by Peter A. Levine, Ph.D.
(Full text available, along with other articles of interest, at http://www.traumahealing.com)
Trauma is a Fact of Life
A single brief exposure to an overwhelming event can throw a normally functioning individual into an abyss of emotional and physical suffering. Whether or not a person rebounds from this dark edge of near insanity or tumbles more deeply into the ”black hole” of trauma remains a mystery. Modern psychiatry has little understanding of why one individual helplessly succumbs to a traumatic circumstance, while another remains unscathed or even fortified from the same event.
Because human responses to potential threat vary so greatly, it is difficult to identify or classify sources of trauma. Most people (both lay and professional) associate trauma with events like war, extremes of physical, emotional or sexual abuse, crippling accidents, or natural disasters. However, many ”ordinary” or seemingly benign events can be equally traumatic. For example, so-called minor ”whiplash” automobile accidents frequently lead to bewildering and debilitating physical, emotional, and psychological symptoms. Common invasive medical procedures and surgeries (particularly those performed on frightened children who are restrained while being anesthetized), can be profoundly traumatizing. Children often become fearful, hyperactive, clinging, withdrawn, ”bed-wetters”, or impulsively aggressive after such ”routine” events. Sometimes the effects from these experiences do not show up for months or even years. They may appear in the form of ”psychosomatic” complaints (such as head and tummy aches) or as inexplicable anxiety or depression.
In a story from the pages of Reader’s Digest entitled Everything is not Okay, a father describes his son Robbie’s “minor” knee surgery: The doctor tells me that everything is okay. The knee is fine, but everything is not okay for the boy waking up in a drug induced nightmare, thrashing around on his hospital bed– a sweet boy who never hurt anybody, staring out from his anesthetic haze with the eyes of a wild animal, striking the nurse, screaming ‘Am I alive?’ and forcing me to grab his arms….staring right into my eyes and not knowing who I am.
Dr. David Levy (writing in 1946) found that children in hospitals for routine reasons often experienced the same kinds of severe symptoms as “shell-shocked” soldiers that had to be brought back from the front lines in Africa and Europe. Sadly, our medical establishment has been slow to acknowledge and incorporate this extremely vital information, which, if implemented, could prevent unnecessary suffering from the debilitating effects of trauma. It is evident that what makes an event potentially traumatizing is the perception (conscious or unconscious) that it is life-threatening.
A positive aspect of recent medical research on trauma is that it raises critical questions concerning the damage that is being inflicted upon a generation of children ravaged by wars throughout the world, and by violence in our inner cities. Unless we can learn to resolve the effects of trauma, we may be creating a generation of hyperactive, learning impaired, violence-prone, brain-damaged ”citizens”, whose actions will pale Hollywood’s wildest nihilistic fantasies. This tendency is by no means limited to war and violence torn areas of the globe. Many middle class children and adults suffer from anxiety, depression, and psychosomatic disorders. Some of them are prone to violence or are functioning at greatly reduced potentials due to the effects of what we have termed ”common everyday occurrences.” Unresolved trauma leads to re-enactment, and is a major factor in the escalation and perpetuation of violent behavior. Solving this threat to local and global social stability is and will be one of our greatest challenges.
It is through the study of the natural world that we may begin to understand the critical role of biology and instinct in the formation and resolution of trauma. We are living, breathing, pulsing, self-regulating, intelligent organisms, not merely complex chemistry sets. We need to identify with our animal roots and dare to inhabit the Serengeti plain that dwells in our collective soul. There, we will become aware of many things. Our senses will rise from their slumber, and we will behold the crouching cheetah as it readies itself to attack the swift, darting, impala. Track your own responses as you watch the fleet cheetah in a seventy mile an hour surge, overtake its prey. You notice that the impala falls to the ground an instant before the cheetah makes contact. It is almost as if the animal has surrendered to its pending demise.
It’s Physiology – Not Pathology
The fallen Impala is not dead. Although on the ‘outside’ it appears limp and motionless, on the ‘inside’ its nervous system is still activated from the seventy-mile-an-hour chase. Though barely breathing, the Impala’s heart is pumping at extreme rates. Its brain and body are being flooded by the same chemicals (e.g. adrenaline and cortisol) that helped fuel its attempted escape.
It is possible that the impala will not be devoured immediately. The mother cheetah may drag its fallen (apparently dead) prey behind a bush and seek out its cubs, who are hiding at a safe distance. Herein lies a short window of opportunity. The temporarily ”frozen” impala has a chance to awaken from its state of shock, shake and tremble in order to discharge the vast amount of energy stored in its nervous system, then, as if nothing had happened, bound away in search of the herd. Another function of the frozen (immobility) state is its analgesic nature. If the impala is killed, it will be spared the pain of its own demise.
Three little girls (described in US News and World Report, Nov. 11, 1996) are sitting in plastic molded chairs in the hospital waiting room. They seem calm, betraying nothing of the horror they experienced the night before. The children were tied up, the three year old threatened with a gun, and then they watched as their teenage sister was shot in the head (though not killed). They appear ”calm” on the outside, but their physiology’s tell a very different story. Hearts still racing at one hundred beats per minute, their blood pressure remains high. Inside their heads, the biological stress chemicals are saturating their brains. Like the fallen Impala, these ”frozen” kids, while appearing calm (if not unresponsive), are still internally prepared for the extremes of activation necessary to initiate the flight or fight procedures they never had a chance to execute. Those chemicals are now turning against their very futures. The increased heart rate is associated with the hair-trigger fight/flight response, and is played out in the hostile/withdrawing behaviors that will characterize their bleak and agitated days at school and sleepless nights at home. Bruce Perry of Children’s Hospital at Bayhn College of Medicine gives teachers and parents of traumatized children devices that allow them to monitor the child’s heart rate at a distance. This way they can refrain from making demands that are likely to cause the children to explode in rage or withdraw in fear. He also prescribes clonidine, a drug that seems to help block the fight or flight response.
I believe both of these approaches can be of some use. Unfortunately, by focusing on pathology and the suppression of symptoms, the essential biological ingredient of resolving trauma is missed-that is, completion of the thwarted fight or flight defensive procedures and the close human contact that is required to support this completion. Without completion and resolution, people remain frightened, isolated and hopeless. When completion occurs, like the impala, a person can be transformed and rejoin the herd.
Though it appears that we have separated ourselves from animals, like the impala and cheetah, human responses to threat are biologically formed. They are innate and instinctual functions of our organisms. For the impala, life-threatening situations are an everyday occurrence, so it makes sense that the ability to resolve and complete these episodes is built into their biological systems. Threat is a relatively common phenomenon for humans as well. Though we are rarely aware of it, we also possess the innate ability to complete and resolve these experiences. From our biology comes our responses to threat, and it is also in our biology that the resolution of trauma dwells.
In order to remain healthy, all animals (including humans) must discharge the vast energies mobilized for survival. This discharge completes our activated responses to threat, and allows us to return to normal functioning. In biology, this process is called homeostasis: it is the ability of an organism to respond appropriately to any given circumstance, and then return to a base line of what could be called ”normal” functioning.
In the National Geographic video “Polar Bear Alert” (available at video stores), a frightened bear is run down by a pursuing airplane, shot with a tranquilizer dart, surrounded by wildlife biologists, and then tagged. As the massive animal comes out of its shock state it begins to tremble, peaking with an almost convulsive shaking–its limbs flailing (seemingly) at random. The shaking subsides and the animal takes three spontaneous breaths which seem to spread through its entire body. The (biologist) narrator of the film comments that the behavior of the bear is necessary because it ”blows off stress” accumulated during the capture. If this sequence is viewed in slow motion it becomes apparent that the ”random” leg gyrations are actually coordinated running movements – it is as though the animal completes its running movements (truncated at the moment it was trapped), discharges the ”frozen energy,” then surrenders in a full bodied ”orgiastic” breath.
I was first made aware of the profound significance of these kinds of physiological reactions in the healing of trauma quite by accident. In 1969, a psychiatrist referred a patient to me who was suffering from acute anxiety and panic attacks. The attacks had become so severe that the woman (Nancy) was unable to leave her home unaccompanied. The psychiatrist, who knew of my interest in mind/body healing (a fledgling field at that time), thought that perhaps she would benefit from techniques I had developed that utilized sensory awareness as a way to deep relaxation.
Relaxation was not the answer. In our first session, as I naively and with the best of intentions attempted to help her relax, Nancy went into a full-blown anxiety attack. She appeared paralyzed and unable to breathe. Her heart was pounding wildly, and then it slowed to almost a stop. I became quite frightened as we entered together into her nightmarish attack.
Surrendering to my own intense fear, yet somehow managing to remain present, I had a fleeting vision of a tiger jumping toward us. Swept along by the experience, I exclaimed loudly, ”You are being attacked by a large tiger. See the tiger as it comes at you. Run toward that tree; climb it and escape!” To my surprise, her legs started trembling in running movements. She let out a bloodcurdling scream that brought in a passing police officer (fortunately my office partner somehow managed to explain the situation). She began to tremble, shake, and sob in waves of full-bodied convulsions.
Nancy continued to shake for almost an hour. She recalled a terrifying childhood memory. At the age of three, she had been strapped to a table for a tonsillectomy. The anesthetic was ether. Unable to move, feeling suffocated (common reactions to ether), she had terrifying hallucinations. This early experience had a deep impact on her. Nancy was threatened, overwhelmed, and as a result, had become physiologically frozen in what biologists call the ”immobility response”. In other words, her body had literally resigned itself to defeat, and the act of escaping could not exist. In this pervasive state of ”core anxiety,” Nancy lost her real and vital self, as well as a secure and spontaneous personality. Though she hadn’t literally died, parts of herself had suffered a kind of death.
After the breakthrough that occurred in our initial visit, Nancy left my office feeling, in her words, “Like she had herself again.” Although we continued working together for a few more sessions, where she gently trembled and shook, the anxiety attack she experienced that day was her last.
Waking the Tiger
Over three million Americans suffer from regular panic attacks, a majority being women–the more likely prey when it comes to our species. We see in the definition of panic anxiety-the sense of imminent danger or impending doom associated with an urge to escape. This is the essence of trauma; the urge to escape coupled with the perception of not being able to.
At the time I met Nancy, I was studying animal predator-prey behaviors. I was intrigued by the similarity between Nancy’s paralysis when her panic attack began, and what happened to the impala discussed previously. Most prey animals use the immobility response when attacked by a larger, more powerful predator from which they can’t escape. I am quite certain that these studies strongly influenced the fortuitous vision of the imaginary tiger. For several years after that I worked to understand the significance of Nancy’s anxiety attack and her response to the image of the tiger. I now know that it was not the dramatic emotional catharsis and reliving of her childhood tonsillectomy that was catalytic in her recovery, but the discharge of energy she experienced when she flowed out of her passive, frozen immobility response into an active, successful escape. The image of the tiger awoke her instinctual, responsive self. The other insight I reaped from Nancy’s experience was that the resources which enable a person to succeed in the face of a threat can be used for healing. This is true not just at the time of the experience, but even years after the event.
I learned that to heal trauma it was unnecessary to dredge up and relive memories. In fact, severe emotional pain can be re-traumatizing. What we need to do to be freed from our symptoms and fears is to arouse our deep physiological resources and consciously utilize them. If we remain ignorant of our power to change the course of our instinctual responses in a proactive rather than reactive way, we will continue being frozen, imprisoned, and in pain.
The Root of Many Disorders
It is estimated that as many as thirty to forty million Americans (twelve to fifteen percent of the population) have experienced persistent anxiety. Another twelve million have been troubled by a milder form of anxiety known as ”restless leg syndrome” (an explanation for this jitteriness of the legs due to incomplete survival responses can be gleaned from the image of Nancy as she escapes from the tiger). Add to this figure twelve and a half million people who suffer from obsessive-compulsive disorder (a condition that keeps people in a constant alert state known as hyper-vigilance), ceaselessly searching for threat even when none exists.
Stress-related illness (mental and physical), may account for the vast majority of symptoms for which people seek medical help. Serious psychiatric disorders (involving anxiety, depression, sleep disturbances, and substance abuse) are on the rise in America and in other industrialized nations. In 1994, the conservative Archives of General Psychiatry reported that half of the entire American adult population meets the formal diagnostic criteria that denote serious psychiatric illness. Since World War Two, the rates of adolescent depression and suicide have both tripled. As startling as these statistics are, even more alarming is the sharp rise in violence among our youth. Concurrently, hyperactivity and Attention Deficit Disorder (ADD) are approaching epidemic proportions. Various school districts are reporting that as high as ten to twenty percent of their elementary school population is regularly using Ritalin (a type of amphetamine prescribed by doctors to counteract hyperactivity and ADD). The trouble with Ritalin (and other drugs used for similar purposes), is that not only are they potentially addictive and dangerous, they fail to get to the root of the problem. I believe that a substantial percentage of violence-prone children (as well as many of those diagnosed as hyperactive or having ADD) are actually suffering from the effects of unresolved trauma. The behaviors they exhibit (which we term disorders) are often manifestations of hyper-arousal and hyper-vigilance, both which are core symptoms of trauma.
Eight-year-old Anna has enormous brown eyes. She could have been a model for one of David Keane’s popular paintings of almond-eyed children. The school nurse has just brought her in to see me. Pale, head hanging in defeat, barely breathing–she is like a fawn frozen by the bright lights of an oncoming car. Her frail face is expressionless, and her right arm hangs limply, as if it was on the verge of detaching itself from her shoulder.
Two days earlier, Anna went on a school outing to the beach. She and a dozen of her classmates were frolicking in the water when a sudden riptide swept them swiftly out to sea. Anna was rescued, but Mary (one of the mothers who volunteered for the outing) drowned after courageously saving several of the children. Mary had been a surrogate mom to many of the neighborhood kids, including Anna, and the entire community was in shock from her tragic death. We had asked the nurse to be on the lookout for children who displayed a sudden onset of symptoms (e.g., pain, head and tummy aches, and colds). Anna had already been to see the nurse three times that morning, reporting severe pain in her right arm and shoulder.
One of the mistakes often made by “trauma responders” is to try to get children to talk about their feelings immediately following an event. Although it is rarely healthy to suppress feelings, this practice can be re-traumatizing, because in these vulnerable moments children (and adults as well) can be easily overwhelmed. Previous traumas can re-surface in the aftermath of ”overwhelm”, creating a complex situation that may involve ”deep secrets”, untold shame, guilt feelings, rage, and pain. For this reason, we sought out and learned some of Anna’s history from several helpful elementary school teachers prior to seeing the child. The following information was revealed:
At age two, Anna was present when her father shot her mother in the shoulder and then took his own life. More recently, Anna had been infuriated when Mary’s sixteen-year-old son Robert had bullied her twelve-year-old brother. There was a strong possibility that Anna harbored ill will towards Robert, and sought retribution. This raised the likelihood that Anna might feel profound guilt about Mary’s death-perhaps even responsible for it.
I ask the nurse to gently cradle and support Anna’s injured arm. This will help Anna contain the frozen “shock energy” locked in her arm, as well as heighten the child’s inner awareness. With this containment and support, like the impala, Anna will be able to slowly, gradually, thaw, and access the feelings and responses that will help her come back to life.
“How does it feel to be inside of your arm, Anna?” I ask her softly.
“It hurts so much” she answers faintly. Her eyes are downcast, and I say,
“It hurts bad, huh?”
“Where does it hurt? Can you show me with your finger?” She points to a place on her upper arm and says, “Everywhere, too.” There’s a little shudder in her right shoulder followed by a slight sigh of breath. Momentarily, her drawn face takes on a rosy hue.
“That’s good, sweetheart-does that feel a little better?” She nods slightly, then takes another breath. After this slight relaxation, she immediately stiffens, pulling her arm protectively towards her body. I seize the moment.
“Where did your mommy get hurt?” She points to the same place on her arm, and begins to tremble. Nothing more is said. The trembling intensifies, then moves down her arm and into her neck. “Yes, Anna, just let that shaking happen-just like a bowl of jello-would it be red, or green, or even bright yellow? Can you let it shake? Can you feel it tremble?”
“It’s yellow,” she says, “like the sun in the sky.” She takes an almost full breath, then looks at me for the first time. I smile and nod. Her eyes grasp mine for a moment, then turn away.
“How does your arm feel now?”
“The pain is moving down to my fingers.” Her fingers are trembling gently. I speak to her quietly, softly, rhythmically.
“You know, Anna sweetheart….I don’t think there is anybody in this whole town that doesn’t feel like that in some way it was their fault that Mary died.” She glances at me briefly, and I continue-“Now, of course that’s not true…but that’s how everybody feels…and that’s because they all love her so much.” She turns now and looks at me. There is a sense of self-recognition in her demeanor. With her eyes now glued on me, I continue…”Sometimes, the more we love someone, the more we think it was our fault.” Two tears spill slowly from the outside corners of each eye before she slowly turns her head away from me.
“And sometimes if we’re really angry at someone when something bad happens to them, then we also think that it happened because we wanted it to happen.” Anna looks me straight in the eye, and I say, “And you know, when a bad thing happens to someone we love or hate, it doesn’t happen because of our feelings. Sometimes bad things just happen…and feelings, no matter how big they are, are only feelings.” Anna’s gaze is penetrating and grateful. I feel myself welling with tears. I ask her if she wants to go back to her class now. She nods, looks once more at the three of us, then walks out the door, her arms swinging freely.
Alex (like several of the children who witnessed the tragedy from the beach), was having trouble sleeping and eating. His father brought him to us because the youngster had barely eaten in the last two days.
As we sit together, I ask him if he can feel the inside of his tummy. He places his hand gently on his belly, and, with a sniffle, says “Yes.”
“What does it feel like in there?”
“It’s all tight like a knot.”
“Is there anything inside that knot?”
“Yeah. It’s black….and red….I don’t like it.”
“It hurts, huh?”
“You know, Alex, it’s supposed to hurt…but it won’t hurt forever.” Tears cascade down the boy’s cheeks, and color returns to his face and fingers. That evening, Alex ate a full meal. At Mary’s funeral Alex wept openly, smiled warmly, and hugged his friends.
Because trauma is “locked” in the body, it is in the body that it must be accessed and healed. With proper support, the body will discharge the locked-in energy as surely as a stream flows to the sea. Words are used as compassionate reflections, not as explanations. We don’t need to help each other “get our feelings out,” we need to be compassionately present for one another. This kind of acknowledgment creates the ambiance that will allow the frozen sensations and feelings to soften and flow at their natural pace. Don’t Push the River.
Trauma is about broken connections. Connection is broken with the body/self, family, friends, community, nature, and spirit, perpetuating the downward spiral of traumatic dislocation. Healing trauma is about restoring these connections.
There is much we can do to heal trauma and create a pathway towards connection. As individuals, families, and professionals, we can be present for our children in the aftermath of potentially traumatic experiences. Automobile accidents, injuries, serious illness, emergency and necessary medical procedures, violence, natural disasters, and loss (from death or separation) do not have to leave children frozen. Children possess an innate and vibrant resiliency that can enable them to rebound from “overwhelm” and injury. In a 1994 article published in Mothering Magazine called Understanding Childhood Trauma, and in a forthcoming book, It Won’t Hurt Forever, I discuss first-aid for trauma–how to provide the support and guidance necessary to help children resolve and prevent traumatic reactions. It is possible for all of us to learn a few simple (compassionate) guidelines that can be employed to help children (and adults) move through the intense fear often associated with injuries and medical procedures. If this information is incorporated into our existing medical and paramedical model, it could prevent much unnecessary suffering and reduce health care costs dramatically.
“Give me a place to put my lever,” decried Archimedes, “and I will move the world.” Dominated by conflict, destruction, and trauma, we may find this fulcrum, this focal point, in the tender, physical, rhythmic pulsation between a mother and her infant. When the primary connection is strong and vital, the world outside becomes a less threatening, more hospitable place. When the broken connection between the body, mind, and spirit is restored, when the severed bonds between people and nature have been re-woven, we can begin, as a species, to feel at home on this beautiful planet Earth.