all children could attend well-staffed preschools that cultivated cooperation, self-regulation, perseverance, and concentration (as opposed to focusing on passing tests, which will likely happen once children are allowed to follow their natural curiosity and desire to excel, and are not shut down by hopelessness, fear, and hyperarousal)?

I have a family photograph of myself as a five-year-old, perched between my older (obviously wiser) and younger (obviously more dependent) siblings. In the picture I proudly hold up a wooden toy boat, grinning from ear to ear: “See what a wonderful kid I am and see what an incredible boat I have! Wouldn’t you love to come and play with me?” 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.” As long as we feel safely held in the hearts and minds of the people who love us, we will climb mountains and cross deserts and stay up all night to finish projects. Children and adults will do anything for people they trust and whose opinion they value.

But if we feel abandoned, worthless, or invisible, nothing seems to matter. Fear destroys curiosity and playfulness. In order to have a healthy society we must raise children who can safely play and learn. There can be no growth without curiosity and no adaptability without being able to explore, through trial and error, who you are and what matters to you. Currently more than 50 percent of the children served by Head Start have had three or more adverse childhood experiences like those included in the ACE study: incarcerated family members, depression, violence, abuse, or drug use in the home, or periods of homelessness.

People who feel safe and meaningfully connected with others have little reason to squander their lives doing drugs or staring numbly at television; they don’t feel compelled to stuff themselves with carbohydrates or assault their fellow human beings. However, if nothing they do seems to make a difference, they feel trapped and become susceptible to the lure of pills, gang leaders, extremist religions, or violent political movements—anybody and anything that promises relief. As the ACE study has shown, child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.

My colleagues and I focus much of our work where trauma has its greatest impact: on children and adolescents. Since we came together to establish the National Child Traumatic Stress Network in 2001, it has grown into a collaborative network of more than 150 centers nationwide, each of which has created programs in schools, juvenile justice systems, child welfare agencieshomeless shelters, military facilities, and residential group homes.

The Trauma Center is one of NCTSN’s Treatment Development and Evaluation sites. My colleagues Joe Spinazzola, Margaret Blaustein, and I have developed comprehensive programs for children and adolescents that we, with the help of trauma-savvy colleagues in Hartford, Chicago, Houston, San Francisco, Anchorage, Los Angeles, and New York, are now implementing. Our team selects a particular area of the country to work in every two years, relying on local contacts to identify organizations that are energetic, open, and well respected; these will eventually serve as new nodes for treatment dissemination. For example, I collaborated for one two-year period with colleagues in Missoula, Montana, to help develop a culturally sensitive trauma program on Blackfoot Indian reservations.

The greatest hope for traumatized, abused, and neglected children is to receive a good education in schools where they are seen and known, where they learn to regulate themselves, and where they can develop a sense of agency. At their best, schools can function as islands of safety in a chaotic world. They can teach children how their bodies and brains work and how they can understand and deal with their emotions. Schools can play a significant role in instilling the resilience necessary to deal with the traumas of neighborhoods or families. If parents are forced to work two jobs to eke out a living, or if they are too impaired, overwhelmed, or depressed to be attuned to the needs of their kids, schools by default have to be the places where children are taught self-leadership and an internal locus of control.

When our team arrives at a school, the teachers’ initial response is often some version of “If I’d wanted to be a social worker, I would have gone to social work school. But I came here to be a teacher.” Many of them have already learned the hard way, however, that they cannot teach if they have a classroom filled with students whose alarm bells are constantly going off. Even the most committed teachers and school systems often come to feel frustrated and ineffective because so many of their kids are too traumatized to learn. Focusing only on improving test scores won’t make any difference if teachers can’t effectively address the behavior problems of these students. The good news is that the basic principles of trauma-focused interventions can be translated into practical day-to-day routines and approaches that can transform the entire culture of a school.

Most teachers we work with are intrigued to learn that abused and neglected students are likely to interpret any deviation from routine as danger and that their extreme reactions usually are expressions of traumatic stress. Children who defy the rules are unlikely to be brought to reason by verbal reprimands or even suspension—a practice that has become epidemic in American schools. Teachers’ perspectives begin to change when they realize that these kids’ disturbing behaviors started out as frustrated attempts to communicate distress and as misguided attempts to survive.

More than anything else, being able to feel safe with other people defines mental health; safe connections are fundamental to meaningful and satisfying lives. The critical challenge in a classroom setting is to foster reciprocity: truly hearing and being heard; really seeing and being seen by other people. We try to teach everyone in a school community—office staff, principals, bus drivers, teachers, and cafeteria workers—to recognize and understand the effects of trauma on children and to focus on the importance of fostering safety, predictability, and being known and seen. We make certain that the children are greeted by name every morning and that teachers make face-to-face contact with each and every one of them. Just as in our workshops, group work, and theater programs, we always start the day with check-ins: taking the time to share what’s on everybody’s mind.

Many of the children we work with have never been able to communicate successfully with language, as they are accustomed to adults who yell, command, sulk, or put earbuds in their ears. One of our first steps is to help their teachers model new ways of talking about feelings, stating expectations, and asking for help. Instead of yelling, “Stop!” when a child is throwing a tantrum or making her sit alone in the corner, teachers are encouraged to notice and name the child’s experience, as in “I can see how upset you are”; to give her choices, as in “Would you like to go to the safe spot or sit on my lap?”; and to help her find words to describe her feelings and begin to find her voice, as in: “What will happen when you get home after class?” It may take many months for a child to know when it is safe to speak the truth (because it will never be universally safe), but for children, as for adults, identifying the truth of an experience is essential to healing from trauma.

It is standard practice in many schools to punish children for tantrums, spacing out, or aggressive outbursts—all of which are often symptoms of traumatic stress. When that happens, the school, instead of offering a safe haven, becomes yet another traumatic trigger. Angry confrontations and punishment can at best temporarily halt unacceptable behaviors, but since the underlying alarm system and stress hormones are not laid to rest, they are certain to erupt again at the next provocation.

In such situations the first step is acknowledging that a child is upset; then the teacher should calm him, then explore the cause and discuss possible solutions. For example, when a first-grader melts down, hitting his teacher and throwing objects around, we encourage his teacher to set clear limits while gently talking to him: Would you like to wrap that blanket around you to help you calm down?” (The kid is likely to scream, “No!” but then curl up under the blanket and settle down.) Predictability and clarity of expectations are critical; consistency is essential. Children from chaotic backgrounds often have no idea how people can effectively work together, and inconsistency only promotes further confusion. Trauma-sensitive teachers soon realize that calling a parent about an obstreperous kid is likely to result in a beating and further traumatization.

Our goal in all these efforts is to translate brain science into everyday practice. For example, calming down enough to take charge of ourselves requires activating the brain areas that notice our inner sensations, the self-observing watchtower discussed in chapter 4. So a teacher might say: “Shall we take some deep breaths or use the breathing star?” (This is a colorful breathing aid made out of file folders.) Another option might be having the child sit in a corner wrapped in a heavy blanket while listening to some soothing music through headphones. Safe areas can help kids calm down by providing stimulating sensory awareness: the texture of burlap or velvet; shoe boxes filled with soft brushes and flexible toys. When the child is ready to talk again, he is encouraged to tell someone what is going on before he rejoins the group.

Kids as young as three can blow soap bubbles and learn that when they slow down their breathing to six breaths per minute and focus on the out breath as it flows over their upper lip, they will feel more calm and focused. Our team of yoga teachers works with children nearing adolescence specifically to help them “befriend” their bodies and deal with disruptive physical sensations. We know that one of the prime reasons for habitual drug use in teens is that they cannot stand the physical sensations that signal fear, rage, and helplessness.

Self-regulation can be taught to many kids who cycle between frantic activity and immobility. In addition to reading, writing, and arithmetic, all kids need to learn self-awareness, self-regulation, and communication as part of their core curriculum. Just as we teach history and geography, we need to teach children how their brains and bodies work. For adults and children alike, being in control of ourselves requires becoming familiar with our inner world and accurately identifying what scares, upsets, or delights us.

Emotional intelligence starts with labeling your own feelings and attuning to the emotions of the people around you. We begin very simply: with mirrors. Looking into a mirror helps kids to be aware of what they look like when they are sad, angry, bored, or disappointed. Then we ask them, “How do you feel when you see a face like that?” We teach them how their brains are built, what emotions are for, and where they are registered in their bodies, and how they can communicate their feelings to the people around them. They learn that their facial muscles give clues about what they are feeling and then experiment with how their facial expressions affect other people.

We also strengthen the brain’s watchtower by teaching them to recognize and name their physical sensations. For example, when their chest tightens, that probably means that they are nervous; their breathing becomes shallow and they feel uptight. What does anger feel like, and what can they do to change that sensation in their body? What happens if they take a deep breath or take time out to jump rope or hit a punching bag? Does tapping acupressure points help? We try to provide children, teachers, and other care providers with a toolbox of ways to take charge of their emotional reactions.

To promote reciprocity, we use other mirroring exercises, which are the foundation of safe interpersonal communication. Kids practice imitating one another’s facial expressions. They proceed to imitating gestures and sounds and then get up and move in sync. To play well, they have to pay attention to really seeing and hearing one another. Games like Simon Says lead to lots of sniggering and giggling—signs of safety and relaxation. When teenagers balk at these “stupid games,” we nod understandingly and enlist their cooperation by asking them to demonstrate games to the little kids, who “need their help.”

Teachers and leaders learn that an activity as simple as trying to keep a beach ball in the air as long as possible helps groups become more focused, cohesive, and fun. These are inexpensive interventions. For older children some schools have installed workstations costing less than two hundred dollars where students can play computer games to help them focus and to improve their heart rate variability (HRV) (discussed in chapter 16), just as we do in our own clinic.

Children and adults alike need to experience how rewarding it is to work at the edge of their abilities. Resilience is the product of agency: knowing that what you do can make a difference. Many of us remember what playing team sports, singing in the school choir, or playing in the marching band meant to us, especially if we had coaches or directors who believed in us, pushed us to excel, and taught us we could be better than we thought was possible. The children we reach need this experience.

Athletics, playing music, dancing, and theatrical performances all promote agency and community. They also engage kids in novel challenges and unaccustomed roles. In a devastated postindustrial New England town, my friends Carolyn and Eli Newberger are teaching El Sistema, an orchestral music program that originated in Venezuela. Several of my students run an after-school program in Brazilian capoeira in a high-crime area of Boston, and my colleagues at the Trauma Center continue the Trauma Drama program. Last year I spent three weeks helping two boys prepare a scene from Julius Caesar. An effeminate, shy boy was playing Brutus and had to summon up his full force to put down Cassius, played by the class bully, who had to be coached to play a corrupt general begging for mercy. The scene came to life only after the bully talked about his father’s violence and his own vow never to show weakness to anyone. (Most bullies have themselves been bullied, and they despise kids who remind them of their own vulnerability.) Brutus’s powerful voice, on the other hand, emerged after he realized that he’d made himself invisible to deal with his own family violence.

These intense communal efforts force kids to collaborate, compromise, and stay focused on the task at hand. Tensions often run high, but the kids stick with it because they want to earn the respect of their coaches or directors and don’t want to let down the team—all feelings that are opposite to the vulnerability of being subjected to arbitrary abuse, the invisibility of neglect, and the godforsaken isolation of trauma.

Our NCTSN programs are working: Kids become less anxious and emotionally reactive and are less aggressive or withdrawn; they get along better and their school performance improves; their attention deficit, hyperactivity, and “oppositional defiant” problems decrease; and parents report that their children are sleeping better. Terrible things still happen to them and around them, but they are now able to talk about these events; they have built up the trust and resources to seek the help they need. Interventions are successful if they draw on our natural wellsprings of cooperation and on our inborn responses to safety, reciprocity, and imagination.

Trauma constantly confronts us with our fragility and with man’s inhumanity to man but also with our extraordinary resilience. I have been able to do this work for so long because it drew me to explore our sources of joy, creativity, meaning, and connection—all the things that make life worth living. I can’t begin to imagine how I would have coped with what many of my patients have endured, and I see their symptoms as part of their strength—the ways they learned to survive. And despite all their suffering many have gone on to become loving partners and parents, exemplary teachers, nurses, scientists, and artists.

Most great instigators of social change have intimate personal knowledge of trauma. Oprah Winfrey comes to mind, as do Maya Angelou, Nelson Mandela, and Elie Wiesel. Read the life history of any visionary, and you will find insights and passions that came from having dealt with devastation.

The same is true of societies. Many of our most profound advances grew out of experiencing trauma: the abolition of slavery from the Civil War, Social Security in response to the Great Depression, and the GI Bill, which produced our once vast and prosperous middle class, from World War II. Trauma is now our most urgent public health issue, and we have the knowledge necessary to respond effectively. The choice is ours to act on what we know.