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August 16 - October 7, 2025
All too often, however, drugs such as Abilify, Zyprexa, and Seroquel, are prescribed instead of teaching people the skills to deal with such distressing physical reactions. Of course, medications only blunt sensations and do nothing to resolve them or transform them from toxic agents into allies.
The most striking difference between normal controls and survivors of chronic trauma was in activation of the prefrontal cortex in response to a direct eye gaze. The prefrontal cortex (PFC) normally helps us to assess the person coming toward us, and our mirror neurons help to pick up his intentions. However, the subjects with PTSD did not activate any part of their frontal lobe, which means they could not muster any curiosity about the stranger. They just reacted with intense activation deep inside their emotional brains, in the primitive areas known as the Periaqueductal Gray, which
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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.
Henry Murray had, among other things, become famous for designing the widely used Thematic Apperception Test. The TAT is a so-called projective test, which uses a set of cards to discover how people’s inner reality shapes their view of the world.
As we grow up, we gradually learn to take care of ourselves, both physically and emotionally, but we get our first lessons in self-care from the way that we are cared for. Mastering the skill of self-regulation depends to a large degree on how harmonious our early interactions with our caregivers are. Children whose parents are reliable sources of comfort and strength have a lifetime advantage—a kind of buffer against the worst that fate can hand them.
Secure attachment develops when caregiving includes emotional attunement. Attunement starts at the most subtle physical levels of interaction between babies and their caretakers, and it gives babies the feeling of being met and understood. As Edinburgh-based attachment researcher Colwyn Trevarthen says: “The brain coordinates rhythmic body movements and guides them to act in sympathy with other people’s brains. Infants hear and learn musicality from their mother’s talk, even before birth.”
A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life.7 Securely attached children learn what makes them feel good; they discover what makes them (and others) feel bad, and they acquire a sense of agency: that their actions can change how they feel and how others respond. Securely attached kids learn the difference between situations they can control and situations where they need help. They learn that they can play an active role when faced with difficult situations. In contrast, children with
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Attachment researchers think that the three “organized” attachment strategies (secure, avoidant, and anxious) work because they elicit the best care a particular caregiver is capable of providing.
In a study of attachment patterns in over two thousand infants in “normal” middle-class environments, 62 percent were found to be secure, 15 percent avoidant, 9 percent anxious (also known as ambivalent), and 15 percent disorganized.21 Interestingly, this large study showed that the child’s gender and basic temperament have little effect on attachment style; for example, children with “difficult” temperaments are not more likely to develop a disorganized style. Kids from lower socioeconomic groups are more likely to be disorganized,22 with parents often severely stressed by economic and family
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Bowlby wrote: “What cannot be communicated to the [m]other cannot be communicated to the self.”38 If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.
Karlen’s research showed that dissociation is learned early: Later abuse or other traumas did not account for dissociative symptoms in young adults.40 Abuse and trauma accounted for many other problems, but not for chronic dissociation or aggression against self. 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: Poverty, single parenthood, or maternal psychiatric symptoms did not predict these symptoms. This does
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Truth, like love and sleep, resents Approaches that are too intense.
As I discussed in the previous chapter, attachment researchers have shown that our earliest caregivers don’t only feed us, dress us, and comfort us when we are upset; they shape the way our rapidly growing brain perceives reality. Our interactions with our caregivers convey what is safe and what is dangerous: whom we can count on and who will let us down; what we need to do to get our needs met. This information is embodied in the warp and woof of our brain circuitry and forms the template of how we think of ourselves and the world around us. These inner maps are remarkably stable across time.
Her immune system, her muscles, and her fear system all had kept the score, but her conscious mind lacked a story that could communicate the experience. She reenacted her trauma in her life, but she had no narrative to refer to.
Children are also programmed to be fundamentally loyal to their caretakers, even if they are abused by them. Terror increases the need for attachment, even if the source of comfort is also the source of terror. I have never met a child below the age of ten who was tortured at home (and who had broken bones and burned skin to show for it) who, if given the option, would not have chosen to stay with his or her family rather than being placed in a foster home. Of course, clinging to one’s abuser is not exclusive to childhood. Hostages have put up bail for their captors, expressed a wish to marry
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Trauma is not stored as a narrative with an orderly beginning, middle, and end.
I gradually came to realize that the only thing that makes it possible to do the work of healing trauma is awe at the dedication to survival that enabled my patients to endure their abuse and then to endure the dark nights of the soul that inevitably occur on the road to recovery.
Initiation, intimidation, stigmatization, isolation, helplessness and self-blame depend on a terrifying reality of child sexual abuse. . . . “Don’t worry about things like that; that could never happen in our family.” “How could you ever think of such a terrible thing?” “Don’t let me ever hear you say anything like that again!” The average child never asks and never tells.
Psychiatry, as a subspecialty of medicine, aspires to define mental illness as precisely as, let’s say, cancer of the pancreas, or streptococcal infection of the lungs. However, given the complexity of mind, brain, and human attachment systems, we have not come even close to achieving that sort of precision. Understanding what is “wrong” with people currently is more a question of the mind-set of the practitioner (and of what insurance companies will pay for) than of verifiable, objective facts.
A psychiatric diagnosis has serious consequences: Diagnosis informs treatment, and getting the wrong treatment can have disastrous effects. Also, a diagnostic label is likely to attach to people for the rest of their lives and have a profound influence on how they define themselves. I have met countless patients who told me that they “are” bipolar or borderline or that they “have” PTSD, as if they had been sentenced to remain in an underground dungeon for the rest of their lives, like the Count of Monte Cristo.
The dictionary defines diagnosis as “a. The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data. b. The opinion derived from such an evaluation.”
81 percent of the patients diagnosed with BPD at Cambridge Hospital reported severe histories of child abuse and/or neglect; in the vast majority the abuse began before age seven.
When children feel pervasively angry or guilty or are chronically frightened about being abandoned, they have come by such feelings honestly; that is because of experience. When, for example, children fear abandonment, it is not in counterreaction to their intrinsic homicidal urges; rather, it is more likely because they have been abandoned physically or psychologically, or have been repeatedly threatened with abandonment. 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,
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The ACE study revealed that traumatic life experiences during childhood and adolescence are far more common than expected.
As Felitti notes, “Traumatic experiences are often lost in time and concealed by shame, secrecy, and social taboo,” but the study revealed that the impact of trauma pervaded these patients’ adult lives. For example, high ACE scores turned out to correlate with higher workplace absenteeism, financial problems, and lower lifetime income. When it came to personal suffering, the results were devastating. As the ACE score rises, chronic depression in adulthood also rises dramatically. For those with an ACE score of four or more, its prevalence is 66 percent in women and 35 percent in men, compared
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Self-acknowledged suicide attempts rise exponentially with ACE scores. From a score of zero to a score of six there is about a 5,000 percent increased likelihood of suicide attempts. The more isolated and unprotected a person feels, the more death will feel like the only escape. When the media report an environmental link to a 30 percent increase in the risk of some cancer, it is headline news, yet these far more dramatic figures are overlooked.
People with an ACE score of four were seven times more likely to be alcoholic than adults with a score of zero. Injection drug use increased exponentially: For those with an ACE score of six or more, the likelihood of IV drug use was 4,600 percent greater than in those with a score of zero.
Women in the study were asked about rape during adulthood. At an ACE score of zero, the prevalence of rape was 5 percent; at a score of four or more it was 33 percent.
Those with an ACE score of six or above had a 15 percent or greater chance than those with an ACE score of zero of currently suffering from any of the ten leading causes of death in the United States, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, and liver disease. They were twice as likely to suffer from cancer and four times as likely to have emphysema. The ongoing stress on the body keeps taking its toll.
The ACE study group concluded: “Although widely understood to be harmful to health, each adaptation [such as smoking, drinking, drugs, obesity] is notably difficult to give up. Little consideration is given to the possibility that many long-term health risks might also be personally beneficial in the short term. We repeatedly hear from patients of the benefits of these ‘health risks.’ The idea of the problem being a solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely coexist in biological systems. . . . What one sees, the
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The notion that early childhood adverse experiences lead to substantial developmental disruptions is more clinical intuition than a research-based fact. There is no known evidence of developmental disruptions that were preceded in time in a causal fashion by any type of trauma syndrome.
Research on the effects of early maltreatment tells a different story: that early maltreatment has enduring negative effects on brain development. Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds. Childhood abuse isn’t something you “get over.” It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence in this country.
We can hope to solve the problems of these children only if we correctly define what is going on with them and do more than developing new drugs to control them or trying to find “the” gene that is responsible for their “disease.” The challenge is to find ways to help them lead productive lives and, in so doing, save hundreds of millions of dollars of taxpayers’ money. That process starts with facing the facts.
With such pervasive problems and such dysfunctional parents we would be tempted to ascribe their problems simply to bad genes. Technology always produces new directions for research, and when it became possible to do genetic testing, psychiatry became committed to finding the genetic causes of mental illness. Finding a genetic link seemed particularly relevant for schizophrenia, a fairly common (affecting about 1 percent of the population), severe, and perplexing form of mental illness and one that clearly runs in families. And yet after thirty years and millions upon millions of dollars’
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Recent research has swept away the simple idea that “having” a particular gene produces a particular result. 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.
“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.”
An example of the far-ranging power of having a specific diagnosis is the fact that between 2007 and 2010 the Department of Defense spent more than $2.7 billion for the treatment of and research on PTSD in combat veterans, while in fiscal year 2009 alone the Department of Veterans Affairs spent $24.5 million on in-house PTSD research.
The DSM definition of PTSD is quite straightforward: A person is exposed to a horrendous event “that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” causing “intense fear, helplessness, or horror,” which results in a variety of manifestations: intrusive reexperiencing of the event (flashbacks, bad dreams, feeling as if the event were occurring), persistent and crippling avoidance (of people, places, thoughts, or feelings associated with the trauma, sometimes with amnesia for important parts of it), and increased arousal
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Eighty two percent of the traumatized children seen in the National Child Traumatic Stress Network do not meet diagnostic criteria for PTSD.
Children who develop in the context of ongoing danger, maltreatment and disrupted caregiving systems are being ill served by the current diagnostic systems that lead to an emphasis on behavioral control with no recognition of interpersonal trauma. Studies on the sequelae of childhood trauma in the context of caregiver abuse or neglect consistently demonstrate chronic and severe problems with emotion regulation, impulse control, attention and cognition, dissociation, interpersonal relationships, and self and relational schemas. In absence of a sensitive trauma-specific diagnosis, such children
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Early in puberty the abused girls had three to five times the levels of testosterone and androstenedione, the hormones that fuel sexual desire, as the girls in the control group.
When DSM-V was published in May 2013 it included some three hundred disorders in its 945 pages. It offers a veritable smorgasbord of possible labels for the problems associated with severe early-life trauma, including some new ones such as Disruptive Mood Regulation Disorder,26 Non-suicidal Self Injury, Intermittent Explosive Disorder, Dysregulated Social Engagement Disorder, and Disruptive Impulse Control Disorder.27
Could the fact that the APA had earned $100 million on the DSM-IV and is slated to take in a similar amount with the DSM-V (because all mental health practitioners, many lawyers, and other professionals will be obliged to purchase the latest edition) be the reason we have this new diagnostic system?
As a therapist treating people with a legacy of trauma, my primary concern is not to determine exactly what happened to them but to help them tolerate the sensations, emotions, and reactions they experience without being constantly hijacked by them. 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.
Under ordinary conditions these two memory systems—rational and emotional—collaborate to produce an integrated response. But high arousal not only changes the balance between them but also disconnects other brain areas necessary for the proper storage and integration of incoming information, such as the hippocampus and the thalamus.5 As a result, the imprints of traumatic experiences are organized not as coherent logical narratives but in fragmented sensory and emotional traces: images, sounds, and physical sensations.
Freud reaffirmed that lack of verbal memory is central in trauma and that, if a person does not remember, he is likely to act out: “[H]e reproduces it not as a memory but as an action; he repeats it, without knowing, of course, that he is repeating, and in the end, we understand that this is his way of remembering.”
Our bodies are the texts that carry the memories and therefore remembering is no less than reincarnation.
Total memory loss is most common in childhood sexual abuse, with incidence ranging from 19 percent to 38 percent.
There were two major differences between how people talked about memories of positive versus traumatic experiences: (1) how the memories were organized, and (2) their physical reactions to them. 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.
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.
