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20 Stress can also lead to ulceration of the gastrointestinal tract, triggering symptoms in ulcerative colitis and in inflammatory bowel disease. The brain itself is susceptible to the long-term effects of sustained stress, including damage to the hippocampus, and so to memory. In general, says McEwen, “evidence is mounting that the nervous system is subject to ‘wear and tear’ as a result of stressful experiences.” 21 Particularly compelling evidence for the medical impact from distress has come from studies with infectious diseases such as colds, the flu, and herpes. We are continually exposed to such viruses, but ordinarily our immune system fights them off—except that under emotional stress those defenses more often fail. In experiments in which the robustness of the immune system has been assayed directly, stress and anxiety have been found to weaken it, but in most such results it is unclear whether the range of immune weakening is of clinical significance—that is, great enough to open the way to disease. 22 For that reason stronger scientific links of stress and anxiety to medical vulnerability come from prospective studies: those that start with healthy people and monitor first a heightening of distress
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start with healthy people and monitor first a heightening of distress followed by a weakening of the immune system and the onset of illness.
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In one of the most scientifically compelling studies, Sheldon Cohen, a psychologist at Carnegie-Mellon University, working with scientists at a specialized colds research unit in Sheffield, England, carefully assessed how much stress people were feeling in their lives, and then systematically exposed them to a cold virus. Not everyone so exposed actually comes down with a cold; a robust immune system can—and constantly does—resist the cold virus. Cohen found that the more stress in their lives, the more likely people were to catch cold. Among those with little stress, 27 percent came down with a cold after being exposed to the virus; among those with the most stressful lives, 47 percent got the cold—direct evidence that stress itself weakens the immune system. 23 (While this may be one of those scientific results that confirms what everyone has observed or suspected all along, it is considered a landmark finding because of its scientific rigor.) Likewise, married couples who for three months kept daily checklists of hassles and upsetting events such as marital fights showed a strong pattern: three or four days after an especially intense batch of upsets, they came down with a cold or upper-respiratory
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infection. That lag period is precisely the incubation time for many common cold viruses, suggesting that being exposed while they were most worried and upset made them especially vulnerable. 24 The same stress-infection pattern holds for the herpes virus—both the type that causes cold sores on the lip and the type that causes genital lesions. Once people have been exposed to the herpes virus, it stays latent in the body, flaring up from time to time. The activity of the herpes virus can be tracked by levels of antibodies to it in the blood. Using this measure, reactivation of the herpes virus has been found in medical students undergoing year-end exams, in recently separated women, and among people under constant pressure from caring for a family member with Alzheimer’s disease. 25 The toll of anxiety is not just that it lowers the immune response; other research is showing adverse effects on the cardiovascular system. While chronic hostility and repeated episodes of anger seem to put men at greatest risk for heart disease, the more deadly emotion in women may be anxiety and fear. In research at Stanford University School of Medicine with more than a thousand men and women who
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School of Medicine with more than a thousand men and women who had suffered a first heart attack, those women who went on to suffer a second heart attack were marked by high levels of fearfulness and anxiety. In many cases the fearfulness took the form of crippling phobias: after their first heart attack the patients stopped driving, quit
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their jobs, or avoided going out. 26 The insidious physical effects of mental stress and anxiety—the kind produced by high-pressure jobs, or high-pressure lives such as that of a single mother juggling day care and a job—are being pinpointed at an anatomically fine-grained level. For example, Stephen Manuck, a University of Pittsburgh psychologist, put thirty volunteers through a rigorous, anxiety-riddled ordeal in a laboratory while he monitored the men’s blood, assaying a substance secreted by blood platelets called adenosine triphosphate, or ATP, which can trigger blood-vessel changes that may lead to heart attacks and strokes. While the volunteers were under the intense stress, their ATP levels rose sharply, as did their heart rate and blood pressure. Understandably, health risks seem greatest for those whose jobs are high in “strain”: having high-pressure performance demands while having little or no control over how to get the job done (a predicament that gives bus drivers, for instance, a high rate of hypertension). For example, in a study of 569 patients with colorectal cancer and a matched comparison group, those who said that in the previous ten years they had experienced severe on-the-job aggravation
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were five and a half times more likely to have developed the cancer compared to those with no such stress in their lives. 27 Because the medical toll of distress is so broad, relaxation techniques—which directly counter the physiological arousal of stress —are being used clinically to ease the symptoms of a wide variety of chronic illnesses. These include cardiovascular disease, some types of diabetes, arthritis, asthma, gastrointestinal disorders, and chronic pain, to name a few. To the degree any symptoms are worsened by stress and emotional distress, helping patients become more relaxed and able to handle their turbulent feelings can often offer some reprieve. 28 The Medical Costs of Depression She had been diagnosed with metastatic breast cancer, a return and spread of the malignancy several years after what she had thought was successful surgery for the disease. Her doctor could no longer talk of a cure, and the chemotherapy, at best, might offer just a few more months of life. Understandably, she was depressed—so much so that whenever she went to her oncologist, she found herself at some point
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bursting out into tears. Her oncologist’s response each time: asking her to leave the
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office immediately. Apart from the hurtfulness of the oncologist’s coldness, did it matter medically that he would not deal with his patient’s constant sadness? By the time a disease has become so virulent, it would be unlikely that any emotion would have an appreciable effect on its progress. While the woman’s depression most certainly dimmed the quality of her final months, the medical evidence that melancholy might affect the course of cancer is as yet mixed. 29 But cancer aside, a smattering of studies suggest a role for depression in many other medical conditions, especially in worsening a sickness once it has begun. The evidence is mounting that for patients with serious disease who are depressed, it would pay medically to treat their depression too. One complication in treating depression in medical patients is that its symptoms, including loss of appetite and lethargy, are easily mistaken for signs of other diseases, particularly by physicians with little training in psychiatric diagnosis. That inability to diagnose depression may itself add to the problem, since it means that a patient’s depression—like that of the weepy breast-cancer patient— goes unnoticed and untreated. And that failure to diagnose and treat
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may add to the risk of death in severe disease. For instance, of 100 patients who received bone marrow transplants, 12 of the 13 who had been depressed died within the first year of the transplant, while 34 of the remaining 87 were still alive two years later. 30 And in patients with chronic kidney failure who were receiving dialysis, those who were diagnosed with major depression were most likely to die within the following two years; depression was a stronger predictor of death than any medical sign. 31 Here the route connecting emotion to medical status was not biological but attitudinal: The depressed patients were much worse about complying with their medical regimens—cheating on their diets, for example, which put them at higher risk. Heart disease too seems to be exacerbated by depression. In a study of 2,832 middle-aged men and women tracked for twelve years, those who felt a sense of nagging despair and hopelessness had a heightened rate of death from heart disease. 32 And for the 3 percent or so who were most severely depressed, the death rate from heart disease, compared to the rate for those with no feelings of depression, was four times greater.
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four times greater. Depression seems to pose a particularly grave medical risk for heart
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attack survivors. 33 In a study of patients in a Montreal hospital who were discharged after being treated for a first heart attack, depressed patients had a sharply higher risk of dying within the following six months. Among the one in eight patients who were seriously depressed, the death rate was five times higher than for others with comparable disease—an effect as great as that of major medical risks for cardiac death, such as left ventricular dysfunction or a history of previous heart attacks. Among the possible mechanisms that might explain why depression so greatly increases the odds of a later heart attack are its effects on heart rate variability, increasing the risk of fatal arrhythmias. Depression has also been found to complicate recovery from hip fracture. In a study of elderly women with hip fracture, several thousand were given psychiatric evaluations on their admission to the hospital. Those who were depressed on admission stayed an average of eight days longer than those with comparable injury but no depression, and were only a third as likely ever to walk again. But depressed women who had psychiatric help for their depression along with other medical care needed less physical therapy to walk again
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and had fewer rehospitalizations over the three months after their return home from the hospital. Likewise, in a study of patients whose condition was so dire that they were among the top 10 percent of those using medical services— often because of having multiple illnesses, such as both heart disease and diabetes—about one in six had serious depression. When these patients were treated for the problem, the number of days per year that they were disabled dropped from 79 to 51 for those who had major depression, and from 62 days per year to just 18 in those who had been treated for mild depression. 34 THE MEDICAL BENEFITS OF POSITIVE FEELINGS The cumulative evidence for adverse medical effects from anger, anxiety, and depression, then, is compelling. Both anger and anxiety, when chronic, can make people more susceptible to a range of disease. And while depression may not make people more vulnerable to becoming ill, it does seem to impede medical recovery and heighten the risk of death, especially with more frail patients with severe conditions.
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But if chronic emotional distress in its many forms is toxic, the opposite range of emotion can be tonic—to a degree. This by no means says that positive emotion is curative, or that laughter or happiness alone will turn the course of a serious disease. The edge positive emotions offer seems subtle, but, by using studies with large numbers of people, can be teased out of the mass of complex variables that affect the course of disease. The Price of Pessimism—and Advantages of Optimism As with depression, there are medical costs to pessimism—and corresponding benefits from optimism. For example, 122 men who had their first heart attack were evaluated on their degree of optimism or pessimism. Eight years later, of the 25 most pessimistic men, 21 had died; of the 25 most optimistic, just 6 had died. Their mental outlook proved a better predictor of survival than any medical risk factor, including the amount of damage to the heart in the first attack, artery blockage, cholesterol level, or blood pressure. And in other research, patients going into artery bypass surgery who were more optimistic had a much faster recovery and fewer medical complications during and after surgery than did more pessimistic
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complications during and after surgery than did more pessimistic patients. 35 Like its near cousin optimism, hope has healing power. People who have a great deal of hopefulness are, understandably, better able to bear up under trying circumstances, including medical difficulties. In a study of people paralyzed from spinal injuries, those who had more hope were able to gain greater levels of physical mobility compared to other patients with similar degrees of injury, but who felt less hopeful. Hope is especially telling in paralysis from spinal injury, since this medical tragedy typically involves a man who is paralyzed in his twenties by an accident and will remain so for the rest of his life. How he reacts emotionally will have broad consequences for the degree to which he will make the efforts that might bring him greater physical and social functioning. 36 Just why an optimistic or pessimistic outlook should have health consequences is open to any of several explanations. One theory proposes that pessimism leads to depression, which in turn interferes with the resistance of the immune system to tumors and infection—an unproven speculation at present. Or it may be that pessimists neglect
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themselves—some studies have found that pessimists smoke and drink
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more, and exercise less, than optimists, and are generally much more careless about their health habits. Or it may one day turn out that the physiology of hopefulness is itself somehow helpful biologically to the body’s fight against disease. With a Little Help From My Friends: The Medical Value of Relationships Add the sounds of silence to the list of emotional risks to health—and close emotional ties to the list of protective factors. Studies done over two decades involving more than thirty-seven thousand people show that social isolation—the sense that you have nobody with whom you can share your private feelings or have close contact—doubles the chances of sickness or death. 37 Isolation itself, a 1987 report in Science concluded, “is as significant to mortality rates as smoking, high blood pressure, high cholesterol, obesity, and lack of physical exercise.” Indeed, smoking increases mortality risk by a factor of just 1.6, while social isolation does so by a factor of 2.0, making it a greater health risk. 38 Isolation is harder on men than on women. Isolated men were two to three times more likely to die as were men with close social ties;
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for isolated women, the risk was one and a half times greater than for more socially connected women. The difference between men and women in the impact of isolation may be because women’s relationships tend to be emotionally closer than men’s; a few strands of such social ties for a woman may be more comforting than the same small number of friendships for a man. Of course, solitude is not the same as isolation; many people who live on their own or see few friends are content and healthy. Rather, it is the subjective sense of being cut off from people and having no one to turn to that is the medical risk. This finding is ominous in light of the increasing isolation bred by solitary TV-watching and the falling away of social habits such as clubs and visits in modern urban societies, and suggests an added value to self-help groups such as Alcoholics Anonymous as surrogate communities. The power of isolation as a mortality risk factor—and the healing power of close ties—can be seen in the study of one hundred bone marrow transplant patients. 39 Among patients who felt they had strong emotional support from their spouse, family, or friends, 54 percent survived the transplants after two years, versus just 20
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percent among those who reported little such support. Similarly, elderly people who suffer heart attacks, but have two or more people in their lives they can rely on for emotional support, are more than twice as likely to survive longer than a year after an attack than are those people with no such support. 40 Perhaps the most telling testimony to the healing potency of emotional ties is a Swedish study published in 1993. 41 All the men living in the Swedish city of Göteborg who were born in 1933 were offered a free medical exam; seven years later the 752 men who had come for the exam were contacted again. Of these, 41 had died in the intervening years. Men who had originally reported being under intense emotional stress had a death rate three times greater than those who said their lives were calm and placid. The emotional distress was due to events such as serious financial trouble, feeling insecure at work or being forced out of a job, being the object of a legal action, or going through a divorce. Having had three or more of these troubles within the year before the exam was a stronger predictor of dying within the ensuing
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seven years than were medical indicators such as high blood pressure, high concentrations of blood triglycerides, or high serum cholesterol levels. Yet among men who said they had a dependable web of intimacy— a wife, close friends, and the like— there was no relationship whatever between high stress levels and death rate. Having people to turn to and talk with, people who could offer solace, help, and suggestions, protected them from the deadly impact of life’s rigors and trauma. The quality of relationships as well as their sheer number seems key to buffering stress. Negative relationships take their own toll. Marital arguments, for example, have a negative impact on the immune system. 42 One study of college roommates found that the more they disliked each other, the more susceptible they were to colds and the flu, and the more frequently they went to doctors. John Cacioppo, the Ohio State University psychologist who did the roommate study, told me, “It’s the most important relationships in your life, the people you see day in and day out, that seem to be crucial for your health. And the more significant the relationship is in your life, the more it matters for your health.” 43
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matters for your health.” 43 The Healing Power of Emotional Support
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In The Merry Adventures of Robin Hood , Robin advises a young follower: “Tell us thy troubles and speak freely. A flow of words doth ever ease the heart of sorrows; it is like opening the waste where the mill dam is overfull.” This bit of folk wisdom has great merit; unburdening a troubled heart appears to be good medicine. The scientific corroboration of Robin’s advice comes from James Pennebaker, a Southern Methodist University psychologist, who has shown in a series of experiments that getting people to talk about the thoughts that trouble them most has a beneficial medical effect. 44 His method is remarkably simple: he asks people to write, for fifteen to twenty minutes a day over five or so days, about, for example, “the most traumatic experience of your entire life,” or some pressing worry of the moment. What people write can be kept entirely to themselves if they like. The net effect of this confessional is striking: enhanced immune function, significant drops in health-center visits in the following six months, fewer days missed from work, and even improved liver enzyme function. Moreover, those whose writing showed most
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enzyme function. Moreover, those whose writing showed most evidence of turbulent feelings had the greatest improvements in their immune function. A specific pattern emerged as the “healthiest” way to ventilate troubling feelings: at first expressing a high level of sadness, anxiety, anger—whatever troubling feelings the topic brought up; then, over the course of the next several days weaving a narrative, finding some meaning in the trauma or travail. That process, of course, seems akin to what happens when people explore such troubles in psychotherapy. Indeed, Pennebaker’s findings suggest one reason why other studies show medical patients given psychotherapy in addition to surgery or medical treatment often fare better medically than do those who receive medical treatment alone. 45 Perhaps the most powerful demonstration of the clinical power of emotional support was in groups at Stanford University Medical School for women with advanced metastatic breast cancer. After an initial treatment, often including surgery, these women’s cancer had returned and was spreading through their bodies. It was only a matter of time, clinically speaking, until the spreading cancer killed them. Dr.
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David Spiegel, who conducted the study, was himself stunned by the findings, as was the medical community: women with advanced breast cancer who went to weekly meetings with others survived twice as long as did women with the same disease who faced it on their own. 46 All the women received standard medical care; the only difference
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was that some also went to the groups, where they were able to unburden themselves with others who understood what they faced and were willing to listen to their fears, their pain, and their anger. Often this was the only place where the women could be open about these emotions, because other people in their lives dreaded talking with them about the cancer and their imminent death. Women who attended the groups lived for thirty-seven additional months, on average, while those with the disease who did not go to the groups died, on average, in nineteen months—a gain in life expectancy for such patients beyond the reach of any medication or other medical treatment. As Dr. Jimmie Holland, the chief psychiatric oncologist at Sloan-Kettering Memorial Hospital, a cancer treatment center in New York City, put it to me, “Every cancer patient should be in a group like this.” Indeed, if it had been a new drug that produced the extended life expectancy, pharmaceutical companies would be battling to produce it. BRINGING EMOTIONAL INTELLIGENCE TO MEDICAL CARE The day a routine checkup spotted some blood in my urine, my doctor sent me for a diagnostic test in which I was injected with a radioactive
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dye. I lay on a table while an overhead X-ray machine took successive images of the dye’s progression through my kidneys and bladder. I had company for the test: a close friend, a physician himself, happened to be visiting for a few days and offered to come to the hospital with me. He sat in the room while the X-ray machine, on an automated track, rotated for new camera angles, whirred and clicked; rotated, whirred, clicked. The test took an hour and a half. At the very end a kidney specialist hurried into the room, quickly introduced himself, and disappeared to scan the X-rays. He didn’t return to tell me what they showed. As we were leaving the exam room my friend and I passed the nephrologist. Feeling shaken and somewhat dazed by the test, I did not have the presence of mind to ask the one question that had been on my mind all morning. But my companion, the physician, did: “Doctor,” he said, “my friend’s father died of bladder cancer. He’s anxious to know if you saw any signs of cancer in the X-rays.” “No abnormalities,” was the curt reply as the nephrologist hurried on to his next appointment.
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My inability to ask the single question I cared about most is repeated a thousand times each day in hospitals and clinics everywhere. A study of patients in physicians’ waiting rooms found that each had an average of three or more questions in mind to ask the physician they were about to see. But when the patients left the physician’s office, an average of only one and a half of those questions had been answered. 47 This finding speaks to one of the many ways patients’ emotional needs are unmet by today’s medicine. Unanswered questions feed uncertainty, fear, catastrophizing. And they lead patients to balk at going along with treatment regimes they don’t fully understand. There are many ways medicine can expand its view of health to include the emotional realities of illness. For one, patients could routinely be offered fuller information essential to the decisions they must make about their own medical care; some services now offer any caller a state-of-the-art computer search of the medical literature on what ails them, so that patients can be more equal partners with their physicians in making informed decisions. 48 Another approach is programs that, in a few minutes’ time, teach patients to be effective
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questioners with their physicians, so that when they have three questions in mind as they wait for the doctor, they will come out of the office with three answers. 49 Moments when patients face surgery or invasive and painful tests are fraught with anxiety—and are a prime opportunity to deal with the emotional dimension. Some hospitals have developed presurgery instruction for patients that help them assuage their fears and handle their discomforts—for example, by teaching patients relaxation techniques, answering their questions well in advance of surgery, and telling them several days ahead of surgery precisely what they are likely to experience during their recovery. The result: patients recover from surgery an average of two to three days sooner. 50 Being a hospital patient can be a tremendously lonely, helpless experience. But some hospitals have begun to design rooms so that family members can stay with patients, cooking and caring for them as they would at home—a progressive step that, ironically, is routine throughout the Third World. 51 Relaxation training can help patients deal with some of the distress their symptoms bring, as well as with the emotions that may be triggering or exacerbating their symptoms. An exemplary model is Jon
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Kabat-Zinn’s Stress Reduction Clinic at the University of
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Massachusetts Medical Center, which offers a ten-week course in mindfulness and yoga to patients; the emphasis is on being mindful of emotional episodes as they are happening, and on cultivating a daily practice that offers deep relaxation. Hospitals have made instructional tapes from the course available over patients’ television sets—a far better emotional diet for the bedridden than the usual fare, soap operas. 52 Relaxation and yoga are also at the core of the innovative program for treating heart disease developed by Dr. Dean Ornish. 53 After a year of this program, which included a low-fat diet, patients whose heart disease was severe enough to warrant a coronary bypass actually reversed the buildup of artery-clogging plaque. Ornish tells me that relaxation training is one of the most important parts of the program. Like Kabat-Zinn’s, it takes advantage of what Dr. Herbert Benson calls the “relaxation response,” the physiological opposite of the stress arousal that contributes to such a wide spectrum of medical problems. Finally, there is the added medical value of an empathic physician or nurse, attuned to patients, able to listen and be heard. This means
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fostering “relationship-centered care,” recognizing that the relationship between physician and patient is itself a factor of significance. Such relationships would be fostered more readily if medical education included some basic tools of emotional intelligence, especially self-awareness and the arts of empathy and listening. 54 TOWARD A MEDICINE THAT CARES Such steps are a beginning. But for medicine to enlarge its vision to embrace the impact of emotions, two large implications of the scientific findings must be taken to heart: 1. Helping people better manage their upsetting feelings—anger, anxiety, depression, pessimism, and loneliness—is a form of disease prevention . Since the data show that the toxicity of these emotions, when chronic, is on a par with smoking cigarettes, helping people handle them better could potentially have a medical payoff as great as getting heavy smokers to quit. One way to do this that could have broad public-health effects would be to impart most basic emotional intelligence skills to children, so that they become lifelong habits.
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Another high-payoff preventive strategy would be to teach emotion management to people reaching retirement age, since emotional well- being is one factor that determines whether an older person declines rapidly or thrives. A third target group might be so-called at-risk populations—the very poor, single working mothers, residents of high-crime neighborhoods, and the like—who live under extraordinary pressure day in and day out, and so might do better medically with help in handling the emotional toll of these stresses. 2. Many patients can benefit measurably when their psychological needs are attended to along with their purely medical ones . While it is a step toward more humane care when a physician or nurse offers a distressed patient comfort and consolation, more can be done. But emotional care is an opportunity too often lost in the way medicine is practiced today; it is a blind spot for medicine. Despite mounting data on the medical usefulness of attending to emotional needs, as well as supporting evidence for connections between the brain’s emotional center and the immune system, many physicians remain skeptical that their patients’ emotions matter clinically, dismissing the evidence for this as trivial and anecdotal, as “fringe,” or, worse, as the
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exaggerations of a self-promoting few. Though more and more patients seek a more humane medicine, it is becoming endangered. Of course, there remain dedicated nurses and physicians who give their patients tender, sensitive care. But the changing culture of medicine itself, as it becomes more responsive to the imperatives of business, is making such care increasingly difficult to find. On the other hand, there may be a business advantage to humane medicine: treating emotional distress in patients, early evidence suggests, can save money—especially to the extent that it prevents or delays the onset of sickness, or helps patients heal more quickly. In a study of elderly patients with hip fracture at Mt. Sinai School of Medicine in New York City and at Northwestern University, patients who received therapy for depression in addition to normal orthopedic care left the hospital an average of two days earlier; total savings for the hundred or so patients was $97,361 in medical costs. 55 Such care also makes patients more satisfied with their physicians and medical treatment. In the emerging medical marketplace, where patients often have the option to choose between competing health
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plans, satisfaction levels will no doubt enter the equation of these very personal decisions—souring experiences can lead patients to go elsewhere for care, while pleasing ones translate into loyalty. Finally, medical ethics may demand such an approach. An editorial in the Journal of the American Medical Association , commenting on a report that depression increases fivefold the likelihood of dying after being treated for a heart attack, notes: “[T]he clear demonstration that psychological factors like depression and social isolation distinguish the coronary heart disease patients at highest risk means it would be unethical not to start trying to treat these factors.” 56 If the findings on emotions and health mean anything, it is that medical care that neglects how people feel as they battle a chronic or severe disease is no longer adequate. It is time for medicine to take more methodical advantage of the link between emotion and health. What is now the exception could—and should—be part of the mainstream, so that a more caring medicine is available to us all. At the least it would make medicine more humane. And, for some, it could speed the course of recovery. “Compassion,” as one patient put
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it in an open letter to his surgeon, “is not mere hand holding. It is good medicine.” 57
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PART FOUR WINDOWS OF OPPORTUNITY
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12 The Family Crucible It’s a low-key family tragedy. Carl and Ann are showing their daughter Leslie, just five, how to play a brand-new video game. But as Leslie starts to play, her parents’ overly eager attempts to “help” her just seem to get in the way. Contradictory orders fly in every direction. “To the right, to the right—stop. Stop. Stop!” Ann, the mother, urges, her voice growing more intent and anxious as Leslie, sucking on her lip and staring wide-eyed at the video screen, struggles to follow these directives. “See, you’re not lined up … put it to the left! To the left!” Carl, the girl’s father, brusquely orders. Meanwhile Ann, her eyes rolling upward in frustration, yells over his advice, “Stop! Stop!” Leslie, unable to please either her father or her mother, contorts her jaw in tension and blinks as her eyes fill with tears. Her parents start bickering, ignoring Leslie’s tears. “She’s not moving the stick that much!” Ann tells Carl, exasperated. As the tears start rolling down Leslie’s cheeks, neither parent makes any move that
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indicates they notice or care. As Leslie raises her hand to wipe her eyes, her father snaps, “Okay, put your hand back on the stick … you wanna get ready to shoot. Okay, put it over!” And her mother barks, “Okay, move it just a teeny bit!” But by now Leslie is sobbing softly, alone with her anguish. At such moments children learn deep lessons. For Leslie one conclusion from this painful exchange might well be that neither her parents, nor anyone else, for that matter, cares about her feelings. 1 When similar moments are repeated countless times over the course of childhood they impart some of the most fundamental emotional messages of a lifetime—lessons that can determine a life course. Family life is our first school for emotional learning; in this intimate cauldron we learn how to feel about ourselves and how others will react to our feelings; how to think about these feelings and what
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choices we have in reacting; how to read and express hopes and fears. This emotional schooling operates not just through the things that parents say and do directly to children, but also in the models they offer for handling their own feelings and those that pass between husband and wife. Some parents are gifted emotional teachers, others atrocious. There are hundreds of studies showing that how parents treat their children—whether with harsh discipline or empathic understanding, with indifference or warmth, and so on—has deep and lasting consequences for the child’s emotional life. Only recently, though, have there been hard data showing that having emotionally intelligent parents is itself of enormous benefit to a child. The ways a couple handles the feelings between them—in addition to their direct dealings with a child—impart powerful lessons to their children, who are astute learners, attuned to the subtlest emotional exchanges in the family. When research teams led by Carole Hooven and John Gottman at the University of Washington did a microanalysis of interactions in couples on how the partners handled their children, they found that those couples who were more emotionally competent in the marriage were also the most effective in helping their children with their
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were also the most effective in helping their children with their emotional ups and downs. 2 The families were first seen when one of their children was just five years old, and again when the child had reached nine. In addition to observing the parents talk with each other, the research team also watched families (including Leslie’s) as the father or mother tried to show their young child how to operate a new video game—a seemingly innocuous interaction, but quite telling about the emotional currents that run between parent and child. Some mothers and fathers were like Ann and Carl: overbearing, losing patience with their child’s ineptness, raising their voices in disgust or exasperation, some even putting their child down as “stupid”—in short, falling prey to the same tendencies toward contempt and disgust that eat away at a marriage. Others, however, were patient with their child’s errors, helping the child figure the game out in his or her own way rather than imposing the parents’ will. The video game session was a surprisingly powerful barometer of the parents’ emotional style. The three most common emotionally inept parenting styles proved to be:
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• Ignoring feelings altogether . Such parents treat a child’s emotional upset as trivial or a bother, something they should wait to blow over. They fail to use emotional moments as a chance to get closer to the child or to help the child learn lessons in emotional competence. • Being too laissez-faire . These parents notice how a child feels, but hold that however a child handles the emotional storm is fine—even, say, hitting. Like those who ignore a child’s feelings, these parents rarely step in to try to show their child an alternative emotional response. They try to soothe all upsets, and will, for instance, use bargaining and bribes to get their child to stop being sad or angry. • Being contemptuous, showing no respect for how the child feels . Such parents are typically disapproving, harsh in both their criticisms and their punishments. They might, for instance, forbid any display of the child’s anger at all, and become punitive at the least sign of irritability. These are the parents who angrily yell at a child who is trying to tell his side of the story, “Don’t you talk back to me!” Finally, there are parents who seize the opportunity of a child’s
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Finally, there are parents who seize the opportunity of a child’s upset to act as what amounts to an emotional coach or mentor. They take their child’s feelings seriously enough to try to understand exactly what is upsetting them (“Are you angry because Tommy hurt your feelings?”) and to help the child find positive ways to soothe their feelings (“Instead of hitting him, why don’t you find a toy to play with on your own until you feel like playing with him again?”). In order for parents to be effective coaches in this way, they must have a fairly good grasp of the rudiments of emotional intelligence themselves. One of the basic emotional lessons for a child, for example, is how to distinguish among feelings; a father who is too tuned out of, say, his own sadness cannot help his son understand the difference between grieving over a loss, feeling sad in a sad movie, and the sadness that arises when something bad happens to someone the child cares about. Beyond this distinction, there are more sophisticated insights, such as that anger is so often prompted by first feeling hurt. As children grow the specific emotional lessons they are ready for—
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As children grow the specific emotional lessons they are ready for— and in need of—shift. As we saw in Chapter 7 the lessons in empathy begin in infancy, with parents who attune to their baby’s feelings. Though some emotional skills are honed with friends through the years, emotionally adept parents can do much to help their children
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with each of the basics of emotional intelligence: learning how to recognize, manage, and harness their feelings; empathizing; and handling the feelings that arise in their relationships. The impact on children of such parenting is extraordinarily sweeping. 3 The University of Washington team found that when parents are emotionally adept, compared to those who handle feelings poorly, their children—understandably—get along better with, show more affection toward, and have less tension around their parents. But beyond that, these children also are better at handling their own emotions, are more effective at soothing themselves when upset, and get upset less often. The children are also more relaxed biologically , with lower levels of stress hormones and other physiological indicators of emotional arousal (a pattern that, if sustained through life, might well augur better physical health, as we saw in Chapter 11 ). Other advantages are social: these children are more popular with and are better-liked by their peers, and are seen by their teachers as more socially skilled. Their parents and teachers alike rate these children as having fewer behavioral problems such as rudeness or
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children as having fewer behavioral problems such as rudeness or aggressiveness. Finally, the benefits are cognitive; these children can pay attention better, and so are more effective learners. Holding IQ constant, the five-year-olds whose parents were good coaches had higher achievement scores in math and reading when they reached third grade (a powerful argument for teaching emotional skills to help prepare children for learning as well as life). Thus the payoff for children whose parents are emotionally adept is a surprising—almost astounding—range of advantages across, and beyond, the spectrum of emotional intelligence. HEART START The impact of parenting on emotional competence starts in the cradle. Dr. T. Berry Brazelton, the eminent Harvard pediatrician, has a simple diagnostic test of a baby’s basic outlook toward life. He offers two blocks to an eight-month-old, and then shows the baby how he wants her to put the two blocks together. A baby who is hopeful about life, who has confidence in her own abilities, says Brazelton, will pick up one block, mouth it, rub it in her hair, drop it over the side of the table, watching to see whether you will retrieve it for her. When you do, she finally
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completes the requested task—place the two blocks together. Then she looks up at you with a bright-eyed look of expectancy that says, “Tell me how great I am!” 4 Babies like these have gotten a goodly dose of approval and encouragement from the adults in their lives; they expect to succeed in life’s little challenges. By contrast, babies who come from homes too bleak, chaotic, or neglectful go about the same small task in a way that signals they already expect to fail. It is not that these babies fail to bring the blocks together; they understand the instruction and have the coordination to comply. But even when they do, reports Brazelton, their demeanor is “hangdog,” a look that says, “I’m no good. See, I’ve failed.” Such children are likely to go through life with a defeatist outlook, expecting no encouragement or interest from teachers, finding school joyless, perhaps eventually dropping out. The difference between the two outlooks—children who are confident and optimistic versus those who expect to fail—starts to take shape in the first few years of life. Parents, says Brazelton, “need to understand how their actions can help generate the confidence, the
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to understand how their actions can help generate the confidence, the curiosity, the pleasure in learning and the understanding of limits” that help children succeed in life. His advice is informed by a growing body of evidence showing that success in school depends to a surprising extent on emotional characteristics formed in the years before a child enters school. As we saw in Chapter 6 , for example, the ability of four-year-olds to control the impulse to grab for a marshmallow predicted a 210-point advantage in their SAT scores fourteen years later. The first opportunity for shaping the ingredients of emotional intelligence is in the earliest years, though these capacities continue to form throughout the school years. The emotional abilities children acquire in later life build on those of the earliest years. And these abilities, as we saw in Chapter 6 , are the essential foundation for all learning. A report from the National Center for Clinical Infant Programs makes the point that school success is not predicted by a child’s fund of facts or a precocious ability to read so much as by emotional and social measures: being self-assured and interested; knowing what kind of behavior is expected and how to rein in the impulse to misbehave; being able to wait, to follow directions, and to
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turn to teachers for help; and expressing needs while getting along with other children. 5 Almost all students who do poorly in school, says the report, lack
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one or more of these elements of emotional intelligence (regardless of whether they also have cognitive difficulties such as learning disabilities). The magnitude of the problem is not minor; in some states close to one in five children have to repeat first grade, and then as the years go on fall further behind their peers, becoming increasingly discouraged, resentful, and disruptive. A child’s readiness for school depends on the most basic of all knowledge, how to learn. The report lists the seven key ingredients of this crucial capacity—all related to emotional intelligence: 6 1. Confidence . A sense of control and mastery of one’s body, behavior, and world; the child’s sense that he is more likely than not to succeed at what he undertakes, and that adults will be helpful. 2. Curiosity . The sense that finding out about things is positive and leads to pleasure. 3. Intentionality . The wish and capacity to have an impact, and to act upon that with persistence. This is related to a sense of competence, of being effective. 4. Self-control . The ability to modulate and control one’s own actions in age-appropriate ways; a sense of inner control. 5. Relatedness . The ability to engage with others based on the sense
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Relatedness . The ability to engage with others based on the sense of being understood by and understanding others. 6. Capacity to communicate . The wish and ability to verbally exchange ideas, feelings, and concepts with others. This is related to a sense of trust in others and of pleasure in engaging with others, including adults. 7. Cooperativeness . The ability to balance one’s own needs with those of others in group activity. Whether or not a child arrives at school on the first day of kindergarten with these capabilities depends greatly on how much her parents—and preschool teachers—have given her the kind of care that amounts to a “Heart Start,” the emotional equivalent of the Head Start programs. GETTING THE EMOTIONAL BASICS Say a two-month-old baby wakes up at 3 A.M . and starts crying. Her mother comes in and, for the next half hour, the baby contentedly
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nurses in her mother’s arms while her mother gazes at her affectionately, telling her that she’s happy to see her, even in the middle of the night. The baby, content in her mother’s love, drifts back to sleep. Now say another two-month-old baby, who also awoke crying in the wee hours, is met instead by a mother who is tense and irritable, having fallen asleep just an hour before after a fight with her husband. The baby starts to tense up the moment his mother abruptly picks him up, telling him, “Just be quiet—I can’t stand one more thing! Come on, let’s get it over with.” As the baby nurses his mother stares stonily ahead, not looking at him, reviewing her fight with his father, getting more agitated herself as she mulls it over. The baby, sensing her tension, squirms, stiffens, and stops nursing. “That’s all you want?” his mother says. “Then don’t eat.” With the same abruptness she puts him back in his crib and stalks out, letting him cry until he falls back to sleep, exhausted. The two scenarios are presented by the report from the National
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The two scenarios are presented by the report from the National Center for Clinical Infant Programs as examples of the kinds of interaction that, if repeated over and over, instill very different feelings in a toddler about himself and his closest relationships. 7 The first baby is learning that people can be trusted to notice her needs and counted on to help, and that she can be effective in getting help; the second is finding that no one really cares, that people can’t be counted on, and that his efforts to get solace will meet with failure. Of course, most babies get at least a taste of both kinds of interaction. But to the degree that one or the other is typical of how parents treat a child over the years, basic emotional lessons will be imparted about how secure a child is in the world, how effective he feels, and how dependable others are. Erik Erikson put it in terms of whether a child comes to feel a “basic trust” or a basic mistrust. Such emotional learning begins in life’s earliest moments, and continues throughout childhood. All the small exchanges between parent and child have an emotional subtext, and in the repetition of these messages over the years children form the core of their
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these messages over the years children form the core of their emotional outlook and capabilities. A little girl who finds a puzzle frustrating and asks her busy mother to help gets one message if the reply is the mother’s clear pleasure at the request, and quite another if it’s a curt “Don’t bother me—I’ve got important work to do.” When such encounters become typical of child and parent, they mold the child’s emotional expectations about relationships, outlooks that will
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flavor her functioning in all realms of life, for better or worse. The risks are greatest for those children whose parents are grossly inept—immature, abusing drugs, depressed or chronically angry, or simply aimless and living chaotic lives. Such parents are far less likely to give adequate care, let alone attune to their toddler’s emotional needs. Simple neglect, studies find, can be more damaging than outright abuse. 8 A survey of maltreated children found the neglected youngsters doing the worst of all: they were the most anxious, inattentive, and apathetic, alternately aggressive and withdrawn. The rate for having to repeat first grade among them was 65 percent. The first three or four years of life are a period when the toddler’s brain grows to about two thirds its full size, and evolves in complexity at a greater rate than it ever will again. During this period key kinds of learning take place more readily than later in life—emotional learning foremost among them. During this time severe stress can impair the brain’s learning centers (and so be damaging to the intellect). Though as we shall see, this can be remedied to some extent
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by experiences later in life, the impact of this early learning is profound. As one report sums up the key emotional lesson of life’s first four years, the lasting consequences are great: A child who cannot focus his attention, who is suspicious rather than trusting, sad or angry rather than optimistic, destructive rather than respectful and one who is overcome with anxiety, preoccupied with frightening fantasy and feels generally unhappy about himself—such a child has little opportunity at all, let alone equal opportunity, to claim the possibilities of the world as his own. 9 HOW TO RAISE A BULLY Much can be learned about the lifelong effects of emotionally inept parenting—particularly its role in making children aggressive—from longitudinal studies such as one of 870 children from upstate New York who were followed from the time they were eight until they were thirty. 10 The most belligerent among the children—those quickest to start fights and who habitually used force to get their way —were the most likely to have dropped out of school and, by age thirty, to have a record for crimes of violence. They also seemed to be handing down their propensity to violence: their children were, in
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grade school, just like the troublemakers their delinquent parent had
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been. There is a lesson in how aggressiveness is passed from generation to generation. Any inherited propensities aside, the troublemakers as grownups acted in a way that made family life a school for aggression. As children, the troublemakers had parents who disciplined them with arbitrary, relentless severity; as parents they repeated the pattern. This was true whether it had been the father or the mother who had been identified in childhood as highly aggressive. Aggressive little girls grew up to be just as arbitrary and harshly punitive when they became mothers as the aggressive boys were as fathers. And while they punished their children with special severity, they otherwise took little interest in their children’s lives, in effect ignoring them much of the time. At the same time the parents offered these children a vivid— and violent—example of aggressiveness, a model the children took with them to school and to the playground, and followed throughout life. The parents were not necessarily mean-spirited, nor did they fail to wish the best for their children; rather, they seemed to be simply repeating the style of parenting that had been modeled for them by their own parents. In this model for violence, these children were disciplined
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In this model for violence, these children were disciplined capriciously: if their parents were in a bad mood, they would be severely punished; if their parents were in a good mood, they could get away with mayhem at home. Thus punishment came not so much because of what the child had done, but by virtue of how the parent felt. This is a recipe for feelings of worthlessness and helplessness, and for the sense that threats are everywhere and may strike at any time. Seen in light of the home life that spawns it, such children’s combative and defiant posture toward the world at large makes a certain sense, unfortunate though it remains. What is disheartening is how early these dispiriting lessons can be learned, and how grim the costs for a child’s emotional life can be. ABUSE: THE EXTINCTION OF EMPATHY In the rough-and-tumble play of the day-care center, Martin, just two and a half, brushed up against a little girl, who, inexplicably, broke out crying. Martin reached for her hand, but as the sobbing girl moved away, Martin slapped her on the arm. As her tears continued Martin looked away and yelled, “Cut it out! Cut it out!” over
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Cut it out!” over and over, each time faster and louder.
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When Martin then made another attempt to pat her, again she resisted. This time Martin bared his teeth like a snarling dog, hissing at the sobbing girl. Once more Martin started patting the crying girl, but the pats on the back quickly turned into pounding, and Martin went on hitting and hitting the poor little girl despite her screams. That disturbing encounter testifies to how abuse—being beaten repeatedly, at the whim of a parent’s moods—warps a child’s natural bent toward empathy. 11 Martin’s bizarre, almost brutal response to his playmate’s distress is typical of children like him, who have themselves been the victims of beatings and other physical abuse since their infancy. The response stands in stark contrast to toddlers’ usual sympathetic entreaties and attempts to console a crying playmate, reviewed in Chapter 7 . Martin’s violent response to distress at the day-care center may well mirror the lessons he learned at home about tears and anguish: crying is met at first with a peremptory consoling gesture, but if it continues, the progression is from nasty looks and shouts, to hitting, to outright beating. Perhaps most
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hitting, to outright beating. Perhaps most troubling, Martin already seems to lack the most primitive sort of empathy, the instinct to stop aggression against someone who is hurt. At two and a half he displays the budding moral impulses of a cruel and sadistic brute. Martin’s meanness in place of empathy is typical of other children like him who are already, at their tender age, scarred by severe physical and emotional abuse at home. Martin was part of a group of nine such toddlers, ages one to three, witnessed in a two-hour observation at his day-care center. The abused toddlers were compared with nine others at the day-care center from equally impoverished, high-stress homes, but who were not physically abused. The differences in how the two groups of toddlers reacted when another child was hurt or upset were stark. Of twenty-three such incidents, five of the nine nonabused toddlers responded to the distress of a child nearby with concern, sadness, or empathy. But in the twenty-seven instances where the abused children could have done so, not one showed the least concern; instead they reacted to a
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crying child with expressions of fear, anger, or, like Martin, a physical attack. One abused little girl, for instance, made a ferocious, threatening face at another who had broken out into tears. One-year-old Thomas, another of the abused children, froze in terror when he heard a child
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crying across the room; he sat completely still, his face full of fear, back stiffly straight, his tension increasing as the crying continued—as though bracing for an attack himself. And twenty-eight-month-old Kate, also abused, was almost sadistic: picking on Joey, a smaller infant, she knocked him to the ground with her feet, and as he lay there looked tenderly at him and began patting him gently on the back—only to intensify the pats into hitting him harder and harder, ignoring his misery. She kept swinging away at him, leaning in to slug him six or seven times more, until he crawled away. These children, of course, treat others as they themselves have been treated. And the callousness of these abused children is simply a more extreme version of that seen in children whose parents are critical, threatening, and harsh in their punishments. Such children also tend to lack concern when playmates get hurt or cry; they seem to represent one end of a continuum of coldness that peaks with the brutality of the abused children. As they go on through life, they are, as a group, more likely to have cognitive difficulties in learning, more
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likely to be aggressive and unpopular with their peers (small wonder, if their preschool toughness is a harbinger of the future), more prone to depression, and, as adults, more likely to get into trouble with the law and commit more crimes of violence. 12 This failure of empathy is sometimes, if not often, repeated over generations, with brutal parents having themselves been brutalized by their own parents in childhood. 13 It stands in dramatic contrast to the empathy ordinarily displayed by children of parents who are nurturing, encouraging their toddlers to show concern for others and to understand how meanness makes other children feel. Lacking such lessons in empathy, these children seem not to learn it at all. What is perhaps most troubling about the abused toddlers is how early they seem to have learned to respond like miniature versions of their own abusive parents. But given the physical beatings they received as a sometimes daily diet, the emotional lessons are all too clear. Remember that it is in moments when passions run high or a crisis is upon us that the primitive proclivities of the brain’s limbic centers take on a more dominant role. At such moments the habits the
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emotional brain has learned over and over will dominate, for better or worse. Seeing how the brain itself is shaped by brutality—or by love— suggests that childhood represents a special window of opportunity for emotional lessons. These battered children have had an early and
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steady diet of trauma. Perhaps the most instructive paradigm for understanding the emotional learning such abused children have undergone is in seeing how trauma can leave a lasting imprint on the brain—and how even these savage imprints can be mended.
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13 Trauma and Emotional Relearning Som Chit, a Cambodian refugee, balked when her three sons asked her to buy them toy AK-47 machine guns. Her sons—ages six, nine, and eleven—wanted the toy guns to play the game some of the kids at their school called Purdy. In the game, Purdy, the villain, uses a submachine gun to massacre a group of children, then turns it on himself. Sometimes, though, the children have it end differently: it is they who kill Purdy. Purdy was the macabre reenactment by some of the survivors of the catastrophic events of February 17, 1989, at Cleveland Elementary School in Stockton, California. There, during the school’s late-morning recess for first, second, and third graders, Patrick Purdy—who had himself attended those grades at Cleveland Elementary some twenty years earlier—stood at the playground’s edge and fired wave after wave of 7.22 mm bullets at the hundreds of children at play. For seven minutes Purdy sprayed bullets toward the playground, then put a pistol to his head and shot himself. When the police arrived they found five children dying, twenty-nine wounded. In ensuing months, the Purdy game spontaneously appeared in the
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In ensuing months, the Purdy game spontaneously appeared in the play of boys and girls at Cleveland Elementary, one of many signs that those seven minutes and their aftermath were seared into the children’s memory. When I visited the school, just a short bike ride from the neighborhood near the University of the Pacific where I myself had grown up, it was five months after Purdy had turned that recess into a nightmare. His presence was still palpable, even though the most horrific of the grisly remnants of the shooting—swarms of bullet holes, pools of blood, bits of flesh, skin, and scalp—were gone by the morning after the shooting, washed away and painted over. By then the deepest scars at Cleveland Elementary were not to the building but to the psyches of the children and staff there, who were trying to carry on with life as usual. 1 Perhaps most striking was how the memory of those few minutes was revived again and again by any small detail that was similar in the least. A teacher told me, for
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example, that a wave of fright swept through the school with the announcement that St. Patrick’s Day was coming; a number of the children somehow got the idea that the day was to honor the killer, Patrick Purdy. “Whenever we hear an ambulance on its way to the rest home down the street, everything halts,” another teacher told me. “The kids all listen to see if it will stop here or go on.” For several weeks many children were terrified of the mirrors in the restrooms; a rumor swept the school that “Bloody Virgin Mary,” some kind of fantasied monster, lurked there. Weeks after the shooting a frantic girl came running up to the school’s principal, Pat Busher, yelling, “I hear shots! I hear shots!” The sound was from the swinging chain on a tetherball pole. Many children became hypervigilant, as though continually on guard against a repetition of the terror; some boys and girls would hover at recess next to the classroom doors, not daring to venture out to the playground where the killings had occurred. Others would only play in small groups, posting a designated child as lookout. Many continued for months to avoid the “evil” areas, where children had died.
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died. The memories lived on, too, as disturbing dreams, intruding into the children’s unguarded minds as they slept. Apart from nightmares repeating the shooting itself in some way, children were flooded with anxiety dreams that left them apprehensive that they too would die soon. Some children tried to sleep with their eyes open so they wouldn’t dream. All of these reactions are well known to psychiatrists as among the key symptoms of post-traumatic stress disorder, or PTSD. At the core of such trauma, says Dr. Spencer Eth, a child psychiatrist who specializes in PTSD in children, is “the intrusive memory of the central violent action: the final blow with a fist, the plunge of a knife, the blast of a shotgun. The memories are intense perceptual experiences—the sight, sound, and smell of gunfire; the screams or sudden silence of the victim; the splash of blood; the police sirens.” These vivid, terrifying moments, neuroscientists now say, become memories emblazoned in the emotional circuitry. The symptoms are, in effect, signs of an overaroused amygdala impelling the vivid memories of a traumatic moment to continue to intrude on awareness.
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As such, the traumatic memories become mental hair triggers, ready to sound an alarm at the least hint that the dread moment is about to happen once again. This hair-trigger phenomenon is a hallmark of
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emotional trauma of all kinds, including suffering repeated physical abuse in childhood. Any traumatizing event can implant such trigger memories in the amygdala: a fire or an auto accident, being in a natural catastrophe such as an earthquake or a hurricane, being raped or mugged. Hundreds of thousands of people each year endure such disasters, and many or most come away with the kind of emotional wounding that leaves its imprint on the brain. Violent acts are more pernicious than natural catastrophes such as a hurricane because, unlike victims of a natural disaster, victims of violence feel themselves to have been intentionally selected as the target of malevolence. That fact shatters assumptions about the trustworthiness of people and the safety of the interpersonal world, an assumption natural catastrophes leave untouched. Within an instant, the social world becomes a dangerous place, one in which people are potential threats to your safety. Human cruelties stamp their victims’ memories with a template that regards with fear anything vaguely similar to the assault itself. A man who was struck on the back of his head, never seeing his attacker, was so frightened afterward that he would try to walk down the street
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directly in front of an old lady to feel safe from being hit on the head again. 2 A woman who was mugged by a man who got on an elevator with her and forced her out at knifepoint to an unoccupied floor was fearful for weeks of going into not just elevators, but also the subway or any other enclosed space where she might feel trapped; she ran from her bank when she saw a man put his hand in his jacket as the mugger had done. The imprint of horror in memory—and the resulting hypervigilance —can last a lifetime, as a study of Holocaust survivors found. Close to fifty years after they had endured semistarvation, the slaughter of their loved ones, and constant terror in Nazi death camps, the haunting memories were still alive. A third said they felt generally fearful. Nearly three quarters said they still became anxious at reminders of the Nazi persecution, such as the sight of a uniform, a knock at the door, dogs barking, or smoke rising from a chimney. About 60 percent said they thought about the Holocaust almost daily, even after a half century; of those with active symptoms, as many as
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eight in ten still suffered from repeated nightmares. As one survivor said, “If you’ve been through Auschwitz and you don’t have nightmares, then you’re not normal.”
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HORROR FROZEN IN MEMORY The words of a forty-eight-year-old Vietnam vet, some twenty-four years after enduring a horrifying moment in a faraway land: I can’t get the memories out of my mind! The images come flooding back in vivid detail, triggered by the most inconsequential things, like a door slamming, the sight of an Oriental woman, the touch of a bamboo mat, or the smell of stir-fried pork. Last night I went to bed, was having a good sleep for a change. Then in the early morning a storm front passed through and there was a bolt of crackling thunder. I awoke instantly, frozen in fear. I am right back in Vietnam, in the middle of the monsoon season at my guard post. I am sure I’ll get hit in the next volley and convinced I will die. My hands are freezing, yet sweat pours from my entire body. I feel each hair on the back of my neck standing on end. I can’t catch my breath and my heart is pounding. I smell a damp sulfur smell. Suddenly I see what’s left of my buddy Troy … on a bamboo platter, sent back to our camp by the Vietcong.… The next bolt
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of lightning and clap of thunder makes me jump so much that I fall to the floor. 3 This horrible memory, vividly fresh and detailed though more than two decades old, still holds the power to induce the same fear in this ex-soldier that he felt on that fateful day. PTSD represents a perilous lowering of the neural setpoint for alarm, leaving the person to react to life’s ordinary moments as though they were emergencies. The hijacking circuit discussed in Chapter 2 seems critical in leaving such a powerful brand on memory: the more brutal, shocking, and horrendous the events that trigger the amygdala hijacking, the more indelible the memory. The neural basis for these memories appears to be a sweeping alteration in the chemistry of the brain set in motion by a single instance of overwhelming terror. 4 While the PTSD findings are typically based on the impact of a single episode, similar results can come from cruelties inflicted over a period of years, as is the case with children who are sexually, physically, or emotionally abused. The most detailed work on these brain changes is being done at the National Center for Post-Traumatic Stress Disorder, a network of
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research sites based at Veterans’ Administration hospitals where there are large pools of those who suffer from PTSD among the veterans of Vietnam and other wars. It is from studies on vets such as these that most of our knowledge of PTSD has come. But these insights apply as well to children who have suffered severe emotional trauma, such as those at Cleveland Elementary.
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“Victims of a devastating trauma may never be the same biologically,” Dr. Dennis Charney told me. 5 A Yale psychiatrist, Charney is director of clinical neuroscience at the National Center. “It does not matter if it was the incessant terror of combat, torture, or repeated abuse in childhood, or a one-time experience, like being trapped in a hurricane or nearly dying in an auto accident. All uncontrollable stress can have the same biological impact.” The operative word is uncontrollable . If people feel there is something they can do in a catastrophic situation, some control they can exert, no matter how minor, they fare far better emotionally than do those who feel utterly helpless. The element of helplessness is what makes a given event subjectively overwhelming. As Dr. John Krystal, director of the center’s Laboratory of Clinical Psychopharmacology, told me, “Say someone being attacked with a knife knows how to defend himself and takes action, while another person in the same predicament thinks, ‘I’m dead.’ The helpless person is the one more susceptible to PTSD afterward. It’s the feeling that your life is in danger
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danger and there’s nothing you can do to escape it —that’s the moment the brain change begins.” Helplessness as the wild card in triggering PTSD has been shown in dozens of studies on pairs of laboratory rats, each in a different cage, each being given mild—but, to a rat, very stressful—electric shocks of identical severity. Only one rat has a lever in its cage; when the rat pushes the lever, the shock stops for both cages. Over days and weeks, both rats get precisely the same amount of shock. But the rat with the power to turn the shocks off comes through without lasting signs of stress. It is only in the helpless one of the pair that the stress-induced brain changes occur. 6 For a child being shot at on a playground, seeing his playmates bleeding and dying—or for a teacher there, unable to stop the carnage—that helplessness must have been palpable. PTSD AS A LIMBIC DISORDER It had been months since a huge earthquake shook her out of bed and sent her yelling in panic through the darkened house to find her four- year-old son. They huddled for hours in the Los Angeles night cold
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under a protective doorway, pinned there without food, water, or light while wave after wave of aftershocks tumbled the ground
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beneath them. Now, months later, she had largely recovered from the ready panic that gripped her for the first few days afterward, when a door slamming could start her shivering with fear. The one lingering symptom was her inability to sleep, a problem that struck only on those nights her husband was away—as he had been the night of the quake. The main symptoms of such learned fearfulness—including the most intense kind, PTSD—can be accounted for by changes in the limbic circuitry focusing on the amygdala. 7 Some of the key changes are in the locus ceruleus, a structure that regulates the brain’s secretion of two substances called catecholamines: adrenaline and noradrenaline. These neurochemicals mobilize the body for an emergency; the same catecholamine surge stamps memories with special strength. In PTSD this system becomes hyperreactive, secreting extra-large doses of these brain chemicals in response to situations that hold little or no threat but somehow are reminders of the original trauma, like the children at Cleveland Elementary School who panicked when they heard an ambulance siren similar to those they had heard at their school after the shooting.
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school after the shooting. The locus ceruleus and the amygdala are closely linked, along with other limbic structures such as the hippocampus and hypothalamus; the circuitry for the catecholamines extends into the cortex. Changes in these circuits are thought to underlie PTSD symptoms, which include anxiety, fear, hypervigilance, being easily upset and aroused, readiness for fight or flight, and the indelible encoding of intense emotional memories. 8 Vietnam vets with PTSD, one study found, had 40 percent fewer catecholamine-stopping receptors than did men without the symptoms—suggesting that their brains had undergone a lasting change, with their catecholamine secretion poorly controlled. 9 Other changes occur in the circuit linking the limbic brain with the pituitary gland, which regulates release of CRF, the main stress hormone the body secretes to mobilize the emergency fight-or-flight response. The changes lead this hormone to be oversecreted— particularly in the amygdala, hippocampus, and locus ceruleus— alerting the body for an emergency that is not there in reality. 10 As Dr. Charles Nemeroff, a Duke University psychiatrist, told me,
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“Too much CRF makes you overreact. For example, if you’re a Vietnam vet with PTSD and a car backfires at the mall parking lot, it is the triggering of CRF that floods you with the same feelings as in the original trauma: you start sweating, you’re scared, you have chills
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and the shakes, you may have flashbacks. In people who hypersecrete CRF, the startle response is overactive. For example, if you sneak up behind most people and suddenly clap your hands, you’ll see a startled jump the first time, but not by the third or fourth repetition. But people with too much CRF don’t habituate: they’ll respond as much to the fourth clap as to the first.” 11 A third set of changes occurs in the brain’s opioid system, which secretes endorphins to blunt the feeling of pain. It also becomes hyperactive. This neural circuit again involves the amygdala, this time in concert with a region in the cerebral cortex. The opioids are brain chemicals that are powerful numbing agents, like opium and other narcotics that are chemical cousins. When experiencing high levels of opioids (“the brain’s own morphine”), people have a heightened tolerance for pain—an effect that has been noted by battlefield surgeons, who found severely wounded soldiers needed lower doses of narcotics to handle their pain than did civilians with far less serious injuries. Something similar seems to occur in PTSD. 12 Endorphin changes
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12 Endorphin changes add a new dimension to the neural mix triggered by reexposure to trauma: a numbing of certain feelings. This appears to explain a set of “negative” psychological symptoms long noted in PTSD: anhedonia (the inability to feel pleasure) and a general emotional numbness, a sense of being cut off from life or from concern about others’ feelings. Those close to such people may experience this indifference as a lack of empathy. Another possible effect may be dissociation, including the inability to remember crucial minutes, hours, or even days of the traumatic event. The neural changes of PTSD also seem to make a person more susceptible to further traumatizing. A number of studies with animals have found that when they were exposed even to mild stress when young, they were far more vulnerable than unstressed animals to trauma-induced brain changes later in life (suggesting the urgent need to treat children with PTSD). This seems a reason that, exposed to the same catastrophe, one person goes on to develop PTSD and another does not: the amygdala is primed to find danger, and when life presents it once again with real danger, its alarm rises to a higher pitch.
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pitch. All these neural changes offer short-term advantages for dealing with the grim and dire emergencies that prompt them. Under duress, it is adaptive to be highly vigilant, aroused, ready for anything,
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impervious to pain, the body primed for sustained physical demands, and—for the moment—indifferent to what might otherwise be intensely disturbing events. These short-term advantages, however, become lasting problems when the brain changes so that they become predispositions, like a car stuck in perpetual high gear. When the amygdala and its connected brain regions take on a new setpoint during a moment of intense trauma, this change in excitability—this heightened readiness to trigger a neural hijacking—means all of life is on the verge of becoming an emergency, and even an innocent moment is susceptible to an explosion of fear run amok. EMOTIONAL RELEARNING Such traumatic memories seem to remain as fixtures in brain function because they interfere with subsequent learning—specifically, with relearning a more normal response to those traumatizing events. In acquired fear such as PTSD, the mechanisms of learning and memory have gone awry; again, it is the amygdala that is key among the brain regions involved. But in overcoming the learned fear, the neocortex is critical. Fear conditioning is the name psychologists use for the process whereby something that is not in the least threatening becomes dreaded as it is associated in someone’s mind with something
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dreaded as it is associated in someone’s mind with something frightening. When such frights are induced in laboratory animals, Charney notes, the fears can last for years. 13 The key region of the brain that learns, retains, and acts on this fearful response is the circuit between the thalamus, amygdala, and prefrontal lobe—the pathway of neural hijacking. Ordinarily, when someone learns to be frightened by something through fear conditioning, the fear subsides with time. This seems to happen through a natural relearning, as the feared object is encountered again in the absence of anything truly scary. Thus a child who acquires a fear of dogs because of being chased by a snarling German shepherd gradually and naturally loses that fear if, say, she moves next door to someone who owns a friendly shepherd, and spends time playing with the dog. In PTSD spontaneous relearning fails to occur. Charney proposes that this may be due to the brain changes of PTSD, which are so strong that, in effect, the amygdala hijacking occurs every time
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something even vaguely reminiscent of the original trauma comes along, strengthening the fear pathway. This means that there is never a time when what is feared is paired with a feeling of calm—the amygdala never relearns a more mild reaction. “Extinction” of the fear, he observes, “appears to involve an active learning process,” which is itself impaired in people with PTSD, “leading to the abnormal persistence of emotional memories.” 14 But given the right experiences, even PTSD can lift; strong emotional memories, and the patterns of thought and reaction that they trigger, can change with time. This relearning, Charney proposes, is cortical. The original fear ingrained in the amygdala does not go away completely; rather, the prefrontal cortex actively suppresses the amygdala’s command to the rest of the brain to respond with fear. “The question is, how quickly do you let go of learned fear?” asks Richard Davidson, the University of Wisconsin psychologist who discovered the role of the left prefrontal cortex as a damper on distress. In a laboratory experiment in which people first learned an aversion to a loud noise—a paradigm for learned fear, and a lower-
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key parallel of PTSD—Davidson found that people who had more activity in the left prefrontal cortex got over the acquired fear more quickly, again suggesting a cortical role in letting go of learned distress. 15 REEDUCATING THE EMOTIONAL BRAIN One of the more encouraging findings about PTSD came from a study of Holocaust survivors, about three quarters of whom were found to have active PTSD symptoms even a half century later. The positive finding was that a quarter of the survivors who once had been troubled by such symptoms no longer had them; somehow the natural events of their lives had counteracted the problem. Those who still had the symptoms showed evidence of the catecholamine-related brain changes typical of PTSD—but those who had recovered had no such changes. 16 This finding, and others like it, hold out the promise that the brain changes in PTSD are not indelible, and that people can recover from even the most dire emotional imprinting—in short, that the emotional circuitry can be reeducated. The good news, then, is that traumas as profound as those causing PTSD can heal, and that the route to such healing is through relearning.
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One way this emotional healing seems to occur spontaneously—at least in children—is through such games as Purdy. These games, played over and over again, let children relive a trauma safely, as play. This allows two avenues for healing: on the one hand, the memory repeats in a context of low anxiety, desensitizing it and allowing a nontraumatized set of responses to become associated with it. Another route to healing is that, in their minds, children can magically give the tragedy another, better outcome: sometimes in playing Purdy, the children kill him, boosting their sense of mastery over that traumatic moment of helplessness. Games like Purdy are predictable in younger children who have been through such overwhelming violence. These macabre games in traumatized children were first noted by Dr. Lenore Terr, a child psychiatrist in San Francisco. 17 She found such games among children in Chowchilla, California—just a little over an hour down the Central Valley from Stockton, where Purdy wreaked such havoc—who in 1973 had been kidnapped as they rode a bus home from a summer day camp. The kidnappers buried the bus, children and all, in an ordeal that lasted twenty-seven hours.
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ordeal that lasted twenty-seven hours. Five years later Terr found the kidnapping still being reenacted in the victims’ games. Girls, for example, played symbolic kidnapping games with their Barbie dolls. One girl, who had hated the feeling of other children’s urine on her skin as they lay huddled together in terror, washed her Barbie over and over again. Another played Traveling Barbie, in which Barbie travels somewhere—it doesn’t matter where—and returns safely, which is the point of the game. A third girl’s favorite was a scenario in which the doll is stuck in a hole and suffocates. While adults who have been through overwhelming trauma can suffer a psychic numbing, blocking out memory of or feeling about the catastrophe, children’s psyches often handle it differently. They less often become numb to the trauma, Terr believes, because they use fantasy, play, and daydreams to recall and rethink their ordeals. Such voluntary replays of trauma seem to head off the need for damming them up in potent memories that can later burst through as flashbacks. If the trauma is minor, such as going to the dentist for a
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filling, just once or twice may be enough. But if it’s overwhelming, a child needs endless repetitions, replaying the trauma over and over again in a grim, monotonous ritual. One way to get at the picture frozen in the amygdala is through art,
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which itself is a medium of the unconscious. The emotional brain is highly attuned to symbolic meanings and to the mode Freud called the “primary process”: the messages of metaphor, story, myth, the arts. This avenue is often used in treating traumatized children. Sometimes art can open the way for children to talk about a moment of horror that they would not dare speak of otherwise. Spencer Eth, the Los Angeles child psychiatrist who specializes in treating such children, tells of a five-year-old boy who had been kidnapped with his mother by her ex-lover. The man brought them to a motel room, where he ordered the boy to hide under a blanket while he beat the mother to death. The boy was, understandably, reluctant to talk with Eth about the mayhem he had heard and seen while underneath the blanket. So Eth asked him to draw a picture—any picture. The drawing was of a race-car driver who had a strikingly large pair of eyes, Eth recalls. The huge eyes Eth took to refer to the boy’s own daring in peeking at the killer. Such hidden references to the traumatic scene almost always appear in the artwork of traumatized
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traumatic scene almost always appear in the artwork of traumatized children; Eth has made having such children draw a picture the opening gambit in therapy. The potent memories that preoccupy them intrude in their art just as in their thoughts. Beyond that, the act of drawing is itself therapeutic, beginning the process of mastering the trauma. EMOTIONAL RELEARNING AND RECOVERY FROM TRAUMA Irene had gone on a date that ended in attempted rape. Though she had fought off the attacker, he continued to plague her: harassing her with obscene phone calls, making threats of violence, calling in the middle of the night, stalking her and watching her every move. Once, when she tried to get the police to help, they dismissed her problem as trivial, since “nothing had really happened.” By the time she came for therapy Irene had symptoms of PTSD, had given up socializing at all, and felt a prisoner in her own house. Irene’s case is cited by Dr. Judith Lewis Herman, a Harvard psychiatrist whose groundbreaking work outlines the steps to recovery from trauma. Herman sees three stages: attaining a sense of safety, remembering the details of the trauma and mourning the loss it has
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remembering the details of the trauma and mourning the loss it has brought, and finally reestablishing a normal life. There is a biological
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logic to the ordering of these steps, as we shall see: this sequence seems to reflect how the emotional brain learns once again that life need not be regarded as an emergency about to happen. The first step, regaining a sense of safety, presumably translates to finding ways to calm the too-fearful, too easily triggered emotional circuits enough to allow relearning. 18 Often this begins with helping patients understand that their jumpiness and nightmares, hypervigilance and panics, are part of the symptoms of PTSD. This understanding makes the symptoms themselves less frightening. Another early step is to help patients regain some sense of control over what is happening to them, a direct unlearning of the lesson of helplessness that the trauma itself imparted. Irene, for example, mobilized her friends and family to form a buffer between her and her stalker, and was able to get the police to intervene. The sense in which PTSD patients feel “unsafe” goes beyond fears that dangers lurk around them; their insecurity begins more intimately, in the feeling that they have no control over what is happening in their body and to their emotions. This is understandable, given the hair trigger for emotional hijacking that PTSD creates by
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given the hair trigger for emotional hijacking that PTSD creates by hypersensitizing the amygdala circuitry. Medication offers one way to restore patients’ sense that they need not be so at the mercy of the emotional alarms that flood them with inexplicable anxiety, keep them sleepless, or pepper their sleep with nightmares. Pharmacologists are hoping one day to tailor medications that will target precisely the effects of PTSD on the amygdala and connected neurotransmitter circuits. For now, though, there are medications that counter only some of these changes, notably the antidepressants that act on the serotonin system, and beta-blockers like propranolol, which block the activation of the sympathetic nervous system. Patients also may learn relaxation techniques that give them the ability to counter their edginess and nervousness. A physiological calm opens a window for helping the brutalized emotional circuitry rediscover that life is not a threat and for giving back to patients some of the sense of security they had in their lives before the trauma happened. Another step in healing involves retelling and reconstructing the story of the trauma in the harbor of that safety, allowing the
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emotional circuitry to acquire a new, more realistic understanding of and response to the traumatic memory and its triggers. As patients retell the horrific details of the trauma, the memory starts to be
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transformed, both in its emotional meaning and in its effects on the emotional brain. The pace of this retelling is delicate; ideally it mimics the pace that occurs naturally in those people who are able to recover from trauma without suffering PTSD. In these cases there often seems to be an inner clock that “doses” people with intrusive memories that relive the trauma, intercut with weeks or months when they remember hardly anything of the horrible events. 19 This alternation of reimmersion and respite seems to allow for a spontaneous review of the trauma and relearning of emotional response to it. For those whose PTSD is more intractable, says Herman, retelling their tale can sometimes trigger overwhelming fears, in which case the therapist should ease the pace to keep the patient’s reactions within a bearable range, one that will not disrupt the relearning. The therapist encourages the patient to retell the traumatic events as vividly as possible, like a horror home video, retrieving every sordid detail. This includes not just the specifics of what they saw, heard, smelled, and felt, but also their reactions—the dread, disgust, nausea. The goal here is to put the entire memory into words, which
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