The Body Keeps The Score

Prologue - Facing Trauma

Trauma is commonplace in people's lives, far beyond people who go to war or visit refugee camps:

• 1 in 5 Americans were sexually molested as a child.
• 1 in 4 were beaten by a parent.
• 1 in 3 couples engage in physical violence.
• 1 in 4 grew up with relatives who were alcoholics.
• 1 in 8 saw their mother being beaten.

Humans typically rebound from traumatic events, but the events do leave traces both at a society level (in history and culture) and at a personal level. This affects sufferers' capacity for joy and intimacy, as well as manifesting in our biology, e.g. immune system problems.

Trauma also affects the people around those who suffered it. The resulting rage or emotional absence may cause fear or worry in their loved ones. The wives of male PTSD suffers tend to become depressed, and their children may grow up insecure and anxious. Being exposed to family violence as a child makes it hard to establish stable and trusting relationships as an adult.

Most trauma sufferers find it upsetting to think about their experience so try to push it out of their minds and carry on like nothing happened. It takes a lot of energy to carry on with life whilst experiencing terrifying memories and the shame of feeling weak and vulnerable.

The unconscious features of our brain that exist to ensure our survival are not build for denial. Long after the experience of trauma has finished it may be reactivated by any hint of danger, altering our brain function and releasing stress hormones that lead to unpleasant emotions, physical sensations and impulsive and aggressive actions. Sufferers often fear they are damaged and irreparable.

The mind and our social connections are extremely complex. Psychiatrists know little about the origins of these problems.

3 new branches of science have led to massively increased knowledge about the effects of trauma:

• Neuroscience: how the brain supports mental processes.
• Developmental psychopathology: the impact of adverse experiences of the development of our mind and brain.
• Interpersonal neurobiology: how our behaviour influences the emotions, biology and mindsets of people around us.

Trauma produces physiological changes, including:

• Recalibrating the brain's alarm system.
• An increase in stress hormone activity.
• Changes in how we filter relevant vs irrelevant information.

Traumatised people become hypervigilant to threats, making it hard to engage in their normal lives. They often repeat damaging behaviours and seem not to learn from experience. This isn't a "moral failing" or lack of willpower, but rather originates in changes in their brains.

Learnings from recent research opens up new possibilities for treatment:

• Top down: talking and reconnecting with other people, processing our memories, understanding what's going on with us.
• Medications and technologies that change how the brain organises information, including reducing inappropriate alarm reactions.
• Bottom up: allowing the body to have experiences that contradict the feelings of helplessness, rage and collapse that the trauma resulted in.

Part 1: The rediscovery of trauma

Lessons from Vietnam Veterans

Veterans returning from war sometimes:

• experience immediate attacks of rage. The appearance can be similar to children throwing temper tantrums - but with children we don't worry about it as it's expected that with care they will learn to deal with frustration and disappointment.
• feel an overwhelming sense of futility.
• become withdrawn and detached.
• become hypervigilant and sensitive to threat.

Today we acknowledge this as symptoms of PTSD (formerly considered traumatic neuroses).

Rape victims show similar symptoms.

PTSD has a physiological basis - it isn't "all in the head".

Most of us don't want to know what soldiers experience in combat, fooling ourselves that cruelty only occurs in faraway places. It's unsurprising that traumatised individuals often use drugs, alcohol or self-mutilation to stop themselves remembering.

Whether it's from something done to you, or something you did, trauma usually makes it difficult to sustain intimate relationships. Trusting other people or even yourself is challenging.

Traumatised people usually find it very hard to confront their shame about how they behaved during the episode concerned, whether it's in some sense warranted (e.g. they committed an atrocity) or not (e.g. they're a victim of child abuse).

Victims of child abuse usually feel shame about actions they took to survive and maintain a connection to their abuser, particularly when it was e.g. a family member. There's internal confusion about whether they're "truly" a victim or a willing participant, the difference between love and terror, pain and pleasure.

Traumatic events at least end, whereas the resulting unpredictable flashbacks may feel like they never will.

The Rorschach test asks people to describe what they see in meaningless ink blots. Humans have a tendency to create images and stories from meaningless stimuli which gives insights into how their mind works. Tests show that traumatised people tend to either impose their trauma on everything around them - seeing horrific images of their past experiences in the ink blots - or see nothing at all. Either way, trauma has damaged their imagination.

Imagination is critical to the quality of our lives, providing a basis for creativity, relieving boredom, lowering pain, increasing pleasure and enhancing relationships. Without imagination there's no hope, no imagining a better future or achieving goals.

Traumatised people see the world differently to other people. A man walking down the street may be seen as someone who is about to molest them by a rape victim. They become distrustful of non-traumatised people who can't understand them, including close family.

Some people's trauma becomes the sole source of meaning in their lives, feeling alive only when mentally revisiting the traumatic episode.

• About 25% of soldiers serving in war zones develop serious posttraumatic problems.
• The majority of Americans experience a violent crime at some point.
• 12 million US women have experienced rape, most of these being when aged under 15.
• 10 children are abused in the own homes for every solider serving in war abroad. It's difficult to recover when the abuser is your caretaker.

Trauma alters how the mind is organised, how the brain perceives things, what and how we think.

Talking about the traumatic episode can be important and helpful but doesn't in itself change the automatic physical and hormonal responses in the body that create hypervigilance and constant preparation for a future assault. In order to alleviate trauma more fully, the body has to learn that the danger is in the past, and to live in the reality of now.

Revolutions in Understanding Mind and Brain

More than 50% of people who seek psychiatric care have been assaulted, abandoned, neglected, raped or witnessed family violence as a child.

The typical approach to treatment is to dispassionately try to manage any suicidal thoughts and self-destructive behaviour, rather than examining potential causes of the despair. There's little desire to understand of the "ecology" of the patient's life.

Patients may have hallucinations. It is not yet clear whether they are fully fictional or whether they are fragmented versions of past experiences. Victims of child abuse often feel sensations such as pain that have no obvious physical cause. They may hear voices alerting them to danger or accusing them of crimes.

Human suffering is related to love and loss. Therapists should help people "acknowledge, experience and bear" the ups and downs of life. Patients often need therapists to know what they know and feel what they feel in order to get better.

However, the psychiatry profession has followed a different direction since the 1960s where studies showed that schizophrenic patients who received drugs had a better outcome than those who received talking therapy. Psychological problems became scene as a set of individual disorders that resulted in "brain diseases".

The approach medicine takes to human suffering is determined by the technology available at the time:

• Pre-Enlightenment, aberrant behaviour was attributed to God, sin, magic, witches, evil spirits etc.
• In the 19th century scientists starts to see it as an adaption to the complexities of the world.
• Now typical human problems are thought of as disorders that can be fixed by pharmaceuticals.

Sometimes drugs work extremely well. Antipsychotics were a big factor in reducing the number of patients living in US mental hospitals from >500k in 1955 to < 100k in 1996.

Abnormal levels of norepinephrine are associated with depression, and dopamine with schizophrenia. This caused hope that drugs could target these issues.

The need for a precise and systematic way to communicate findings led to researchers creating a "Research Diagnostic Criteria". This evolved into The Diagnostic and Statistical Manual of Mental Disorders (DSM).

Maier and Seligman popularised the concept of "learned helplessness" via experiments that involved painful electric shocks being given to dogs who were trapped in cages. When the cages were opened, whilst the shocks continued, the dogs made no attempt to flee in comparison to the control group dogs who immediately left.

The mere opportunity to escape does not necessarily make traumatized animals, or people, take the road to freedom.

To teach the traumatised dogs to leave the cage it was necessary to repeatedly physically drag them out of their cages until they learned to leave.

Traumatised people secrete stress hormones long after any acute danger has gone away. This is expressed as agitation and panic, and is long-term harmful to a person's health.

Scared animals return to their homes irrespective of the safety of them. There may be a parallel in patients returning to their abusive families.

Many traumatised people seek out experiences that seem very unpleasant to most of us. They feel empty or bored when they've not angry, stressed or involved in a dangerous activity.

Reliving trauma in therapy may actually lead to more preoccupation and fixation.

The body adjusts to stimuli. As well as getting addicted to drugs, activities like sauna usage, marathon running or parachute jumping that may first seem uncomfortable or frightening can become enjoyable as a new chemical balance is created within the body. We may get cravings for and withdrawals from the absence of such activities.

When Beecher noted that 75% of wounded soldiers didn't request morphine he speculated that strong emotions can block pain. One hypothesis is that morphine-like chemicals called endorphins that are secreted in response to stress may play a role.

Re-exposure to stress might provide similar relief for traumatised people. An experiment exposing veterans to combat movies whilst measuring their pain thresholds suggested that the resulting analgesia was equivalent to 8mg of morphine, an amount that would be used to treat crushing chest pain.

The amygdala is the part of the brain that perceives threats. Animal experiments showed that the amount of serotonin in the amygdala alters its sensitivity. In animals, inducing low levels produced hyperactive responses to threat, whereas high levels dampened the fear system, making them less likely to become aggressive or freeze.

Dominant male monkeys have higher levels of serotonin than lower-ranking animals, but the levels dropped if they were prevented from maintaining eye contact with them. Low ranking monkeys who had their serotonin supplemented became leaders - the social environment interacts with brain chemistry.

Traumatised people are often hyperreactive and struggle with social situations.

Most treatment studies for PTSD find a significant placebo effect. This might relate to the attention given to the participants or the fact that those who sign up to studies are intrinsically motivated to pursue solutions.

When traumatised people were into a study to test Prozac, everyone improved to some degree, even in the placebo arm. However Prozac performed better than placebo, except for combat veterans. In fact there's very few pharmacological studies that show improvements for combat veterans' trauma - we don't know why this is.

Medications such as Prozac, Zoloft, Celexa, Cymbalta, and Paxil have greatly contributed to the treatment of trauma disorders. They help patients gain perspective and impulse control. However they should only be considered part of a wider treatment approach.

The resulting theory that mental illness is caused by brain chemical imbalances that can be corrected by certain drugs is popular. Drug treatment has displaced therapy, helping patients only to suppress rather than deal with any issues causing their problems.

Antidepressants are now very popular - 10% of Americans now take them - but yet there has not been a decrease in depression (as measured by e.g. hospitalisations due to depression).

500k US children take antipsychotic drugs.

• Rates are 4x higher in children from low-income families that others.
• 12.4% of children in foster care receive them vs 1.4% of other Medicaid-eligible children.

The medications are used to make children more manageable and less aggressive. But they may impair motivation, play and curiosity with negative effects on their development. They also add risk of obesity and diabetes, and contribute to drug overdoses.

4 facts the brain-disease model overlooks:

1. We are able to heal each other. Strengthening relationships and community is central to restoring well-being.
2. We can change ourselves and others with language - communicating our experiences, defining our knowledge, and finding common meaning.
3. We are able to regulate our own physiology, by things like breathing, moving and touching.
4. We can make changes to environments such that people feel safe and thrive.

Looking into the Brain: The Neuroscience Revolution

PET and fMRI scans let us visualise how different parts of the brain activate in response to stimuli - e.g. when people complete certain tasks or remember past events. These neuroscience techniques have changed our understanding of trauma.

Even years after the event, when traumatised people see images or sounds or have thoughts about their experience their amygdala is activated. This triggers:

• the release of stress hormones.
• nerve impulses.
• high blood pressure.
• increased heart rate.
• increased oxygen intake.

i.e. the fight or flight response.

There's also a decrease in brain activity in the Broca's area region. This area is associated with speech. When that region is deactivated you can't express your thoughts and feelings in words. This area is often affected in stroke patients when the blood supply to that region is cut off - the effects of trauma can be the same as the effects of those sort of physical lesions.

Trauma is preverbal. People may scream in terror, demand their mothers or shut down. Often victims sit mute and frozen. Even years later there it can be extremely difficult to tell others what happened to them. Most survivors come up with some story that offers an explanation to others for their symptoms and behaviour, but it rarely will it tell the inner truth of the experience. It's hard to provide a coherent account of a traumatic experience.

Brodmann's area of the brain is activated during flashbacks. This area of the visual cortex registers images when they enter the brain; it's as if the trauma was actually re-occurring.

Images of past trauma activate the right hemisphere of the brain, which is associated with intuitive, emotional, visual, spatial, and tactual processing. They deactivate the left side , which is associated with linguistic, sequential, and analytical processing.

Memory-wise, the right brain stores memories of sound, touch, smell and the emotions they evoke. In remembering trauma it reacts as though the event is actually happening.

The left brain recalls facts, statistics and the vocabulary of events. With deactivation, it makes it hard to organise experiences into logical sequences or express them in words. People may not realise they're re-enacting the past and react with fury, terror, rage shame, become frozen and look for someone or something to blame.

Traumatised people's rise in heart rate and blood pressure after being triggered to recall their experience is due to the adrenaline hormone. Their stress hormones take longer to return to baseline and spike faster and to a level that disproportionate to mildly stressful stimuli.

Constantly elevated stress hormones can cause problems with memory, attention, irritability, sleep and other long term health issues.

Some victims go into denial - consciously they act as though nothing happened. However their bodies still act as though threatened. Medication, drugs and alcohol dull these unbearable sensations.

It's much easier for trauma victims to talk about what's been done to them than to develop an awareness and put into words the reality of their internal experience.

2 perspectives can be taken on the above that lead to different treatment implications:

1. The neurochemical and physiological disruptions show that there is a biochemical imbalance that is reactivated when trauma is re-triggered. Potentially a drug can reduce or eliminate that reaction.
2. The hypersensitivity to these memories is the issue, so treatments to decrease the sensitisation would be helpful - e.g. talking through the trauma repeatedly with a therapist, reinforcing that it's in the past.

Part 2 - This is your brain on trauma

Running for Your Life: The Anatomy of Survival

During traumatic events children tend to follow the lead of their caregivers; if the adults remain calm and responsive then they don't usually develop psychological scars from it.

2 aspects of the threat response are important to well-being:

• Being able to take an active role in "rescuing yourself" from the disaster. Being able to take action to protect yourself is a critical factor in whether a terrible experience will leave mental scars.
• Quieting the alarm the body and brain feels once you're out of danger; allowing your mind to make sense of what happened and creatively imagine alternatives.

Traumatised people get stuck because they can't integrate what they experienced into their lives, so continue to live as though the trauma was ongoing. Their energy moves from that required for spontaneous involvement in life to suppressing the inner chaos they feel. This constant effort can result in physical symptoms including fibromyalgia, chronic fatigue, and other autoimmune diseases. Treatment must involve the patient's body, mind and brain.

If the brain's unconscious physical escape reaction to a traumatic event is blocked - e.g. because the victim is trapped so can't take action - the brain keeps secreting stress chemicals and firing electrical circuits in vain.

The brain is optimised for ensuring your survival, even under miserable conditions. To do this, brains:

1. Generate internal signals registering what our bodies need e.g. food, rest, protection.
2. Generate a map of the world that indicates to us where to go to meet those needs.
3. Generate the energy and actions to get us there.
4. Alert us to danger and opportunities en-route.
5. Adjust our actions based on present requirements.

Being mammals, humans thrive in groups; all of the above require coordination and collaboration with others. Damage to our relationships, as well as to the 5 abilities above, lead to psychological problems.

The rational brain allows us to understand how things and people work, figure out how to complete goals, and manage our time and actions. A separate part deals with the immediate registration and management of our physiology and recognition of comfort, safety, threat, hunger, fatigue, desire, longing, excitement, pleasure, and pain.

The brain develops in sequence.

1. The reptilian brain first, which controls the things that newborn babies do: eat, sleep, wake, cry, breathe; feel temperature, hunger, wetness, and pain; and rid the body of toxins by urinating and defecating.
2. The brain stem and hypothalamus control the energy levels of the body; coordinating the heart, lungs, endocrine and immune systems so as to main a stable internal balance (homeostasis).
3. The limbic system is responsible for emotions, monitoring danger, deciding what's important for survival, how to live in complex social networks, and deciding what is pleasurable vs scary. It's shaped by genetic makeup, inborn temperament but also experience - what happens to a baby alters their emotional and perceptual map of the world.

When a brain circuit fires repeatedly it becomes the default setting (neuroplasticity). Feeling safe and loved allows specialisation in exploration, play, co-operation. Feeling frightened and unwanted specialises in managing feelings of fear and abandonment.

The reptilian/limbic system - "emotional brain" - alerts you to danger or opportunity via releasing hormones, which result in visceral sensations that subconsciously re-focus your mind and move you physically and mentally in a certain direction, based on recognising rough similarities.

The neocortex enables language and abstract thought, allowing us to absorb information and create meaning. The frontal lobes enable empathy and let us plan, reflect, imagine, play out scenarios, predict what will happen, enable creativity and the making of choices. They're necessary for harmonious relationships.

The first discovery of mirror neurons was in monkeys where it was noted that the same brain cells that fired when the monkey ate or moved did so when they were simply watching the researcher do the same things. They explain phenomena like empathy, imitation, synchrony, language and our ability to understand other people's emotional state and intentions.

Trauma treatment needs to reactivate the ability to mirror/be mirrored whilst not being overwhelmed by other people's negative emotions.

Sense information from the world arrives via organs such as the eyes and ears. The thalamus processes these perceptions into an integrated experience of what is happening to you, and passes them to the amygdala and frontal lobes. If this processing breaks down the sights, smells, etc. are encoded as isolated fragments.

The amygdala determines if the input is relevant to our survival. If so it releases stress hormones and uses the autonomic nervous system (ANS) to create a whole-body responses. It works faster than the fontal lobes so this happens before we're consciously aware of the danger.

Trauma increases misinterpretations of whether a situation is dangerous. The result can be inappropriate blowups or shutdowns. Getting on well with people requires that you can accurately judge their intentions as being benign vs dangerous.

The frontal lobes (especially the medial prefrontal cortex - MPFC) act as a watchtower, able to inhibit responses. In PTSD the balance shifts from the MPFC to the amygdala, making it hard to control emotions and impulses. Fear, sadness and anger increase the activation of the emotional brain and reduce the activity in the frontal lobes.

To manage your emotions better you can either regulate:

• Top-down: strengthen the capacity of your watchtower to monitor bodily sensations, e.g. via mindfulness or yoga.
• Bottom-up: recalibrating the ANS, which can be done via breath, movement or touch.

Emotion assigns value to experiences; it's the foundation of reason, not it's opposite.

Few psychological problems are a result of poor understanding. Insight doesn't stop the emotional brain alerting you that you're in danger.

A conflict between emotional and rational brains causes physical (e.g. in your gut, heart, lungs) and psychological discomfort.

Trauma leads to dissociation, where the overwhelming experience is fragmented and each sensation takes on its own life. The sensory fragments intrude into the patient's present, and until resolved will cause the stress hormones, defensive movements and emotional responses to be replayed.

People who suffer flashbacks often organise their lives around avoiding them. This is exhausting and leads to fatigues, depression, weariness. Each time the trauma is revisited it gets etched more deeply onto the mind. The inability to take in what's currently going on means you cannot feel fully alive.

Triggered responses manifest in various ways, usually irrational and out of anyone's control. Sufferers may feel inhuman, dominated by shame and hiding what's going on. Physical reactions are directed by past experiences.

Simply accepting what happened isn't enough; one has to master the internal sensations and emotions. Sensing, naming and identifying what's going on is the first step.

2 brain systems are relevant for mentally processing trauma; those dealing with emotional intensity and those dealing with context.

When the right and left dorsolateral prefrontal cortex are deactivated people lose their sense of time, being trapped in the moment with no sense of the past or future. The DLPFC is a timekeeper, letting us understand how our present experience relates to the past and future. Knowing that whatever is happening will eventually come to and end makes most things tolerable; the opposite is also true.

Visiting the past in therapy should be done only when the patient is rooted in the present, feeling calm, safe and grounded. This increases the sense that the terrible events are in the past.

Traumatised people often depersonalise, seemingly having blank stares and absent minds. They can't think, feel, remember or make sense of things. Talk therapy is useless in this case. Bottom-up therapy is necessary here; aiming to change the patient's physiology and their relationship to bodily sensations, e.g. heart rate, breathing.

Many trauma survivors start out with explosive flashbacks and later become numb. Both phases are damaging. The challenge is both dealing with the past and enhancing the patient's current experience of life. If you can't find satisfaction in everyday things like taking a walk, playing with your kids or cooking then life passes you by.

When you feel absent from the present you return to places you did feel alive, even if they're awful.

Body-Brain Connections

Darwin considered mammalian emotions to be rooted in biology. They provide the motivation for us to take action, initiating movement to keep us safe and in equilibrium. Expressed via the muscles of our face and body, they also communicate our mental state and intention to other people. Being highly attuned to detect emotional shifts in people and animals, we can immediately understand the dynamic between two people based on their tension, relaxation, postures, vocal tone and facial expressions.

If trapped in survival mode, our energy is dedicated to protecting us from enemies, leaving no room for nurture, care or love.

Whilst experiencing emotions in our heads we can remain in control. But when they manifest in our gut and heart they become unbearable and we'll do anything to make them stop.

All of the signals we intuitively register during a conversation, from other people or our own internal state, are regulated by the autonomic nervous system (ANS). This has two parts:

• The sympathetic nervous system (SNS): Responsible for arousal including our fight or flight response. It shifts blood to the muscles to allow immediate action to be taken by triggering the adrenal glands to release adrenaline, speeding up heart rate and increasing blood pressure. Breathing in deeply activates the SNS.
• The parasympathetic nervous system (PNS): Responsible for self-preservation function like digestion and wound healing. It triggers the release of acetylcholine, lowering arousal, heart rate, muscle tension and resetting breathing to normal. Exhaling activates the PNS.

Heart rate variability (HRV) measurements can be used to test the flexibility of the ANS; a high amount of fluctuation indicates the PNS and SNS are functioning well.

Polyvagal Theory provides an understanding of the biology around safety and danger based on the confluence of our body's visceral experiences and the voices and faces of nearby people.

The vast majority of mental suffering involves difficulties in creating satisfying relationships or difficulties in regulating arousal (e.g. often becoming enraged or shut down). Feeling safe with, and truly heard and seen by, other people is the most important aspect of good mental health. Reciprocity is key.

Traumatised people often feel out of sync with others. They may feel more comfortable in groups of similar sufferers where they can replay their experiences. This reduces isolation but may require them to deny their individual differences and may promote the idea that other people outside of this narrow group are irrelevant or dangerous.

Relationships with other mammals can help when people are unable to feel comfort from humans. Dogs and horses have been used to treat trauma patients.

The word "neuroception" refers to the capacity to evaluate relative danger and safety in one's environment. Fixing someone's broken neuroception requires resetting their physiology to stop their survival mechanisms working against them.

Porges theory claims that the ANS regulates 3 physiological states:

• Social engagement: when we feel threatened we call for help, support and comfort from people around us. The ventral vagal complex (VVC) signals our upset via facial expressions and vocal tone.
• If that fails we switch to a primitive fight or flight status. The SNS primes our muscles, heart and lungs. Our voice becomes faster and more strident. Nearby dogs will stir and growl as they smell the activation of our sweat glands.
• If that fails (e.g. we're trapped) we try to preserve our energy by shutting down, freezing and collapsing. The dorsal vagal complex (DVC) reduces metabolism, dropping our heart rate, preventing normal breathing and our gut shuts down or empties.

By default mammals are somewhat on guard. But to feel close to other humans, to play, mate and nature others, we need to shut off our natural vigilance.

When the smoke detectors of the brain malfunction people stop running or fighting when they normally they would. The Adverse Childhood Experiences study (ACE) showed that:

• Women who were abused or neglected in early life were 7x more likely to be raped as an adult.
• Women who saw their mothers being assaulted when a child were much more likely to later be a victim of domestic violence themselves.

Many people feel safe when in superficial conversations, but physical contact may trigger adverse reactions. Deep intimacy typically requires allowing yourself to be immobilised without feeling afraid (e.g. in a hug or sleeping next to a partner).

Humans respond to harsh voices with fear, anger or shutdown, and playful tones by opening up and relaxing.

Our educational system and many methods of treating trauma ignore the emotional-engagement system and focus on changing the cognitive aspects of the mind. But if people don't feel safe then they won't learn well. This is one reason why activities like PE, choir and recess that involve movement, play and joy are important.

Non-pharmacological approaches to health are traditionally practiced outside of Western medicines. They tend to utilise interpersonal rhythms, visceral awareness, and vocal and facial communication to shift people's perception of danger, move people out of fight or flight states and enhance their ability to manage relationship.

Losing Your Body, Losing Your Self

Chronic emotional abuse and neglect can be as damaging as physical abuse and sexual molestation, particularly for young children.

Trauma patients who self harm are rarely suicidal. They're trying to make themselves better the only way they now how. If they've no experience of anyone trying to help them when in danger they turn to anything else - drugs, alcohol, bingo eating or self-harm - that may offer relief.

They often are so physically disconnected that they can't feel whole areas of their body; their sensory perceptions don't work.

Recognising an object held in your hand requires sensing it's shape, weight, temperature, textures and position. Your brain needs to integrate these inputs into a single perception. People with PTSD sometimes can't do this. Their muffled senses makes them no longer feel fully alive.

When the brain is idling the default state network (DSN) is activated. This allows areas of the brain to activate that give you your sense of 'self'.

PTSD patients see almost no activation of any of these areas of the brain when idling; only a slight activation in the part that reports back your basic orientation in space. Patients have learned to shut down the brain areas that transmit the feelings and emotions associated with terror. But these are the same areas that are responsible for registering all other emotions and sensations that provide us a sense of self-awareness and who we are. Some victims of childhood trauma cannot even recognise themselves in a mirror. This may explain why many traumatised people have no sense of purpose or direction; they can't make decision or plans when they can't register what the sensations in their body that form the basis of emotions are telling them.

Our self-awareness comes from the physical sensations that transmit information about the inner states of our body. Our conscious self acts on these sensations in order to keep us safe; for example determining that we feel cold will ensure we wear a jumper.

Reliving strong negative emotions causes changes in brain areas that are needed to regulate basic bodily functions; the muscles, gut and skin. We re-experience the sensations felt during the event.

Trauma sufferers are constantly aroused mentally and physically as if they're in danger. They are startled by slight noises, frustrated by mild irritations, don't sleep well and food often loses its sensual pleasures. They try to shut these feelings down by freezing and dissociation.

Agency is the feeling of being in charge of your life. It requires interoception, the awareness of sensory body-based feelings. The more awareness you have, the more potential control you have over your life. This is why mindfulness practice is helpful for trauma victims.

Somatic therapies try to:

• Draw out blocked sensory information.
• Help patients embrace the energy released by their inner experience.
• Let patients complete the self-preserving physical actions that they couldn't when they were immobilised and terrified.

If you can trust your inner sensations to reveal accurate information you feel safe and in charge of your body. Traumatised people often learn to ignore their gut feelings and lose awareness. They become vulnerable to panicking or shutting down about any sensory shift they detect.

Panic symptoms are maintained by the person learning to fear the bodily sensations associated with panic attacks.

Self regulation requires you to have a good relationship with your body. Otherwise people turn to external regulation, e.g. medication, alcohol, dependencies on reassurance or always complying with other people's wishes.

Many trauma patients do not notice and name feeling stress, but instead respond with migraine headaches or asthma attacks. Somatic symptoms with no physical basis are common, including chronic back and neck pain, fibromyalgia, migraines, digestive problems, spastic colon/irritable bowel syndrome, chronic fatigue, and some forms of asthma. Traumatised children have 50x the rate of asthma as non-traumatised peers.

Suppressing our feelings don't prevent stress hormones affecting our body.

Alexithymia means to not have words to describe feelings. This is common in trauma patients. They interpret emotions as being physical problems rather than signals - e.g. instead of anger they may have muscle pain or bowel irregularities. 3/4 of patients with anorexia nervosa and half of patients with bulimia are confused by their emotional feelings.

Many patients may be successful in their jobs. Suppressing feeling allows success in the business world, but at the price of forming intimate relationships. There is often a lack of interest in therapy.

The only cure to alexithymia is to learn to recognise the connection between physical sensations and emotions. But these patients often lack interest in therapy and a preference for getting doctors to treat conditions that never get better.

Patients should be encouraged to notice and describe the physical sensations in their both, e.g. pressure, heat, tingling, and then to identify sensations associated with relaxation and pleasure. This can be distressing at first.

Drugs such as Abilify, Zyprexa, and Seroquel are used to blunt sensations - this mitigates reactions but doesn't actually resolve them.

Patients that have been physically violated crave touch at the same time as being terrified of body contact. Their mind needs to be taught to feel physical sensations and their body to tolerate them.

Depersonalised people live in a dream-like world that feels strange. Objects appear differently. They don't experience pain or pleasure.

Similar out of body type experiences can be induced by delivering a mild electric current to the temporal parietal junction of the brain.

• One patient sensed she was on the ceiling looking down at her body.
• Another felt that someone was standing behind her.

The self can clearly be detached from the physical body.

...mind and brain are indistinguishable—what happens in one is registered in the other

Part 3 - The Minds of Children

Getting on the Same Wavelength: Attachment and Attunement

The Thematic Apperception Test (TAT) is a projective test that asks participants to tell a story about what is happening in a photo, and what happened before and after. Their interpretations can reveal the themes that occupy their mind and what shapes their world-view. Children with trauma tend to tell horrific stories, featuring danger, aggression, sexual arousal and terror, in comparison to the more positive endings given by non-traumatised children.

Many traumatised children are diagnosed as ADHD and take Ritalin.

Non-abused children can imagine ways out of bad situations. They feel protected. safe and loved within their families. They're more eager to learn and engage in school work. But the world is filled with triggers for abused children. They only imagine terrible outcomes, perceiving any person or image as a potential threat.

Treatment often is limited to diagnostic labels such as "bipolar disorder", rather than acknowledging the terrible things that have happened to the children.

As children group up, they learn to take care of themselves physically and emotionally based on the way they're cared for. Mastering self-regulation is dependent on our interactions with caregivers. Children are very sensitive to facial expression, posture, tone of voice, physiological changes, tempo of movement and incipient action.

Children often pick one adult to develop a primary attachment to. If they're responsive then the child is more likely to develop healthy ways of responding to other people around them. Feeling safe encourages self-reliance, sympathy and helpfulness. Children learn that other people have thoughts and feelings that may be similar or different to their own. They develop self-awareness, empathy, impulse control, and self-motivation, making a huge difference to their later life.

Secure attachment requires emotional attunement, the feeling of being understood.

We imitate the behaviour of people around us.

When infants and caregivers are emotionally synchronised, they're also in sync physically. The child's heartbeat and breathing is steady with low levels of stress hormones, calm in body and emotions. When emotional disruption occurs physiological factors also change.

Managing arousal is a critical skill; parents must do it for babies until they can do it themselves. e.g. when hunger gnaws at their stomach, parents provide a bottle. Associating intense sensations with safety, comfort and master enables self-regulation, self-soothing, and self-nurturing.

A secure attachment combined with the cultivation of competency builds an internal locus of control, the key factor in healthy coping throughout life.

Securely attached children learn what makes them and others feel good or bad. They feel agentic - that their actions influence how they and others feel and respond. They learn that you can take action in challenging situations, and when they can control the situation vs when they need help.

Neglected / abused children learn that their fear, begging and crying doesn't register with anyone, conditioning them to give up when facing challenges later on.

Donald Winnicott observed that things start with the way a mother holds her baby. If a mother can't meet her baby's needs then the baby becomes what the mother's idea of the baby is.

Abused children are as sensitive as others to changes in voices and faces but respond to them as threats rather than cues for staying in sync.

Most humans can't tolerate being disengaged from others - if they can't connect through work, friendships or family they will find other ways to bond e.g. via illnesses, lawsuits or feuds.

Children instinctively attach - no matter how abusive their parents are they develop a way to cope in order to get some of their needs met.

A research tool called "Strange Situation" examines how children respond to temporary separation from their mother.

• Securely attached children are upset when their mother leaves, but are happy when she returns and settle down to continue playing.
• Avoidant attachment children appear unbothered by the absence or return of their mother, but their increased heart rates show they're constantly hyperaroused. Mothers of these children tend to dislike touching them.
• Anxious or ambivalent attachment children draw attention to themselves by crying and screaming, even when their mother returns. They focus on her and do not play.

These styles likely evolve to elicit the best care the caregiver is capable of.

Attachment styles continue into adulthood, although they can be altered by other life experiences.

When a caregiver is a source of distress to the child they may develop a disorganised attachment style. They don't know who to trust so may be overly affectionate or distrustful of everyone. They may develop psychiatric disorders.

Parents don't need to be perfect - children learn that broken connections can be restored. But it's key that they feel safe with their caregivers.

62% of children in a study were secure, 15% avoidant, 9% anxious and 15% disorganised.

• Gender and temperament do not affect attachment style much.
• Children from lower socioeconomic groups are more likely to be disorganised, as parents are stressed with economic and family instability.
• Parents who are preoccupied with their own trauma may be too unstable to offer comfort and protection.

Problems that results from disorganised attachment resemble those from trauma.

A child's reaction to traumatic events is largely determined by how calm/stressed their parents are.

• Whether or not children that are hospitalised with severe burns develop PTSD is affected by how safe they felt with their mothers. Also the more secure the attachment the fewer painkillers were needed.

Hostile/intrusive mothers are more likely to have experienced physical abuse or witnessed domestic violence in their childhood. Withdrawn mothers are more likely to have histories involving sexual abuse or parental loss.

Children with disrupted emotional communication patterns with their mothers are more likely to develop into less stable, impulsive adults, with inappropriate levels of intense anger and suicidal tendencies. Emotional withdrawal had the most impact.

There's an association between maternal disengagement/misattunement and experiencing dissociative symptoms later in life (e.g. feeling lost, overwhelmed, abandoned, disconnected from the world, unloved, empty, helpless, trapped, or weighed down.). These symptoms are not associated with abuse or trauma later in life.

Securely attached infants learn to communicate their interests and preferences.

If you can't tolerate what you know/feel then you live in denial and dissociate - even to the point of not feeling real. This make it feel like nothing matters.

Early attachment affect our relationships in the rest of our life, in what we expect from other people and how much comfort and pleasure we experience.

Understanding what causes these feelings is not enough to reverse them.

Being in sync with ourselves and others requires integrating our bodily senses - vision, hearing, touch and balance.

Trapped in Relationships: The Cost of Abuse and Neglect

Patients need to learn to tolerate their feelings and their knowledge, which can take a very long time to do.

Sometimes patients express their inner conflicts by losing some bodily function.

Incest survivors have abnormal CD45 RA-to-RO ratios. These are the memory cells of the immune system. RA cells are activated by past exposure to toxins. RO cells are used for new challenges. Incest survivors had increased proportions of RA cells, making the immune system oversensitive to the point where it will mount a defence where none is needed or even attack the body's own cells. Incest victims struggle to differentiate danger and safety even at this biological level; the they don't understand how to feel safe.

Children interpret everything egocentrically. If parents tell them they're the best thing they will innately believe that and realise that people that mistreat them are bad. But if abused or ignored in childhood they may feel contempt and humiliation about themselves and think any later bad treatment is what they deserve. Children can't understand that their parents depression, anger. withdrawal or other behaviours may have nothing to do with them.

Therapists need to help these people rewrite their inner map of the world. These maps are often stable over time but can be modified by experience, e.g. falling in love, having a child, experiences that lead to intimacy, trust or spiritual enhancement. Likewise otherwise "healthy" childhood maps can be distorted by trauma suffered in later life.

These responses don't come from reason, so reframing irrational beliefs and behaviours isn't enough. But learning to recognise the irrationality can be a useful first step.

The rational brain can usually override the emotional brain as long as we don't feel trapped, angry, rejected or afraid. We have to own our emotions; observe and tolerate the awful sensations in us that signal misery and humiliation.

People who have experienced trauma may not know what happened to them; their immune system, muscles and fear system show the consequences, but their conscious mind may not have a narrative that could communicate the experience.

Focusing on deep breathing, tapping acupressure points, mindfulness and observing one's inner experience can be helpful.

Child abuse victims who try to tell someone about it are often met with silence and disbelief. They sense they'll be punished if they tell anyone, so they don't. Inwardly they focus their energy on not thinking about what has happened or feeling terror. Because they can't tolerate the knowledge of what they experienced they can't put it together that their anger, terror or collapse has anything to do with that.

Erasing awareness and living in denial can seem essential to survival, but with that comes the inability to keep track of who you are, your feelings and who you can trust.

What's Love Got To Do With It?

Traumatised patients often receive several unrelated diagnoses in the course of their treatment.

Psychiatry tries to define mental illness as precisely as e.g. cancer of the pancreas. But the complexity of the mind, brain and attachment systems means we haven't come close to doing that. The diagnosis given is often more about the mindset of the medical practitioner.

The The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official list of all mental diseases from the APA. It warned explicitly that the categories are not precise enough to be used for forensic or insurance purposes. However that guidance has often been ignored and it's become very powerful.

A psychiatric diagnosis is consequential. It informs the treatment given, and provides a label that may be attached to a patient for the rest of their life, even influencing how they define themselves.

In practice diagnoses are often just tallies of symptoms.

Most patients diagnosed with Borderline Personality Disorder in a study reported histories of child abuse and neglect. The impact of abuse depends on what age it started; different forms of abuse have impacts on different brain areas at different development stages.

When children feel constantly angry, guilty or scared of abandonment most often this is a true reflection of what they have experienced.

People who deal with distress via suicide attempts and self-harm are more likely to have histories of childhood sexual and physical abuse. The patients who didn't benefit from therapy tended to report not feeling safe with anyone when a child. Perhaps the brain receptors that respond to human kindness never developed.

There are clear difference between groups of people who have:

• histories of childhood physical/sexual abuse.
• recent victims of domestic violence.
• been through a natural disaster.

But yet the DSM doesn't differentiate between these types of trauma patients. Thus they are not accurately diagnosed and researchers and clinicians can't work on developing appropriate treatments.

You cannot develop a treatment for a condition that does not exist.

The Adverse Childhood Experiences (ACE study showed that traumatic life experiences during childhood/adolescence are much more common than most people expect. Even from a pool of mostly white, middle-class, middle-aged, well educated and financially secure base, only 1/3 reported no adverse childhood experiences.

Whilst they're studied separately, adverse experiences are typically interrelated. It's unusual for someone suffering one AE to live an otherwise happy life.

People with higher ACE scores are more likely than other people to:

• develop learning or behavioural problems at school.
• have higher workplace absenteeism.
• have financial problems.
• have lower lifetime income.
• suffer from chronic depression in adulthood.
• be prescribed antidepressants or painkillers - although depressed patients without histories of abuse of neglect tend to respond better to antidepressants than those who do have these AEs.
• attempt suicide.
• develop alcoholism or drug dependency.
• suffer a rape during adulthood.
• end up in violent relationships (as the victim if female, as the perpetrator if male.
• smoke
• develop obesity.
• have an unintended pregnancies
• have more sexual partners.
• have more STDs.
• suffer from any of the 10 leading medical causes of death in the US, including chronic obstructive pulmonary disease (COPD), ischemic heart disease, liver disease, cancer and emphysema.

Clinicians may thus be treating experiences that originated decades ago.

Sometimes what appears as a symptom is actually the solution from the point of view of the patient. For example, obesity is considered a problem for public health, but it may have been developed as a coping mechanism for issues more devastating to the person concerned; e.g. rape victims who see being obese as a way of being overlooked, or prison guards who feel safer by being the biggest person on the cellblock.

From the ACE report:

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

If we could stop child abuse in America, it would dramatically reduce the rate of depression, alcoholism, suicide, IV drug use, domestic violence, incarceration and poor workplace performance.

The 1964 surgeon general’s report on smoking and health kicked off a lengthy legal and medical campaign that dramatically decreased the number of US people who smoked, preventing 800,000 lung cancer deaths between 1975 and 2000. But the ACE report did not lead to any kind of similar response.

Developmental Trauma: The Hidden Epidemic

To solve the problems traumatised children have we need to accurately define what's going on with them. Developing new drugs or looking for the gene that causes the "disease" is not enough.

There are no simple genetic relationships on this topic. Many genes work together to influence a given outcome. Genes can be activated or deactivated in reaction to life events via methylation. These methylation patterns can be passed to one's children - epigenetics.

How much a mother rate grooms her pups during their first 12 hours after being born permanently affects the brain chemicals that respond to stress and the configuration of 1000+ genes. In comparison to those who had inattentive mothers, those who were intensively licked:

• Appear to be braver.
• Have lower levels of stress hormones.
• Recover from stress faster.
• Develop thicker connection in their hippocampus, a brain area related to learning and memory.
• Are better at escaping from mazes.

We've recently learned that stressful experience affect gene expression in humans too.

Rhesus monkeys show similar attachment patterns to humans. There's two types of monkeys that don't thrive: uptight anxious moneys who are appear fearful, withdrawn and depressed, and highly aggressive monkeys that are often shunned, assaulted or killed. Both types show biological differences from their peers; differences in arousal levels, stress hormones and brain chemicals. These can be detected very soon after birth and don't tend to change over time.

The social environment impacts them too - anxious females lack social support when they give birth so often neglect or abuse their offspring. Aggressive mothers are violent towards their offspring and stop them making friends with others. Monkeys who are taken away from their mothers at birth and brought up with their peers become intensely attached to them, to the extent of not participating in exploration or play. They grow up uptight, scared and lack curiosity irrespective of their genetics.

Having a certain short allele in humans is associated with depression, but only for those who also had a childhood history of abuse or neglect.

In reality you cannot determine whether a human's aggressive/uptight behaviour is the result of genetics or their upbringing.

The DSM's 1980 inclusion of the PTSD diagnosis enabled huge expenditure on the treatment and research . Its definition of PTSD is:

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 (insomnia, hypervigilance, or irritability).

82% of traumatised children did not meet those diagnostic criteria, leading to the author's group proposing a new diagnosis "Developmental Trauma Disorder" (DTD). People suffering from this were consistent in having:

• a pattern of dysregulation.
• problems with attention and concentration.
• difficulties getting along with themselves and others.

The continual expression of stress hormones in their bodies leads to:

• sleep disturbances.
• headaches.
• unexplained pain.
• oversensitivity to touch and sound.
• inability to focus attention or concentration on anything that isn't directly relevant to survival (e.g. school work).
• difficulties with language processing and fine-motor coordination
• clinginess and neediness even with their abusers.
• self-identification as being defective and worthless, self-loathing.
• inability to trust other people.
• difficulty making friends.
• turning to chronic rocking, masturbation, self-harming to relieve their tensions.

Despite a campaign urging the APA to add the diagnosis of DTD to the DSM they did not, citing that the idea that childhood adverse experiences lead to developmental disruptions is intuition, not fact, with no prospective studies evidencing it.

However there are in fact several such studies, including the Minnesota Longitudinal Study of Risk and Adaptation which showed that the mother’s personality, child's neurological anomalies at birth, its IQ or temperament were not predictors of serious behavioral problems in adolescence. The key predictor was the qualities of the parent-child relationship, how parents felt about and interacted with their children. Strikingly similar to what was found in the monkey studies above, children of inflexible caregivers turned out clingy and uptight. Insensitive and intrusive caregiving predicted hyperactivity and attention problems.

Putnam and Trickett carried out the first longitudinal study of the impact of sexual abuse on female development. Compared to a control group, abused girls suffered from:

• cognitive deficits.
• depression.
• dissociative symptoms.
• troubled sexual development.
• higher rates of obesity.
• higher rates of self-mutilation.
• dropping out of high school.
• major illnesses.
• health care utilisation.
• abnormalities in stress hormone responses.
• early onset of puberty. Sexual abuse speeds up their biological clocks and secretion of sex hormones - abused girls and 3-5x the levels of the "sexual desire" hormones testosterone and androstenedione.
• lots of seemingly unrelated psychiatric diagnoses.

Years later, when asked what the worst thing that happened to them last year, control group girls became distressed. But the abused girls shut down and became number. They themselves or other people may not realise when they're upset.

Before puberty, nonabused girls usually have several female friends and maybe one boy friend, increasing friendships with boys after puberty. Abused girls often have no close friends, but during puberty have many chaotic and traumatising contacts with boys.

At the start of the 19th century, doctors would classify illnesses by their symptoms, e.g. fevers or boils. Once Pasteur and Koch discovered the role of bacteria that caused these manifestations, medicine transformed to look at ways of getting rid of bacteria rather than just their symptoms. But for mental illnesses, the the DSM still uses the 19th century approach of diagnosis via symptom, even though we know the origins of many of the conditions.

The American Journal of Psychiatry published validity tests of some of the diagnoses which showed low reliability, i.e. they didn't produce consistent and replicable results. If people can't agree on what illness someone has, they can't treat it appropriately.

Treating someone whose behaviour originates from a real need to protect themselves as "oppositional" is risky.

The British Psychological Society has complained that the sources of psychological suffering in the DSM-5 are all identified as being located within individuals, and overlook the real social causation of many issues. The NIMH has also dropped support for the DSM. Mental problems often involve not being able to fit in with other people or feel belonging.

The consequence of realising that the effect of childhood trauma on development is large should not be to blame parents. Assume that parents generally do the best they can, but all need help to best raise their children.

• A program where nurses visited mothers at home to help them provide a safe and stimulating environment for children saw that 20 years later the children were healthier, less likely to report being abused or neglected, more likely to finish school, stayed out of prison and being working in well-paid jobs than a comparison group.
• On average $1 invested in home visitation, day care, and preschool programs results in $7 savings on welfare, health-care, substance abuse treatment and imprisonment, plus higher tax revenues from better paid jobs.
• Countries such as Norway and Netherlands already have universal health care and parent-friendly policies. Perhaps this might contribute to their rates of imprisonment being 1/10th of the US, lower crime and much lower health-care costs?

Part 4 - The Imprint of Trauma

Uncovering Secrets: The Problem of Traumatic Memory

The main concern of a therapist treating trauma is not to determine exactly what happened to the patient, but rather to help them tolerate the sensations, emotions and reactions they feel about it. Generally the only relevant blame to consider is the self-blame a victim may inappropriately have. However if a legal case is involved then obtaining evidence as to who is culpable becomes necessary.

Our memory is unreliable - the stories it tells frequently alter over time.

• The Grant Study of Adult Development found that 45 years after World War 2 ended, most participants told a very different story of their involvement compared to what they'd reported immediately afterwards. Most participants no longer felt intense horror. PTSD sufferers were the exception; their memories remained intact.

Whether and how accurately we remember something depends on how personally meaningful and emotional it was for us. Events that fall outside of the norm capture our attention, particularly the injuries we suffer. The more adrenaline you secrete, the more precise you memory will be. But at extremes, under conditions of horror, the system may be overwhelmed and break down. Traumatic memories become stored as fragmented sensory and emotional traces with no narrative story.

In the 19th century, psychologist, psychotherapists et al determined that trauma, particularly that of childhood sexual abuse, underlie hysteria. Studying the physiological and neurological correlates of hysteria revealed and embodied memory and lack of language.

• LeLog, a patient who had suffered a traffic accident in 1889 had no memory of it. His legs were paralysed despite there being no physical injury. It was determined that before he passed out he'd believed he was to be run over. Instead of consciously remembering the accident, he developed paralysis of his legs.

After being traumatised, patients keep repeating actions, emotions and sensations related to the incident.

Differences between narrative memory and traumatic memory:

• Traumatised people may have no conscious memory of the incident, but involuntarily physically act it out.
• Traumatic memories are instigated by specific triggers.
• Traumatic memory is not "summarised" - patients may re-enact their experience over many hours, vs telling a story that takes a few minutes.
• Ordinary memory is adaptive, flexible and alters depending on the circumstances. Traumatic memory has no function.
• Ordinary memory is social; we tell a story for a purpose. Traumatic reenactments are useless, unchanging, lonely, humiliating and alienating.

Without being able to integrate their traumatic memories, patients lose the capability to assimilate new experiences. They may experience a decline in personal and professional functioning. Dissociation stops the trauma being integrated into the ever-changing standard autobiographical memory. Treatment involves enabling that association so the brain can recognise the events were in the past.

Since Breuer and Freud’s 1893 paper we've treated trauma with the "talking cure". They claimed that they could cure every "hysterical symptom" patients presented with by helping the patient remembering the event that provoked it and the affect they felt at the time. The assumption that telling the story of your trauma is helpful in getting over it remains to this day.

It's hard for doctors, police officers and social workers to recognise that someone who re-enacts rather than remembers their stress as doing so. Sometimes the patient may not know themselves. This causes them to be labelled as crazy or punished as criminals rather than treated appropriate.

The Unbearable Heaviness of Remembering

Denying the consequences of mass trauma can damage the social fabric of societies. The refusal to face the psychological damage caused by World War 1 and an intolerance of "weakness" from the survivors played a role in the rise of fascism and militarism around the world in the 1930s.

Germany treated traumatised war veterans as inferior creatures, setting the stage for the catastrophic debasement of human rights under the Nazi regime and allowing that the strong must vanquish the inferior: the rationale for WW2.

Culture shapes how traumatic stress is expressed.

Doctors shape how patients communicate their distress. If when reporting some psychological effect the patient orders an X-ray, the patient learns that they get better care if they focus on the physical effects of their problems.

The Vietnam war led to many research studies and the creation of the PTSD diagnosis. The public also became interested in trauma.

The feminist movement at the time enabled huge numbers of childhood sexual abuse, domestic abuse and rape survivors to come forward. Related groups were formed and popular books published. A backlash occurred when in the 1990s many articles started to appear about False Memory Syndrome. Suffers of that supposedly created elaborate false memories of sexual abuse which they claimed had been dormant for many years before recovery.

Delayed remembering of trauma was accepted when World War I combat neuroses were first studied. But as the same memory problems in women and children who had been abused were reported and justice was sought against the perpetrators, the issue moved domains from science into politics and law.

There are 100s of scientific papers detailed how traumatic memories can be repressed and resurface years later. It's been reported in victims of natural disasters, accidents, war trauma, kidnapping, torture, concentration camps, and physical and sexual abuse.

Total memory loss is most common in childhood sexual abuse, with rates of between 19-38% of victims.

One study on women who had hospital records showing that they'd suffered childhood sexual abuse showed that:

• Those who were younger at the time of the incident or molested by someone they knew were more likely to have forgotten the abuse.
• 1 in 10 women (16% of those that remembered the abuse) had forgotten it at some point in the past but later remembered it.
• Their recovered memories were as accurate as the memories of those who had never forgotten (neither were perfect, but both recalled the main points well.)

Memories that are retrieved are returned to the memory bank with modifications. Whilst memories aren't accessible the mind can't adapt them. But when a story is told, especially if done so repeatedly, the act of telling it changes the memory.

A key challenge in researching this topic is that traumatised patients which are seen in emergency rooms, on psychiatric wards and battlefields are very different from those scientists study in their safe laboratories. Scientists cannot ethically create conditions in the lab that are equivalent to those where traumatic memories form (although people who already have a disorder can of course be studied.)

People do not tend to temporarily forget major non-traumatic events, such as weddings, graduations etc.

Modern research refutes Breuer and Freud's claim that remembering the trauma and the associated affects always resolves it. Language cannot substitute for action. Likewise CBT based exposure therapy does not cure PTSD. Becoming able to describe what happened to you can be useful and transformative in other ways, but don't always cure your physical, psychological or emotional symptoms.

Those of us without trauma prefer to live in a safe and predictable world, and thus are reluctant to truly listen to the stories survivors tell us. Trauma is overwhelming, unbelievable, and unbearable and requires the listener to forget what is normal and accept the reality of the speaker's experience.

Waking up during an operation - anaesthesia awareness - happens to ~ 30k surgical patients in the US each year. It can cause trauma to those subject to it.

Part 5 - Paths to Recovery

Healing from Trauma: Owning Your Self

You cannot treat or undo a traumatic event. Instead you treat the imprints the trauma left on the body, mind and soul.

The key challenge is to regain ownership over your body and mind, typically by:

• Finding a way to become calm and focussed.
• Becoming able to keep calm in response to images, thoughts, sounds, or physical sensations that remind you of the traumatic event.
• Engaging with the people around you, feeling fully alive and present.
• Stopping keeping secrets from yourself.

The same techniques can be useful for people with temporary stress.

First we need to cope with feeling overwhelmed by the sensations and emotions triggered by the past.

Understanding why you feel a certain way don't change the feeling, but it can help you control your reactions. We need to restore the balance between the rational and emotional brain.

If people are hyperaroused or shut down they can't learn from experience. Remaining in control is possible, but in an uptight way that results in inflexibility, stubbornness and depression. True recovery restores executive functioning, self-confidence, playfulness and creativity. This requires limbic system therapy, in order to repair the brain's faulty alarm systems and allow the emotional bring to do its standard job, quietly taking care of the body.

The way to change how we feel is to become aware of and make peace with our inner experience. To consciously access our emotional brain we must practice self-awareness.

Dealing with hyperarousal

Pharmaceutical drugs have become the accepted way to deal with hyper and hypo arousal in Western society. However humans have built-in skills that can address the issue.

We can train our arousal system by breathing, chanting and moving. These principles have been used throughout history in places like China and India and in religious practice, but are viewed as "alternative" in our culture. Traditions such as Yoga, Tai Chi, Qigong. rhythmical drumming and martial arts are practices that utilise mindfulness, movement, rhythms and actions.

• 10 weeks of yoga practice reduced the PTSD symptoms of patients that didn't respond to any other treatments.
• Neurofeedback can be effective for people who have trouble focusing and prioritising.

Becoming able to breath calmly and feeling relatively physically relaxed even when accessing painful memories is essential to recovery.

Taking slow deep breaths puts a parasympathetic break on your arousal.

No mind without mindfulness

Self-awareness is key to recovery.

Avoiding feeling unpleasant sensations in our body makes us vulnerable to overwhelm from them. Fear of these sensations freezes the body and mind. By paying attention to our body's sensations we can recognise the ebb and flow of our emotions and increase control over them.

1. Focus your mind on the sensations you feel, noticing how physical sensations are transient and responsive to e.g. body position or breathing style.
2. Label them - "Feeling anxious makes me feel like my chest is being crushed".
3. Observe how your thoughts affect your physical sensations and vice versa.

Mindfulness calms the sympathetic nervous system. You must learn to observe and tolerate your current physical reactions before trying to revisit the past.

We can tolerate discomfort as long as we're aware that it's transient.

Mindfulness has a positive effect on:

• psychiatric, psychosomatic, and stress-related symptoms, including depression and chronic pain.
• physical health such as immune response, blood pressure and cortisol levels.
• activation of brain regions involved in emotional regulation.
• changing brain regions associated with body awareness and fear.
• decreasing the activity of the amygdala, and subsequent reaction to triggers.

Relationships

The single most powerful protection against developing trauma is having a good social support network.

• Frightened adults need the same comforting as children - holding, rocking, the assurance that someone is taking care of things, so they can safely let go and sleep.
• After a traumatic incident, survivors need the presence of familiar people, faces, voices, physical contact, food, shelter, a safe place and the time to sleep.
• Children who are separated from their parents after a traumatic event are more likely to suffer negative long-term consequences. e.g. Children sent away from London to safety in the countryside in WW2 ended up faring worse than those who remained with their parents even whilst the latter endured terrifying experiences of bombing.

Relationships can be formed with families, loved ones, AA meetings, veterans’ organizations, religious communities, or professional therapists. They must provide physical and emotional safety (including from feeling shamed, blamed or judged) and support the courage needed to face up to and process what has happened.

As reconnecting to humans is so important to recovery, trauma that has happened within a relationship is usually harder to treat. People who feel like they no-one to turn to shut down and ignore their feelings. This leads to dissociation, despair, addiction, constant panic, and alienated, disconnected, explosive relationships.

Patients often don't know that their feelings and behaviour are connected to a traumatic event - they just feel that everything is unmanageable. They are stuck until they acknowledge what has happened.

Most trauma patients need coaching and support to find someone they trust.

In choosing a therapist, a critical question is whether you feel like your therapist is curious to find out about you as an individual rather than as a generic trauma patient.

For people who don't recall feeling safe with anyone as a child, engaging with horses and dogs may be a safer first step.

Communal rhythms and sychrony

Our social relationships are enacted via responsive faces, gestures and touch. Trauma breaks this physical synchronisation.

Choral singing, akido, tango dancing, kickboxing and sensorimotor therapy have helped repair it. Parent-child interaction therapy and SMART therapy helps parents and children become re-attuned.

When we play together we feel connection, joy and attunement. Improvisation exercises can help with this.

Getting in touch

Being touched, hugged and rocked is a natural way humans can calm their distress. It lowers arousal and makes us feel safe.

Types of bodywork like therapeutic massage, Feldenkrais, or craniosacral therapy can help.

Mindful touch and movement lets people discover tensions they have had so long they don't notice them any more. Patients effortfully tighten their shoulders and facial muscles to hold back anything that might reveal their inner state, e.g. tears. When the physical tension is released the feelings can also be.

Movement also helps induce deep breathing.

Taking action

The stress hormones the body secretes during extreme situations aim to enable the strength and endurance needed to respond to the conditions. People who have been able to use them to deal with a disaster are at low risk of trauma. But if the victim is rendered helpless or immobilised the hormones are still produced, but cannot be channeled to the actions they are supposed to support. The body needs to be returned to a baseline state of safety, whilst being able mobilisation again to take action if there is real danger.

Sensorimotor psychotherapy and somatic experiencing may help.

Once patients become aware of their traumatising physical experiences they may feel physical impulses e.g. hitting, pushing, running that were triggered during the trauma but supressed so as to survive. They may manifest now as subtle body movements. Amplifying those movements and modifying them helps bring the incomplete actions to completion, helping resolve the trauma.

Taking effective action helps restore a sense of agency and ability to protect oneself.

Often people forced into submission survive via resigned compliance. Breaking out of that pattern can be done by restoring the physical ability to engage and defend oneself. Interventions such as simulated muggings where patients are taught to fight off a simulated attack might help.

Integrating traumatic memories.

Eye movement desensitization and reprocessing (EMDR) may help.

Hypnosis has become unfashionable but can create a state of relative clam and allow patients to observe their experiences without overwhelm so may be useful.

Cognitive behavioural therapy (CBT)

CBT was developed to treat phobias via desensitisation. When patients are repeatedly exposed to a the stimulus and nothing bad happens they will become less fearful over time via a "correction" to their memories. This can help with fear and anxiety but there's no evidence it helps with complex emotions like guilt.

Exposure has been studied for PTSD repeatedly. 100+ minutes of flooding with anxiety-provoking triggers is needed before any reduction in anxiety occurs.

CBT hasn't yet proven to be very effective for traumatised individuals, especially those with childhood abuse. Only 1/3 of participants in studies show any improvement, a similar level of efficacy as being in a supportive therapy relationship.

Patients can only benefit from reliving their trauma if they are not overwhelmed by it.

Desensitisation

Systematic desensitisation helps reduce patients' reactivity to certain emotions or feelings. But integration might be a better goal; putting the traumatic event into its proper place.

Drugs that blunt emotions or techniques to desensitise ourselves exist. They might be useful in some scenarios e.g. doctors that have to treat burns patients. But desensitisation to our/other's pain may lead to a more general blunting of emotional sensitivity.

Drugs to access trauma

Holocaust survivors have been treated with LSD with spectacular claims being made, although there's little evidence to support this.

In searching for medication that enhance the effectiveness of psychotherapy, Mithoefer et al. looked at MDMA. It reduces fear, defensiveness, and numbing, and helps people access their own inner experience. Studies on this have shown positive results.

Traditional desensitisation techniques attempt to blunt how a person emotionally responds to past trauma, whereas this enables association and integration of the memory. However psychedelics are powerful agents which can be misused if administered without care or proper reference to therapeutic boundaries.

Medications

People have always used drugs to deal with stress. Different cultures/generations have their own preferences, e.g. alcohol, cannabis, cocaine, opioids, tranquilizers.

Mainstream psychiatry embraces this approach. 20% of US active-duty troops surveyed were taking some psychotropic drug.

Drugs cannot cure trauma; they just reduce how much a disturbed physiology expresses itself. They don't help someone develop self-regulation. They can help control feelings and behaviour, but at the cost of blocking the chemical systems that relate to engagement, motivation, pain and pleasure.

Almost every type of psychotropic agent has been used to treat PTSD.

• Patients on SSRIs can feel calmer and in control, sometimes making it easier to engage with therapy. Some feel blunted in general though. If one SSRI doesn't work, another may.
• Autonomic nervous system drugs can decrease hyperarousal and stress reactivity. They block the effects of adrenaline, reducing nightmares, insomnia and reactivity to triggers. They can help the rational brain remain in control.
• Tranquilising drugs are often favoured by patients. They give them calmness and prevent them from worrying. Similarly to alcohol benzodiazepines lower inhibitions against saying hurtful things. They also can be highly addictive and may interfere with the processing of trauma which puts many doctors off prescribing them.
• Anti-convulsant and mood stabilisers may be helpful in reducing hyperarousal or panic.
• Second-generation antipsychotics like Risperdal and Seroquel may help patients calm down. But they block the dopamine system which is associated with pleasure and motivation. Patients may gain weight, develop diabetes, become inert (leading to further isolation), or be unable to notice subtle signals of pleasure, danger or satisfaction. This makes these drugs controversial. More that 500k US children take antipsychotic drugs, which may be calming but interfere with learning skills and peer friendship development.

Traumatised civilians typically respond much better to mediations than combat veterans do. Nonetheless, they're very extensively prescribed for veterans, often without any other form of therapy.

Language: Miracle and Tyrant

People who escaped the 9/11 Twin Towers disaster reported that acupuncture, massage, yoga, and EMDR were the most helpful techniques to help overcome that experience. They relieved the physical burdens the trauma induced.

Therapists tend to believe that talking can resolve trauma - but traumatic events are often impossible to put into words. Nonetheless, words are an important part of recovery. You must acknowledge and label what happened.

It takes huge amounts of energy to keep secrets, supress information and hide feelings. You'll lose motivation to pursue goals, feel bored and shut down. Continual stress hormones will lead to headaches, muscle aches, bowel or sexual problems, and irrational behaviors. Ignoring your own reality damages your self, identity and purpose.

Symptoms of PTSD include feelings like:

• “I feel dead inside.”
• “I will never be able to feel normal emotions again.”
• “I have permanently changed for the worse.”
• “I feel like an object, not like a person.”
• “I have no future.”
• “I feel like I don’t know myself anymore.”

We've two forms of self-awareness.

1. The autobiographical self, connecting experiences into coherent stories.
2. Moment-to-moment self-awareness, based mostly on physical sensations. We can describe it in words though if we feel safe. Only this system can alter the emotional brain.

Getting the story behind someone's trauma is important because:

• it reduces the patient's isolation.
• it provides an explanation for their feelings.
• it allows a diagnosis to be made.
• it can provide the patient with something/someone to blame - a human trait that helps people feel good whilst feeling bad.

However stories mask that trauma changes people. This is hard to express because language evolved mostly to share things outside of our ourselves, rather than our inner state.

Writing about upsetting events can be helpful in accessing your inner feelings and also helps with physical and mental health.

• Writing letters to people that betrayed or abandoned us can make us feel better even if we don't send them. Writing to yourself means you don't have to fear judgment.
• In "free writing" you start with an object and write down the first thing that comes to mind, repeating that several times. You're left with your own personal set of associations, like a Rorschach test.

Patients switch emotional and physiological states as they move topics. Their personality may change. Their handwriting may become more childlike when writing about their deepest fears.

Many art, music, and dance therapists work with trauma patients, but we don't yet have much scientific evidence of their effectiveness - it would be hard to study.

Trauma overwhelms the listeners as well as the speaker. Sometimes talking about traumatic events gets you rejected by families, friends or organisations.

• Survivor groups like Alcoholics Anonymous, Adult Children of Alcoholics, Narcotics Anonymous can be helpful.
• Professional therapists are trained to listen to trauma stories and ideally themselves received therapy so they can self-care and remain emotionally available even if their patient's stories make them feel anger or disgust.

Sometimes victims become unable to speak coherently at all. They may come across as evasive, unreliable or non-credible.

PTSD patients may develop general attention and problems learning new information. Their focus is simply on making it through the day.

The cognitive part of CBT assumes that dysfunctional thinking can be corrected if it doesn't make sense. This is a myth - traumatised patients do have irrational thoughts but they're better dealt with as cognitive flashbacks and not argued against. EMDR therapy may work better.

Many of our conscious thoughts are really rationalisations for our unconscious instincts, reflexes, motives, and memories.

Trauma patients have abnormal insulas, the part of the brain that integrates and interprets the inputs from internal organs. They feel on edge, unable to focus or have a sense of doom, which cannot be fixed simply with reason or understanding. They may develop alexithymia - being unable to sense and communicate what is going on with themselves.

Our sense of Self requires us to organise our memories into a coherent narrative. Traumatised people may therefore feel like someone else or no-one..

Letting Go of the Past - EMDR

In eye movement desensitization and reprocessing (EMDR) therapy, the therapist asks patients to hold images, starting with their traumatic event, in their minds, and to use eye movements to watch the therapist's fingers move back and forth. The patient observes what associations are next formed in their mind.

It seems to loosen up the brain such that people can access loosely associated memories and images, allowing them to understand their traumatic experience in a larger or context or perspective.

EMDR therapy does not necessarily require patients to talk about their trauma. It can work even when the patient doesn't trust the therapist, or when they don't speak the same language well. The therapist just needs to tell the patient to "notice that" during their memories.

EMDR activates the prefrontal lobe ,anterior cingulate and the basal ganglia.

It is useful for PTSD patients. In one study, EMDR substantially outperformed Prozac and placebo (typically just showing up for a study gives a 30-42% improvement from baseline, with drugs adding another 5-15%). It also lasted - when the Prozac group stopped taking the medication they relapsed, whereas most of the EMDR group felt completely cured several months afterwards.

EMDR works better on patients who were traumatised as adults, although it may help some of those who were traumatised as children. It may be that sustained childhood abuse causes different mental/biological adaptations than a specific adulthood traumatic event does, with the former type of trauma typically taking longer to resolve.

It works well for combat veterans with PTSD.

Despite much evidence in favour, many doctors remain skeptical of EMDR.

EMDR isn't a form of exposure therapy. It integrates rather than desensitises the traumatic memories. Similar to the other therapies in the book (internal family systems, yoga, neurofeedback, psychomotor therapy, and theater) it can help restore a sense of agency, engagement and commitment in a way that exposure therapy usually doesn't.

There's a suggestion that EMDR is related to rapid eye movement (REM) sleep, the sleep phase where dreaming occurs. It may be that EMDR is reproducing some of what happens in our brains whilst dreaming.

Sleep, especially dream sleep, has a role in mood regulation. Increasing our time in REM reduces depression. PTSD is associated with poor sleep quality, with veterans often waking up soon after entering the REM stage.

Deep and REM sleep allows the brain to reshape memories by increasing the imprint of emotionally important information whilst reducing the memories deemed irrelevant. Our minds can create more distant associations when in REM sleep. This enables the brain to make sense of information which when we're awake we don't know the relevance of.

We don't yet know exactly how EMDR works, but this is also true of medications like Prozac or why talking to a trusted friend helps.

Learning to Inhabit Your Body: Yoga

Tapping acupressure points on your body is a technique taken from EFT (Emotional Freedom Technique) that's been shown to help with PTSD symptoms.

Memories of helplessness are often stored as muscle tension or feelings of disintegration in the relevant body areas. Constant muscle tension can lead to spasms, back pain, migraine headaches, fibromyalgia or other pain. Patients may receive various pain-related diagnoses, none of which identify trauma as the root cause.

Trauma survivors may orientate their lives based on trying to avoid undesirable sensory experiences. This might manifest in obesity, anorexia, addictions to exercise, work, drugs, alcohol, risk-seeking or self-harming behaviours - either trying to numb their feelings or seek sensations to override them.

Heart rate variability (HRV) is a biological marker that measures how effectively the autonomic nervous system is working, measuring the balance between sympathetic and the parasympathetic systems. It looks at how well heart rate fluctuates in response to breathing - normally it will increase upon breathing in and decrease when breathing out.

High HRV helps us control our impulses and emotions. Poor HRV has negative effects on thinking, feelings and response to stress. It's associated with physical illnesses like heart disease and cancer, and mental conditions such as depression and PTSD. People with PTSD have low HRV; unbalanced sympathetic vs parasympathetic systems.

Studies have shown that altering one's breathing patterns can help with anger, depression, and anxiety. Yoga can help with medical problems including high blood pressure, elevated stress hormone secretion, asthma, and back pain.

There are handheld devices and smartphone apps that train people to improve their HRV. These can be useful for patients unable to e.g. practice yoga, martial arts or qigong.

Yoga involves a combination of breath practices, stretches, postures and meditation. It improves PTSD arousal problems and trauma patients' relationship to their bodies, as well as helping with energy in some cases.

It is difficult for trauma patients to enter a state of total relaxation.

People with alexithymia feel physically uncomfortable but can't describe the problem. Doctors struggle to diagnose the issue. They also can't understand how they themselves feel about a particular situation or what makes them feel better or worse. Yoga allows you to improve your relationship with your inner world and a caring relationship to the self. You need to understand what your body needs in order to take care of it.

Focusing attention on breathing and sensations during yoga lets you notice the connection between your emotions and you body. It improves emotional regulation. It teaches that sensations come and go.

Improving interoception can be upsetting. Early yoga / trauma studies saw high dropout rates due to participants finding it too intense - for example postures involving the pelvis could create panic or flashbacks. Instructors should proceed very slowly.

Intensive meditation and yoga increases activation of the brain's self-system, the insula and the medial prefrontal context - brain areas important for physiological self-regulation,

When someone feels safe in their body, they can start to express previously overwhelming memories in language.

Putting the Pieces Together: Self-Leadership

Everyone feels a sense of being inhabited by conflicting impulses or parts at times. Part of us might want to work, whereas another part wants to sleep. The extreme version of this is dissociative identity disorder (DID), previously known as multiple personality disorder.

Traumatised people feel a strong sense of this, having had to resort to extreme measures to survive. Exploring and making peace with these parts is necessary for healing.

When we're humiliated we devote all our energy to protecting ourselves. Many behaviours that are attributed to psychiatric disorders, e.g. obsessions, compulsions, panic attacks, self-destructive behaviours, start out as self-protection strategies.

Thinking of the resulting behaviours as permanent disabilities focuses the treatment on finding the right drug, sometimes producing lifelong dependence. It's more useful to consider symptoms such as aggression, depression, arrogance or passivity as behaviours we learned. Something triggered the patient to believe that their best chance of survival lay in exhibiting these characteristics. The adaptions to trauma will continue until the patient feels safe and integrated.

Every trauma survivor is resilient in some way, but coping with their trauma comes at a cost. e.g. children may feel safer by hating themselves rather than by expressing anger to their caregivers. The only way they can understand why they were abused is to believe that they're unlovable.

Ignoring intense feelings can be useful in the short term, but leads to problems in the long term.

The brain and mind of trauma survivors was constructed to cope with their horrific experience, and must be reconfigured as part of treatment. We need to explore the parts of us that developed defensive habits.

Our parts can be considered as full ways of being, each having their own beliefs, agendas, and life roles. We must use internal leadership skills to listen to each part, ensure they are looked after and stop them sabotaging each other. A part may appear to ourselves and others as our entire being at times when in reality they're just one element in an intricate web of thoughts, emotions, and sensations.

Psychology and neuroscience have the idea that the mind is like a society. Split brain studies suggests we have several selves that don't always communicate with each other. Therapists can help patients explore this system via many treatment approaches, including the structural dissociation model and internal family systems therapy (IFS).

IFS regards our mind as being like a family. As "family members", parts differ in terms of maturity, excitability, wisdom, and pain. Each has its own history, abilities, needs, and worldview, and can affect the others.

Traumatised patients face dissociation whereby the parts fight each other, e.g. self-loathing existing alongside and fighting grandiosity, love with hate. Parts can be taken over by trauma-induced beliefs. For example, in child abuse patients parts that are childlike and fun may become frozen with pain and terror and locked away as part of denial - the "exiles".

Other parts are organised to protect their internal family from the exiles. Critical or perfectionistic "managers" might help us stay in control by making sure we never get close to anyone else. "Firefighters" act impulsively if an exile is triggered, perhaps screaming insults at others or running away.

Parts might not be aware of each other. But all parts have the overall function of trying to save us from feeling the terror of annihilation. Therapists help us welcome each part.

Healing in IFS comes via cultivating a mindful self-leadership over these parts, giving a vision and resources that recognise all the parts.

"Blending" occurs when the self isn't in charge any more and starts to identify with a single part - "I want to kill myself" instead of "A part of me wishes I was dead".

IFS assumes a confident, curious and calm self exists in us all, but has been sheltered by protector parts. Once the protectors believe it's safe to separate the self will be revealed. The parts can then trust the self to handle things. Unlike in some forms of meditation, the self isn't there to observe, but rather to actively lead.

Therapists help patients separate the blend into distinct entities - "This part of me is like a child." Patients are encouraged to ask each protective part to temporarily stand aside to show what it protects. They then identify the part that drives their current problem and ask the patient how they feel about it.

Keeping exiles locked up prevents our self becoming blended with and focussed on them alone, but also ignores the parts of us that hold their memories and emotions, often our sensitive, creative, intimate, lively or playful parts. IFS helps us listen to ourselves and others from a curious and compassionate standpoint, freeing us from the past.

Nursing our exiled parts back to health is called "unburdening" in IFS.

Rheumatoid Arthritis (RA) is an autoimmune disease that causes inflammation, chronic pain and disability. Medications can help but there's no cure. Patients often suffer from depression, anxiety, isolation, and overall impaired quality of life.

Using IFS to teach RA patients how to accept and understand their feelings about their condition led to improvements in self-assessed joint pain, physical function, self-compassion, and overall pain. Many of these benefits survived into the longer terms despite the fact that medical tests couldn't detect quantifiable improvements in pain or function. IFS appears to have improved the patients ability to live with their disease.

CBT and mindfulness practices have a positive impact on pain, joint inflammation, physical disability, and depression.

Filling in the Holes: Creating Structures

Filling the inner void after experiencing trauma is difficult. People who don't remember ever feeling safe when growing up do not benefit from standard psychotherapy, perhaps because they could not activate a feeling of being cared for they never before had.

90% of human communication happens in the nonverbal, right-hemisphere part of the brain.

Psychomotor therapy doesn't attempt to interpret the past, but rather to allow you to feel what you felt in the past, visualise what you saw and say what you weren't able to at the time. The therapist and group members are there to provide the protagonist with the necessary support to enable them to explore things they're scared of or hid from themselves. They validate you so you feel safe.

The right amygdala is activated when people hear a statement that accords with their inner state.

Enacting a 3-D display of your inner world as a "structure" lets you see what's happening in your mind and get a clearer perspective on your past reactions to people and events. Being in a scene more engaging than telling a story.

Positioning placeholders for people important in your life can activate unexpected memories, thoughts and emotions. Moving them around and directing them to do things the person they represent never did impacts you. It may bring relief and an unburdening of guilt and helplessness. Your inner shame can be moved to where it belongs; the people who hurt you.

Whilst the technique doesn't erase or neutralise bad memories, simulating experiences of what it would have been like to grow up in a safe and affectionate setting may induce supplemental memories and new options.

Everyone has had to deal with some challenging situations when growing up, but it helps to have had steady and predictable parents who are delighted with who you are to act as role models. Without that it's hard to become self-confident and capable. Someone who has been ignored or humiliated may lack self-respect. Those who could not assert themselves may continue to have issues standing up for themselves. Abused children may suffer from rage.

Adult relationships with other people are greatly affected. Affected children are more likely to interpret people's actions as being targeted against them and struggle to understand other people's struggles and concerns.

When our body doesn't send signals of safety to us we expect rejection and ridicule everywhere and refuse to explore new options. Psychomotor therapy allows people to visualise their inner reality in an external space that includes other people. Feeling safe and valued within this structure helps people re-write their inner experience, learning that they can interact with other people without rejection or pain. Exercising imagination in this way can change the stories we inwardly tell ourselves and release us from our self-imposed constraints - an antidote to memories of pain.

Being mirrored gives you implicit permission to feel what you feel and know what you know, which is a precondition to recovering from trauma.

Rewiring the Brain: Neurofeedback

Since the first recording of the brain's electrical activity in 1924 we've learned that different brain-wave patterns reflect different mental activities.

The hope was that EEG irregularities would correspond to correspond to specific psychiatric problems. The discovery of new psychiatric drugs in the 1970s switched the focus to a chemical model of the mind and brain. But now the US FDA has certified slow-wave prefrontal activity as being a biomarker for ADHD. They imply a lack of control over one's emotional brains, which is also a symptom of abuse and trauma. PTSD patients also show EEG irregularities.

Neurofeedback displays a person's own brain waves to them, and asks them to try and modify what is being displayed by altering which frequencies are created in an effort to enhance the brain's natural complexity and control over self-regulation. The concept is similar to how we read someone else's face when talking to them and feel rewarded when they nod or smile.

For trauma patients the hope is to intervene in the brain circuitry that sustains fear, shame and rage, stablising the brain and increasing resilience. Events are only intrinsically stressful based on how we label and react to them.

PTSD patients undergoing neurofeedback improve their PTSD scores, interpersonal comfort, emotional balance, self-awareness, were less frantic, slept better and felt more calm and focussed.

Neurofeedback also helps epilepsy patients.

Each line on an EEG chart shows the activity of a different part of the brain. The devices measures the amplitudes and frequencies of the activity.

• Delta waves are low frequency, most often seen during sleep. Excessive delta wave activity when awake leads to foggy thinking, poor judgement and low impulse control. Most children with ADHD and many PSTD sufferers have excessive slow waves in their frontal lobes.
• Theta frequencies are usually found at the edge of sleep. They associate with a mind with no regard for logic or reality, enabling new connections and associations to be built. The ability to remove frozen associations and learn new ones is leveraged it neurofeedback for patients with PTSD. But they also occur when we're oblivious or depressed.
• Alpha waves engender a sense of peace and calm. They are associated with e.g. mindfulness mediation. They help traumatised people who are too numb or agitated to relax.
• Beta wave are high frequency, and direct the brain to the outer world, enabling focussed attention. But in excess they associate with agitation, anxiety, and body tenseness.

Neurofeedback training can improve creativity athletic ability and inner awareness even in highly proficient people. It's most often been studied in the context of performance enhancement, used by e.g. football clubs or musicians. It's about as effective as drugs are for ADHD, and has the advantage over them that the benefits persist even when treatment is ended.

Quantitative EEG (qEEG) allows very detailed computer analysis of EEG signals. We can compare someone's results to large databases of other people's results who have similar issues.

qEEG suggests that the boundaries of the DSM diagnostic categories are arbitrary. The diagnoses do not line up with specific brain activation patterns. But specific patterns do line up with mental states that feature in multiple DSM diagnoses, including confusion, agitation or feeling disembodied.

Showing trauma patients the patterns of electrical activity in their brains responsible for difficulties with focus or emotional control is helpful. They learn to process information differently and stop blaming themselves.

Trauma patients may have excessive activity in the right temporal lobe and frontal slow-wave activity. Calming the areas associated with fear improves the problems associated with trauma, executive functioning, PTSD scores, mental clarity and self-regulation when encountering minor provocations.

The number of months soldiers experience combat during was associated with increasing reductions in alpha power and a development of front-lobe activity that resembles that seen in ADHD patients.

Childhood abuse and neglect prevents the normal wiring of sensory-integration symptoms. This can result in learning disabilities. Neurofeedback may reverse these. Neither drugs or standard therapy has yet been successful in helping people organise time, space, distance and relationships if trauma interfered with the development of those capacities.

Alpha-theta training can induce hypnagogic states that help reduce the connections trauma patients have between certain stimuli (e.g. loud bangs) and their responses. New associations can be created. There's evidence that it helps with hyperarousal, PTSD symptoms and physical complaints.

1/3 - 1/2 of severely traumatised people go on to get substance abuse problems. Alcohol abuse increases carelessness and the risk of suffering a new traumatic incident.

Being drunk during an assault reduces the likelihood of developing PTSD.

75-80% of patients admitted to detox treatment relapse. Studies suggest neurofeedback treatment can dramatically reduce this.

Neurofeedback treatment may be helpful for many other conditions, including:

• tension headaches.
• improving cognitive functioning after a brain injury.
• anxiety and panic attacks.
• autism.
• seizure control.
• self-regulation in mood disorders. as well as helping to deepen meditation states.

Finding Your Voice: Communal Rhythms and Theater

How much we feel in control of ourselves is defined by how we relate to our body and its rhythms. We need to feel we're in our bodies, able to access our inner sensations, not dissociated.

Throughout history humans have used communal rituals to process terrifying feelings. Every major religion has rituals that involve rhythmic movements. The US civil rights movement used music. Armies leverage marching and military bands.

Collective music and movement give our lives context, and bind us with other people who may also be individually terrified but together can become powerful advocates for the group, brining a sense of hope and courage.

There are several programs that aim to treat trauma via theatre. They all aim to allow sufferers to confront the realities of life and transform via communal action. Emotions associated with trauma - love, hate, betrayal, surrender - are part of theatrical performances.

Society trains us to ignore how we feel. Acting requires you to access those deep feelings and convey them to the audience. Contrary to traumatised people's desire to avoid their feelings, theatre is all about embodying and vocalising emotions, becoming engaged and testing out different roles, exploring different ways of living.

The first challenge is to get participants to be more present in the room. Mirroring exercises can help synchronise people, alongside exercises to develop trust.

Urban Improve creates scripted skits showing people facing every-day problems such as exclusion, rivalry, anger, homophobia and family strife. A volunteer is asked to act how they would in a real life version of this situation. Others are asked to try different approaches, enabling the students to see how alternative choices play out.

For younger children, this produced improvements in aggression, cooperation, and self-control. It didn't help older children with more exposure to violence.

At first students sided with the aggressive characters, being as unable to accept a sign of weakness in others as in themselves. But towards the end they started volunteering for parts involving vulnerability or fear.

Opportunities to develop competence and bonding such as music, art, theatre and sports are unfortunately being reduced in schools.

One theatre program aims at helping children in the foster-care system. The abandonment associated with fostering makes it hard to trust anyone. Normally. 5 years after leaving foster care, 60% of people are convicted of a crime, 75% are on benefits and only 6% have a degree.

Foster children often have several people in charge of them and learn to play them. Permanency is important, perhaps the most important form of which is a long-term group of friends which these programs aim to provide.

First the program builds a group ethos, and then has the participants share stories about their life. They learn that people will listen. Later, they shift their focus from their history of fear to becoming the best actor, set designer etc. they can be; gaining competence defends against the feelings of helplessness from trauma.

This is true for everyone. When an upsetting event happens to you it's always helpful to physically move around and do something that requires focus.

The sword fighting in Shakespeare plays allows the practice of contained aggression, leveraging negotiation and language to remain safe.

Embodying roles shows the participants they have many differing emotions. They learn to stand up straight and project their voice, finally facing their community.

Some see this is the opposite of research. Most research aims to step outside people's personal experience and be objective. Effective therapy requires a focus on the subjective feelings and truth that lives within the body.

Epilogue: Choices to be Made

Society is becoming more conscious of trauma. People take the research data seriously and work to develop and apply interventions to help manage it. We now know a lot about how to treat and to some extent prevent it.

However in some ways US society is going backwards, for instance:

• eliminating food stamps for children whose parents are unemployed or in prison.
• refusing to introduce universal healthcare.
• refusing to accept that psychic suffering is connected to certain social conditions. Your income, family structure, housing, employment, and educational opportunities are associated with both your risk of developing trauma and your access to getting help with it.
• refusing to control weapons which are designed to kill large numbers of people.
• imprisoning large numbers of people.

Trauma is a public health issue, possibly the greatest threat to well-being.

• Americans are much more likely to be killed by their family or partners than in war.
• Women are twice as likely to experience domestic violence as breast cancer.
• Guns kill twice as many children as cancer does.

But yet there is no big effort to help people learn to deal with the consequence of trauma.

The increasing use of drugs doesn't address the real issue of what it is that patients are struggling to cope with. Good mental health requires the ability to feel safe with other people.

Child abuse and neglect is the most preventable cause of mental illness, the commonest cause of drug and alcohol abuse, and a contributor to diabetes, heart disease, cancer, stroke, and suicide. Perhaps the best hope for traumatised children is getting an education in schools where they are seen and learn to regulate themselves in an "island of safety".

Trauma confronts us with our fragility, the horror of what people can do to each other and also demonstrates our resilience.

Most people who create great social change have experienced trauma. This is also true at a society level. Many progressive advances came via traumatic events: the US civil war led to the ending of slavery, the Great Depression led to the creation of social security, and World War 2 led to a large and prosperous middle class via the GI bill.

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