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by Martha Manning
MY FAMILY IS HAUNTED BY DEPRESSION. MY MOTHER CAN trace it back in her family at least six generations and it's in my father's family, too. When it hits, it hits hard. We don't get "down in the dumps," we get lost in the pits. Some people find themselves or are found, others get lost forever. The melancholies, nerves and breakdowns of my ancestors landed them in sanitariums, rest homes or in upstairs rooms from which they never emerged. Treatment involved the state-of-the-art interventions of the time cold packs, electric current, sedating drugs. Sometimes people got better. Sometimes they didn't.
Six months into my own treatment for an episode of depression that scared me in its speed, severity and stubbornness, I had placed most of my emotional cards on the table, but was disappointed that my therapist still hadn't constructed some brilliant framework in which my difficulties and those of my family could be finally uncovered and our dysfunction excised. Since he never volunteered his opinion on the subject, I finally just demanded, "Why are there so many problems in my family?" He shrugged and replied calmly, "Because there are so many people in it."
My first reaction was, "I'm paying $100 an hour for this?" And yet, eight years later, his comment still stands firm among my list of top 10 therapeutic interventions of all time. The poet Mary Karr, author of the celebrated Liars' Club, a memoir of a colorful and tremendously chaotic family, recently echoed my therapist's comment when she wrote that her definition of a dysfunctional family is "a family with more than one person in it."
My therapist's comment looks naive sandwiched between some of the more elaborate observations other therapists and clinical supervisors have made to me over the years. But in addition to comforting me with its common sense about the variety of ways families suffer, his words have been an insistent caution whenever I am seduced too quickly into facile interpretations of psychopathology. There is, after all, a very thin line between theoretical elegance and bullshit. These days, the easier the explanation of something as complicated as the relationship between families and depression, the less I trust it.
For every connection we find between our favorite theories and what we see in our consulting rooms, there are probably a hundred such families whose members somehow muddle through in defiance of our ideas about how dysfunctional they and their families are. Understanding the legacy of depression in a family requires more than genetic mapping, family diagrams, or symptom checklists. Each of us is the product of a complex weaving of genes and expectations, biochemistry and family myths, and the configuration of our family's strengths, as well as its vulnerabilities. To truly appreciate the complexity of the weave, we have to sort out the contributions of individual threads to the overall design. Yet, in describing a weaving it would be ridiculous to say, "Well, there's a red thread and over there is a blue thread and here's a gold thread." While these separate observations yield pieces of information, they provide no overall view of the fabric. It is only when we see how red threads braided with blue threads influence the pattern in particular ways that we can even begin to grasp the design of the whole.
MY OWN MEMORY OF BEING haunted by depression extends back to my great-grandmother who lived into her nineties and died when I was about 10. As I began to put things together about the relationship between my grandmother and her mother, I started to wonder whether the dulling of self I sometimes experienced, and its power to contaminate energy and joy, played leap frog with the generations hopping over my great-grandmother and landing on my grandmother, leaping over my mother and crashing down on me.
My great-grandmother was either authoritative or controlling, depending on how negatively her behavior was affecting you at the time. When we made our annual family visit to my grandmother in Massachusetts, we knew our visit would include a pilgrimage to her mother, Grammy Hale. As young as 6 or 7, I knew that there was a whole lot more going on during those visits than I could grasp. My intuitions were confirmed whenever children were dismissed immediately following raised voices. I sensed something big happened during those dismissals. Something bad. Later I found out that these were the times my great-grandmother roundly castigated my grandmother. It didn't matter for what. It could have been my grandmother's break away from a middle-class Irish Catholic neighborhood after her marriage to reside in a big house on the Waspiest street in the town. Or it could have been the tone of a brief comment my grandmother had made weeks before. The crime didn't matter. The punishment was always the same: my great-grandmother's total and complete disgust.
After each visit, as we drove back from Salem, I noticed the way my grandmother deflated, remaining silent on the way back to her house. She was almost impossible to distract from her brooding, even with our most entertaining attempts. Even when we arrived back to her wonderful beach house and celebrated our freedom from creaking musty homes and strange old women, my grandmother was elusive. She stayed in her room, shades drawn against the sun and the ocean, windows shut tight against the clean salt air. It frustrated me to think that she was making herself oblivious to the most obvious ways to feel better.
When we kids asked what was wrong with Grandmother, grown-ups always told us the same things. Grandmother was "tired," Grandmother "needed some rest," Grandmother "wasn't well." And we were told that the only thing we could possibly do to make her feel better was nearly impossible: "Be quiet." Trays that were delivered to her room earlier in the day were retrieved untouched. She didn't even want to see me, her "golden girl" who could usually snap her out of anything. Sometimes, I'd sneak into her room and lie next to her when she was sleeping, matching my breathing to hers and stroking her hair and face. She didn't have a fever, she wasn't throwing up and I didn't see spots anywhere so she wasn't sick in any way I knew about. I wondered if sadness grew with age and actually made people sick. The reasons each siege of sadness finally ended were no clearer to me than the reasons it began. When I asked about these things, unlike other times when I knew information was intentionally withheld, I almost believed my mother when her smile flickered for a moment and she said she didn't know.
On her good days my grandmother was magic extravagant, energetic and always interested. She allowed my cousins and me to tag along with her on her many errands and activities. She let us know that we were all perfectly wonderful children, despite our parents' petty complaints about us. She was fun in a way my mother never was. But as I grew older, I learned about the other side. On her bad days, I could see my grandmother wilt before my eyes. There was nowhere to tag along, because she didn't go anywhere. She never got fully dressed and when she did, it wasn't worth it. She didn't laugh. She didn't think I was perfect anymore. The air felt heavy around her, very still and hard to breathe. My grandfather, a C.P.A., seemed always to be working. My grandmother went to bed early (many times before dark). For a woman who spent as much time in bed as she did, I was always puzzled by her daily complaint that she didn't get any sleep. My grandfather recedes in my memory as a major player when my grandmother was nursing her depressions and sulks. It's like he just disappeared at those times.
In early adolescence, my relationship with my grandmother changed. Now I felt some unspoken expectation that with my new maturity, I owed her something. Now she wanted me to listen to her complaints of how badly she slept or how my grandfather worked too much or how her children didn't understand her. I couldn't stand her laments. And, since I couldn't do anything about her complaints, I left each interaction frustrated and resentful. She scared me in a way I couldn't and didn't want to understand. I felt an uneasy resonance with her, a sonar that picked up on cues that predicted a shift in her mood.
My mother was not magic. She was practical, rational and smart. As a little kid, I knew that and I loved her for it, because to me it meant that she would always take care of me, that no matter what happened, she was a constant. As our personalities diverged, she seemed more formidable. My mother was in control of her feelings. Mine spilled out all over the place. To my mother, the fact that every day was a new day was a good thing. I was never so sure. I also learned that my own dark moods were best kept to myself. As the oldest of six, I, like my mother before me, was praised for being so responsible, so capable at such an early age. I loved the praise, but I hated the reasons for it.
My mother had a no-nonsense approach to unhappiness. Stay busy, think of someone worse off than yourself, offer it up for the souls in Purgatory. At the pediatrician's office when two or three of us lined up with our bare asses vulnerable to imminent medical intervention, one of us invariably burst into loud and contagious tears, protests and screams. I remember more than once my mother leaning over and whispering, "If you must cry, cry quietly."
I recall her curiosity and impatience at my unremitting despair following being dumped by a boy when I was 13. She was sympathetic to the pain of such an experience and allowed that there was nothing like a good, cleansing cry. It was the intensity and duration of it that proved problematic. My mother had about 15 minutes in mind, whereas I was planning to make a weekend out of it.
Early on, I considered myself flawed in a way that she wasn't. Unlike my mother, I had difficulty with what she calls "compartmentalizing." She could quickly extricate herself from awful feelings; I became mired in them. By my mid to late teens, I began to struggle with the variability of my moods, something that the steamroller approach to life I had learned from my mother could not control. I wondered which woman, my mother or my grandmother, was the preview of my future. My unspoken fear that increased with age was that I was destined to become my grandmother.
I UNDERSTOOD MORE ABOUT THE nature of my mother's strength when I saw her in the context of my grandmother's vulnerability. As I grew old enough to realize that my mother and I could experience diametrically opposed feelings on the same exact subject, I realized she hated visits to my grandmother the very same trips I loved. When I was 6, I looked at the calendar and cried out, "Two more days till vacation." My mother's face got as stormy as it ever gets. She clenched her teeth and spit out, "This is many things, but it is definitely not a vacation.
When my grandmother's mood changed, my mother's did, too. Upon our annual arrival at my grandparents' beach house, it seemed like my grandmother almost willfully fell backward into helplessness and depression. And, in response, my mother went into overdrive. After feeding her own six kids dinner in our adjoining cottage, she rushed up to the main house to feed my grandparents, who somehow made it through the other 50 weeks of the year just fine.
But cooking was the least of my mother's duties. She was my grandmother's personal cheerleader, her therapist, the person who got her up and going, who tried to shift my grandmother's automatic negative outlook at least to neutral. One of my most common memories of those visits is the way my mother and grandmother sat around the kitchen table. My mother always looked like she was sitting on tacks and my grandmother always looked like she was sinking in mud. The sheer exhaustion she conveyed in the act of stirring her tea made it look like she was mixing cement.
Their conversations always stopped short when I walked in the room, but my mother didn't look at all like she looked in the many kitchen-table conversations she shared with her friends. When I became a therapist, I realized that during those times my grandmother and mother were "in session." It was only once we were on our way home again that I could see my mother's shoulders relax. She started smiling again and tolerated our loud and stupid car games.
In retrospect, I sec how that pattern repeated itself with my therapist-husband when I was depressed, as we sat on the bed or at the table and he tried to get me to articulate what was wrong. Anyone who has ever been seriously depressed knows that that task is as daunting as asking a lame man to tap dance. In addition, it leads to mutual frustration, anger and, ultimately, helplessness. It was only when we both gave up the expectation that my husband could somehow "cure" me that we moved from pseudo therapy to true support. Instead of reaching out with well-intentioned "therapeutic" interventions, he shifted to questions like, "What would help right now?" My therapist was always willing to include Brian in our sessions and, even though they were not present, to recognize Brian and my daughter, Keara, not only as my support system but as people who were suffering also. This freed them from the responsibility of those awful sessions at the kitchen table, where the certainty is that if you stay with this depressed person for one minute longer, you will drown as well.
My grandmother constantly sighed, something my mother never did. It was not an "Oh well" kind of sigh or a "That's life" kind of sigh. Hers was an exhalation that sounded like it could possibly end in her demise. It was a sigh of surrender. But as I got older, I understood that it wasn't pure fatigue or sorrow or hopelessness. It was, in its essence, an angry sigh. It was a challenge: "Just you try and make me feel better. I dare you."
In my twenties, my mother began to tell me about her childhood. She recalled being very happy until she was a teenager. My grandmother was dynamic an energetic cleaner and planner. She loved children and was always wonderful with them. But in early adolescence, something changed. My mother began to return from school to a sink full of dirty dishes, her mother in bed for no obvious reason and no dinner planned. "My memory of ninth grade," she told me "is of gritting my teeth and thinking, 'Oh God, now I have that mess to face.'" But my mother did more than face it. She took care of it.
The expectation that she do it and keep on doing it was never articulated. It was assumed and rewarded with abundant praise, which totally hooked my mother in very short order.
As children, we believed all of my grandmother's promises that things would be better "if only" "If only you lived closer, I'd be happier." "If only your aunt was easier to deal with." "If only your grandfather didn't work so hard." When I was 10, my mother (who rarely said bad things about people) insinuated that we shouldn't count on those extravagant promises our grandmother had made. When we leapt to our poor grandmother's defense, my mother responded, "This is the truth. It's what goes on. I'm giving you the truth. I never got that from my mother. But you will always have it from me."
When I had my own child at the age of 25, my mother became much more open in expressing her frustration with my grandmother for not changing and with herself for not being able to make her. In my late twenties and thirties, the depressive fog that had shadowed me for a long time grew more difficult to override or outrun.
I MOVED TO BOSTON WITH MY husband and daughter to do a postdoctoral fellowship at McLean Hospital. We found a house several miles away from my grandmother, to her great delight. I was thoroughly unhappy with the fellowship, McLean and the move, especially as I realized why my mother had consciously put 500 miles between her mother and herself. It was so sad to see my grandmother's magic destroyed by something so insidious and powerful, that neither my love nor my training could change it. I knew she was in her own hell, yet there were times I wanted to coax her or kick her out of it, dismiss her complaints and sighs, but I couldn't. And I feared I was looking at my future. I didn't want anyone to feel that way about me.
My first cousin the firstborn in her family of seven was going through her own hell at the time from depression, a hell that culminated in suicide in her early twenties. My own deepening depression and my cousin's suicide catapulted me into psychotherapy with a psychiatrist referred by my health plan. I told him I was anxious. He told me I was depressed. Yeah, I admitted, I had my moods, but no way was I depressed in the way my cousin or grandmother was. As evidence against his diagnosis, I listed my accomplishments, the many responsibilities I fulfilled. But 30 minutes into my session with him I was convinced that I was indeed depressed. At the end of our first session, he turned to me solemnly and said, "You really believe that life is something to be endured, to be overcome." I looked back at him suspiciously, wondering if it was a trick question. "It isn't?" I asked. He told me we had our work cut out for us and scheduled a session for the next week.
Our work in the five months that remained in my fellowship was fairly structured and involved learning ways to manage my anxiety and set limits in the many areas in which I felt overwhelmed. Perhaps the most significant result of the work was that I decided not to accept a job at my fellowship and remain in the Boston area, but to return to Washington to accept an academic position there.
Not long after we moved back, I began to hear my grandmother's sighs in my own labored breathing. I, too, felt the weight of the spoon as I stirred my tea. I knew that making a peanut butter and jelly sandwich should be far less than a 30-minute operation. I entered individual psychotherapy, found it extremely helpful, particularly in quieting the loud voice of perfection that used to rule my expectations of myself, and the panic that had begun to sneak up from behind and immobilize me.
But my depression continued despite insight, despite a good marriage, despite a child I dearly loved. I finally agreed to try antidepressants and was horrified when my psychiatrist recommended imipramine, the same medicine my grandmother had used in her late seventies, with moderate success, but difficult side effects. My psychiatrist must have registered the horror on my face. He reassured me that he always chooses as the first antidepressant a drug that has worked with other family members.
He was right. The medicine helped quickly and dramatically. It lifted a lifelong weight off my back and made me wonder, "Is this how regular people feel?" But like many people who take psychotropic medications for significant periods of time, I struggled with questions like, "Why can't I do this on my own?" or, looking at the tiny pills, I wondered, "Is this all that stands between hell and me?"
Fortunately my psychiatrist and I already had a strong therapeutic relationship. Yet despite the benefits of the antidepressant, I still feared that I was destined to be my grandmother, a fear no drug could erase. I didn't want her resignation, her helplessness, her just-be-low-the-surface bubbling anger or her genuine and horrible suffering. I also didn't want to have the impact that she had on her family, particularly on my mother. I did not want my daughter to take on the yoke of responsibility and resent me for it. I had already watched three generational scenarios: My great-grandmother's influence on my grandmother, both of their influences on my mother and all three of their influences on me. The one that scared me most was the next one the weight of all four of us on my 11-year-old daughter.
In addition to support, the therapy focused on developing an understanding of the commonalities I shared with each woman, appreciating aspects of our shared legacies as some of the things I most valued in myself. I also had to articulate the differences between myself and each of them. I worked to understand that depression did not negate me, it just made my life different and difficult hopefully, for a limited amount of time, and that no one genetically, biologically or psychologically is the blueprint for anyone else. Being haunted is not the same as being cursed.
The fact that in little more than a year's time, I descended into a very serious depression does not negate the impact of the psychotherapy or the medicine. For reasons that were never clear, I began to metabolize my medications so rapidly that to keep a therapeutic dose in my blood, I required doses that became untenable. The benefits of each new medicine bottomed out within a matter of weeks.
My daughter tried to tease me, tempt me, annoy me, entertain me and soothe me all to no avail. Her constant question was, "Why are you so sad?" No wonder that I worried about the impact of my depression on her. The self-absorption caused by the acute pain of a severe depression makes being a good parent very difficult. I had difficulty following the rambling conversations in the car that I usually loved. Her new friends' names were hard to remember. Our 11-year-old bedtime ritual, with its whispers, soft songs and backrubs dwindled down to a quick goodnight.
She and my husband hovered and worried. In reaction to my early experience of whispered adult conversations, my husband and I tried to be straightforward with Keara. I remembered what my mother had wished for in her adolescence "Just some knowledge. What's going on and what's being done to help it."
Now, five years since my last serious depression, my daughter teases us that we went a bit overboard in providing the information my mother had wanted. She insists that the information we gave her about depression was a lot like the information we gave her about sex a lot of big words with little context. Her concerns had less to do with having a technical command of depression than about the continuity of her care and protection. Two years ago, at the age of 16, she spoke to an interviewer who was writing a story about my depression: "The thing about having someone close to you suffer from depression is that your feelings go from worried, to angrily impatient, to guilty. One of the worst things was seeing my mom in so much pain and being constantly reminded that it wasn't my fault and there was nothing I could do to make her feel better."
We tried to keep her life as stable as possible. Given my mother's experience, 1 definitely did not want my daughter to "rise to the occasion." In the interview, Keara said: "My mom worked hard to take care of me, to make sure I was taken care of, which I was. I was so lucky to have my father. My parents always shunned the value system where the mother would be the singular child raiser. I was always close to my dad, even closer at the time because I spent more time with him as my mom got worse. Anyway, the shift in my standard of living was not too dramatic."
Despite pills, therapy, love, professional expertise and faith, my symptoms worsened. I didn't sleep more than two hours a night. I stopped eating it was too hard to swallow. I thought about the wisecrack about someone who is "out of it": the lights are on, but nobody's home. In depression, the lights are off, but somebody's definitely home. She just can't make it to the door to let you in.
My ruminations turned to comforting thoughts of death. I had always thought of myself as living in a series of concentric circles that connected me to life. My outermost circles included my interests and acquaintances, my work and goals. Then came my friends. Then my parents and siblings. Then my husband and daughter. As the depression worsened, those connections dissolved. They were no longer reasons to stay in the game. Life could go on without me.
In the final days before my hospitalization, I was staying alive for my husband and my daughter. I never told them this. In the last clays, I kept going only for my daughter. My daughter and her songs. Every morning, Keara stumbles semi-conscious into the bathroom and turns on the shower. Within the space of 30 seconds, she starts to sing. She starts out humming so softly that her voice blends with the spray as it bounces off the wall. And then she chooses her song sometimes sweet and lyrical, sometimes loud and rocking. Each morning, when I had to face another day on two hours of sleep and no hope, I leaned against the bathroom door waiting for her to sing and let her voice invite me to try for one more day.
One morning, finally convinced that suicide was an act of love, not hate, I leaned for what I thought would be the last time against the door. I tried to memorize that voice, with all of its exuberance and hope. And then I realized that ending my life would silence that voice, perhaps forever. And I knew what I had to do. I would finally agree to electroconvulsive therapy (ECT), which had been recommended to me for several weeks. I had always said I'd step in front of a moving train for the sake of my child. Now it was time to prove it.
ECT was the tractor that pulled me out of the mud. Its power was hard to believe. Within several treatments, I was adding 20 to 30 minutes to my sleep per night. Having lost 30 pounds in three months, I began to look forward to meals. My face, which felt like a mask, regained its elasticity. It was as if several heavy backpacks had been taken from my shoulders. But it wasn't a magic cure. I still had to walk the whole way home a journey that took more than a year, assisted greatly by medicine, therapy and the support of many people.
FINDING MY PLACE AGAIN IN MY Family took some time. When her bedtime approached on my first night home from the hospital, Keara announced, "I don't need you to tuck me into bed anymore. I do it myself now." For several weeks, no one raised a voice or a broke a rule. I was being watched very carefully. At some point, my daughter must have experienced a critical mass of the old me. She started challenging me again, testing the limits of my authority and my capacity for following through.
Over the course of that year, I had to struggle with self-recriminations about the ways I had failed the people I loved. I was ashamed that I'd been unavailable to Keara and embarrassed that she had seen me so vulnerable. As a psychologist whose profession has historically enjoyed the sport of mother-bashing, it was easy to revert to it myself. Keara would be ruined for life and it would be all my fault.
For a long time after my hospitalization, my daughter dropped her middle name, Manning, and began making it clear that her name came only from my husband, Keara Depenbrock. I knew how important it was for her to see herself as separate from me currently but more important, in the future. It was helpful for my husband to point out to me that although some of it was due to my depression, it was also a normal function of adolescence. When she wrote, "While I have a lot in common with my mother, I have inherited my father's mental health," I was able to see it as a fact as well as a wish.
Over the next several years, I marveled at my child's blooming, despite the scarcity of light in our house at a critical point in her development. Keara later remembered: "My mom's depression was definitely an impediment to us being close at the time. Because she wasn't available to me, and because something so horrible was happening inside of her, it was really hard for her to have this great relationship with other people. I think that she spent all the time and energy she had with me and for me but it wasn't as much as I wanted. I don't blame her for that. She didn't make a choice to be that way. But sometimes I'd get really frustrated and impatient with her anyway."
I recalled psychoanalyst D.W. Winnicott, one of the less judgmental voices in the psychological wilderness, who disputed the necessity of a perfect mother for a child's healthy development, substituting the more attainable standard of "good-enough mother." My faith in Winnicott was confirmed the night my daughter invited me back into
her room for the nightly ritual that had taken so much effort only months before. Now, smoothing her rumpled sheets, straightening her comforter to her exact specifications and rubbing her back with the precise level of finger pressure were gifts, not burdens.
Depression and I are not finished with each other. Four years ago, two years after my first round of ECT, I started sliding in the same dangerous direction. This time, we all saw it coming. If I didn't improve quickly, we knew the plan. This time, I had more ECT treatments, on an outpatient basis. I left for the hospital in the morning, after I'd seen Keara off to school, and I was back before she returned home. Life was not business as usual, but we managed the details with the help of our families and friends.
With the addition of a mood stabilizer (lithium), which I had refused after my first ECT, I have since enjoyed the best years of my life. They have also been the best years of my relationship with my daughter. There was something in the combination of vulnerability and stability that protected us. She saw me go to hell. Exit she was there for the return trip as well. Her fears of depression invading our family again were confirmed so quickly that in some ironic way she got to really learn the drill and find comfort in the evidence that our plans worked. We both learned that lousy things can happen and that they can be so bad and so powerful that they stand good solid relationships on their heads.
The differences between Keara and me are clear. Temperamentally, she resembles my husband and my mother, not me. That knowledge frees her from having to deny the ways in which we are so alike. She can claim our similarities without the fear of turning into me. Several months ago, at the end of her senior year, she came home, leaned against the kitchen counter while I peeled carrots and described having to fill out a form with her name exactly as she wanted it on her high school diploma. "I was afraid it wouldn't all fit," she told me.
"Yeah, Keara Depenbrock is a mouthful," I replied.
"No, Mom," she laughed, "it's worse than that. My real name, Keara Manning Depenbrock."
Our children inhale our imperfections and failings as easily as our love. Perhaps they are meant to. How else will they ever learn to tolerate themselves? My goal is no longer to make a perfect impression. Now, I'm shooting for an imperfect impression and helping my daughter deal with it. I look ahead and hope that she is spared the torment of severe depression. I think she will be. But on the chance that she might get lost in it, or in any of the other ways life tests our faith and our patience and our endurance, I wish for her exactly what she gave to me: a sweet voice in the distance that penetrates her darkness and calls her gently toward home.
Martha Manning, Ph.D., is the author of Undercurrents: A Life Beneath the Surface and Chasing Grace: Reflections of a Catholic Girl, Grown Up, both published by HarperCollins San Francisco. Address: 716 S. George Mason Drive, Arlington, VA 22204.
by Richard Simon
IT'S BEEN ALMOST 20 YEARS SINCE I FIRST SAW SALVADOR MINUCHIN in action. Back then, I was a young Ph.D., just a few months into my first clinical job. In graduate school I had of course read Minuchin's books Families of the Slums and Families and Family Therapy, which were, as far as I was concerned, practically sacred texts, but I had never actually seen him do therapy in person. The family field was at the peak of its messianic, we-shall-change-the-world phase and Minuchin, in his staunch opposition to psychiatric orthodoxy, was both its leading visionary and presiding clinical wizard, part Moses, part Merlin with a little dash of Rush Limbaugh thrown in on the side.
So my trip to the Philadelphia Child Guidance Clinic for an introductory workshop Minuchin was giving on structural family therapy was more than a quest for a few C.E.Us. It was a pilgrimage to the place that Minuchin had turned into the Mecca of family therapy itself, an initiation into the mysteries of how to put the airy abstractions of systems theory to work transforming lives. Standing in front of the audience of 200 therapists, Minuchin, a compact, dapper man with a Latin accent as thick as his black mustache, exuded an air of brusque command at odds with the traditionally pacifist culture of psychotherapy. Heaven protect anyone who stumbled through a lame question or tried to say a kind word about psychoanalysis. He seemed to me the most confident person I had ever met, as if he had been to the mountaintop, seen the Truth and discovered he was It. Of course, he was exactly the kind of hero I was looking for. And when he began to explain a clinical strategy by quoting from a 16th-century book called The Way of the Samurai, any last reservations I may have had completely disappeared.
The centerpiece of the workshop was a live family therapy session broadcast to the audience via closed circuit TV Once the interview started, Minuchin's intimidating aura dissolved and he became a kind of therapeutic sleuth patient, respectful, infinitely curious, frequently playful, surprisingly gentle, but, above all, utterly focused on figuring out the puzzle of what was maintaining the problem the family was trying to resolve. Sometimes Minuchin leaned back in his chair and took long drags on his cigarette as he questioned the family a poor, black, single mother and her three young children about their presenting problem, the 8-year-old boy's disobedience and school difficulties. Hyperalert to the family's every gesture, every pause, every shift of mood, he seemed to drink in information through all his pores as he pursued his inquiry.
Toward the end of the session, Minuchin asked the defiant 8-year-old to stand up, explaining, "I am still trying to figure out what makes you so powerful." The boy smiled slyly as he rose to his feet, clearly delighted to take part in whatever game this curious man was devising. After speaking with the boy for a while and complimenting him on how strong and healthy he looked, Minuchin asked the mother to stand up. As she did, towering over her small child, Minuchin asked, "Where has he got the idea that he is so powerful? He is a healthy boy, but look, he is just a little kid who somehow has convinced you that he is much older than he really is." It was, I learned later, one of Minuchin's favorite gambits, but as I watched it unfold, I was stunned by both the power and the sweetness of the moment. Both mother and son were smiling, basking in the attention they were receiving, coming more fully to life as if renewed by the prospect of order being restored in the family. And later, as the mother, with Minuchin's gentle, persistent coaching, was finally able to lay down some simple rules in the session with a newfound authority in her voice, there was no doubt that she and her family had recorded a small victory in that room.
I am equally sure that over the next weeks and months, the therapists in that audience went on to direct hundreds of children and their parents through a similar routine, the image of Minuchin's mastery still alive in their memories. The fact is that once you saw Salvador Minuchin at work, a little part of him lived on indelibly inside you. Through family therapy's formative years, he became the standard against which therapists measured their best work, and when they failed miserably with a family, they asked themselves what Minuchin might have done. From his early work with delinquents and their families at New York's Wiltwyck School in the 1960s through his long stewardship at the Philadelphia Child Guidance Clinic, he was probably the most renowned and most imitated family therapist in the world.
For the past 15 years, although he has continued to write about family therapy, conduct workshops and direct a small training center in New York, Minuchin has seemed to be in search of fresh worlds to conquer. He spent some years traveling and pursuing his interest in play writing, seeing if he could transfer his flair for the drama of the consultation room to the theatrical stage. For more than a decade, he jousted with the New York City child welfare bureaucracy, trying to apply his ideas about family systems to reforming the foster care system.
Today, at 75, he speaks with some bemusement about his reputation for consultation-room charisma, as if fondly recalling a brash younger brother who had yet to learn some of life's later lessons. Fifty years of experience with families has smoothed the keen edge of absolute certainty that once gave his work its sense of urgency. These days, he sees himself less as an advocate for a particular clinical method or theory than as a philosophical meta-observer of a profession he, as much as anyone, helped to create and to which he continues to feel responsible. He has just completed his ninth book, Mastering Family Therapy: Journeys of Growth and Transformation, cowritten with nine of his supervisees, which offers his current take on the state of family therapy training. The interview that follows was conducted in the Back Bay town-house in Boston where Minuchin lives with his wife, Pat, a clinical psychologist who has been his collaborator in his efforts to revolutionize foster care, to whom he has been married for 45 years. Here, Minuchin reflects on some of the latest developments in family therapy, discusses his own evolution as a clinician and offers his perspective on nearly 50 years of the field's history.
FTN : How would you contrast your work with the approaches that are popular among younger therapists today?
MINUCHIN : I think I am much more interested in the exploration of conflict than many therapists today. My therapy grew out of the "try, try again" active therapy of the 1960s, with all its optimism and energy, experimentalism, creativity and naivete. I bring the family drama into the therapy room. I encourage members to interact directly with one another in the belief that the family is the arena in which people can most fully express themselves in all their complexity. So family interaction with all its potential for both destruction and healing continues to occupy center stage in my practice.
But today therapists are wary of my brand of therapeutic interventionism. They seem to believe it is impossible for a therapist to produce specific, targeted changes in a family. They want to be noninterventionist and turn therapy into a simple conversation among people. The therapist asks questions that provide people the opportunity to reconsider meanings and values that up until then they have considered as "given" or normative. The solution-focused and the narrative therapists say, "Let's not deal with problems. Let's deal with solutions." But in the process, it seems to me, the therapist is restricted to operating only in a collaborative, symmetrical posture. Gone is the latitude to play, to give opinions, to be the complex, multi-faceted person in the therapy room that you are outside of it. All that remains is to be a distant, respectful questioner.
FTN : Janet Malcolm once wrote in The New Yorker, "Watching a Minuchin session, or a tape of it, is like being at a tightly constructed, well-directed, magnificently acted play." You seemed to relish dealing with explosive situations in therapy. What do you like about dealing with those situations?
MINUCHIN : I think what drew me to family therapy was the excitement. Every family represented an exciting puzzle. When I worked with delinquents and their families at the Wiltwyck school back in the '60s, the particular challenge was to help them find concrete ways to calibrate relationships. We were concerned with helping disorganized families to give more order to their relationships. So we would interrupt a fight in the family to say, "When your mother talks, you cannot talk. Okay, now you can answer." The emphasis was on guidance. At that time Virginia Satir had developed a very popular therapy that emphasized nurturance and the mid-wifing of feeling. But we felt that in the families we saw, people already knew how to nurture. The problem was that the parents were ineffective in taking control of their kids. What they did not have was the constancy that allowed them to give the children a sense of self-efficacy.
FTN : A lot of your reputation as a master therapist had to do with your getting seemingly resistant families to do what you asked them to do. How did you manage to accomplish that?
MINUCHIN : At the time I wrote Families of the Slums, I was full of political passion in defense of the underdog. I had an enormous amount of zeal and people responded to that. All of us back then were tremendously hopeful about teaching poor people to become competent in this social laboratory that was the family. We relied on techniques of moving in and out of the conflict, of being both an observer and a participant in the session. So we would say, "Mom, talk with Jimmy and find a way to make sure he really listens." The goal was to get the parents to exert competence in an area in which they could succeed. The more competent people felt, the more they would listen. Our naivete at that time was that we could not yet look beyond the boundaries of the family and recognize the impact of the larger culture. That came later.
FTN : When I think of the teaching tapes you made at the Philadelphia Child Guidance Clinic, what stands out for me is the art of the small victory going through some hellish struggle to get somebody in a family to do something they have never done before. Of all the cases that you treated, is there one that stands out for you?
MINUCHIN : There is a famous tape of an anorexic girl eating a hot dog. That was a family situation that was horrendous. There was this girl named Carol who was so underweight that she was in danger. So I said to the parents, "Unless she eats, she will die. You are the parents. Don't let her die. Do something." So I tried to help the family discover a new pattern of interaction by creating a crisis in which the parents had to do something that was novel for them. Now these parents were faced with an impossible situation. The mother starts by saying, "Carol, I want you to eat," but soon she and father are beginning to fight, so I say, "Look what's happening now. Carol is still not eating." And the parents now attack the girl, "You will eat!" And food is no longer the issue, and questions of power, autonomy and control become the central issue in this transaction. At that point, it is possible to enter by supporting the girl's autonomy not around eating, but around what her parents are doing.
FTN : But how did you get out of being stuck in the power struggle?
MINUCHIN : A therapist must walk both sides of the street. At the same time you are getting the parents to take control, you also talk about the girl's autonomy. You explain that good parenting is not just control, it is also about giving space. And while you encourage the girl's autonomy, you talk to her about the parents' need to be respected. Bringing the conflict into the therapy room is just the first step in challenging the old pattern and moving parents outside of the world of the girl. Maybe I'm thinking of this particular family because Carol just called me a few months ago to tell me that her father, whom I had not seen in 25 years, was dying and wanted to speak with me one last time. After all these years, he still felt connected to me and what had happened in the therapy. Somehow talking with me at the end of his life was his way of closing a circle. I am frequently surprised how long the memory of a therapist can last in the life of a family.
FTN : Your ability to handle conflict seems to come out of your skill at convincing both sides that you are with them. What keeps families from just seeing you as a manipulator?
MINUCHIN : For people to accept my interventions, they must know that I really see them. They must say to themselves, "Yeah, that's me. Yes, he has my number." I think that what it comes down to is that I really care. Once I work with a family, I am absolutely concerned for them. I suffer with them. I cry with them. Even though I am like Jiminy Cricket I am their conscience I also care for them. When Jay Haley wrote about Milton Erickson, he emphasized his inventive interventions and his command of hypnosis and metaphor. But when you look at tapes of Erickson with patients, what you see above all else is a man who is absolutely benign.
FTN : Since the early days of structural family therapy, you've been considered a champion of a here-and-now approach to change. So I was surprised to hear you say in your new book, "We have tended to overlook family history."
MINUCHIN : I believe that to understand the present one must always make incursions into the past, in order to become free of it. The analysts also believed this, but for them, the investigation of the past was open-ended and took a lot of time "First, tell me about your father. Now tell me about your mother." And one would go on exploring and exploring, weaving together all these strands to make an interpretation of the present. My idea of how to explore the past was different. I saw it not as an intellectual exploration, but as a search for new responses. You start by seeing the narrowness of people's responses in the present and ask, "How did you learn this narrowness?" You then explore the past, looking for something very specific and focused. The exploration is in search of a solution that will make the client more complex in the present.
F TN : So what exactly are you looking for in that exploration?
MINUCHIN : You explain to people that families make people into specialists. The specialty may be "I need to defend myself from criticism," or "I am accepted when I help others," or "I am acknowledged only when I am a winner." Each one of the these labels for the self comes with a view of the complementary roles others take and with certain preferred strategies for dealing with life. So people develop a set style of transacting with significant others, and while they may have other alternatives, they are specialists in this one. As a therapist, you look at the past in order to see how the past created constraints that are not useful now. And you say to the client, "Let's use that understanding to free you from the constraints that don't serve you anymore."
FTN : Does that understanding in itself free people?
MINUCHIN : It's basically Harry Stack Sullivan's concept of parataxic distortion, the idea that you are not really responding to the present, but seeing it through blinders that you have forgotten you are wearing. And the therapist says, in effect, "Let's take those blinders off."
FTN : What do you think of the statement by Jay Haley in his most recent book that "Rather than assume that insight into the past causes change, it's better to think of change causing insight into the past."
MINUCHIN : I think he is wrong and he is right. I am an old man, but I still have memories of my childhood that cannot be erased. Some of them are uncomfortable and I would like to erase them, but they don't go away even though I have changed and am experientially much richer. I know the way in which these early experiences still organize my thinking today. But to a certain extent, I am able to marginalize them so that they are not significant in the way in which I function. Still they are part of me, and I really do believe in the importance of understanding the past in order to give people the freedom to take their blinders off and see how the past organizes the present. From this perspective, I would disagree with Jay. But I also think he is right. There is something else that happens when you deal with memory. Not only do you change how people look at the present, you also rearrange the past.
FTN : What do you mean?
MINUCHIN : I think that we are always rearranging our past. Some therapists, like Milton Erickson, would sometimes deliberately introduce through hypnosis old memories that never actually took place. But even outside therapy that happens automatically all the time. I'll give you an example. Years ago I paid a visit to my high school in Argentina, where I met a woman about my age who asked me what I was doing there. And I replied, metaphorically, "I am lassoing ghosts," which is a very Argentinean thing to say. As we talked, we discovered that we both had been in that high school at the same time. But even though she had told me her name, I could not remember who she was. So later I went to the office in the high school and asked for a roster of former students. As soon as I saw her name on the roster, the memory of her as an adolescent came full-blown into focus. Clearly her presence as an adult interfered with my memory. Suddenly all kinds of memories that had not come to mind for 50 years came back to me, not in the competitive and timid way in which I originally saw them, but from the perspective of being older and looking back. My memory created something very different in that moment from earlier memories of the same period.
FTN: So you think we're always "recovering" memories?
MINUCHIN : I think so.
FTN : So what do you think about the criticisms of "recovered memory therapy?"
MINUCHIN : The mistake some therapists make is to believe in the immutability of memories. I think that we always create memories that's a very normal, natural process. What I don't agree with is that once these memories appear in therapy, they represent truth or reality. Therapists must be very careful not to see memories as immutable truth.
FTN: Since the last interview we had 12 years ago, what have you discovered about being a good therapist?
MINUCHIN : During these 12 years, the certainty that I had when I was younger has disappeared. I no longer believe that I own the truth and I have become more accepting of other points of view. I know myself better and realize that when something new happens in the field, my first response is to oppose it and only later do I begin to incorporate it. My first response to the feminist group was to respond negatively to what I saw as its stridency, especially since I was the target of much of its criticism of the field. But I learned to incorporate many of the feminists' ideas. And even though I still have problems with the constructivists, as I was saying earlier, the same was true of the work of Michael White and Steve de Shazer. I begin with polemical opposition and move toward assimilating what I find useful.
FTN : So, for example, what do you find useful in solution-focused therapy?
MINUCHIN : I like looking beyond problems to solutions, saying to clients, "What if one day you get up in the morning and your problem disappears? What would that look like?" I use those questions sometimes, just as I have incorporated pretty much everything that has been written on family therapy, particularly the ideas of Jay Haley and certainly all the thinking of Carl Whitaker. Today, technically, I am much more complex than I was as a younger therapist. A lot of that, of course, is a result of age. As you get older, all certainties become question marks. You also begin to ask yourself fundamental questions like, "Would the world be different if I did not exist?" So you become less attached to your particular contribution.
FTN : How have you assimilated pieces of feminism in your work?
MINUCHIN : The feminists made me realize that I had put women in certain narrow categories and that my labels for women had gender biases: for me a mother's concern could too easily be dismissed as "overprotectiveness." I focused on men providing guidance and women nurturance, and my work emphasized the importance of guidance and took nurturance for granted. I don't think I do that anymore. I'm more aware of the messages of the labels and I pay attention to what I privilege. But I still work systematically, seeing how couples trigger each other in their interactions. I've always thought that working with the man is an important way to bring him closer to the family, make him more of a participant and ease the burdens of the woman, but I pay more attention now to making sure that her voice is heard, her pain expressed and her need for respect understood.
FTN : And what about the narrative approach?
MINUCHIN: Do you remember Nathan Epstein?
FTN : Of course.
MINUCHIN : Nathan Epstein had an extraordinary quality of inspiring family members and transforming them very, very fast into talmudim.
FTN : Into what?
MINUCHIN : Talmudim literally, it means, students, but I think of it as students of the rabbi. Epstein would say to his patients, "I want you to study your family," and somehow he managed to generate such a lively atmosphere of intellectual inquiry that everyone would get very involved. Externalization has the same ability to reduce emotionality and put people into a position of inquiry about the effects of the world upon them, while highlighting the intellectual possibilities of something new. It gives families the idea that the enemy is outside them and that family members are all okay, banded together against outside forces. I think that's very clever and very good.
FTN : So you've assimilated these various influences, but do you think your therapy has really changed very much?
MINUCHIN : Theoretically, I do what I have always done. I still look at the way in which the current transactions in a family support conflict. I am always saying to people, in one way or another, "There are more possibilities in you than you think. Let us find a way to help you become less narrow." But the ways that I say that today are less dramatic than they used to be. I ask more questions and give fewer prescriptions.
FTN: As you look at the way family therapists practice today, what most disturbs you about the direction the field is taking?
MINUCHIN : Let me give you a little roundabout answer to that question. I think that what therapists do is to make people respond to the tools they use. So if my favorite tool is the question, "Imagine that one day the problem has disappeared," then I will need to create an articulate patient that responds to this tool. The same is true of externalizing questions. I remember seeing Michael White do a very masterful session of narrative therapy, but it was like watching a sheep dog at work. He kept pushing people through a series of constructed questions into the groove of seeing their stories in the more positive way that he wanted for them. The therapist changes the old story and convinces the client that the new story is more true than the old. We all offer our patients a language, and we say, "Let's begin to see your life in this language, and I will give you solutions in this language." I do it. Everybody does it. What disturbs me now is that, as a field, we have gotten so interested in these therapeutic techniques and our particular language that we are paying little attention to the family therapist as a system and the therapist as an instrument of change.
FTN: Why do you think we have gone in this direction of what you call the "noninterventionist, restrained" therapist?
MINUCHIN: Some talk about doing a more "respectful" therapy that does not impose the therapist's biases. But I don't think it has anything to do with being more respectful of clients. I think it has to do with changes in social outlook. As citizens of this pessimistic society, therapists have lost their optimism and just have fewer expectations of effecting changes.
FTN : Does that include you?
MINUCHIN : No.
FTN : How did you manage to escape?
MINUCHIN : I grew up as the child of immigrants in a world that was expanding, where people felt that, through hard work, you could realize your dreams and control your destiny. To many people today, those beliefs seem naive. Maybe I am still a part of the 19th century. But I think it is also important that I stopped thinking of myself as a family therapist years ago and became interested in how the skills of systems therapists can be applied in the larger world. I went from thinking about the small unit of the family to thinking about the possibilities of affecting larger institutions. So by working in a field in which there are new possibilities, I still am optimistic. I am exploring with the Department of Mental Health in Massachusetts some ways of making home-based therapy more effective, which is the kind of challenge that I love. Probably if I were working only as a therapist, then I would need to respond to the constraints of the market just like everybody else. I would be tinkering with alternative therapy approaches that are easier to use or simple methods in which you can train people more cheaply.
FTN : We've been talking about trends in the therapy world today. I see a lot of therapists growing more interested in the connection between spirituality and psychotherapy. Is that a connection that interests you?
MINUCHIN : Not especially. My whole life I have been interested in logic and order. I have always been a very politically involved person. Maybe it comes from being Jewish, but being concerned about the underdog has always been important to me. I suppose my version of spirituality is connected to the dream of social justice. The kind of spiritual thing that you seem to be talking about has not been a big part of my life. Maybe that's part of my limitations.
FTN: How do you see your relationship today to the field?
MINUCHIN : I used to influence the field from the center. Now I do it from the periphery. I am now an elder. I support other people who are doing interesting work. I think it is part of being an elder to be a critic. I also think an elder is the carrier of the oral history of the field, so I feel bad when young therapists don't acknowledge the influence of people like Murray Bowen, Virginia Satir, Jay Haley, Carl Whitaker and Lyman Wynne.
FTN : Do you feel satisfied with life at age 75?
MINUCHIN : I thought that at 75 I was going to retire and become a full-time grandfather. But retirement is not a comfortable niche for me. Other people at 75 find that this is a time to paint, to play the piano. But that is not enough for me at this point. Pat and I have moved to Boston to be near our children and our granddaughter. My relationship with my granddaughter is very, very special. So there is renewal in that. But I am a person who likes to help other people. 1 don't find it useful to look too much at the past or way ahead to the future. I relate to the immediacy of the present. Even though financially we are okay, I need to work in order to maintain myself intellectually and because I love it. After all these years, if a family calls and wants to come to therapy with me, I still love it.
Richard Simon, Ph.D., is the editor of The Family Therapy Networker.
by Mary Sykes Wylie
ACCORDING TO AUSTRALIAN THERAPIST MICHAEL WHITE, a disconcerting effect of his new celebrity on the international therapy conference circuit is the recurrent experience of getting off a plane, being met by a workshop sponsor and told something like, "We sure have a real humdinger of a family for your live consultation. Oh, and by the way, about 500 people have signed up to watch." Whereupon White, the most visible representative of what is loosely called the "narrative method" of therapy, is plunked down in front of an impossible situation, while the audience waits breathlessly for a therapeutic miracle. White, who finds the hoopla attached to his new status puzzling, denies that there is anything magical about what he does. He says he is just very "thorough," very painstaking, and that "it's silly that people expect to get a good idea of this kind of work by setting me up in one meeting with the most complex situations they can find." Then he adds, "Certainly, the idea that I've got all the answers doesn't fit the spirit of the work."
Nonetheless, over the past decade, White has developed a worldwide following of both senior therapists and neophytes on several continents who insist he has something vitally important to say that the field needs to hear. But it can hardly be his therapeutic style that explains his elevation to the ranks of the illuminati. Watching him in session is a far cry from seeing one of the recognized lions of clinical performance sweep grandly into the middle of a dysfunctional family circle and in one session transform it into a little kingdom of love and harmony, while being wildly entertaining in the process. Far from it. His pace is measured, even monotonous some find it maddeningly slow the therapeutic persona respectful, solicitous, inquisitive, slightly donnish, almost deferential, the circuitous language an eccentric mix of the folksy and the politically correct. It is hard to imagine the following questions appearing in any psychotherapy textbook: "Do you know how you got recruited into these habits of thought that have been so capturing of your life?" "What skills have you developed as a couple that allowed you to hold on to your relationship in the face of adversity, and in spite of the politics of heterosexist dominance and ageism that marginalize your ways of being?" "What's it like for Anorexia Nervosa, which has been pulling the wool over your eyes, to witness these recent, more positive developments in your life?"
During sessions, White hunches down in his chair over his notes he seems almost to recede from view. He almost never asserts anything, rarely utters a declarative sentence, just patiently asks questions, hundreds of questions, often repeating back the answers and writing them down. Like an archaeologist, White sifts through the undifferentiated debris of experience for minuscule traces of meaning the tiny, precious shards of struggle, defeat and victory that reveal a life all the while doggedly taking notes, even occasionally requesting the speaker to slow down so he can take it all in.
At the same time, there is a startling tenacity about the process, a kind of polite but unshakable insistence on participation, a refusal to let people off the hook, even after hours and days of non-response long silences, embarrassed shrugs, parrot-like reiterations of "I don't know." White will not allow the people who consult him to slip away into the sad night of their misery. He simply will not give up.
In one session, for example, the parents of a deeply shy and isolated pre-adolescent girl, are trying to coax her away from her perch in front of the television and go walking with her father. But the girl's reluctance is such that even when she does consent, she dawdles so that her father says he must then take a second walk in order to get any exercise for himself. He is disheartened and wonders if the effort is worth it. In this segment, White tries to get a statement of feeling from the girl herself. It is uphill work. White asks, "Do you have different paces of walking? A snail's pace? A tortoise's pace?... Are you faster or slower when you go walking with your dad?" After a long pause, she murmurs, "Probably slower." "Probably slower," volleys White. "That means you do have more than one gear. [Do you walk more slowly] because you don't want to go walking with him?" "I don't want to do it," she says finally.
Ignoring this response, he asks her how she could help her dad work out what to do abandon their walks together or persist. She yawns hugely. Building on a microscopically tiny advance in the girl's life emerging earlier in the session (when he had elicited from her a barely spoken acknowledgement that she might like to be "taking more initiative in life, rather than being a passenger") White asks, "What would you like to do with your dad that would fit with this new direction of yours?" a "new direction" that would have been invisible to anyone but White. She mumbles "Go walking." "Going walking would that fit this new direction?" he pushes. "Fits," she barely murmurs. "It does fit," White continues enthusiastically, "So would you like him to keep on trying to go walking, or would you like him to stop?" "Hmmm, hmmm, hmmm," she replies. "You have to say what you'd like," says White the closest he comes to making a demand. "Keep on walking," she finally answers. It is an achievement, says White, because she has determined that the decision to keep on walking "fits more with self-care than self-neglect." By the end of a later session, while she doesn't exactly seem as "bright, open, chirpy, communicative, chatty" as White suggests to her, she is clearly much more engaged. She looks at him out of the corner of her eye and smiles shyly, and even produces some whole, unequivocal answers (short ones) to his questions, obviously delighting her parents. Their daughter, who had rarely been able to identify any of her own likes, dislikes, desires, interests, purposes, who had rarely even talked to anybody, has begun, however hesitantly and timidly, to say out loud what she wants for her life.
This kind of work may look to some practitioners like cutting grass blade by blade, but it is probably more like panning for gold in an overworked stream long since abandoned by other prospectors. Slowly, meticulously, steadfastly, White sifts through the sandy deposit, patiently extracting almost invisible flakes until, by imperceptible increments, he has amassed an astonishing mound of precious metal. Clearly, White's reputation rests less on therapeutic bravura than on the extraordinary, transfiguring moments that occur in his practice epiphanies that take place with people most therapists would write off as hopeless.
Mary, a young woman horribly abused as a child, appears in White's office anorexic and bulimic to the point of near death, suicidal, actively hallucinating, unable to leave her house or talk with anybody except her husband. Discharged from her last psychiatric hospital with the medical prognosis of death by starvation within a few weeks, she is brought in to therapy by Harry, her despairing husband, and spends the session curled up in a fetal position, rocking to and fro on the floor in the corner of White's office. "She would not answer any questions, and I did not get to see her face for the first three sessions," says White.
When Mary does not respond to his gentle, persistent probing, he asks her husband to pose the questions to her, and when she still remains silent, White wonders aloud if Harry would like to "speculate" on what her answers might be. At the end of the third session, after one of White's typical questions what did Harry think her answer might be if he asked her how she had been recruited into such self-hatred she moves a little and whispers something into her husband's ear. "For that one instant, hateful-ness did not speak to Mary the truths of her identity," says White, "and from then on, she began to speak more and more in a different voice for herself."
With time, this almost unbearably fragile woman has acquired a small puppy and talks about how sweetly the dog licks her chin in the morning at first, she had thought she was so hateful the dog would perish in her care. Once terrified into paralysis by the possibility of personal rejection, some months later she has organized an outing for herself, her husband and her in-laws. She has reestablished a relationship with her mother and, mir-abile dictu, she has gone, by herself on the train to a shopping mall, walked into a coffee shop, ordered a cappuccino and drunk the whole thing. When White asks what this event tells her about her life and her identity, this woman, who has believed she was worthy only of death, says in a small, frail, but unwavering voice, "I would like to do something for my own self."
In Mary's life, these ordinary events are miracles, of which nobody who views the tape can have the least doubt. Still mysterious, however, is what White has done that has made the difference. By now, the theories and methods that have given White and David Epston, his New Zealand colleague, an international following are well-known, and they clearly figure in Mary's case. Through "externalizing conversations," for example, White has helped Mary think about her anorexia nervosa and the attendant "self-hate" as hostile, outside forces in her life, not at all intrinsic to her nature and personality "When you were drinking the cappuccino," he asks her, "did you or Anorexia and Self-hate have the upper hand?" "I had the upper hand," she answers softly, but with something that sounds very like pride. When anorexia and self-hate are no longer inherent to her very being, she can fight them without fighting herself; she does not have to die in the act of resistance.
White and Epston also look for evidence of what they call the "unique outcomes" in people's lives and the "counterplots" associated with them seemingly ephemeral, often forgotten experiences that contradict the dominant story of abnormality, deficiency and failure. "There is always a history of struggle and protest always," says White. He finds the tiny, hidden spark of resistance within the heart of a person trapped in a socially sanctioned psychiatric diagnosis "anorexia nervosa," "schizophrenia," "manic-depression," "conduct disorder" that tends to consume all other claims to identity. White liberates little pockets of noncooperation, moments of personal courage and autonomy, self-respect and emotional vitality beneath the iron grid of lived misery and assigned pathology.
Even in Mary's history, for instance, in an almost unimaginably bleak and brutal childhood, he finds the saving remnant of another, untold story. "In her darkest hours," he says, "at a time when she was being sexually abused by several people, she used to run away into the woods to the same tree whose trunk she could just stretch her arms around she said she could hear the tree speak to her. She had found a living thing that didn't abuse her, a simply fantastic achievement." Such heartbreaking moments of spiritual valor are hints, in White's credo, of Mary's subtle, half-forgotten, almost unrecognized dissent from the dominant story of abuse and self-hatred, official psychiatric labeling and social ostracism. When people like Mary remember and speak about these tiny saving fragments of formerly lost experience, says White, they also relive and perform them as well transforming meaningless autobiographical aberrations into the palpable material of new stories, new lives.
IN EVERY KNOWN CULTURE, PEOPLE give meaning to their individual stories (what happened to me as a child that affects me now, how I met my husband, why I got sick and why I got well) by organizing them according to a time-line with a beginning, middle and (perhaps hypothesized) end. In this way, we create our personal history. White's therapeutic method may depend more on exploring people's history than any other current approach, barring psychoanalysis but with a profound difference. Whereas practitioners of the latter delve into personal history like surgeons looking for hidden tumors, a lump of pathology in the far distant past, White seeks out the healthy tissue, the protective antibodies, which he always finds. For White, people's present lives cannot be reduced to their diagnoses, which are much too tight, too confining to contain the capacious possibilities revealed in their histories.
And, unlike other therapists who may take history into account, but only as individual case histories, White both brings history with a capital 'H' into the lives of the people he sees and, in turn, brings them into the broad current of historical time and place. He might be described by an Eriksonian therapist as breaking the "trance" imposed on people by the powerful forces of history and culture, making visible the invisible pattern of ordinary humiliations and terrors, routine tyrannies and acts of violence that comprise much of "civilized" life.
John, for example, a therapist in training, came to see White because, says White, "he was a man who never cried" he had never been able to express his emotions and he felt isolated and cut off from his own family. As a child, John had been taught, both at home and at his Australian grammar school, that any show of gentleness or "softness" was unmanly and would be met with harsh punishment and brutal public humiliation. White asks John a series of questions that are at once political and personal, eliciting information about the man's "private" psychological suffering and linking it to the "public" cultural practices, rigidly sexist and aggressively macho, that dominated his youth. "How were you recruited into these thoughts and habits [of feeling inadequate, not sufficiently masculine, etc.]? What was the training ground for these feelings? Do you think the rituals of humiliation [public caning by school authorities, ridicule by teachers and students for not being good at sports or sufficiently hard and tough] alienated you from you own life? Were they disqualifications of you? Did these practices help or hinder you in recognizing a different way of being a male?"
Having clarified the social context of John's alienation from himself in the "dominant men's culture," White helps him acknowledge and appreciate his ability to resist it and "reclaim" the other stories of his life, the other selves and ways of being gentle, kind, loving that he had managed to keep alive, though hidden, in spite of his tormentors. White asks what it would have been like for John, as a young boy, to have himself as a father. That little boy would have loved it, John replies. It would have meant having a father who talked with him, who showed him love, gentleness, kindness; it would have meant being accepted for himself; it would have meant having more fun. "I try to do that with my kids, now," he says.
Then one of those White epiphanies occurs. While John is still in a kind of reverie about the little boy he had been and the father he had needed, thinking aloud about his own sons and the father he tries to be affectionate, emotionally open, warm, playful White asks him what is happening to him right then, in the session. A look of wonder comes over John's face, and he says, "It's okay . . . It's okay to be that way. It's alright," and for the first time in his adult life, he begins to cry. "Yeah. Wow. Whew," he says over and over, blowing his nose. "Yeah, thanks. That's really strong, that's really powerful. Yeah, I did resist it somehow. This is rare. Yeah." And it is rare, to see two trajectories meet the abstract knowledge about the power of cultural conditioning, and the gut realization of what that conditioning has meant in one's own life.
Even more striking is White's ability to cut through the maze of social opinion, psychiatric ideology and individual indoctrination that reinforces the very symptoms of people labeled "chronic" mental patients. Often, these people, particularly diagnosed schizophrenics, have what sociologist Erving Goffman referred to as "spoiled identity," and, says White, "perceive themselves to have failed rather spectacularly in their attempts to be persons," that is, in their attempts to force themselves to behave, feel and think along stereotyped lines considered "normal" and "healthy" in the dominant culture. The cost is often excruciatingly high for people already particularly vulnerable, for biological and/or psychological reasons, to emotional stress.
According to White, the hallucinatory voices heard by people diagnosed as schizophrenic, telling them they are sick, helpless, crazy, deranged outcasts, bear an uncanny resemblance to common negative cultural stereotypes. Men's voices, for example, tell them they are wimps and weaklings, while women's voices attack their sexuality calling them sluts and whores. In both cases they harp relentlessly on the hearer's stupidity, worthlessness, social unacceptability and failure to measure up to social norms and rules. All-knowing and opinionated, the disembodied, magisterial voices speak in tones of great authority the voices of correct opinion and unimpeachable judgment (one imagines a malevolent Dan Rather or Peter Jennings) that the hearer would have heard repeatedly in the "real" world.
What perplexes White isn't the odd parallelism between the "internal" voices and "external" social messages, but the difficulty most people have seeing the connection. "Although it seems relatively easy for us to entertain the idea that much of what we think and believe, and much of what we do, is informed by culture," he said in a recent interview, "for some reason it seems rather more difficult for us to entertain the idea that psychotic phenomena are similarly informed; that regardless of etiology, the content, form and expression of psychotic phenomena, such as auditory hallucinations, are shaped by culture."
In his own terms, White "deconstructs" the dominant authority by taking people's voices very seriously accepting their validity as hostile forces "out there" collaborating with the person to unmask them as the lying scoundrels they are and develop strategies that will undermine their power. "What is it that the voices are trying to convince you of?" he asks. "What are they trying to talk you into? Are these voices for you having your own opinion, knowing what you want, or are they against you having your own opinion? Does the confusion caused by the voices contribute to their goals for your life, or yours?"
Jane, for example, steadily regressing at home with a diagnosis of schizophrenia, heavily medicated, unable to leave her parents' house for years, has recently moved into her own home, after working with White. She says that the six hostile voices that used to harass her constantly have been reduced to one, which seems to be on the defensive. "They used to dominate my life totally," she remembers, "told me I had to stay in bed all the time, that I was queer, that nobody liked me, that I didn't deserve to have any company." As he does ordinarily with people who have experienced psychotic episodes and suffer hallucinations, White equipped Jane with transcripts of their sessions together, along with various other "documents of identity" (i.e. written "charters" celebrating the person's strengths, capacities and current progress and intended to be shared with family and friends), which protect her from her hostile auditory ensemble. Whenever one of the voices threatens to have a "tantrum" or otherwise attack her, she reads a transcript and "I get a picture of what I really am like ... a much better picture than the voices [give me] . . . and I'm not so scared. [I can see] that I'm a nice person, attractive, good personality, independent.. . [It] shows through." The action of reading the transcript makes the voices just "go away," says Jane, though they go with much grumbling, in ill grace and it is hard not to envision a swarm of evil, wrathful little trolls retreating before a determined woman wielding a particularly effective magic talisman. Together, Jane and White have transformed a hopeless story with a foreordained ending into a dramatic epic, in which Jane is not a victim, a defeated mental patient, a crazy lady, but a hero engaged in a valiant struggle against a formidable enemy.
White has been roundly criticized by the psychiatric profession for reinforcing hallucinations and failing to help people "own" and "integrate" the voices to recognize that they are part of themselves, and take responsibility for having, in effect, invented them. White rejects such criticism because he rejects the foundation on which it is based that every human being comes outfitted with a single, unitary, core-personality, the center and source of all human meaning. Those who admit to hearing tyrannical voices coming from "somewhere else" break all the rules of self-containment, self possession, self-definition, self-control, self-determination that are the earmarks of "healthy personality development" in our culture. This view, White contends, is far less an objective description of human nature than a culturally determined prescription for the way people should be, not to mention an implicit damnation of people who don't measure up. "This work is not about people discovering their 'true' nature, their 'real' voice," says White, "but about opening up possibilities for people to become other than who they are."
For White, the personal is, and must be, deeply embedded in the political. The stories of the people he sees John, Mary, Jane are of personal struggle and transcendence, no doubt, but in White's eyes they are also unmistakably tales of power politics, the "politics of local relationship," as well as the larger social politics of gender, class, professional and institutional dominance. Mary's anorexia is both the result and the expression of the damage done to her by the misuse of power by her family, by a society that countenances male domination of women and children, and also by the mental health establishment that defines her life, reducing her to a kind of psychiatric object a "case" of anorexia.
White's thinking is legions away from the clinical Zeitgeist suggested by the standard family therapy metaphors of cybernetics or systems theory, suggests Gene Combs, codirector of the Evanston Family Therapy Center in Evanston, Illinois. "You have to think more in anthropological, sociological metaphors; you need to have pictures and ideas in your mind about how social and moral values, political and intellectual practices are transmitted in a culture, and how they influence the way people are. When Michael talks about stories, he's not just talking about individual anecdotes, but the story of Western civilization and how it has already 'storied' our lives for us before we were born."
WORDS ARE SO IMPORTANT," White said in an interview with The Family Journal last January. "In so many ways, words are the world." Yes, but so are the people who utter them. And it is hard to avoid the sense that the White persona is a very powerful element in the therapeutic equation. He dislikes the terms "client" and "intervention," which suggest to him the sort of expert domination of people in therapy that reproduces the social control and disqualification they already experience outside. And yet, in spite of a distinctly unshowy clinical manner in sessions, he is clearly the director of the ongoing drama.
Sometimes, the stream of formulaic questions intended to elicit externalization and re-storying can seem relentless, almost conveying the impression of a benevolent salesman hammering away at a hesitating customer: "Come on, you know you are better than you think you are, more than this paltry story you've been given, so when are you going to get with the program, take the deal, sign the papers, buy the product?" It's as if he is trying to convince them not only to buy themselves but to consider the sale as good a deal as he does. He clearly believes in the people who consult him more than most others do more, probably, than many of the therapists observing and certainly more than they believe in themselves. In one live interview with the family of an 18-year-old boy involuntarily hospitalized by the legal system for setting fires, he spends a major part of the session following a line of questions apparently aimed at building a greater sense of personal agency in both the boy and his 12-year-old sister (herself hospitalized for suicide attempts), while helping the two of them get along better. It is not an easy job even getting the siblings, both following their own eccentric and antagonistic orbits, to respond to a line of questions about their accomplishments, much less focus on what they might have in common. Nonetheless, White pries from each (buttressed by appeals to the parents) admissions of small, but legitimate "new developments" related to their increasing maturity: Mike now takes a shower "at his own suggestion," and helps his mother with kitchen chores; Debbie keeps her room neater and can handle more school classes.
In a segment that looks like the equivalent of pulling seriously impacted wisdom teeth, White manages to get from brother and sister, syllable by syllable, grudging concessions that each notices the changes in the other, and approves of them, sort of. As usual, White is only asking questions not, presumably, "imposing expert knowledge" on the people he is interviewing. But, he is generating the lion's share of talk, energy and conviction, and it is hard not to see at least the shadow of an unflagging preacher cornering the town sinner and extracting from him an admission that, yes, he probably does feel an attack of salvation coming on.
In the question-and-answer period that followed this live interview, one observer said he had found White "directive" and "suggestive" in his questions and noticed that he had "blocked" Mike from saying things and "interrupted" him on several occasions. Was this an important part of the narrative method as White practiced it? White answered that what looked like direction, suggestion and interruption was, in fact, a form of differential attention. He was not "blocking" some material as much as he was "attending to" other material the "sparkling facts" and "unique outcomes" that had been totally ignored or quashed in the family's dominant story of sickness and failure. As powerful coauthors and coconstructors of the realities that people forge in the process of therapy, White suggested, clinicians have a rigorous responsibility for what they choose to select from the multitudinous possibilities given them in session, and for whether the stories they help create are newer, more helpful, more healing or just regurgitated chapters from an old chronicle of despair: "Old dominant, problem-saturated stories are not good for you there's not one old story that's good for you, despair is not good for you."
But old stories sometimes die hard people have been imprisoned in them too long. Coming into the light of a new story can be blinding at first It isn't likely, suggests White, that people will always be able to leap immediately to a new possibility, to instantly invest old, half-forgotten, devalued experiences with new meanings. If therapy with White is a process of coauthoring new stories, many of the people he sees could be said to suffer from paralyzing writer's block they sometimes need to be nudged out of their immobility, persuaded to fit those first awkward words to experience, embarking on the reflective reverie that begins with "Once upon a time . . ."
The therapist who wishes to be coauthor, or creative agent and impresario, cannot hide behind passive silence or pretend neutrality. "There is no way of asking neutral questions," says White, "and you can't just drop a question when they don't answer right away and go on to something else. I'm very much the coauthor at first, but gradually, the person becomes far more active about articulating what these new developments mean in their lives. They become fascinated with neglected elements of their own stories, and as they step into that fascination, my role diminishes. I ask fewer questions, while they come up with ideas, notions, solutions I never would have imagined, unravel mysteries in a way I never could do." As the "alternative plot" gets rooted in people's own memory and imagination, says White, the story "runs away from me, it takes over, it has no end . . . and I can't know in advance whether the story will be beneficial or not. Only the people with whom I am working can determine this, and I keep encouraging them to do so."
Although White claims that Western ideals of individualism, self-determination, personal authenticity have become tyrannical measures of human worth in our society, he seems particularly good at producing these old-fashioned, perfectly unexceptional therapeutic outcomes. In fact, the people he sees seem to believe that his practice of nurturing a freer, more robust feeling of personal agency and individual identity is what distinguishes his therapy from the multitude of other treatments they have had.
Diane, for example, hospitalized several times for anorexia nervosa, compares the repressive, distrustful hospital environment with her experience of being treated by White. In the former, where food intake was rigidly watched, toilets were locked so that food couldn't be flushed away, rooms were searched if inmates didn't gain weight and therapists tried to extract from her admissions that she must have been sexually abused as a child, she felt degraded, brain-washed and rebellious "The way they treated you made you feel as if they had all the answers and you were nothing." White, on the other hand, "helps me along the way, but I'm the one who chooses what I want to eat; I'm the one who's got control. In the hospital I was forced to eat, and [when I gained weight] I wanted it off as quickly as possible, whereas with him, I did it myself, when / was ready, and it will stay on." If this isn't self-determination, what is? White words it differently, arguing that such responses "are the outcome of people stepping into ways of being and thinking that bring new options and possibilities for action." Still, a rose by any other name ...
Even people considered to be chronically psychiatrically ill and particularly at the mercy of the Western cult of individual selfhood, according to White, seem to emerge from his therapy with a much expanded sense of... individual selfhood! They also have a greater sense of community, White points out, because they have begun to engage family members, friends and others in the "renegotiation" of their life-stories making them witnesses, so to speak, to their changed realities. Still, White seems to have an inside grasp of the profound demoralization felt by people who are not only denied agency for their own lives, but told constantly that they are unworthy of having it so they become nonpersons to themselves. "I used to try to be everyone's [else's] person," says James, who holds a handful of diagnoses, including schizophrenia, schizo-affective disorder and manic-depression, and has suffered, as he puts it, from the judgmental, unrelenting "expectations" of others (including his own tyrannical voices) to get a job, to exercise, to give up smoking, to act "normal," to behave, to be the person others "expected" him to be. With White's help, he says, he could learn to say "no . . . Michael hands it over to me to decide what I want. He empowers me, he doesn't take over the reins for the management of my case. He's somehow very clever in allowing me the freedom to be the person I need to be, while also managing myself so I don't go overboard."
Gene Combs describes a tape in which a woman diagnosed as schizophrenic compares the hospital chart that had accompanied her for years on a mental ward with White's case notes based on his sessions with her. "When she read the hospital chart, she said she felt like a chronic, medicated schizophrenic, like someone stuck, with no hope, not worthwhile in the eyes of other people," says Combs. "When she read what Michael had documented, she saw clear movement in her life. She felt like a valuable person who lived a meaningful life that she was making even better. She said she felt respected." What really impressed Combs, however, was the difference on her face, in her voice and in her bearing when she talked about the hospital chart on the one hand, and White's notes, on the other. "When she talked about the former, she looked like a chronic mental patient; when she talked about Michael's story, she looked like a person."
This transfiguration seems at bottom a mystery, which challenges notions of the "unitary self" certainly, if that self is predetermined by culture and politics, and if it is a static, hard-wired entity of predictable operations and predilections. Is this newly transfigured "self" more "real," more "true" than the old one? Will this new self be more successful than the old? "I don't know what these stories are going to bring with them," says White. "I can't know whether they will be beneficial or not all I can do is keep on asking the person what the effects of the story are, asking him or her to judge it. I can't assume anything there are always lots of surprises."
In "The Power and Culture of Therapy," White quotes social philosopher Michel Foucault's words, which probably come close to White's own views on the issue of selfhood: " "The main interest in life and work is to become someone else that you were not in the beginning. If you knew when you began a book what you would say at the end, do you think that you would have the courage to write it? What is true for writing and for a love relationship is true also for life.'"
WHITE'S IMPACT ON THE PEOPLE he sees cannot be explained solely as the product of an interesting theoretical worldview that makes its way into some interesting new techniques. His work, perhaps like that of any gifted therapist, any inspirational spiritual leader, any talented artist, depends upon something like what 18th-century English evangelist John Wesley called "the heart strangely warmed." In White's case, there is no question that he is literally "warmed" by the people he sees, that there is a degree of devotion and loyalty to the people who consult him, a vital faith in them and their possibilities, and he insists upon their knowing it. When Mary tells him how she accomplished the triumph of her solo trip to the coffee shop she "took Michael and the team with her" in her mind, she says, when she boarded the train for the mall his own emotional response is as vivid as her narrative. "What do you think this does to my life, to know you have invited me and the team into your life this way, and to hear about you going to the coffee shop how do you think I'm feeling right now?" "Happy?" Mary asks faintly, after a pause. "More than happy," says White. "Joyful."
Probably all therapists worth the title feel privileged to be doing the work they are doing; many also feel gratitude, occasionally even awe, at the willingness of vulnerable and defensive people to trust their lives and sorrows to virtual strangers. Few, however, can have such a radical sense of solidarity with the people who seek their help, can consider the therapeutic relationship with them so profoundly sustaining and transformative of their own lives as does White, with every person he sees, regardless of how apparently unreachable and disturbed, how ground down by years in the psychiatric mill. "Inevitably, we change each other's lives, often in ways that are hard to speak of," White said in a recent interview. "These interactions are life changing for me ... In saying this, I am not talking of anything ingratiating,.. . And I am definitely not proposing something that has some strategic aim, like a one-down position for therapists, which I believe to be ingenuine, patronizing and disqualifying."
This attitude tends to raise skepticism, partly because it suggests an almost superhuman single-mindedness and integrity. Doesn't he ever fake it? No, according to colleagues who have worked closely with him. His vision of the people he helps, of the work he does, is apparently uncorrupted by the normal doubts, exasperation, weariness, disappointment and ordinary ill-temper about clients vented by even the most dedicated therapists from time to time. It is, for example, a point of deepest honor and professional integrity with him not to speak differently in private, entrenous with other therapists, about the people he sees than he will in front of them. This is part of the famous White "congruence" that his colleagues describe, which is not only a matter of political correctness undermining professional hierarchies, equalizing the relationship between therapist and client but a matter of utmost importance to the morality of the entire therapeutic enterprise.
"There is nothing about him that turns on and then turns off," says David Moltz, medical director at Shoreline Community Mental Health Services in Brunswick, Maine. Moltz recently attended a three-day workshop featuring White, who did a live consultation with a family in which the father, thought Moltz, was "completely impossible." But there was never a moment, Moltz said, when White indicated any remote difference between his apparent feelings about the family how he appeared to them and his "real" feelings; there was no moment afterward, says Moltz, when he let down his guard and said something like, "Oh, my God were they something else!" Says Moltz, "He has no guard to let down; there are no hidden corners or agendas ... no second order of business, no waiting for the family to leave before you say your real feelings." What you see is what you get.
A particularly revealing story about White and his work is one he tells himself. As a young man, before formally taking up the profession of social worker, he worked as a gardener for what was then politically incorrectly called an "old folks home." Paying no attention to official instructions from the institution's administrator, he collaborated with the elderly inhabitants to create the gardens they wanted in front of their units. "They would come out and tell me where they wanted to plant shrubs, and how they wanted things pruned," he recalls. "It was great because I didn't know much about gardening and they were teaching me." Eventually, White was fired for what might be called "client-centered gardening," but he remembers the experience as at least as important as other more personal or professional biographical tales.
In a sense, White has remained a gardener in the work he does now; doing therapy, like planting and tending a garden, is a matter of methodical attention, small steps and hard labor digging, spading, pruning, watering, mulching. Good gardeners are both practical and visionary. They don't expect to turn the desert into a Garden of Eden, at least not overnight, but they are optimistic enough to believe that with time and effort, and the blessings of rain and sun and decent soil, they can collaborate with nature to transform even quite desolate spots into little oases.
Good gardeners are forced to be modest. They can provoke and prompt and support nature in certain directions, but they can't control it they can't make anything happen. An acceptance of their own limitations is perhaps part of the ethic of gardeners, along with a renunciation of grandiosity and a respect for the self-created, self-sustaining rhythms of living things. In a sense, White's ethic of therapy is not dissimilar. It is an ethic that eschews the grand therapeutic gesture implicit in the myths of the one-session cure, the personality makeover, the eradication of mental "disease" through biochemical wizardry. Like a gardener who knows that even the most elaborate landscape must be tended step-by-step, plant-by-plant, square foot-by-square foot, White carefully nurtures the small triumphs in the lives of the people he sees, honors the transient moments of competency, initiative, resoluteness.
These marginal stories are usually neglected in the grand schemes of psycho-pathology as accidental, insignificant epiphenomena that are too small to count, but they are the seeds and the soil of human transformation. "People neglect the landscapes of their own lives they think they are uninteresting and dull," says White, "but I'm very curious about them, and I always find it interesting to hear people talk about themselves in ways they've never done before. I often find myself up against the limitations of my knowledge and vision, when I don't feel equal to the task, but the questions I'm faced with become the impetus for further explorations that extend the limits of what I know. I don't have any grand account of the work I do I don't think it is so fantastic, it's not heroic it just addresses a few things. We don't need to teach people anything new, just help them reach stuff that's already there."
Mary Sykes Wylie, Ph.D., is senior editor of The Family Therapy Networker.
by Babette Rothschild
Much as we don't like to admit it publicly, it's an open secret among therapists that the road to recovery from trauma can be fraught with clinical missteps. In the past few years, I've frequently been consulted by highly competent colleagues who were dumbfounded by the speedy decline of clients contending with traumatic memories.
Eight of these clients included a nurse, a businesswoman, a salesman, a therapist, and other men and women who'd functioned relatively well prior to therapy. Yet after attempts to address their traumatic pasts (including rape, mugging, childhood abuse, and household fire), three were hospitalized, two went on disability, and the rest endured debilitating flashbacks, panic attacks, or other symptoms of dysfunction.
All the therapists involved were experienced and well trained. Each one favored a different, theoretically sound, therapeutic modality (psychodynamic psychotherapy, EMDR, body psychotherapy, and cognitive-behavioral). None was irresponsible. So what exactly went wrong?
In each instance, I eventually discovered, traumatic material was addressed before the client was equipped to manage it. These therapists were proceeding in a manner consistent with the usual aim of psychotherapy: helping a client open up. They knew very well how to call the genie of traumatic experience out of the bottle, but as is all too common, they didn't know how to get the genie back in.
My approach to trauma work, which is more cautious, is rooted in an experience I had in college. A friend asked me to teach her to drive--in a new car my father had just given me. Sitting in the passenger seat next to her as she prepared to turn on the ignition, I suddenly panicked. I quickly realized that before I taught her how to make that powerful machine go, I had to make sure that she knew how to put on the brakes.
I apply the same principle to therapy, especially trauma therapy. I never help clients call forth traumatic memories unless I and my clients are confident that the flow of their anxiety, emotion, memories, and body sensations can be contained at will. I never teach a client to hit the accelerator, in other words, before I know that he can find the brake.
Following this principle not only makes trauma therapy safer and easier to control, it also gives clients more courage as they approach this daunting material. Once they know they're in the driver's seat and can stop the flow of distress at any time, they can dare to go deeper. Developing "trauma brakes" makes it possible for clients, often for the first time, to have control over their traumatic memories, rather than feeling controlled by them.
My client Paula, for instance, first came to see me for problems in her marriage. She was in her mid-thirties and had three children under the age of 10. When she was a child, her mother had sometimes harshly beaten her. Paula still lived in fear of her mother's aggression, although now it took the form of yelling and criticism, rather than physical violence.
One morning, Paula came into her session pale, with her head bowed. Hardly looking up at me, she moved to her chair and crouched in it, shaking. I'd later learn that she'd just finished a searing telephone conversation with her mother.
Asking Paula about the source of her distress first thing would have let the genie of her traumatic past out of the bottle, increasing her distress. First I needed to help her calm down, to put her in charge of her somatic and emotional responses.
"You're really shaking, aren't you?" I said, drawing her attention to her body sensations. Sometimes this type of intervention is enough to help a client calm down, though for Paula it wasn't. "Y-y-ye-s," she replied with difficulty. "I s-sometimes s- shake a lot." A few seconds later, she was no longer able to speak and could only show me how fast her heart was beating by a rapid movement of her hand.
Paula was exhibiting symptoms of what neuroscientists call hyperarousal--a flood of adrenaline and other stress hormones that made her feel threatened and confused. The brain structures most involved in rational thought and memory were, practically speaking, out of commission. In neurophysiological terms, her sympathetic nervous system (which responds to situations of danger, threat, and stress) was in overdrive, giving her a pounding heart, a dry mouth, and muscle tremors.
To help a client when she comes as unglued as Paula was that day, it's useful to understand what's currently known about how the brain handles danger and emotion, especially in the limbic system and two of its major structures: the hippocampus and the amygdala.
The limbic system is survival central, the area of the mid-brain that initiates fight, flight, or freeze responses in the face of threat. (Paula was on the verge of freezing.) The amygdala and the hippocampus, part of the limbic system, are also deeply involved in responding to traumatic events.
The cortex, the more rational, outermost layer of the brain, is the seat of our thinking capacity and our ability to judge, deliberate, contrast, and compare. It's where most memory--traumatic and otherwise--is stored. The cool, rational cortex is in constant communication with the amygdala and the hippocampus.
The Early-Warning System
The amygdala is our early-warning system. It processes emotion before the cortex even gets the message that something has happened. When you smile at the sight or sound of someone you love even before you consciously recognize her, for instance, the amygdala is at work. Here's what happens: the sound of the loved one's voice is communicated to the amygdala via exteroceptive auditory nerves in the sensory nervous system. The amygdala then generates an emotional response to that information (pleasure or happiness, in this example) by releasing hormones that stimulate the visceral muscles of the autonomic nervous system and can be felt as pleasant sensations in the stomach and elsewhere. Lastly, the amygdala sets in motion an accompanying somatic nervous system (skeletal-muscle) response, in this case, tensing muscles at the sides of the mouth into a smile.
A similar process occurs with other types of stimuli, including trauma. When someone is threatened, the amygdala perceives danger through the exteroceptive senses (sight, hearing, touch, taste and/or smell) and sets in motion the series of hormone releases and other somatic reactions that quickly lead to the defensive responses of fight, flight, and freeze. Adrenaline stops digestive processes (hence the dry mouth) and increases heart rate and respiration to quickly increase oxygenation of the muscles necessary to meet the demands of self-defense.
The amygdala is immune to the effect of stress hormones and may even continue to sound an alarm inappropriately. In fact, that could be said to be the core of post-traumatic stress disorder (PTSD)--the amygdala's perpetuating alarms even after the actual danger has ceased. Unimpeded, the amygdala stimulates the same hormonal release as during actual threat, which leads to the same responses: preparation for fight, flight, or--as with Paula--freeze. In PTSD, this happens regularly, despite outward evidence that these responses are no longer needed. In sum, PTSD could be said to be a healthy survival response gone amok.
Why does the amygdala continue to perceive danger? What makes it possible for the whole body to repeatedly respond as if there is danger, when in fact the danger is past?
The Rational System
The hippocampus helps to process information and lends time and spatial context to memories of events. How well it functions determines the difference between normal and dysfunctional responses to trauma and normal versus traumatic memory. An example will help to explain.
In his book The Emotional Brain, Joseph LeDoux explains the survival response involved when encountering an object that looks like a snake. Naturally, the amygdala signals an alarm message, which sets in motion a series of reactions that culminate in the footstep halting in midair. The amygdala's communication travels at lightning speed. There's a second communication pathway that takes longer, eventually getting the message around to the cortex, where rational thought takes place. When the information "It's a snake!" reaches the cortex, it's then possible to evaluate the accuracy of the amygdala's perception. If the message was accurate and it is a snake, the halted step will freeze until the danger is passed, i.e., the snake slithers away. If, however, there's a discrepancy and what was thought to be a snake is discerned by the cortex to be a bent piece of wood, the cortex sends a new message to the amygdala, "Hey, it's only a stick," to stop the alarm immediately.
The hippocampus assists the transfer of the initial information--the image of stick or snake--to the cortex, where it's then possible to make sense of the situation. This is the normal way information is communicated, as long as the hippocampus is able to function.
The hippocampus, however, is highly vulnerable to stress hormones, particularly adrenaline and noradrenaline, released by the amygdala's alarm. When those hormones reach a high level, they suppress the activity of the hippocampus and it loses its ability to function. Information that could make it possible to determine the difference between a snake and a stick (or, as in Paula's case, past danger and current safety) never reaches the cortex, and a rational evaluation of the situation isn't possible.
The hippocampus is also a key structure in facilitating resolution and integration of traumatic incidents and traumatic memory. It inscribes time context on events, giving each of them a beginning, middle, and--most important with regard to traumatic memory--an end. A well-functioning hippocampus makes it possible for the cortex to recognize when a trauma is over, perhaps even long past. Then it instructs the amygdala to stop sounding an alarm.
This has critical implications for therapy. Safe, successful trauma therapy must maintain stress hormone levels low enough to keep the hippocampus functioning. That's why it's so crucial for both client and therapist to know how to "apply the brakes" in therapy--to keep the hippocampus in commission and return it to action as promptly as possible when the system goes on overload.
When and How to Apply the Brakes
Knowing when to apply the brakes is as important as knowing how . Therapists can know when by watching for physical signals of autonomic system arousal, transmitted by the client's body, tone of voice, and physical movements. When a client turns pale, breathes in fast, panting breaths, has dilated pupils, and shivers or feels cold, her sympathetic nervous system (activated in states of stress) is aroused. Stress hormones are pouring into her body, threatening the hippocampus with shut-down. These symptoms mean it's time to calm the client down.
When, on the other hand, a client sighs, breathes more slowly, sobs deeply, sweats, or flushes, her parasympathetic nervous system (activated in states of rest and relaxation) has been activated, and her stress hormone levels are reducing. Recognizing these bodily signals is invaluable to the therapist. Likewise, a client who learns to recognize them often gains a greater sense of body awareness and self-control.
Paula's Brakes
After identifying Paula's hyperaroused state, I asked her a few specific questions to narrow her focus. For some clients, paying attention to body sensations helps put on the brakes, but that wasn't the case with Paula, as I quickly found out. Her continued hyperarousal told me that her amygdala persisted in assessing danger. I needed to find another way to help her evaluate this situation, in this room with me.
I decided to see if I could directly engage her cortex using what I call dual awareness. If I could help her to accurately see where she was and whom she was with, she might be able to calm down. So I asked her, "Can you see me?" She replied with a nod of the head. "Clearly?" I could see her breathing slow a little and she managed to say, "Yes."
As Paula's arousal lessened, I asked for more information. "Tell me what you see. Describe me: What color are my eyes? What color is my hair? Am I having a good hair day or a bad hair day?"
Breathing slightly easier, Paula was now able to reply, "Your eyes and hair are brown. I think you're having a good hair day." We both laughed a little; laughter is great for calming the nervous system. I could see color returning to her face and she was shaking less.
To increase her body awareness and the connection between what we were doing and her emotional state, I asked, Paula to describe what happened to her shaking as she looked at and described me.
"It's less," she realized. But she was still shaking a bit, so we weren't through. On a hunch I asked if she felt threatened by me in any way.
"No," she said, "but don't come closer."
Her reply gave me a big clue. "Perhaps," I ventured, "I'm actually sitting too close to you. I'd like to try moving back a little. Would that be okay?"
She wanted me to move back a foot. When I complied, she exhaled sharply. I drew her attention to that response as well as another. "Something else changed. Do you know what?"
"I stopped shaking."
At this point Paula was much calmer, visibly to me and noticeably to her. Her cortex was beginning to discern that she was in a safe place, with a person who wouldn't harm her. It seemed that increasing the distance between us was useful for her, and I asked if she wanted to try increasing it more.
This time, she was more assertive, asking me to move back two feet. Then she was aware of physiological changes even before I asked. "I can breathe easier," she said. She also told me that her heart rate was much slower, nearly normal. But she complained that her legs felt rather weak, which is a common consequence of fear--that feeling of being "weak in the knees."
Increasing strength in her legs could help her feel more secure, so I instructed her to put weight on her feet and press them into the floor. "Do it as if you're going to tip your chair back, but don't actually do that. The point is to increase the tone in your thighs. When they begin to get tired, release the tension very, very slowly." That would insure that some of the tone remained.
As her thighs became stronger, Paula felt even calmer, and was able to think clearly. Her hippocampus was functioning now that stress hormones were no longer being released. To facilitate integration I asked, "What have you learned in the last few minutes since you arrived?" I wanted her to know what had helped, so she'd be able to use some of these same tools to combat hyperarousal and anxiety in her daily life.
Paula easily identified that she felt calmer when I sat farther away and that it was helpful when I asked her to describe me. "Looking at you, I stopped thinking about my mother. Just before I came, we had a big fight."
It became obvious to both of us that in her hyperaroused state, Paula had entered the session expecting me to act like her mother. "Actually, I expect everybody to act like her," she said.
That insight laid the groundwork for the rest of the session, in which we focused on helping Paula to differentiate who was a person to fear and who wasn't. That work wouldn't have been possible at the beginning of the session, when her hippocampus was overwhelmed.
Had I immediately begun questioning Paula on the causes of her distress instead of first attending to putting on the brakes, her overwhelmed hippocampus would have made it difficult for her to clearly separate me from her mother, and together we might have wandered into one of those anguished quagmires well known to trauma therapists. Putting on the brakes helped to avoid a potential transference disaster.
There's a common misconception among many trauma survivors and trauma therapists that working in states of high distress, including flashbacks, is the way to resolve traumatic memories. But being in the throes of hyperarousal and flashback indicates that the hippocampus isn't available to distinguish past from present, danger from safety. Under those conditions, working with traumatic images and the emotions they engender can risk a variety of negative experiences. Moreover, as Judith Herman has said, a trauma survivor's primary need is to feel safe, particularly in therapy. Applying the brakes to keep arousal low and the hippocampus functioning makes this goal much easier to achieve.
Babette Rothschild, M.S.W., L.C.S.W., is in private practice in Los Angeles. She's the author of The Body Remembers: The Psychophysiology of Trauma & Trauma Treatment , and the forthcoming The Body Remembers Casebook: Unifying Methods and Models in the Treatment of Trauma and PTSD . Address: P.O. Box 241783, Los Angeles, CA 90024. E-mails to the author can be sent to: firstname.lastname@example.com.
Damasio, Antonio R. Descartes' Error: Emotion, Reason, and the Human Brain New York: Putnam's Sons, 1994.
Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1997.
Nadel, L., & Jacobs, W.J. "The Role of the Hippocampus in PTSD, Panic, and Phobia." In Nobumasa Kato, ed. Hippocampus: Functions and Clinical Relevance. Amsterdam: Elsevier, 1996.
van der Kolk, Bessel A., Alexander C. McFarlane, and Lars Weisaeth, eds. Traumatic Stress. New York: Guilford, 1996.
by Mary Sykes Wylie
In retrospect, it seems bizarre that hundreds of thousands of veterans, all suffering from similar, dramatic symptoms, could be largely ignored by the Veterans Administration (VA) and psychiatry in general. But before the 1970s, almost no mental health authorities--military or civilian--imagined, much less expected and prepared for, traumatic reactions to war to emerge years after the conflict ended. There was yet no official traumatic stress diagnosis, and the VA assumed that any psychiatric problem occurring more than one year after discharge couldn't be related to military service.
During the Korean War, for the first time, clinicians provided frontline treatment for psychiatric breakdowns, returning the soldiers to battle as soon as possible afterward. Because this approach had worked so well--only 6 percent of Korean War evacuations were for psychiatric reasons, compared with World War II, when 23 percent were--the military was prepared to use the same approach in Vietnam. Only, nobody sought help. In fact, during Vietnam, there were proportionately far fewer reported cases of trauma on the actual battlefield than there'd been in previous wars. The primary reason seems to have been that soldiers had one-year rotations and knew that if they could just hold themselves together for 12 months--often with a little help from their friends, marijuana and heroin--they'd be free.
But after they returned stateside full of relief and happy to be alive, many of them--up to 50 percent according to the National Vietnam Veterans Readjustment Survey of 1988--began breaking down, months or even years later. Why? In spite of its time-limited nature for any individual vet, this war was in many ways even more stressful than others in the nation's history. First, troops were deployed individually, not in cohesive units, which undermined a sense of social support and increased their feelings of personal isolation and alienation. Second, troops were younger and less mature; Vietnam was often referred to as a "teenage war." Third, all wars are nasty, but this one had the special kind of nastiness that goes with a brutal guerilla war. There was an air of murderous futility about what soldiers were expected to do, and little experience of victory or accomplishment. A unit would take a hill one day, suffering massive casualties, only to have to take it again the next day.
And the Vietnamese didn't appreciate being "saved" and "liberated"; it was often impossible to tell friend from foe. As one vet said, "We are the unwilling, working for the unqualified, to do the unnecessary, for the ungrateful."
And the coup de grace: when they got home--deposited in the States maybe 36 hours after seeing a buddy's head shot off--they were unloved, unwanted, unappreciated, and often regarded as a kind of embarrassment. The U.S. had just lost its first war, and by the time it was over, a huge number of people thought the whole thing had just been a terrible mistake and wanted to forget about it. They also wanted to forget about the vets--the ones most visibly associated with the debacle, who kept reminding America that the war wasn't really over. Even veterans organizations were prejudiced against Vietnam vets, sometimes closing their doors to them.
Also, many PTSD symptoms didn't show up as the pitiful twitches and tremblings and motor paralysis that had afflicted the shell-shocked or combat-fatigued soldiers of earlier wars. The symptoms Vietnam vets experienced often appeared far more aggressive and less sympathetic. As public support for the war declined, so did the public perception of veterans, who were often undeservedly portrayed as drunk, drug-addled, brawling, wife-beating, unemployable, whacked-out guys. So it was easy for people to think, as one Vietnam vet wrote, "The Vietnam War was a disgusting and useless mess to which we had sent some of our most disgusting and useless people."
Whatever the VA's official position, however, by the early '70s, there were vast, underground rumblings about something going round the country--some strange, debilitating constellation of symptoms that seemed to be afflicting tens of thousands of returning Vietnam veterans. Trauma specialist Charles Figley, whose 1978 book, Stress Disorders Among Vietnam Veterans, was the first to address the problem, remembers when he became aware of this nameless phenomenon. A Vietnam vet himself and antiwar advocate, he recalls circulating among other vets at the massive 1971 peace rally in Washington, D.C., and listening to men talk about their nightmares, their violent rages and irrational fears, their alcoholism and drug addiction, their difficulty holding onto jobs. It was this experience, he says, that convinced him to go back to school and study psychology to find out what was happening to so many of his fellow soldiers.
Beginning in the mid-'70s, vets all over the country became very active, forming hundreds of rap groups to talk about their war experiences and coalescing into large, politically powerful, organizations to struggle for financial, social, and medical recognition of their problems. Many of the psychiatrists and psychologists who treated these vets and led rap groups were Vietnam veterans themselves, and they became forceful allies in the drive to get better care from the VA. Finally, in 1979, Congress officially mandated the VA to provide a network of counseling centers for Vietnam vets, to treat their "readjustment problems," including the as-yet-named PTSD. Even so, VA hospitals didn't begin to provide treatment aimed at trauma until the early '80s, after PTSD was included in the DSM-III (the third edition of the Diagnostic and Statistical Manual of Mental Disorders ).
By the late 1970s, it had become obvious to many therapists that the old diagnostic system had fatal flaws. DSM-II seemed to have been written for a world in which serious trauma virtually never occurred. If somebody did perchance experience what DSM-II called "overwhelming environmental stress" (details never specified), it was assumed that, once the stress had been eliminated, recovery would occur in short order without any special help. If recovery didn't speedily happen, "another mental disorder is indicated"--suggesting that the failure to get better lay in the patient's own inherent psychological weakness or vulnerability, and had nothing to do with the trauma.
While the veterans were struggling for recognition on one front, another campaign was being waged--which included some of the same people--on another, to get traumatic stress back into the DSM. In 1974, psychiatrist Chaim Shatan, who was in the vanguard of the fight for better mental health care for veterans, heard about a New Jersey public defender representing a Vietnam vet accused of committing violence against property--an action for which the vet claimed amnesia. The public defender tried to get his client declared not guilty based on traumatic war neurosis, but the judge rejected the defense, saying there was no such diagnosis.
Shatan told the public defender to contact Robert Spitzer, head of the task force that he knew was then beginning preparations for the new DSM-III, assuming that there'd be such a diagnosis in the upcoming manual. But Shatan and other veteran advocates were shocked to hear that Spitzer had no plans to include any diagnosis for war neurosis in the new edition.
So Shatan contacted other psychiatrists who'd studied the psychological impact of war and genocide--including Robert Lifton, author of a book about Hiroshima victims and later a book about Vietnam, as well as psychiatrists William Niederland and Henry Krystal, researchers studying Holocaust and concentration-camp survivors--to mobilize support to their cause. Eventually, they helped form the Vietnam Veterans Working Group, comprising vets, psychiatrists, mental health organizations, academics, antiwar activists, church groups, and the like to lobby the American Psychiatric Association on behalf of a PTSD diagnosis.
Meanwhile, Charles Figley, who'd founded the Consortium on Veteran Studies at Purdue University and had led several symposia on vets at psychological conferences, published Stress Disorders Among Vietnam Veterans, which also became ammunition in the effort. Eventually, Spitzer agreed to form a committee to study PTSD, and, in 1980, PTSD was finally included in DSM-III.
For the first time, an official DSM diagnosis assumed a psychological disorder was caused not by inner dynamics or neurotic predisposition, but by outer events that happened to the person. In fact, without the trauma, there's no diagnosis. And the trauma itself had to be something truly big and bad. DSM-III distinguished--as DSM-II hadn't--between life's ordinary vicissitudes that might generate a psychological "adjustment reaction" and traumatic events that would most likely overwhelm someone, like natural disasters, rape or assault, bombing, torture, death camps, military combat, plane crashes, and so on. The events had to be "outside the range of normal human experience," represent a threat to life and limb, and be experienced by the victim with intense feelings of fear, helplessness, and horror.
The diagnosis was as much a political victory as a shift in the terrain of mental health. For the first time, political advocacy and social consciousness overtly contributed to the creation of an official diagnostic category for a psychiatric illness, taking into specific account the recent man-made horrors of world history--war, torture, genocide. This was also the same DSM that, in another highly politicized process, removed homosexuality from the list of mental disorders. So it wasn't surprising that some critics maintained--and still contend--that both the inclusion of PTSD and the exclusion of homosexuality owed more to politics than science.
--Mary Sykes Wylie
by Mary Sykes Wylie
Bessel van der Kolk likes to introduce his workshops on Post-Traumatic Stress Disorder (PTSD) with medical film clips from World War I showing veterans diagnosed with what was then called "shell shock." In these dramatic and riveting clips, one soldier sits hunched over on his hospital cot, staring blankly ahead, responding to nothing and nobody until the single word "bomb" is said, whereupon he dives for cover underneath the small bed. Another man lies almost naked on the bare floor, his back rigidly arched, his arms and hands clawing the air as he tries, spasmodically and without success, to clamber onto his side and stand up. Yet another, who once bayoneted an enemy in the face, now opens his mouth wide into a gaping yaw and then closes it, and opens it and closes it, over and over and over again.
The images are disturbing, heartbreaking, and all the stranger because these particular men, technically speaking, are physically unharmed. Their physical symptoms--paralysis, violent trembling, spasmodic movements, repetitive facial grimaces, zombielike demeanor--look exotic to our eyes because PTSD generally doesn't show up like this anymore in most clinicians' offices. Time and Western cultural evolution have changed the way traumatized people express their distress in a therapist's office. Now, trauma patients may look fine on the surface, but complain of nightmares, flashbacks, feelings of numbness, generalized fearfulness, dissociative symptoms, and other problems that aren't as visible to the world at large. But to van der Kolk, these old images still represent what he calls the "pure form" of PTSD. The appearance in these World War I film clips that the veterans are possessed, mind and body, by invisible demons still captures the fundamental truth about PTSD--that it can reduce its victims to mute, almost animal-like, creatures, utterly isolated in their fear and horror from the human community.
Van der Kolk first became aware of the world of trauma in 1978, when he decided to go work for the Veterans Administration (VA), not to study PTSD (it hadn't been recognized yet as a formal diagnosis), but to get the government benefits to pay for his own psychoanalysis. While there, he discovered the reality of PTSD--and the beginnings of a stunning, nationwide phenomenon. "At that time, tens of thousands of men who'd served in Vietnam suddenly seemed to come out of the woodwork, suffering from flashbacks, beating their wives, drinking and drugging to suppress their feelings, closing down emotionally," recalls van der Kolk. "It was a phenomenon that spawned a whole generation of researchers and clinicians fascinated by what had happened to these guys."
Van der Kolk himself soon became intrigued by the mysterious mental and emotional paralysis that seemed to afflict these traumatized veterans. Why, he wondered, did many of his patients seem so stuck emotionally in their horror that they relived it over and over in flashbacks and nightmares? What kept these men circling round and round on an endless treadmill of memory, unable to step off and resume life? In spite of their obvious suffering, why did they seem so obsessively attached to their traumatic experiences?
In the 25 years since then, the trauma field has gone from obscurity, if not disreputability, to become one of the most clinically innovative and scientifically supported specialties in mental health. Trauma researchers have led the pack in setting off an explosion of knowledge about psychobiology and the interaction of body and mind. And van der Kolk, as much as anyone else in the field, has defined the current framework for understanding trauma.
He's the author of more than a hundred peer-reviewed scientific papers on subjects such as self-mutilation, dissociation, the therapeutic efficacy of Eye Movement Desensitization and Reprocessing (EMDR), the developmental impact of trauma, and the nature of traumatic memories. He's also been a featured contributor in most of the standard textbooks in the trauma field. In addition to teaching at Boston University, Tufts, and Harvard, he directs the Trauma Center in Boston, possibly the largest trauma specialty center in the country, with 40 clinicians working with clients who range from infants to geriatrics, from incest survivors to international torture victims. Inhabiting both the world of the clinician and the researcher, he also runs a major research laboratory at the Trauma Center, staffed by 15 researchers who investigate everything from neuroimaging of treatment effects on the brain to the effects of theater groups on violent, traumatized teenagers.
Glowing testimonials about his contributions aren't hard to come by from the field's leading lights. "Very early on, more than anybody else, he introduced neurobiology to the trauma field, and helped us see the interaction between mind and body in trauma," says Charles Figley, professor at the School of Social Work at Florida State University and Vietnam vet, whose early work on war trauma is often credited with prompting the inclusion of PTSD as a diagnosis in the DSM (see sidebar, page X). "He's one of the most generative and creative minds in the trauma field, and his influence has been pervasive," says psychiatrist Judith Herman, renowned trauma expert at Harvard Medical School.
At the same time, van der Kolk is also one of the trauma field's most controversial figures. Often prickly, rarely shy about offering his own opinions, and unafraid of a good fight, he's scandalized a number of cognitive-behavioral therapists and academic researchers by openly embracing EMDR, demonstrating an interest in such truly outre techniques as Thought Field Therapy, enthusiastically taking up nonstandard somatic therapies, and even sending his patients off to participate in theater groups and martial arts training.Van der Kolk's bold criticism of the orthodoxies of psychotherapy and public advocacy of somatic approaches have, in particular, outraged many. "Advocating unproven body psychotherapies is professionally irresponsible," says Edna Foa, professor of psychology in the psychiatry department at the University of Pennsylvania. "He's marginalized himself as a scientific thinker--he's no longer in the mainstream," adds Richard Bryant, noted trauma researcher and psychology professor at the University of New South Wales in Australia. "Until he provides data in support of his new [somatic] approach, the field isn't obligated to pay any attention to what he's doing," sniffs psychologist Richard McNally, author of the widely cited Remembering Trauma, a critique of recovered-memory theory.
The intensity of response van der Kolk kicks up is an indication of the crusader's fervor underlying his work and his determination to make the field viscerally understand that trauma isn't simply a neutral mental health issue, but a profoundly moral concern. Spicing his talks with earthy, Dutch-accented American slang, van der Kolk regularly reminds his audience in a tone of subdued indignation that trauma forces the reality of human evil into our consciousness, often the evil of presumably good and upright people--our neighbors, our leaders, our families, and ourselves. It's not a perspective people always welcome because, as he writes in his book Traumatic Stress, most of us like to believe "that the world is essentially just, that 'good' people are in charge of their lives, and that bad things only happen to 'bad' people. . . . Victims are the members of society whose problems represent the memory of suffering, rage and pain in a world that longs to forget."
A Diagnosis Non Grata
While trauma is always clinically described as a horrifically abnormal event, for any casual student of the human condition, it's actually a perfectly normal feature of history, one that has emotionally scarred billions of men, women, and children since before the beginning of recorded time. And yet, while philosophers, writers, and ordinary people have always known that terrible events can cause a lifetime of psychological pain, until the latter part of the 20th century, mental health professionals were oddly blind to this fact of life. "Psychiatry itself has periodically suffered from marked amnesias in which well-established knowledge has been abruptly forgotten," writes van der Kolk in Traumatic Stress, "and the psychological impact of overwhelming experiences has been ascribed to constitutional or intrapsychic factors alone." In other words, a failure to "get over" a trauma was often ascribed to personal weakness or an unconscious desire not to recover.
Even the official nosology of the psychiatric profession reflected this peculiar obtuseness. The 1952 edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-I ) had included combat-related stress under the diagnosis of "gross stress reaction," but this was dropped from the DSM-II in 1968--the same year that troop strength reached its peak in Vietnam. All that was left of trauma in DSM-II was the pallid diagnosis "adjustment reaction to adult life," under the general heading of "transient situational disturbance." Adjustment reaction was a grab-bag diagnosis, including "fear associated with military combat and manifested by trembling, running and hiding" and "unwanted pregnancy." It wasn't until 1980, after years of lobbying and wrangling, that PTSD was included in DSM-III (see sidebar page 37).
So when van der Kolk first went to the VA in 1978, not only was there no official traumatic stress diagnosis, but the VA assumed that any psychiatric problems occurring more than one year after discharge couldn't be related to military service. Besides denying veterans any compensation for delayed traumatic reactions--probably the overriding consideration in the VA's longstanding lack of interest in the enduring impact of "combat stress"--this rule effectively scotched any research or clinical treatment directly focused on trauma. "When I went to work for the Boston VA," remembers van der Kolk, "there wasn't a single book in the library on war neurosis."
Unable to do research on war trauma because the VA wouldn't fund studies on a diagnosis that didn't exist, van der Kolk and his colleagues did the first study ever on the real nightmares the vets had and, in another first, used the Rorschach inkblot test to reveal the twin pattern of hyperarousal and dissociation that traumatized vets showed. For van der Kolk, this research pointed to the paradoxical conundrum at the heart of trauma. "This is still the issue with traumatized people--they see and feel only their trauma, or they see and feel nothing at all; they're fixated on their traumas or they're somehow psychically absent." In either case, traumatic memories from the past have utterly usurped the present.
By the late-1980s, van der Kolk had had extensive experience working with vets and was becoming a well-known figure among PTSD researchers. He'd been responsible for several important studies, including, besides the Rorschach and nightmare papers, research into psychopharmacology and trauma, and had published the book Post-Traumatic Stress Disorder: Psychological and Biological Sequelae, the first book published specifically about PTSD. But in spite of his impressive re´sume´, he felt deeply discouraged. He'd learned a lot, but he didn't think he was fundamentally helping his patients. Even after months or years of work, his patients still suffered from flashbacks, nightmares, depression, aggressive rage, anxiety. They still either couldn't talk about their trauma at all or when he pushed them to talk about it--as he and many therapists often did, and still do--they began hyperventilating, shaking, yelling, crying, became physically agitated, or just collapsed in a state of helpless fear and dread. "I'd become a reputable PTSD researcher and clinician, but I felt I'd utterly failed my patients," van der Kolk remembers. "I guess they thought I was a good guy, they felt understood by me, but that didn't necessarily help them to get back into their lives."
And what was the treatment that he felt was not really helping his patients to move on? It was standard talk therapy 101--helping them explore their thoughts and feelings--supplemented with group therapy and medications. During individual sessions with clients, he often focused intensely on patients' past traumas, in the interest of getting them to process and integrate their memories. "I very quickly went to people's trauma, and many of my patients actually got worse rather than better," he says. "There was an increase in suicide attempts. Some of my colleagues even told me that they didn't trust me as a therapist."
The Neurobiology of Trauma
The fundamental conundrum of how trauma affects the mind and body that still plays out in treating trauma survivors was already crystallizing in van der Kolk's mind 20 years ago. "When people get close to reexperiencing their trauma, they get so upset that they can no longer speak," he says. "It seemed to me then that we needed to find some way to access their trauma, but help them stay physiologically quiet enough to tolerate it, so they didn't freak out or shut down in treatment. It was pretty obvious that as long as people just sat and moved their tongues around, there wasn't enough real change."
Back in the early 1980s, believing that future progress lay in a better understanding of the biology--particularly the neurobiology--of trauma, van der Kolk had applied for a VA research grant on the subject. Even though PTSD was now "official," his proposal was turned down flat. The opening sentence of the rejection letter still vividly resonates in his mind. "It's never been shown that PTSD is relevant to the mission of the Veterans Administration." Since then, the VA has grown up and become a leading supporter and funder of trauma research, but in the early '80s, it was clearly a diagnosis non grata to the establishment. Both dumbfounded and enraged by the VA's response, van der Kolk says he never read past that first sentence, and decided right then to seek greener pastures and put in his notice.
He moved back to the Massachusetts Mental Health Center, a state hospital and psychiatric teaching institution associated with Harvard Medical School, where he'd received his psychiatric training and, before that, had spent a year as a mental health worker on a research ward for unmedicated schizophrenic patients. Here he discovered how easy it is for the best-intentioned therapist to inadvertently make traumatized patients worse. He was struck how some female patients fell apart during personal contacts with him and other male staff, becoming agitated and assaultive. Why would they so suddenly switch from being pleasant and sensible, to losing their minds when a man would pay attention to them? he wondered. Looking into the histories of the women, most of whom had been diagnosed as borderlines or schizophrenics, he found that they'd all been severely and chronically sexually abused as children and adults.
Van der Kolk began to realize that, for these women, being in a room alone with a man who directed questions at them emotionally hurled them back into their traumas. He noted that their entire bodies responded as if they were being molested again--heart pounding, muscles tensing--they seemed, literally, to take leave of their senses--unable to distinguish now from then. "It seemed that their traumatic memories, like those of Vietnam veterans, prevented them from being able to modulate their autonomic arousal," he observes. "Their physiological housekeeping systems had been messed up by trauma."
It now seemed to him that chronic trauma explained a great deal about how borderline patients acquired their deep impairments, and why they were so hard for therapists to treat. "Borderlines have a terrible reputation because they often are simply impossible," says van der Kolk. "They cling to you and then hate you, and, either way, they won't leave you alone. But if you look at their behavior through their traumatic background, it makes perfect sense. If you've been raped and abused for years as a child and adult, your entire organism and personality has been organized around your trauma. If they have PTSD, the way they act is understandable--they're not just people trying to make your life miserable, but people trying to survive."
Van der Kolk's experience with borderlines reinforced his belief that talk therapy by itself, even in the context of a warm, supportive therapeutic encounter, wasn't enough to reverse the profound physical and emotional changes wrought in his patients by pervasive trauma. But he credits Hurricane Hugo with showing him see just how physical helplessness contributes to the development of serious post-traumatic symptoms, and making him wonder if physical movement might not contribute to healing.
In 1989, directly after Hurricane Hugo had ravaged Puerto Rico, van der Kolk accompanied FEMA officials to lend his expertise to dealing with the traumatic aftermath of the devastating storm. "I arrived in the middle of this devastation, and what I saw were lots and lots of people working with each other, actively putting their lives back together--carrying lumber, rebuilding houses and shops, cleaning up, repairing things."
But the FEMA officials immediately told everybody to cease and desist until assorted bureaucracies could formally assess the damage, establish reimbursement formulas, and organize financial aid and loans. Everything came to a halt. "People were suddenly forced to sit still in the middle of their disaster and do nothing," van der Kolk remembers. "Very quickly, an enormous amount of violence broke out--rioting, looting, assault. All this energy mobilized by the disaster, which had gone into a flurry of rebuilding and recovery activity, now was turned on everybody else. It was one of the first times I saw very vividly how important it is for people to overcome their sense of helplessness after a trauma by actively doing something. Preventing people from moving when something terrible happens, that's one of the things that makes trauma a trauma."
Pondering this striking lesson, van der Kolk wondered if perhaps the most damaging aspect of trauma wasn't necessarily the awfulness of it, but the feeling of powerlessness in the face of it, the experience of being unable to escape or fight or have any impact on what was happening. "The brain is an action organ," he says, "and as it matures, it's increasingly characterized by the formation of patterns and schemas geared to promoting action. People are physically organized to respond to things that happen to them with actions that change the situation." But when people are traumatized, and can't do anything to stop it or reverse it or correct it, "they freeze, explode, or engage in irrelevant actions," he adds. Then, to tame their disorganized, chaotic physiological systems, they start drinking, taking drugs, and engaging in violence--like the looting and assault that took place after Hurricane Hugo. If they can't reestablish their physical efficacy as a biological organism and recreate a sense of safety, they often develop PTSD.
The Monopoly of Talk
Van der Kolk was now sure that, just as the experience of physical helplessness was at the core of trauma, there was something about frustrated action to repair the situation that played a role in developing long-term PTSD. And he began to wonder if helping traumatized people engage in meaningful, physical action would allow them to recover from PTSD. His growing sense that the body, as much as the mind, might hold the key to recovering from trauma ran up against the sacrosanct tradition of the talking cure as the alpha and omega of all psychotherapy. It was about this virtual monopoly of mainstream therapy by institutionalized talk that van der Kolk was becoming increasingly skeptical.
Talk is relevant--even vitally important--he says, for traumatized patients who don't yet really know what's happened to them, who were too young to understand what was happening, who weren't listened to or believed, or who still can't make sense of what happened. His own therapy is still "very talky," he adds. But, van der Kolk continues, "fundamentally, words can't integrate the disorganized sensations and action patterns that form the core imprint of the trauma." Treatment needs to integrate the sensations and actions that have become stuck, so that people can regain a sense of familiarity and efficacy in their "organism."
Van der Kolk is also very tough on the old shibboleth of psychotherapy-as-restorative-relationship. Too often, he insists, trauma patients and therapists both move into a quasi-relationship because, that way, they can both evade the real pain of focusing on and dealing with the physical trauma imprints. "Clients may look for 'relationship' in therapy because they can't stand what they feel in their own bodies--as long as the therapist is with them, they can distract themselves from their inner experience. The 'felt sense' has become a minefield, and clinging to others is one way of avoiding the intolerable sensations within," says van der Kolk. But what patients really need, he believes, is the "therapist's attuned attention to the moods, physical sensations, and physical impulses within. The therapist must be the patient's servant, helping him or her explore, befriend, and trust their inner felt experience." Relationship therapy can seem like a kind of ersatz friendship, but "it doesn't make you better friends with yourself."
To underscore the shocking possibility that neither talk nor relationship may be necessary in trauma treatment, van der Kolk likes to tell the story of his training in Eye Movement Desensitization and Reprocessing (EMDR), an approach held in very low esteem by many of his research colleagues. Although he initially considered EMDR a fad, like est or transcendental meditation, he went for the training after seeing the dramatic effects it had on some of his own trauma patients. "They came back and told me how supportive our therapy relationship had been, but that EMDR had done more for them in a few sessions than therapy with me had done in four years," he recalls. Van der Kolk decided to go see for himself what this weird new thing was all about, and took the training.
He didn't like the training at all: "It felt too packaged, too much like a Billy Graham revival-type thing." He was, however, amazed at what happened to him when he subjected himself to EMDR as part of the training. The Trauma Clinic he'd established at Massachusetts General Hospital in 1991 had recently been closed--ostensibly for budgetary reasons, but most likely, he suspected, because of his high-profile advocacy of clergy-abuse victims, while his then department chair, a Jesuit priest, was serving as the principal advisor to Cardinal Law, who's since resigned after being accused of covering up incidents of pedophilia among more than one hundred priests in the Archdiocese of Boston. The sudden closing of the Trauma Clinic was the focus for his EMDR session. "During the session, I was fascinated by all the different images from my early childhood that made their way very rapidly through my consciousness, and which seemed somehow related to the loss of my clinic. It was like the kind of hynopompic experience you have when you first begin to wake in the morning, with ideas coming and going and being forgotten before you really wake up." Afterward, he felt as if "something had been processed and left behind," and his distress about the clinic's closing had significantly lessened.
His own EMDR practice student during the training was another clinician, who refused to tell van der Kolk anything about what he wanted to work on, except that it was "some very tough stuff between me and my dad when I was little." Overtly hostile and uncommunicative throughout the session, the clinician kept saying that he didn't really want to share what he was upset about. As a result, van der Kolk was totally in the dark about what was going on inside the person he was trying to "help" with the EMDR.
At the end of the session, the man looked relieved of much of his distress.
"How was that?" van der Kolk asked.
"I'd never refer a patient to you," the man barked at him.
Van der Kolk replied, "Oh, why is that?"
The man replied, "I really hated the way you dropped your fingers at the end of each movement!"
"But what about your original problem?" van der Kolk asked.
"Oh, I feel I completely resolved the issue with my dad."
This episode engaged van der Kolk's curiosity about the role of the therapeutic relationship. "This guy didn't trust me. We didn't have a warm relationship. I never knew anything about what was bothering him. Yet he seemed to have processed whatever it was he needed to take care of. It drove home to me the possibility that maybe people can do excellent therapeutic work, even if they don't like and trust you (as happens, of course, in many victims of interpersonal trauma), as long as the therapist knows how to help them "digest" the imprint of the trauma."
Bottom Up, Not Top Down
In 1994, van der Kolk published a paper called "The Body Keeps the Score," in which he reviewed the existing research about the neurobiological underpinnings of traumatic reactions. The paper described how trauma disrupts the stress-hormone system, plays havoc with the entire nervous system, and keeps people from processing and integrating trauma memories into conscious mental frameworks. Because of these complex physiological processes, van der Kolk explained in the paper, traumatic memories, in effect, stay "stuck" in the brain's nether regions--the nonverbal, nonconscious, subcortical regions (amygdala, thalamus, hippocampus, hypothalamus, and brain stem), where they're not accessible to the frontal lobes--the understanding, thinking, reasoning parts of the brain. In short, he demonstrated with four-part scientific harmony that it was our bodies, not our much-vaunted minds, that control how we respond to trauma, what we do and don't consciously remember, and whether we recover from it or live in thrall to it. "We're much less controlled by our conscious, cognitive appraisal than our psychological theories give us credit for being," van der Kolk remarks dryly.
For a densely written article on psychobiology, "The Body Keeps the Score" had a far-reaching impact that brought van der Kolk into much wider circles of therapists than his previous books had done. For this, he credits the article's catchy title. "If you want to write something that gets people's interest, give it a great title. People wanted to know what the hell that article was all about." The paper attracted the interest of Scott Rauch, director of the neuroimaging lab at Massachusetts General, who asked van der Kolk if he'd like to take a look inside the brains of some of his trauma patients--something that would have been unthinkable before the '90s. The neuroimaging team scanned the brains of eight trauma-patient volunteers. The first scan was while they remembered neutral events in their lives, and the second scan was when they were exposed to scripted versions of their traumatic memories.
During the scanning, the images actually showed dissociation happen in the brains of these PTSD patients. When they remembered a traumatic event, the left frontal cortex shut down--particularly Broca's area, the center of speech. But areas of the right hemisphere associated with emotional states and autonomic arousal lit up, particularly the area around the amygdala, which might be called the "smoke detector" center of the brain. According to van der Kolk, what this suggested is that "when people relive their traumatic experiences, the frontal lobes become impaired and, as result, they have trouble thinking and speaking. They no longer are capable of communicating to either themselves or to others precisely what's going on."
Other neuroimaging studies Van der Kolk has collaborated on since also showed that the executive functions of the brain become impaired when traumatized people try to access their trauma. "The imprint of trauma doesn't "sit" in the verbal, understanding, part of the brain, but in much deeper regions--amygdala, hippocampus, hypothalamus, brain stem--which are only marginally affected by thinking and cognition. These studies showed that people process their trauma from the bottom up--body to mind--not top down." But if trauma is situated in these subcortical areas, "then to do effective therapy, we need to do things that change the way people regulate these core functions, which probably can't be done by words and language alone."
So what could trauma therapists do to help people "regulate their core functions"? Perhaps because of its title, van der Kolk's article caught the immediate and excited attention of many body psychotherapists, who'd worked with trauma patients for years, but had generally been dismissed--if noticed at all--by the psychiatric establishment as New Age flakes. To them, "The Body Keeps the Score" was something like an unexpected benediction from on high. "For the first time, a traditional, mainstream psychiatrist and neurobiology researcher was legitimizing the importance of understanding the effects of psychological disturbance on the body," says Babette Rothschild, a private practitioner in Los Angeles and author of The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. "It was very exciting to have him confirm what many practitioners had believed for a long time--that there's something called somatic memory."
If the body people were entranced with van der Kolk, the feeling was mutual. As he looked out into the audience before delivering an address to them at this time, he remembers thinking, "How well put together these people all look compared to a typical audience of psychotherapists." But while they appreciated his presence and what it stood for--his recognition that understanding the body was key to understanding the mind--he seemed to think they had more to teach him than he had to teach them. "I gave my talk, and a bunch of the people there shook their heads and said, 'this poor fellow--he knows a little bit about the body, but he really doesn't understand it.' Several took pity on me and offered to teach me what I needed to learn."
The body therapists made him see how much of the work of healing from trauma is, he says, "really about rearranging your relationship to your physical self. If you really want to help a traumatized person, you have to work with core physiological states and, then, the mind will start changing." He adds, "if clinicians can help people not become so aroused that they shut down physiologically, they'll be able to process the trauma themselves. Therapists must help people regulate their affective states. That's what we do. We do it so a person can find the strength to face her own inner horrors and begin to move and regain a life for herself."
One body therapist whose work especially impressed van der Kolk was Peter Levine, the developer of an approach to trauma treatment called Somatic Experiencing. Trauma, argues Levine, is "'locked' in the body, and it's in the body that it must be accessed and healed." PTSD, he argues, is "fundamentally a highly activated, incomplete, biological response to threat, frozen in time." All animals, including humans, are physically programmed by evolution to flee, fight, or freeze in the face of grave threats to life and limb. But in humans, when these natural responses to danger are thwarted and people are helpless to prevent their own rape, or beating, or car accident, the unfinished defensive actions become blocked as undischarged energy in their nervous systems. They remain physiologically frozen in an "unfinished" state of high biological readiness to react to the traumatic event, even long after the event has passed. The undischarged energy of the blocked response to the trauma eventually metastasizes into the full-fledged panoply of PTSD symptoms. Levine believes that psychological trauma is very much about action interruptus, which the traumatized human organism still needs to complete.
Levine believes that trauma victims, having been totally helpless and unable to move--physically and psychologically--must regain in therapy that lost capacity to move, to fight back, to live fully in their bodies as much as in their minds. Instead of curling up into scared little balls when threatened, these patients need to learn in the very cells of their bodies that they can stand up and kick butt.
Just how to help numbed and terrified trauma clients acquire a little more of the Rambo spirit is demonstrated in another video van der Kolk likes to show at workshops. It features a body therapist named Pat Ogden, originator of a treatment method called Sensorimotor Psychotherapy. In it, the client--a young woman sexually abused as a child--says very faintly early in the session, "I'm not feeling my body" and "I'm just about gone," indicating that the memory of the abuse causes her to shut herself down--go numb, blank, and frozen-in order not to feeling anything. "At this point," comments van der Kolk, "she's basically not there. The moment you're not feeling your body, you're gone, because the body really is the engine of aliveness, of thought. As long as people don't feel their bodies, we're wasting our time and theirs trying to do talking psychotherapy." With great emphasis, he adds, "Becoming comfortable in their bodies is, for our patients, the number-one, paramount issue, and if we can't help them do that, then we can't help them at all."
In the video, Ogden tracks the woman's growing physical discomfort in the early stages of the session, helping her to focus on her feelings, rather than flee them. Says van der Kolk, "Asking her, 'Where do you feel that? How does that feel? What happens in your body when you say this?' helps her stay grounded in her body and in touch with a core part of herself; it allows her to keep her wits about her."
Later in the session, when she's standing, the woman says she feels "mushy" in her midsection, defenseless--"like, if you do anything to me I don't want, I wouldn't have the right to stop you." Gradually, without getting into the content of her trauma at all, Ogden helps the woman "fight back"--first by letting her fulfill an urge she has to push by having her push hard against her (Ogden's) shoulder. The woman looks more alive, stronger. When Ogden asks her what's happened, her hands come together in fists and this woman, who earlier said she didn't even have the right to stop someone from hurting her, now begins to release some pent-up fury: "I want to say to you that if you fuck with me, I'll kill you!" she almost hisses at an invisible attacker. Ogden encourages her to engage in a kind of mock combat--both of her hands pushing both of Ogden's hands, while Ogden braces herself on the floor. It's, in its way, a real struggle, with both woman really getting into it, pushing and grunting, and ending with both out of breath.
The effects are remarkable. The client, who's been almost palpably rigid and shrunken into herself, now is laughing, at ease, confident, even exultant. "I feel totally energized and strong," she says breathlessly. "That was really good!" A week later, she returns--a different woman--alive, open-faced, smiling. "I feel great," she says, telling Ogden that she's bought some new clothes and gone to a party. "Every day, I see a brighter face in the mirror." As for the trauma, she half shrugs and says, "What was done was done."
Van der Kolk emphasizes that at no point during this session does Ogden ask the woman to describe what happend to her. "Her problem isn't that she hasn't told the story, but that her body continues to collapse in the face of reminders of her trauma. Pat helps her stay embodied, so that she doesn't lose control of herself.
"Once you can do what you couldn't do during the trauma," adds van der Kolk, "once you can take the action you need to protect yourself, and once you're able to recenter and refocus yourself on a deep, organismic basis, you'll move on. The trauma is no longer interesting."
A Huge Debate
While some of the mainstream trauma field's leaders are intrigued by the potential in this treatment, many prominent figures are dismissive, when not positively horrified. In fact, the only issue that's generated as much heat in the trauma community has been the recovered-memory debate. Van der Kolk now finds himself in the thick of a battle that, once again, pits people of passionate convictions, high-minded purpose, and not a little professional ambition against each other.
This particular clash over the place of body psychotherapy in trauma treatment exploded at the 2000 World Congress meeting of the International Society for Traumatic Stress Studies in Melbourne, Australia. Van der Kolk himself inadvertently lit the fuse when he was asked to chair a plenary session on body psychotherapy, which featured the work and videos of several somatic therapists. One video (which van der Kolk hadn't seen) showed a practitioner sitting astride a rape victim. Although van der Kolk later repudiated this particular work, saying it exhibited serious boundary violations, the film caused an uproar. "It had a remarkable fallout," says Australian psychology professor and trauma specialist Richard Bryant. "Nearly all the major players in the trauma field were appalled by the fact that he'd used a leading trauma meeting to demonstrate a therapy like this, which was both ethically marginal and had no empirical support whatsoever. A huge debate emerged about the role of evidence in science versus the belief of many therapists that if they 'know' something works, they don't have to wait for the science to prove them right."
The "huge debate" continues to churn on. While this particular skirmish involves somatic therapy, the overall conflict is an old one, which basically reflects the division between two subcultures in the profession--practitioners and scientists. This is certainly not a "pure" division (clinicians do research; researchers do clinical work), but the world views of each differ substantially. Clinicians are immersed in the messy reality of daily clinical practice with multiply-diagnosed patients, and are often glad to try out innovations on the say-so of colleagues and on their own personal experiences that almost none would care to subject to a controlled, double-blind study. To researchers, "innovative" is often just another term for "outlandish." From their perspective, the only safe and dependable treatments are those that have been empirically proven in carefully controlled studies with homogeneous populations, that are easily put in the form of a "treatment protocol."
These differences lead to "enormous tension" between practitioners and scientists, says Bryant, a tension he believes therapists tend to use to their own advantage when they accuse scientists, as they regularly do, of being more interested in their dry paradigms than in real-life patients. "Therapists often put forward the view that the process of validating new treatments is too difficult and takes too long, in the meantime depriving suffering patients of treatment they know from experience works, just because scientists want them to do randomized trials. But, we [researchers] would argue the opposite--that because we're treating people who are in such pain, we have an ethical responsibility to make sure we aren't making them worse."
Edna Foa, one of the foremost authorities on prolonged-exposure therapy--in which traumatized patients repeatedly recount their trauma until it loses its disturbing power--is also not enchanted by van der Kolk's expedition into somatic therapy. Indeed, she suggests that the whole clinical practice of psychotherapy needs to be renovated along more scientific lines. "I think we've come to the point in the scientific research of therapy that clinicians shouldn't be allowed to practice and disseminate treatments without solid evidence that they work. Doctors can lose their licenses if they use unproven treatments. Why shouldn't we be the same way? Why allow practitioners to go wild with unvalidated therapies that may not help and can even make people worse?" Van der Kolk counters that scientific funding organizations virtually never support research in unproven treatments, thus promoting an Orwellian cycle of only advancing the exploration and practice of what is already known and closing the door on true exploration. In essence, such strictures would not only eliminate the practical insights and experience of therapists who actually see the real-life complexity of human suffering, but would put the kibosh on any original and potentially useful ideas emerging from clinical practice.
Living both in the laboratory and in the clinical office, van der Kolk has firsthand experience with the different paradigms that rule these worlds: Laboratory researchers pose a particular question they want answered, choose the subjects and methodology that will provide the best test of that question, and ruthlessly screen out any confounding variables. But "confounding variables" are the stuff of ordinary therapy. "As a clinician, you always have to listen to what your patients are bringing in, listen to what they're telling you that doesn't necessarily fit DSM categories," van der Kolk says. "It's the raw data of daily clinical practice and the variations in clinical experience that generate new research protocols."
More than just about any other field, the town-gown split between scientists and practitioners in psychotherapy reflects sharp differences in fundamental ways of taking in the world. "Skepticism is the core of scientific enquiry," says trauma expert Alexander McFarlane of the University of Adelaide. "Science is based on statistical comparisons between groups--it's not a science of the individual subject. And it's supposed to be critical--scientists make their money out of criticizing ideas. Therapy, on the other hand, happens in the realm of the individual stories people tell, and the variety of ways they do it." The therapeutic endeavor is built on a framework of reasonable trust and belief in what the patient says, not criticism. "You can't treat patients if you don't believe in what you're treating," says McFarlane. In a moment of candor not calculated to endear him to his researcher colleagues, van der Kolk says simply, "It's an issue of temperament: Therapists seem to enjoy living with the uncertainty, unpredictability, and complexity that comes with the intimacy of the relationship, whereas most laboratory scientists are most committed to establishing 'facts,' which, by virtue of the dictates of the scientific method, can only encompass a small slice of the total complexity of human beings."
But van der Kolk is nothing less than an equal-opportunity provocateur. He seems determined to make clinicians fundamentally reconsider their usual responses to the suffering souls who visit their offices, down to the furnishings they choose. With his characteristic wryness, he insists that "As long as people sit on their tochas and simply move their tongues around, they may not be able to make enough of a difference to affect internal sensations and motor actions. People need to learn to regulate their physical states in order to get their minds to work. Once they shift their physiological patterns, their thinking can change."
It's been an implicit premise of psychological science and clinical practice both, as it is of our entire culture, that our singular human identity resides in our disembodied minds. The West's infatuation with Cartesian dualism has made our bodies somehow strange to us, a self-alienation reinforced by clinical psychology. It's hard even to conceive of the lofty mind--our own, anyway--as an indisputably physical, material organ, a wrinkled, ovoid mass of blood and tissue. PTSD--or any deeply painful emotional state--is experienced as a foreign intrusion that smothers our "true self," our mind's self. Most of psychotherapy is geared to getting this mind-self back, and most of it is conducted as a mental exchange between two people sitting quietly in chairs. Even psychopharmacology seems intended more to quell the rebellious body--quiet and soothe it, get it out of the way and under wraps--than acknowledge and welcome its living presence in the therapy room.
For all the ferment he's helped create, van der Kolk admits that he doesn't have any easy answers about how to unravel the tangled web of trauma, much less reconcile our culturally enshrined mind-body split. During a presentation last year, he confessed his discomfort to several hundred therapists. "I always wonder how I can continue to do workshops like this and ask you to sit on your rear ends all day listening to me talk, knowing that people really only learn when they move and act," he says. "I feel increasingly bothered by the real contradiction between what I practice and what I preach." With his penchant for stirring things up and raising questions that can't be ignored, it's a safe bet that as long as van der Kolk feels uncomfortable with therapy's conventional wisdom, the rest of us will, too.
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .
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Dusty Miller
Whether delivered by hand grenade or by hurricane, by fist, machete, or burning plane, traumatic experiences are universal across cultures, and so are attempts to heal them. How well those attempts succeed depends in part on the stories a culture tells itself about victimizers and victimhood--about recovery, wholeness, and resilience. This is particularly true of intimate family violence, which broke into the light in the late 20th century, casting ripples that continue to this day.
As a systems therapist, incest survivor, and recovering alcoholic, I've lived through several stages of our culture's attempt to come to terms with child sexual abuse--as a victim in the silent 1950s; as a therapy client in the oblivious 1960s and 1970s; and as a psychotherapist in the 1980s and 1990s, when once-dismissed accounts of abuse filled my therapy practice (and my television screen) only to be partly discredited within the decade during another swing of the cultural pendulum.
We clinicians are still feeling our way toward a middle path, one that avoids the extremes of disempowering pity and "buck-up" denial. Our clients (and if we're survivors, we ourselves) still struggle to negotiate what sociologist Ervin Goffman called "spoiled identity": the isolating experience of being cast outside the circle of "normal" life, along with gays, paraplegics, and madwomen. Helping a client move from subjugation by the worst thing that ever happened to me to a nuanced and effective life has turned out to be more complex--and oddly enough, more commonplace--than I imagined when I first sought help.
One in a Million
The simplest version of my own story begins with my father. After he came home from World War II, he led at least three separate lives: one in Manhattan with his German mistress and her mother, who followed him to the States; one with my mother and me in Northampton, Massachusetts; and one in my bedroom at night, with my mother seemingly oblivious and asleep at the other end of our house.
Photographs of me at 3, before that secret life began, show a cheerful little girl, eyes full of delight, almost always smiling at the camera, smiling at the man taking the pictures--her father. In my kindergarten picture, taken two years later, my body expresses what none of us would put into words for 20 years. Around the kindergarten table the children sit, posture-perfect, hands folded in front, eyes gazing alertly at the photographer, all of the faces smiling--except one. Thin and awkward, my arms and legs sprawled weirdly over the little chair, my mouth hanging open and my eyes staring vacantly off into space, I'm the only one not looking at the camera.
The year was 1950, a time so different from the present as to be almost another country--a postwar, post-Holocaust world, cocooned in a vast cultural silence about victimization and the aftereffects of victimization. In this world, bleached of any reference to trauma, alcoholism, or child sexual abuse, there was no such thing as Megan's Law, Battered Child Syndrome, the Betty Ford Center, or Post-Traumatic Stress Disorder.
According to a leading psychiatric text, incest was something that happened only once in a million families. No child I knew ever told me she'd been repeatedly struck in the face (as I had) by a father who at other times was playful, loving, and kind. Until I was 17, I didn't try to tell anybody--not even my beloved godmother--that my father forced me to perform sexually. Nor before I was 24 did anyone believe me.
In 1962, as a frightened freshman at Cornell University, I made my way to the college counseling center. I was 17 and an excellent student, but I was already drinking heavily, sleeping around, and generally confused by my sexuality. In my initial interview, I wasn't explicit about my father's incestuous abuse. But I talked about my unhealthy closeness to him, my fear and loneliness, and my feelings of being "different" from others my age.
I began counseling with the head of the center. He asked me endless questions about my relationship with my mother . Although I kept trying to talk about my father, this man said it was because of my "overclose" mother-daughter attachment that I was experiencing the plague of bisexual attractions and recommended that I spend the summer with my father in his one-bedroom apartment in Manhattan. I fled from my would-be helper and waited seven years to try to speak again.
Thoreau once said that it takes two to tell the truth: one to speak and one to listen. The first person to listen to me was Florika, a bright young Romanian immigrant whose father had not only sexually abused her but had begun force-feeding her amphetamines at 13, when she faltered as a virtuoso child violinist. I met her when I was 24, living in New Haven, Connecticut, after graduating from Cornell. I was drinking a lot at the time, working in a women's carpentry collective, practicing karate, learning to run the printing press at a radical newspaper, and playing drums in the New Haven Women's Liberation Rock Band, where Florika was the bass player. Many were the nights we roamed New Haven together, spray-painting buildings with graffiti urging women to smash the patriarchy.
We were alone in the dark in Florika's apartment one night, high on marijuana, when I experienced a state of wordless, paralyzing, bodily fear that I'd now call a flashback. Wrapping me tightly in a blanket the way she'd learned in a mental hospital, Florika told me soothingly that I'd be alright. Finally, she crooned that she "understood" me.
"What do you understand?" I asked.
"That you're one of us," she whispered.
I don't remember exactly what I said next, but I'll never forget the relief that followed my first stumbling words of disclosure and our mutual recognition. For the first time, I heard that I wasn't the only one. In that era of denial, I don't think I yet realized that incest had ever happened to anyone except Florika and me.
Within 24 hours, Florika had also introduced me to the daily use of amphetamines--something that made me feel powerfully in control even though I'd never been more out of control. The pseudocloseness of shared addiction felt familiar, like the secrecy, stimulation, and shame I'd lived so many nights in my father's house.
My pattern of what we now call "trauma reenactment" went undetected for years by mental health professionals: our profession played a cultural role analogous to the Non-Protecting Bystander in the incestuous family system--like my mother sleeping at the other end of the house. Psychiatrists and psychologists repeatedly beat the bushes for any explanation rather than the obvious ones: that I was telling the truth about my sexual abuse; that I was desperately trying to soothe a neurobiology disregulated by trauma; and that my addictions were creating major physical, psychological, and practical problems of their own.
Counterbalancing Experiences
If this narrow story of trauma, rage, misdiagnosis, therapeutic mistreatment, and spoiled identity was all there were to tell, I'd be dead by now--as dead as Florika, who took a fatal overdose of heroin in her late twenties while working as a Hollywood studio musician. But my life, like most lives, included commonplace and counterbalancing experiences that had nothing to do with abuse: the emotional support of my godmother and many teachers; a wordless enjoyment of the natural world; and successful involvements in school, radical politics, work, and athletics.
During my college summers in the '60s, for instance, I was part of the movement to register African American voters in the Deep South, where I met people whose sources of resilience were very different from my own. I particularly remember Jereldine Johnson, a powerfully built African American woman who lived with her 13 children (plus me for one summer) in a cabin in rural Tennessee. Scorching sun; red clay in skin, hair, nostrils; smoke of the wood stove, even when it was 100 degrees out; crying babies--all were part of Jereldine's daily life.
In prayer meetings and rallies in small rural churches in the cotton fields, Jereldine and her neighbors faced poverty, violence, and racism together--with songs, testimonies, political action, and energetic joy. Everyone participated. Everyone, no matter how uneducated or beaten down, was assumed to have something to offer. In contrast to the isolated inner struggle of the abuse survivor, traumatic experiences among the African Americans I met in the South were confronted communally and held in a spiritual perspective, leading to something other than bitterness and despair. It was years before I could put into practice what Jereldine had shown me, and I returned home alone at the summer's end, still closely guarding the secret of my sexual victimization--except when I was drunk (which was often).
So it went until an early winter day in 1978, a year after my father's death, when I found myself in a car on an interstate in Connecticut, being driven back to my job (as a dorm counselor near my childhood home in Northampton, Massachusetts) by someone I hardly knew. After I opened the car door and tried to jump onto the freeway--it seemed like a good idea at the time--the terrified driver delivered me struggling and shouting to the emergency room of a hospital off the nearest exit.
Three days drunk, covered with blood from self-inflicted cuts, my hair disheveled, dressed in jeans and an old army shirt of my dad's, even my gender was unrecognizable. I was wrestled into submission by six emergency room workers, injected with a paralyzing amount of Thorazine, and transported by ambulance to a locked ward for violent women at the Connecticut state hospital in Waterbury. I was 34.
I sobered up in a gloomy, disinfectant-smelling darkness. Was I in a barracks, a dorm, or a concentration camp? I'd stayed briefly in private psychiatric hospitals before, but never had I been forcibly locked in with other violent, despairing women. Life had finally thrown in my face what a half-dozen therapists had overlooked. For a decade, my episodically competent days had been fueled by amphetamines, caffeine, rage, and prescribed antipsychotic drugs like Stelazine; in the evenings, I'd mellowed out with tranquilizers, gin, and sex with near-strangers. This regimen of prescribed and self-prescribed drugging had worsened my flashbacks until they mimicked transient psychotic states.
I don't know what diagnoses I'd been given by my well-intentioned New Haven psychologist, Dr. M., who'd minimized my alcoholism and repeatedly told me that my memories of incest were fantasies representing my disguised yearning for my father. But I suspect my bulging file contained references to borderline personality disorder or depression with psychotic features. Like thousands of other traumatically abused and misdiagnosed women, I was well on my way to developing the "spoiled identity" of a chronic mental patient. Dr. M. had led me to believe that I'd spend the rest of my life in and out of psychiatric units like the one I then found myself in at Waterbury.
Only my middle-class connections, I suspect, saved me from involuntary commitment. Two days after my arrival, three well-dressed, college-educated friends appeared in the middle of an ice storm and talked their way into meeting with the psychiatrist on call. "She needs to be in detox," said the psychiatrist, and released me to them.
It was the beginning of the end of my addictions.
Two months later, in another locked psych unit after another violent, drunken altercation, a psychologist suggested I move to the alcohol treatment unit one floor below. I agreed and for six rocky weeks, I self-consciously sat through 12-step meetings, heard about a Higher Power, and got used to the idea that I was powerless over alcohol and that my life had become unmanageable.
Once I stopped abusing drugs and alcohol, my flashbacks and dissociated states lessened markedly. With my friends' encouragement, I weaned myself from the overpowering antipsychotic medications that had kept me groggy and debilitated. I'd given up the spoiled identity of the mental patient in favor of the more accurate--and therefore more helpful--label of the recovering addict and alcoholic. But in 12-step meetings, I often felt awkward and out of place, and there were still parts of my story that I couldn't tell.
The Politics of Truth
Clean and sober, I returned to graduate school and shot like a rocket from chronic PTSD and rampant addiction to what seemed like the other end of the rainbow. Within six years, I was "Dr. Miller," a clinical psychologist doing postdoctoral work in family and narrative therapy at the University of Calgary Medical School in Alberta. On one memorable day, I visited a Canadian mental hospital as a consultant and expert on domestic violence and addiction. I'll never forget a social worker's giving me an enormous key, which opened all the wards, including a locked ward similar to the one I'd been committed to in Connecticut. Holding that key and remembering the movie King of Hearts , I was tempted to open every door. I was also irrationally terrified that my identity as a former mental patient would somehow be exposed.
As a family systems therapist, I loved drawing connections between a family's surface pain and hidden issues of addiction, patriarchal social assumptions, and domestic violence. I loved the "difficult" families, especially the mistrustful, mislabeled, and misunderstood mothers. I loved being mentored by iconoclastic family therapists who did battle with The System, personified by well-intentioned but oblivious social workers, psychologists, and psychiatrists like those who'd mislabeled and mistreated me.
Then one day in 1985, I sat behind a one-way mirror supervising a graduate student working with a father and his young daughter. Someone in the therapy room--I can't now remember who--said the word "incest," and it resonated through the microphone and into my observation room. A student next to me whispered a question, but I couldn't hear her words. Tears fell onto my hands as I twisted them in my lap.
When I confided in a senior family therapist, he told me not to get too involved and to just do my job. It sounded like the message I'd been given as a child: don't rock the boat, only remember the good times, and don't air family business in public.
But times had changed. If power consists in part in determining whose stories will be told and whose believed, the balance of power was shifting. Stories like mine were being whispered to a new generation of women therapists, spoken out loud in new 12-step meetings for adult children of alcoholics, and aired among feminists involved in the movement to stop domestic violence. The floodgates had opened. Control of the politics of truth had moved from the experts to the experienced.
After nearly a century in which the mental health field had dismissed reports like mine as fantasies, we victims lost patience with being spoken about and began to speak for ourselves. If our culture wanted to play Non-Protecting Bystander, we'd strip away the collective ignorance that had served as its shield. Like gay people and people of color before us, we defiantly embraced and began to dismantle the spoiled identity we'd been assigned. Oprah Winfrey, Maya Angelou, former U.S. Senator Paula Hawkins, and former Miss America Marilyn Van Derbur all said on television that they'd been sexually abused as children. By becoming vocal, we challenged the family and cultural role we'd been assigned: to suffer in silence, save everyone else from discomfort, and internalize the damage.
In the face of the carefree old public narrative--that incest was either imagined or consensual, and in any case, only occurred in one in a million families--we faced what lay in plain sight: that child sexual and physical abuse were real, damaging, and prevalent; and so were rape and other forms of family violence. If childhood and family trauma could be stopped and effectively treated, we figured, whole categories of the DSM --borderline personality disorder, dissociative disorders, substance abuse, cutting, sex addiction, other behavioral addictions, PTSD, and even some forms of anxiety and depression--might practically disappear. The elephant that had crashed unrecognized outside the windows of the consulting room for 80 years was finally seen and named.
We of this new generation of feminist clinicians saw childhood trauma for what it was. What we didn't know--and didn't know we didn't know--was how to treat the multiple layers of disruption it had caused. We recognized the critical importance of telling the story, but not that telling too much, too fast, to a relative stranger could retraumatize us and our clients. Stuck in a Manichean universe, which divided humanity into evil perpetrators and innocent victims, we had no nuanced language for the complex spiritual wounds of intimate violence: the conflicted familial bonds of love and pain; the sense of being isolated and unsafe in the universe; the distrust of the body, love, or pleasure; and the questioning of God's intentions after profound human betrayal. We didn't know that an individualistic and secular talking cure could only take us and our clients half the way home.
By the mid-1980s, we clinicians were experimenting with hypnotherapy, cognitive-behavioral work, and psychodynamic approaches that sometimes fostered inaccurate recall, retraumatization, family cut offs, and regression. Exposure therapy (developed for combat vets), for example, had been used effectively to desensitize adult women who'd suffered a single incident of rape. But when incest survivors repeated their stories over and over, they relived their traumas physiologically, along with the complex relational wounding of betrayal by a close family member. The biologically based rage, terror, and helplessness that followed were then often turned against the self in the form of renewed cutting, self-destruction, and addiction.
I remember, for instance, an incest survivor in Northampton who was coping well and working in a responsible position at a local title insurance company. After entering therapy, she became grossly obese, stopped working, and, to my knowledge, has never worked again.
I'd reentered therapy myself in the mid-1980s and, for the first time, I was assembling a coherent life narrative with a clinician who believed me. But if this was the validation I'd sought, why did I feel worse after nearly every session? Helpless and enraged after reliving detail after detail of how my father had hurt me and my mother had abandoned me, I'd walk out of her office and end up in an expensive shop in Northampton, flipping out my MasterCard for beautiful clothes I couldn't afford.
I stopped exercising, gained weight, and became increasingly isolated. I could barely work. My glands were swollen, my joints ached, I slept erratically, and I was acutely lonely. So it went until I quit therapy--because my therapist continued to insist that I confront my widowed, 80-year-old mother with her failure to protect me.
I wasn't alone in my misgivings. In the early 1990s, I was frequently asked to consult with bewildered therapists, whose clients had entered therapy doing more or less okay and had then fallen apart. I particularly remember Frieda, a talented sculptor who'd been in therapy for seven years. She'd stopped working on her art, became a child instead of a partner to her husband, and was drinking too much and neglecting her children. In consultation, I asked why she was persisting with therapy that apparently wasn't doing any good. I suggested--much to her therapist's shock and dismay--that Frieda take a break from individual therapy, try a group focused on building present-time, real-life competence, return to sculpting, and go to Alcoholics Anonymous.
Frieda's therapy had been modeled on a psychodynamic approach influenced by British researcher John Bowlby, the expert on mother-infant attachment. The idea was to compensate for early betrayal and "insecure attachment" by providing clients with a dynamic, reparative, and trustworthy therapeutic relationship.
In practice, this often meant making excuses for destructive behavior and implying that nothing better could be expected of someone so horribly damaged. The focus was on the wounded child to the exclusion of the competent adult. To make matters worse, many therapists eventually became exhausted by the role of ministering angel and turned punitive with their clients.
This therapeutic quicksand was responsible for slogans, buttons, and bumper stickers like "It's got to get worse before it gets better" and "It's never too late to have a happy childhood." In Northampton, where I live, adult women walked around with teddy bears in their backpacks--and some, I hate to say, still do. Many became disconnected from any community but the community of survivors, and any identity beyond the spoiled identity of victimhood. Their lives consisted mostly of living alone, writing in journals about what had happened to them, and making the rounds of group therapy, individual sessions, support groups, and inpatient units.
Some channeled their rage into confronting or cutting off from their parents, but few looked out the window into a larger social world. No effective equivalent of Mothers Against Drunk Driving emerged to lobby for the next generation of kids. Social attention was diverted instead to a phantasmagorical distraction: the notion--never, to my satisfaction, confirmed--that secretive, satanic cults had subjected thousands of American children to ritual abuse. In Northampton, this hit home when a new psychiatrist took over the women's wing of a nearby psychiatric hospital. Until managed care put an end to it, patients referred there for brief stays emerged, months later, bearing diagnoses of multiple personality disorder and living in terror of the cult members who, they said, had devastated their childhoods.
That's why, when the False Memory Syndrome Foundation (FSMF) burst on the scene in 1992 and began challenging professional licenses and picketing therapists for "splitting up families," I felt ambivalent. On the one hand, they represented such a backlash. On the other hand, as I quietly said behind closed doors, they had a point. We were walking into dense fog where it was hard to tell what was real and what wasn't. Given the way I hadn't been believed myself for so many decades, I wanted the story told by victims about their victimizers to be always simple and always true. It wasn't turning out that way. Yet it was almost taboo among us to admit that much of what we were doing wasn't working. Anyone who criticized therapeutic practice risked being identified with the FMSF, whose members were presumed to all be Abusers and Non-Protecting Bystanders. A new elephant had entered the consulting room, and we were in denial all over again.
Nurturing the Competent Adult
In this state of unease and not-knowing, I reached beyond the incest recovery movement. In 1995, I drove to Burlington, Vermont, for a weekend workshop in "Just Therapy," a New Zealand approach connected to both the Narrative Therapy movement and indigenous movements for social justice. Led by a white man, a Maori man, and a Samoan woman, all from New Zealand, the group opened every session with chanting and prayer, challenging us bemused, secular Americans to do the same.
That day, I awoke to the spiritual thinness of the therapeutic work we were doing. Within the incest recovery movement, victims had been assigned a debilitated and isolated purity, while abusers and nonprotecting parents were monsters without humanity or compensating strengths. In this black-and-white universe--with good and evil people neatly divided--our clients remained as trapped in spoiled identity as their perpetrators, cut off from humanity as a whole, from their own failings and strengths, and from the healing power of acceptance.
I thought variously of Gandhi's independence movement, of Alcoholics Anonymous, and of the Civil Rights movement, all of which had flourished rather than imploded. What had been their secret? Despite their enormous differences, all had transformed participants--and the culture at large--in a way I can only describe as spiritual. All had acted in the present moment--cognizant of, but not enslaved by, the past. All had faith in something bigger than themselves, and none demonized their purported enemies. Could the trauma survivors' movement do the same?
At around this time, I came across journal articles by the pioneering research clinicians Bessel van der Kolk of Boston University and Marsha Linehan of the University of Washington. Both turned attention from the psyche to the body of the trauma victim and hypothesized that self-harmful behavior like cutting could be an attempt to soothe chronic neurobiological disregulation. If this were true, our clients couldn't think, talk, confront, cathart, or "re-story" their way to wholeness. Their nervous systems were continually telling them that the past was the present. Rather than a prolonged version of the Primal Scream, they needed new ways to learn to reregulate their disturbed neurophysiologies.
At this point--please bear with me here--I took up tennis. I was in my late forties and out of shape, and I just wanted to get more play, joy, and exercise into my life. My tennis teacher, Deedie Steele, became such a model of encouraging and demanding realism that if I were still supervising clinical graduate students, I'd require them to watch her teach tennis.
Deedie thought anyone could become a competent tennis player, and her teaching reflected both kindly encouragement and a precise analysis of everything I needed to do to improve. Standing across the net from me on the public court in Northampton, she watched how I placed and moved my feet, knees, elbows, and wrists as carefully as if she were preparing me for Wimbledon. She showed me in minute, persistent detail how to make necessary changes. Good therapists, I thought one sunny day as I ran sweating around the court returning her serves and trying to pay attention to my right wrist, are like Deedie: they believe that each client can function as an effective adult, and they help them gain the skills necessary to make this happen.
In the classroom, in supervisions, and in my therapy office, I widened the lens and began thinking in similar terms, analyzing precisely the outer (relational) skills and inner (self-calming) skills that trauma survivors needed to function better. Then I taught these skills, whether they were considered "therapy" or not. I began asking questions that were once outside the therapist's domain: How much do you exercise? What do you eat? Do you have a sense of a Higher Power or a Protective Presence in your life? How do you play and express yourself creatively? Do you meditate? Are you getting enough sleep?
In my own life, things were moving, too. I entered a long-term relationship with someone who helped me learn to play and have fun. We renovated a house together in Northampton with the help of our son-in-law, a contractor, and I became part of a family that included grown children and grandkids.
I also returned to 12-step meetings--and there, too, things had changed. Women participate more actively in the recovery movement now, and I felt freer to share my story. The time I spent in those church basement rooms opened a door to a deeper spiritual yearning. After years of dabbling in Buddhist books, I began meditating regularly and discovered, in Pema Chodren and Thich Nhat Hanh, the notion of impermanence. This basic Buddhist tenet--that the "self" isn't fixed and that all circumstances and states of mind pass was the perfect antidote to the sense of doomed identity that had brought me to my knees in that mental hospital in Connecticut. I became more solid--and yet, oddly enough, more open to friends and strangers. I was living a fuller life than many people who'd never been abused.
Leaving a church basement one night, I found myself rethinking the whole question of victimhood, healing, and wholeness. As much as my clients needed to understand the links between their victimization and self-destructiveness, I thought, they needed even more to take an ordinary place within the web of life.
In 1995, my graduate students at Antioch New England university suggested we incorporate what I was trying with individual clients into group therapy. Our first three-month group was held in the offices of a domestic violence program in Greenfield, Massachusetts. This notoriously poor, predominantly white area of northwestern Massachusetts is a landscape of played-out farms, abandoned brick factories, and tattered, triple-decker apartments lining the side streets of decaying, 19th-century mill towns. Unemployment is high, and so are heroin addiction, crack use, and domestic violence.
Our first eight participants were women who'd repeatedly called the domestic violence center's hotline--most of them grandmothers, foster mothers, and single mothers with staggering histories of childhood abuse, alcoholism, cutting, drugging, enmeshment in battering relationships, and visits to local psychiatric inpatient units and emergency rooms.
We opened the first session by teaching the women simply to breathe with awareness. Then we talked about the links between their childhood histories, their addictions, and the way they had internalized all three roles: Victim, Abuser, and Bystander. Each week, we asked how trauma had affected them, but we also asked about the roots of their resilience--their successful coping strategies and the people they remembered who'd been there for them, even if not consistently.
Over time, we taught them to turn to other members of the group for support rather than to the group leaders. They painted and drew. In brief guided meditations, we helped them connect to something bigger than themselves. That opened the door to developing a felt sense of Protective Presence, evoked from memories of protective adults, beloved pets, nature, and compassionate religious teachers like Jesus and the Buddha. They learned to reliably evoke this presence to remind themselves that even though they'd been victimized, they'd also been whole people all along.
In the last three weeks of the three-month group, we focused on how they intended to give back to the larger community. Some returned to Alcoholics Anonymous or Narcotics Anonymous. Others went back to school, college, or work. Others chose to volunteer in the storefront drop-in centers I'd helped organize with other therapists, community activists, a small order of radical Catholic nuns, and a visionary federal project dedicated to supporting innovative work with trauma survivors. Self-destructive behaviors diminished and, perhaps more important, participants created an identity for themselves that included, but wasn't limited to, their traumatic past.
Since then, I've trained more than 200 women with histories of trauma, most of them poor, with limited education. I call this program ATRIUM (Addiction and Trauma Recovery Integration Model) after the entry chamber of the heart. The metaphor is meant to suggest that the groups are just a starting point. Their graduates now lead similar groups in local prisons, jail diversion projects, AIDS programs, and the three drop-in centers for survivors. Many of these women--among them many welfare-dependent single mothers and grandmothers--have turned out to be more effective group leaders than some of the highly educated professionals that I've trained. They're helping create what may be the therapy of the 21st century: a blend of peer support, psychoeducation, interpersonal skills training, meditation, creative expression, spirituality, and community action.
Time Is a River
I'm now close to 60--a middle-class, middle-aged professional living on Prospect Street in Northampton, Massachusetts--the same street I grew up on. I still occasionally see women in town with teddy bears in their backpacks and buttons saying "It's never too late to have a happy childhood." I want to tell them that their button is wrong: it is too late. Time is a river that runs in only one direction. Trauma survivors--be they Vietnam veterans, Cambodians, Holocaust survivors, sexually victimized women, or firefighters who escaped from the World Trade Center--never become people to whom trauma didn't happen. But the ripples that flow outward from every traumatic event don't have to sink us, define us, or assign us a single identity. "Victim," I want to tell them, describes a specific moment in time, not permanent self-definition. This is a comforting aspect of the impermanence that transforms every emotional state.
As a culture, we're only just waking from sleep. It's long been easier to blame people covertly for their reactions to childhood abuse than to face what happened to them. We pay staggering public health bills for the addicted and traumatized, but we balk at spending on preventing that trauma in the first place. Protective workers charged with investigating crimes against children, for example, make less than half what we pay the police officers who investigate adult crimes.
There are a few hopeful signs that this may change. In the wake of the priest scandals and the collective public wounding of the September 2001 attacks, words like victim and trauma have enlarged their meanings beyond the mostly female holders of this particular spoiled identity. The psychic damage suffered by the firemen and construction workers of Ground Zero made it clear that not only Vietnam veterans and sexual-abuse survivors suffer from PTSD. Nobody's yet suggested that the "heroes" of 9/11 are part of a culture of complaint. As Jack Rosenthal put it last fall in the New York Times Sunday Magazine, "Before 9/11, trauma often referred to the horrible physical injuries seen on E.R. Now the psychiatric use of the term may just as likely be referring to the time bombs that 9/11 lodged in the minds of thousands."
Meanwhile, I'm continuing to play tennis. Thanks to expert coaching and hard work, our aging, ragtag team, The Courtesans, has progressed from dead last to a respectable standing in our local league. When I travel to Washington, D.C., these days to meet with the federal agencies that fund our grass-roots projects in Franklin County, I sometimes pass the Mall, where, during huge women's rights rallies, I played in the New Haven Women's Liberation Rock Band with Florika. I think back 30 years to that desperate, unconscious, distrustful, and enraged young woman, three days drunk and covered with self-inflicted cuts, who was shot full of Thorazine and bundled off to a state hospital in Connecticut. She'd be both contemptuous and amazed to see who she's become: a physically healthy professional woman who works inside the system without ever quite joining it. And although I still hold in my heart that wild young woman and understand how she came to be, the river of life has flowed a long way since then, and she's now only part of me.
Dusty Miller, Ed.D., is director of the Atrium Consultation and Training Institute in Northampton, Massachusetts. She's the author of Women Who Hurt Themselves; Your Surviving Spirit: A Workbook of Spiritual Resources for Coping with Trauma; and numerous other publications on trauma and addiction. She's also the codirector of the Willing Spirit Retreat Center in Cape Cod, Massachusetts. Address: 229 Prospect Street, Northampton, MA 01060. E-mails to the author may be sent to email@example.com.
Barrett, Mary Jo. "Healing from Trauma." In Spiritual Resources in Family Therapy, edited by Froma Walsh, 193-209. New York: Guilford, 1999.
Chodron, Pema. Awakening Loving-Kindness. Boston: Shambhala Publications, 1996.
Herman, Judith Lewis. Trauma and Recovery: The Aftermath of Violence from Domestic Abuse to Political Terror. New York: Basic Books, 1992.
Jordan, Judith V., et al. Women's Growth in Connection: Writings from the Stone Center. New York: Guilford Press, 1991.
Linehan, Marsha. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press, 1993.
Miller, Dusty. "Incest: The Heart of Darkness." In Secrets in Families and Family Therapy, edited by Evan Imber-Black. New York: W. W. Norton, 1993.
----. Women Who Hurt Themselves: A Book of Hope and Understanding. New York: Basic Books, 1994.
----. "Challenging Self-Harm Through Transformation of the Trauma Story." In Sexual Addiction and Compulsivity, 3, no. 3 (1994): 213-27.
----. Your Surviving Spirit: A Spiritual Workbook for Coping with Trauma. Oakland: New Harbinger Publications, 2003.
Miller, Dusty, and Laurie Guidry. Addictions and Trauma Recovery: Healing the Body, Mind and Spirit. New York: W. W. Norton, 2001.
Najavits, Lisa, R. D. Weiss, S. R. Shaw, and L. R. Muenz. "Seeking Safety: Outcome of a New Cognitive-Behavioral Psychotherapy for Women with Posttraumatic Stress Disorder and Substance Dependence." Journal of Traumatic Stress, 11, no. 3 (1998): 437-56.
van der Kolk, Bessel, Alexander McFarlane, and Lars Weiseth. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press, 1996.